ADULT HEALTH FINAL

What is the primary nursing intervention indicated for a symptomatic patient with a Wedge pressure of 3?

Begin Volume replacement

A client is brought into the ER with partial thickness burns to the face, neck, arms and chest while trying to put out a fire. The nurse should implement which nursing actions? 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed.

2. Assess for airway patency. 3. Administer oxygen as prescribed. 5. Elevate extremities if no fractures are present.

ABG's of someone that has renal failure, the nurse should expect what result? 1. pH 7.49; PaCO2 36; HCO3- 30 2. pH 7.30; PaCO2 35; HCO3- 18 3. pH 7.31; PaCO2 50; HCO3- 23 4. pH 7.43; PaCO2 48; HCO3- 30

2. pH 7.30; PaCO2 35; HCO3- 18

During hemodialysis the patient develops lightheadedness and nausea. What should the nurse do first?

Decrease the rate of fluid removal and infuse normal saline

Pt with complaints of chest pain, SOB, hypotension. Connected to monitor, nurse observes this rhythm (SVT). Appropriate intervention for this rhythm?

Adenosine

A client with a family history of cancer asked what the single most important risk factor for cancer. Which risk factor should the nurse discuss?

Age

A client has an open coli with bile duct exploration following surgery. The client has a T-tube. To evaluate the effectiveness of the T-tube, the nurse should do what? 1. Irrigate the tube with 20 mL of normal saline every 4 hours. 2. Unclamp the T-tube and empty the contents every day. 3. Assess the color and amount of drainage every shift. 4. Monitor the multiple incision sites for bile drainage.

Assess the color and amount of drainage every shift

After cardiac cath, large amount of blood under buttocks. Nurse should

Assess the site

What action should nurse do first with asystole

Confirm in another lead

A client newly diagnosed with chronic kidney disease has recently begun hemodialysis knowing that the client is at risk for disequilibrium syndrome. The nurse should assess the client for which associated manifestations?

Decreased level of consciousness..

The nurse should monitor the patient for cushing's disease for which finding?

Decreased uric calcium levels**

A patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care? a. Restrict the patient to bed rest. b. Encourage 4000 mL of fluids daily. c. Institute routine seizure precautions. d. Assess for positive Chvostek's sign.

Encourage 3000-4000 mL of oral fluids daily

Older client receiving oxygen. Pt coughing—what should nurse do to mobilize secretions? Select all that apply

Encourage coughing Provide chest something Humidified oxygen

Pulmonary embolus, when suction nurse should do what?

Hyperoxygenate before and after suctioning

Which signs and symptoms would make the nurse suspect that the client is experiencing a Thyroid Storm?

Hyperpyrexia and Extreme Tachycardia

A client is admitted after MVA the HCP diagnosis is pelvic fractures, bilateral femur fractures, the blood pressure is falling from 120/76 to 60/40, with increased HR. Which does the nurse recognize as the most likely reason for the assessment findings?

Hypovolemic Shock

Another patient with an inhalation injury comes to the ER on initial assessment they are very confused. The nurse determines that the patient is most likely experiencing?

Hypoxia

Pacemaker malfunction-Failure to capture.

Inability to produce contraction

A client receiving chemotherapy for breast cancer develops myelosuppression. The nurse should include all of the following in the patients discharge planning EXCEPT?

Increase in fresh vegetables

This person has fluid replacement lactated ringers at 375mL/hr. They were burned in 10 hours ago, their temperature is 99.0, HR 122, BP 84/42, CBB 2, ad urine output of 25 mL from the last 2 hours. Using the SBAR the nurse calls the health care provider with which recommendations?

Increase the IV rate

During the initial Chemo client with leukemia develops hyperkalemia and hyperuricemia. The nurse recognizes that these symptoms are an oncological emergency and anticipates which priority treatment? a. Increase urine output with hydration therapy. b. Establish electrocardiographic (ECG) monitoring. c. Administer a bisphosphonate such as pamidronate (Aredia). d. Restrict fluids and administer hypertonic sodium chloride solution.

Increase urine output with hydration therapy

A client with a diagnosis of MI is admitted to the ICU and a pulmonary artery catheter is inserted, therapy is administered to maintain the pulmonary wedge pressure at 16-20 to optimize stroke volume. The clients pulmonary wedge pressure increased to 24. What does the nurse consider as the most likely reason for this change?

Increased instravascular volume

Which info collected by nurse suggest pain is caused by MI?

Occurs longer than 30 minutes

Bedridden patient with sacral edema? Which contributes to the edema?

Right sided heart failure

To provide oral hygiene for a client with recovering transsphenoidal hypophysectomy the nurse should instruct the client to? 1. Rinse the mouth with saline solution. 2. Perform frequent toothbrushing. 3. Clean the teeth with an electric toothbrush. 4. Floss the teeth thoroughly

Rinse the mouth with normal saline

After a cholecystectomy which food would be most appropriate? a. cheese omlet with onions b. peanut butter on wheat toast c. ham salad sandwich made with mayonnaise d. roastbeef sandwhich with lettuce and tomato

Roast beef sandwich with lettuce and tomato

Pt immediately removal of ET, which symptom is reported immediately?

Stridor

This person had an Mi and they developed cardiogenic shock despite treatment in the ER. What client response are related to neurogenic shock?

Tachycardia, increased CBC and decreased CO

Client with acute respiratory failure. Considered for weaning. High pressure alarm keeps going off. Vent inoperable alarm sounds. Nurse should do what?

Take off and ventilate them manually

A patient undergoing chemotherapy has a WBC of 2,300, a hemoglobin of 9.8, platelets of 80,000, and potassium of 3.8. What finding should take priority?

Temperature of 101

Low pressure alarm. Nurse assesses client then attempts to determine cause. If can't determine cause of alarm, what action should be priority?

Ventilate Pt manually

The nurse should teach the patient with chronic pancreatitis to monitor the effectiveness of pancreatic enzyme replacement by? 1. recording daily fluid intake 2. performing glucose fingerstick tests twice a day 3. observing stools for steatorrhea 4. testing urine for ketones

observing stools for steatorrhea

A nurse is developing a plan of care for a patient who is scheduled to return after a liver biopsy, the nurse plans to position the clint on the:

right side in side lying position

A client with advanced small lung cell cancer presents with complaining of SOB and weakness, a serum sodium of 116 is reported by the lab. The nurse can anticipate which order from the physician?

Fluid restriction and 3% Saline

Someone with acute renal failure diet?

Gelatin dessert

Pt intubated for relief of airway obstruction. What actions to prevent complications after intubation. Select all that apply

Chest x-ray to check placement Auscultate lungs BL

Pt with ARDS in prone position for 30 min. Which of the following will require discontinue of position?

Client is tachycardic with drop in BP

When providing care for a patient hospitalized with acute pancreatitis who has abdominal pain, which nursing intervention is appropriate? Select all that apply a. Place the patient in the side lying position with HOB elevated at 45 b. Maintain a high calorie and high protein diet c. Monitor their respiratory status d. Obtain daily weights

A,c, d

Pt w chest trauma after MVA, O2 60% via venturi mask. Which assessment finding indicates ARDS?

BL wheezing and stridor Progressive hypoxia

Which meal would indicate the pt understands recommended diet with CAD?

Baked fish, steamed broccoli, garden salad

A female client who has undergone replacement radiation therapy asks if she can walk with her husband to the lounge at the end of the hall. Which response is the most appropriate?

Because of the treatment you are receiving you need to remain your room

A 33 year old female is diagnosed with hypothyroidism. What should the nurse assess the client for? Select all that apply: 1. Rapid pulse. 2. Decreased energy and fatigue. 3. Weight gain of 10 lb. 4. Fine, thin hair with hair loss. 5. Constipation. 6. Menorrhagia. a. Hypotension b. Rapid pulse c. Decreased energy and fatigue d. Weight gain of 10 pounds e. Fine thin hair with hair loss f. Constipation

C, d, e, f

1st degree heart block on ECG strip

Continue monitoring

Which outcome is a priority for the client with addison's disease?

Continue therapy

Pt experiencing acute pulmonary edema-how should nurse position pt for max ventilation?

Couldn't hear exact answer but sitting straight up gets most oxygen

A patient with heart failure has tachypnea, severe dyspnea, and a SpO2 of 84%. The nurse identifies a nursing diagnosis of impaired gas exchange related to increased preload and mechanical failure. An appropriate nursing intervention for this diagnosis is a. Assist the patient to cough and deep breath every 2 hours b. Assess intake and output every 8 hours and weigh daily c. Encourage to alternate rest and activity to reduce cardiac workload d. Place the patient in a high Fowler's position with the legs horizontal

D..Place pt in high-fowlers position with feet dangling on side

After the client has a shunt placed, which finding indicates the procedure has been effective?

Decrease episodes of variceal bleeding

Permanent demand Ventricular pacemaker, proper pacemaker function by looking at ECG, looking for pacemaker spikes where?

Prior to QRS wave

The nurse is doing a home health visit for a client with Hep A, in order to prevent transmission the nurse should do teaching on?

Proper food handling

A nurse is caring for a client admitted with a diagnosis of hyperthyroidism, the client reports a weight loss of 12 pounds in the past two months despite increased appetite. The additional symptoms include increased perceptions, menstrual irregularities and restlessness. Which of the following measures should the nurse include in the client's plan of care to prevent a thyroid crisis? a) Provide a quiet, low-stimulus environment. b) Administer aspirin as prescribed for any sign of hyperthermia. c) Maintain the client's NPO status. d) Observe the client carefully for signs of hypocalcemia.

Provide a quiet low stimulus environment

The nurse receives report on assigned clients. One client is reported to be at nadir for his cancer chemotherapy. How will this affect the nursing care plan? A. Implement bleeding precautions. B. Reinforce measures and teaching regarding preventing infections. C. Anticipate nutritional problems caused by nausea and vomiting. D. Assess for problems with fluid balance.

Reinforce precautions for decreasing infections

The nurse is preparing for a burn client for a escharotomy procedure being performed for a 3rd degree circumferential burn. The nurse understands that which finding is the anticipated therapy outcome?

Relievement of pressure

The trauma team has admitted a patient involved in an automobile collision, the healthcare provider has identified that they have lost 20% of their blood. Which assessment finding of the client would the nurse expect to find?

a. High heart rate b. capillary refill greater than 3 seconds c. urine output < 30 ...Hypovolemic shock

The nurse is caring for a client with partial and full thickness burns to 65% of the body. When planning additional interventions, what choices should the nurse implement? A. Full liquids only B. Whatever the patient requests C. High-protein and low-sodium foods D. High-calorie and high-protein foods

High calorie and high protein foods

Pt with pulmonary embolus. Which assessment data requires immediate intervention? ________(20:30) 1. The client's ABGs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions. 3. The client's pulse oximeter reading is 90%. 4. The client's urinary output for the 12-hour shift is 800 mL.

3. The client's pulse oximeter reading is 90%

This person has a burn on 20% of her body. BP 90/50, HR 110, Urine output of 20 mL. The nurse reports the findings to the health care provider and anticipates what? 1. Transfusing 1 unit of packed red blood cells 2. Administering a diuretic to increase urine output 3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4. Changing the IV lactated Ringer's solution to one that contains dextrose in water

3.. Increase the IV per hour

18-year-old involved in MVA-Dx with pneumothorax. Chest tube with constant bubbling in water sealed chamber. Most likely a result of?

Air leak

A patient has sustained thermal injuries of 30% of their TBSA. What action should the nurse take first?

Airway, breathing and circulation

Pt develops following rhythm (V.tach). Which intervention should nurse do first?

Assess pt for pulse

The nurse is reviewing the past medical history of a patient diagnosed with chronic renal failure. Which agnition in the patient's history most likely contributed to the patient getting chronic renal failure?

Hypertension

A patient arrives at the ER and is unable to give a health history due to altered mental status.The family reports the patient has gained over 10 pounds in a week and says its mainly water weight. In addition they report the patient has not been able to urinate or eat within the past week, as well as recently diagnosed with small cell lung cancer. On assessment you know that their HR is 115, BP 180/92, and sodium level is 90. Which of the following conditions do you suspect the patient is most likely presenting with? a. Addison's Disease b. Fluid Volume Deficient c. SIADH d. Diabetes Insipidus

SIADH

ECG indicating ischemia

ST segment depression

Client with pneumothorax has chest tube. Gentle bubbling in suction control chamber. Which action is appropriate?

Do nothing; expected in this chamber

Which assessment finding indicates ET tube placement might need to be further evaluated? Select all that apply

Chest rise noted on right side only Breath sounds noted over epigastric Breath sounds audible only on right side

The nurse is preparing a client for a paracentesis.. 1. Have the client void immediately before the procedure. 2. Place the client in a side-lying position. 3. Initiate an IV line to administer sedatives. 4. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure

Have the patient void prior

A clients is hospitalized for possible SIADH, the client is confused and reports having muscle cramps and twitching. The nurse would expect which laboratory results to report what? a. serum sodium of 125 mEq/L (125 mmol/L). b. hematocrit of 52%. c. blood urea nitrogen (BUN) of 22 mg/dl (11.5 mmol/L). d. serum chloride of 110 mEq/L (110 mmol/L).

A decreased sodium

Which information should the nurse include in the teaching plan of female with bilateral adrenalectomy? A. The client will need steroid replacement for the rest of her life. B. The client must decrease the dose of steroid medication carefully to prevent crisis. C. The client will require steroids only until her body can manufacture sufficient quantities. D. The client will need to take steroids whenever her life involves physical or emotional stress.

A. The client will need steroid replacement for the rest of her life.

A patient who has cardiac surgery has a urine output of 20mL/hr for 2 hours. They receive a single bolus of 500mL IV. The urin output of the next our was 25mL. Daily lab results indicate that the BUN is 45 and serum creatinine is 2.2. Based on these findings the nurse will anticipate that the client is at risk for developing which? 1. Hypovolemia 2. Acute renal failure 3. Glomerulonephritis 4. Urinary tract infection

Acute kidney injury

Pt with thorax aortic aneurysm. Which intervention should nurse include in plan of care?

Administer antihypertensive med

A client is beginning external beam therapy to the right axilla after a lumpectomy after breast cancer. Which of the following should the nurse include in client teaching?

Apply deodorant only under the left arm

A nurse is caring for a client who is being treated for cancer of the neck, while assessing the vital signs the nurse assesses bleeding at the site of treatment. Which nursing action is a priority?

Apply pressure

A client with cirrhosis is receiving lactulose, during the assessment the nurse notes increased confusion and asterixis, the nurse should do what? 1. Assess for gastrointestinal (GI) bleeding. 2. Hold the lactulose. 3. Increase protein in the diet. 4. Monitor serum bilirubin levels

Assess for bleeding

Client with Atrial fibrillation—possible treatment interventions. Select all that apply

Cardioversion Anticoag radiofrequency

Cardioversion-ECG pic; ECG indicates what:

Cardioversion was successful

Post op for CABG, monitor for what common complication?

Atrial dysrhythmias

Which information should be included in the teaching plan for a patient with cancer who is experiencing thrombocytopenia? Select all that apply: a. Use electric razor b. Soft Bristle toothbrush c. Avoid frequent flossing d. Monitor temperature e. Report bleeding

B, c, d, e

The physician orders a patient of septic shock receive an IV bolus, How will the nurse know if the treatment was successful? A. The patient's blood pressure changes from 75/48 to 110/82. B. Patient's CVP 2 mmHg C. Patient's skin is warm and flushed. D. Patient's urinary output is 20 mL/hr.

Blood Pressure changes

Your patient is post op from GI and is running a temperature of 103, HR 120, BP 72/42, RR 21, increased WBC, an IV bolus is ordered stat. What findings below indicate that the patient is progressing to septic shock? Select all that apply A. Blood pressure of 70/34 after the fluid bolus B. Serum lactate less than 2 mmol/L C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement D. Central venous pressure (CVP) of 18

Blood pressure of 70/34 after the fluid bolus Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement

Nurse is assessing patient given opioid analgesic. Which ABG value indicates pt is at risk for respiratory failure?

CO2 of 80

Following a transsphenoidal hypophysectomy the nurse should assess the client for? a. Cerebrospinal fluid (CSF) leak. b. Fluctuating blood glucose levels. c. Cushing's syndrome. d. Cardiac arrthymias.

CSF leakage

A physician has decided to use renal replacement therapy to remove large bodies of fluid from someone who is hemodynamically unstable in the ICU. The nurse would expect which treatment? 1) Hemodialysis (HD) three times per week 2) Automated peritoneal dialysis (APD) 3) Continuous venovenous hemofiltration (CVVH) 4) Continuous ambulatory peritoneal dialysis (CAPD)

CVVH

Pulmonary artery catheter has been inserted. What is the nurses primary intervention for using the device?

Call for a chest x-ray

Low pressure volume alarm sounds on vent. Cause for alarm may be?

Displaced tube

Pt complains of sudden dizziness, ECG reveals the following (tachycardia). The nurse understands that dizziness is result of

Decrease CO

Nurse assessing client on vent with ET. Which data confirms tube has migrated too far into trachea?

Decrease breath sounds over left side of chest

The client is suspected a patient of septic shock, due to untreated cellulitis in the lower extremities. What finding would the nurse expect to learn on assessment?

Decreased urine output

High pressure alarm goes off. What action should nurse take?

Empty excess accumulated water in tube

The nurse is caring for a client with bladder cancer and bone METS, which signs and symptoms would the nurse recognize as indications of a possible oncological emergency? 1. Facial edema in the morning 2. Serum calcium level of 12 mg/dL 3. Weight loss of 20 lb in 1 month 4. Serum sodium level of 136 mg/dL 5. Serum potassium level of 3.4 mg/dL 6. Numbness and tingling of the lower extremities

Facial edema and serum calcium of 12

The most reliable early indicator of infection in a client is nutropenins is?

Fever

65-year-old comes to ER with crushing substernal chest pain; diagnosis of acute MI. Orders include oxygen, blood work, chest x ray, ECG, 2 mg morphine. Which to do first?

Give morphine

A 67 year old with a large anterior MI, hemodynamics are CDP of 10, Pulmonary wedge pressure of 25, PVR 400, and BP 82/60 HR 122, and sinus rhythm. Based on this information what does the nurse suspect?

HYPERVOLEMIA. ( hypovolemia is decreasing, NO FLUIDS)

A nurse is providing care to a client with left radial arterial line, which assessment data obtained by the nurse indicates a need for the nurse to take action?

Hands are cool to the touch

A client with acute pancreatitis has a blood pressure of 88/40, HR of 128, RR of 28 and grey turner's sign. What action should the nurse perform first? 1. Initiate intake/output record 2. Place an intravenous line 3. Position on the left side 4. Insert a nasogastric tube.

Insert an IV

The client with chronic renal failure tells the nurse that he takes magnesium hydroxide for constipation. The nurse suggests the client to switch to Psyllium Metamucil because?

It can cause magnesium toxicity

The nurse is caring for a patent with autograph on the right knee. What would the nurse anticipate to be prescribed?

Keep the extremity above the lines

Which of the fluids should you give for...

Lactated ringers

The nurse asks the client to state her name as soon as she regains consciousness post-operatively after a subtotal thyroidectomy at each assessment. The nurse does this to assess for what? a. Internal hemorrhage. b. Decreasing level of consciousness. c. Laryngeal nerve damage. d. Upper airway obstruction.

Laryngeal Nerve damage

Caring for client immediately after insertion of permanent pacemaker via RIGHT subclavian vein

Limiting movement/abduction of RIGHT arm.

Performing assessment on pt with L HF, which component will elicit specific information related to L HF?

Listening to lung sounds

The nurse is teaching a client to perform peritoneal dialysis, the nurse reviews which essential action that will help prevent further complications?

Maintain strict aseptic technique

Pt admitted to CCU Atrial fib and rapid ventricular response, nurse prepares for cardioversion. What nursing action is essential to prevent danger of producing V.fib during cardioversion?

Make sure sync button is turn on

A client has treatment for lymphoma complains of headaches, vomiting fatigue, and constipation, serum electrolyte testing reveals calcium of 14 (hypercalcemia). The appropriate treatment is?

Normal Saline**

Aortic aneurysm repair with graft placement 30 min ago. Posterior tibial pulse not palpable. Nurse priority action?

Notify surgeon

A patient is scheduled to undergo hemodialysis. What is the highest priority action the nurse should plan prior to the start of dialysis?

Obtain their weight

Planning urgent care for a pt with suspected MI, the nurse will administer?

Oxygen, nitroglycerin, and morphine

When planning care for a patient with Hep A, the nurse should review lab of which lab values?

PTT

Nurse performing assessment on pt with complaints of chest pain, which indicates stable angina?

Pain with jogging, subside at rest

The nurse is assessing the patency of a client's left arm AV fistula prior to administering hemodialysis. Which finding indicates that the fistula is patent?

Palpation of a thrill

ECG of pt with suspect MI, which is most indicative of prolong or complete coronary occlusion?

Pathologic P wave

A patient has undergone a sub thyroidectomy is subject to complications in the first 48 hours. The nurse should obtain and keep at the bedside equipment to do what? a. Begin total parenteral nutrition. b. Start a cutdown infusion. c. Administer tube feedings. d. Perform a tracheotomy.

Perform a tracheostomy

The nurse receives one at the ER with extensive electrical burns. The nurse understands that this type of burn instrilates what priority? a. Assess oral temperature. b. Check a potassium level. c. Place on cardiac monitor. d. Assess for pain at contact points.

Place the patient on a cardiac monitor

A Pt admitted to critical care after left pneumonectomy. Receives 40% oxygen via simple facemask. Dx with Right lower lobe pneumonia. After eating breakfast pt aspirates and vomits. Becomes agitated, decrease LOC, inability to maintain saturation. Nurse anticipates next action

Placement of pt on vent

is person was admitted to the burn center with burns to the face and upper chest and hands after fireworks exploded in the garage. The nurse notes the patient coughing up black sputum, singed hairs, and dark oral and nasal membranes and decreased breaths. Increasing shortness of breath and hoarseness. Which action would be most appropriate for the nurse to take next?

Plan the need for endotracheal intubation

The nurse should monitor the client with acute pancreatitis for which sign or complication? A. Heart failure B. Duodenal ulcer C. Cirrhosis D. Pneumonia

Pneumonia

Charge nurse making shift assignment. Which to most experienced nurse?

Pt w sudden onset pulmonary edema

Pt with increased capillary permeability. Which finding does nurse anticipate in pt?

Pulmonary edema

The nurse is admitting a client with chronic kidney disease to the unit that has a potassium level of 6. The nurse should plan for which action as a priority?

Put them on the cardiac monitor

To obtain an accurate CVP with a central venous catheter, the nurse should place the patient in what position?

SUPINE POSITION, 45 degrees

College freshmen or participating in a study abroad program and teaching about Hep B, the nurse should instruct the students on a need for?

Safe sex practice

During a check-up with a diabetic client who has proteinuria on urine analysis. The nurse assesses the client and knows that further testing will need to assess the health of the kidney. Which test is considered the most accurate indicator of kidney function?

Serum Creatinine

The client diagnosed with addison's disease is admitted to the ER after a day at the lake. The client is lethargic, forgetful and weak. Which intervention should be the emergency room nurses first action? a. Start an IV with an 18-gauge needle and infuse NS rapidly. b. Have the client wait in the waiting room until a bed is available. c. Obtain a permit for the client to receive a blood transfusion d. Collect urinalysis and blood samples for a CBC and calcium level.

Start an IV with an 18 gauge needle to infuse NS rapidly

Nurse is suctioning client via intratracheal tube. HR is decreasing. Which nursing intervention is appropriate?

Stop procedure and reoxygenate pt

Following surgery a radical neck dissection for laryngeal cancer, the priority of nursing care is?

Suction the laryngeal tube as much as needed

The nurse is providing care to a patient that had bilateral adrenalectomy. Which assessment information requires the most rapid action by the nurse? a. The blood glucose is 176 mg/dL. b. The lungs have bibasilar crackles. c. The blood pressure (BP) is 88/50 mm Hg. d. The patient reports 5/10 incisional pain.

The blood pressure is 88/50

A nurse is caring for a client after a craniotomy for a pituitary tumor and has developed DI. The client is receiving vasopressors (Pitressin). The desired response of the medication is what?

Urine output to decrease

The nurse is caring for a client immediately after renal transplant, IV fluids are administered as prescribed. The nurse recognizes that the hourly calculi glomerulus of what? 1. A strict hourly rate of 100 mL 2. A strict hourly rate of 150 mL 3. One half of the previous hour's urine output 4. The number of milliliters in the previous hour's urine output

The number of mL in the previous hour's urine output

A client is receiving high dose chemotherapy for a large rapidly dividing tumor. What is the person developing?

Tumor lysis syndrome

When caring for a postoperative client following an incisional coli, the nurse places the highest priority on assisting the client to do what? a. choose low-fat foods from the menu. b. perform leg exercises hourly while awake. c. ambulate the evening of the operative day. d. turn, cough, and deep breathe every 2 hours.

Turn, cough and deep breathe

Which of the following should raise suspicion to the nurse that a head injury is experiencing DI?

Urine Specific gravity is low

The nurse is administering IV fluids as prescribed to someone who sustained superficial partial thickness burns along the back and legs. In evaluating the adequacy of fluid resuscitation the nurse should understand that which assessment finding would provide the most reliable indicator for determining the action of fluid replacement?

Urine output

Nurse in telemetry observes this rhythm-P wave normal, PR lengthen progressively until no QRS

Wenckebach, 2nd degree type 1 heart block

Which of the following is normal for a client during the ictal phase of viral hepatitis?

Yellow sclera

At 0800, the nurse reviews the amount of t-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should: a. report the 24-hour drainage amount at 1200 b. clamp the tube c. evaluate the tube for patency d. irrigate the T tube

evaluate the tube for patency

You are providing care to four patients, which patients are at risk for developing sepsis? Select all that apply A. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. B. A 55-year-old male who is a recent kidney transplant recipient. C. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.

all of the answers

The ambulance reports that you are transporting a patient to the ER is experiencing full thickness thermal burns from a grill. What manifestations should the nurse expect? 1. Severe pain, blisters, and blanching with pressure 2. Pain, minimal edema, and blanching with pressure 3. Redness, evidence of inhalation injury, and charred skin 4. No pain, waxy white skin, and no blanching with pressure

no pain, waxy white skin, no blanching with pressure

After receiving a change in shift report about the following four clients, which should the nurse assess first? a. A 22-year-old admitted with SIADH who has a serum sodium level of 130 mEq/L. b. A 31-year-old who has iatrogenic Cushing's syndrome with a capillary blood glucose level of 244 mg/dl c. A 53-year-old who has Addison's disease and is due for a scheduled dose of hydrocortisone (Solu-Cortef). d. A 70-year-old who recently started levothyroxine (Synthroid) to treat hypothyroidism and has an irregular pulse of 134

➢ A 70-year-old who recently started taking levothyroxine Synthroid and has an irregular pulse of 134