Adult I - Exam One

"The nurse is admitting a patient to the medical surgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia?"

"Encourage the patient to use the incentive spirometer every 2 hours."

"One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?"

"Help distinguish reduced renal blood flow from decreased renal function" ii. Test kidney function, give fluid (100-200 mL NS) to see if there is increased U/O, BP and CVP (normal kidney function)

"The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patients blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs?"

"Hypovolemic shock"

"A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously?"

"Never, because it rapidly enters red blood cells, causing them to rupture"

"The nurse is caring for a patient on the medical surgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?"

"Red, warm, tender incision"

"The ED nurse is caring for an 11-year-old brought in my ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed?"

"Surgery should be done without informed consent."

"The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104F temp in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient?"

"The patient may be at risk for malignant hyperthermia"

"The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and restore the wound. You are aware that the wound will now heal by what means?"

"Third intention"

"The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?"

"Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw."

"A patient is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting coffee-ground like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled?"

"Without delay because the bleed is emergent"

The nurse is assisting in a health fair at a senior citizen center. Which of the following instructions should the nurse include when giving the elderly patient guidelines to remain hydrated in hot weather? a. "If your urine is dark yellow, you are drinking adequate fluids b. "Only drink water to keep yourself properly hydrated c. "Popsicles, gelatin, and ice cream provide fluid intake as well as liquids you drink d. "Use your thirst as a guide to the amount of fluid you should be drinking."

(C) "Popsicles, gelatin, and ice cream provide fluid intake as well as liquids you drink."

An adult patient in the clinic complains of a cough, fever, nausea, and vomiting for three days. Examination reveals dry tongue and oral mucosa, and concentrated urine. The patient reports feeling weak and dizzy. To best assess the patient's fluid status, the nurse checks which of the following assessment parameters? A. Temperature B. Respiratory rate and depth C. BP and pulse in lying and standing positions D. Pulse oximetry reading at rest

(C) BP and pulse in lying and standing positions

EKG changes hypermagnesemia

1. Prolonged PR interval 2. Widened QRS complexes

EKG changes of hypocalcemia

1. Prolonged ST segment 2. Prolonged QT interval

EKG changes of hypercalcemia

1. Shortened ST segment 2. Widened T wave

EKG changes Hypomagnesemia

1. Tall T waves 2. Depressed ST segment

Normal level of magnesium

1.3-2.1 mEq/L

Normal level of sodium

135-145 mEq/L

Normal level of phosphorus

3.0 - 4.5 mg/dL

Normal value of potassium

3.5-5.0 mEq/L

Normal urine pH

4.5-8.0 (6.0 average)

Normal level of calcium

9.0-10.5 mg/dL (total calcium) 4.5-5.5 mg/dL (ionized)

A client with COPD is admitted to the hospital with an exacerbation of the disease. Arterial blood gas (ABG) results are pH 7.30, PaCO2 51, and HCO3 25. How would the nurse interpret these? a. Respiratory acidosis, uncompensated b. Respiratory alkalosis, partially compensated c. Respiratory acidosis, compensated d. Metabolic acidosis, compensated

A - Respiratory acidosis, uncompensated

When caring for a patient receiving intravenous (IV) replacement of magnesium sulfate, the nurse should plan to monitor the patient for which of the following potential complications? a. Rebound hypermagnesemia b. Abdominal cramping c. Tachypnea d. Headaches

A) Rebound hypermagnesemia

The nurse identifies which of the following clients to be at risk for developing metabolic alkalosis? The client who: (Select all that apply.) a. Has a NG tube to continuous suction b. Has had diarrhea for 2 days c. Is admitted with a salicylate toxicity d. Takes antacids frequently for heartburn e. Is admitted with asthmatic bronchitis

A) Has a NG tube to continuous suction D) Takes antacids frequently for heartburn

A patient was brought to the hospital following a near-drowning experience in the Atlantic Ocean. In providing care to this patient, the nurse plans to carefully monitor for which of the following? a. Hypernatremia b. Hyponatremia c. Hypocalcemia d. Hypercalcemia

A) Hypernatremia

The nurse evaluates the hydration status of a patient who has been receiving intravenous (IV) fluids at 150 mL/hour. The nurse identifies that the patient has excess fluid volume after assessing which of the following? (Select all that apply.) a. Neck veins are distended when head of the bed is elevated 45 degrees b. Hand veins empty when hand is raised above the heart c. Peripheral pulses are rapid and weak d. Patient becomes short of breath when ambulating e. Pitting edema is present over tibia

A, D, E

You are teaching a patient deep-breathing and coughing exercises to prevent respiratory complications postoperatively. Which of the following should be included? (Select all that apply). A. Splint or support the incision to promote maximal comfort B. Inhale and exhale slowly through the nose and mouth C. Hold breath for about 5 seconds to expand the alveoli D. Close one nostril while inhaling

A. Splint or support the incision to promote maximal comfort B . Inhale and exhale slowly through the nose and mouth C . Hold breath for about 5 seconds to expand the alveoli

Can occur within seconds to minutes. BP plummets and airway is blocked. Can be fatal. Hypotension and airway obstruction are major signs

Anaphylaxis

A patient receiving treatment for hypernatremia is being monitored for signs and symptoms of complications of therapy. The nurse would assess this patient for which of the following? a. Cellular dehydration b. Cerebral edema c. Red blood cell (RBC) destruction d. Renal shutdown

B) Cerebral edema Treatment is with hypo fluid to counter hyper situation. Too much hypo fluid could cause osmotic shift into cells in brain causing cerebral edema (water dilutes salt in cells)

A patient with hypercalcemia is receiving digoxin (Lanoxin). The nurse plans to incorporate which of the following in patient assessments? a. Checking for Trousseau's sign b. Frequent pulse checks c. Auscultation of bowel sounds d. Inspection of skin for signs of bleeding

B) Frequent pulse checks

Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD When assessing the patient with diabetes insipidus (DI), the nurse expects to find which of the following? a. Nausea and vomiting b. Polyuria and polydipsia c. Dysuria d. Confusion

B) Polyuria and polydipsia

The nurse is providing care to a patient with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse explains to the unlicensed assistant that water intake should be: a. Encouraged b. Restricted c. Given according to the patient's preference d. Given via intravenous fluids only

B) Restricted The patient is retaining water, diluting all electrolytes. Restricting water helps maintain balance

An appendectomy is considered which one of the following classifications of surgery based on purpose? A. Diagnostic B. Ablative C. Palliative

B. Ablative

A 78-year-old patient is admitted with dehydration and urinary tract infection. After IV infusion of 750 mL NS, the patient begins to cough and asks for the head of the bed to be raised to ease breathing. The nurse assesses jugular vein distention (JVD) and increased respiratory rate. What is the nurses interpretation of these signs and symptoms? a. The fluid volume deficit is worsening b. Hypervolemia is developing c. Hypotonic water intoxication is beginning

B. Hypervolemia is developing

The nurse assigned to a patient with hyponatremia would conclude that which of the following patient factors probably contributed to this electrolyte imbalance? a. Osmotic diuretic therapy b. Fever c. Fluid retention d. Excessive hypertonic intravenous infusion

C) Fluid retention

What action should the nurse take initially to avoid acid-base imbalance when a client becomes anxious and starts to hyperventilate? A. Tell the client to stop breathing so fast because he may pass out. B. Give the client a sedative to decrease anxiety and stop hyperventilation. C. Give the client a paper bag to breathe into. D. Notify the physician.

C) Give the client a paper bag to breathe into

A 36-year-old female is admitted with vomiting and dehydration after having the flu for 3 days. Arterial blood gas (ABG) results are pH 7.46, PaCO2 50, HCO3 33, SaO2 95%. What do these values indicate to the nurse? a. Metabolic acidosis, uncompensated b. Respiratory acidosis, compensated c. Metabolic alkalosis, partially compensated d. Metabolic alkalosis, uncompensated

C) Metabolic alkalosis, partially compensated

When developing a plan of care for a patient with hypocalcemia, the nurse chooses which of the following as a high-priority nursing diagnosis? a. Potential complication: electrolyte excess b. Risk for injury r/t sensorium changes c. Risk for injury r/t tetany and seizures d. Deficient fluid volume

C) Risk for injury r/t tetany and seizures

You are preparing to administer a pre- medication sedative for surgery. Which of the following actions should you take first? A. Have the family present B. Ensure that the pre-operative shaving is completed C. Have the patient void

C. Have the patient void

Tests used for hypocalcemia and hyperphosphatemia

Chvostek's sign and Trousseau's sign

Manages the OR. Ensures informed consent is completed, right site, right patient, right procedure. Performs time out

Circulating nurse

Anions (negative)

Cl, HCO3, HPO4/H2PO4

A patient is semiconscious, restless, & exhibits tremors and muscle weakness. Physical exam reveals a dry, swollen tongue, and temperature of 99.8F. The nurse anticipates that the serum sodium value for this patient is most likely to be which of the following? a. 120 mEq/L b. 132 mEq/L c. 142 mEq/L d. 155 mEq/L

D) 155 mEq/L

The nurse anticipates that which of the following patients is at risk for hypermagnesemia? A. An anorexic 16-year-old female b. A 57-year-old male who has alcoholism c. A 47-year-old female with a history of partial gastrectomy d. A 62-year-old male with chronic renal failure

D) A 62-year-old male with chronic renal failure Renal failure interferes with excretion of electrolytes, including magnesium. All of the conditions listed in the incorrect options increase risk of hypomagnesemia by interfering with magnesium absorption in the small intestine

The nurse would assess for which of the following common side effects when administering oral magnesium to a patient? a. Decreased appetite b. Decreased urine output c. Increased thirst d. Diarrhea

D) Diarrhea Oral administration of Mg may cause diarrhea, which would then further decrease Mg absorption. The other options are unrelated items.

Medication used to treat malignant hyperthermia

Dantrium (Dentrolene Sodium)

Labs for FVE fluid volume excess

Decrease in hemoglobin and hematocrit. Decrease in serum and urine osmolality. Decrease in urine sodium and specific gravity.

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurses preoperative assessment of an elderly patient?

Elderly patients have less physiologic reserve than younger patients

Type of surgery needed due to issue that is life threatening, needed without delay. Not planned

Emergent

"The OR nurse is participating in the appendectomy of a 20 year-old female who has a dangerously low body mass index. The nurse recognizes the patients consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia?"

Ensure that IV fluids are warmed to the patients body temperature

"You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?"

Extravasation of the medication

Antagonist to reverse benzodiazepines

Flumazenil (romazicon)

Anesthesia drug administered by inhalation or IV

General Sedation

Signs and symptoms of malignant hyperthermia

HR > 150, hypercapnia, generalized muscle rigidity (early signs); ↓ BP, ↓ cardiac output, oliguria, ventricular dysrhythmia, tetany; hyperthermia (late sign)

Hypertonic solution

Has more particles per volume as plasma. (5% NaCl)

Fluid volume excess

Hypervolemia: OVERHYDRATION: fluid intake or fluid retention exceeds fluid needs of the body. Comprised regulatory mechanisms such as kidney injury, heart failure, and cirrhosis; overzealous administration of sodium containing fluids and fluid shifts.

Fluid volume deficit

Hypovolemia: loss of water and electrolytes, as in vomiting, diarrhea, fistulas, fever, excess sweating, burns, blood loss, gastrointestinal suction, and third space fluid shifts; and decreased intake as in anorexia, nausea, and inability to gain access to fluid

Potassium should never be given via

IV Push or IM or SubQ injections

Labs for FVD fluid volume deficit

Increase in hemoglobin and hematocrit. Increase in serum and urine osmolality and specific gravity. Decreased urine sodium. Increased BUN and creatnine. Increased urine specific gravity and osmolality.

"A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache?"

Keep the patient positioned supine

Anesthesia drug used on mucous membranes, open skin, wounds, and burns

Local. Injections such as lidocain

Secondary classification of hemorrhage

May occur sometime after surgery if a suture slips b/c a blood vessel was not securely tied, became infected, or was eroded by a drainage tube.

Conscious sedation. Used for short term, minimally invasive procedures such as a colonoscopy

Moderate Sedation

Cations (positive)

Na, K, Ca, Mg

Reverses narcotic /opioid analgesics

Narcan/naloxone

"During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take?"

Offer the patient a bedpan or urinal.

pH abnormal, PCO2 abnormal, and HCO3 abnormal

Partially compensated

Phase II of post-op

Prepares patient for at home self-care or for extended care setting

Oncotic pressure

Pulling force of a solution created by proteins (colloids) in fluid. Proteins are equally distributed in plasma = same pressure everywhere

Hydrostatic pressure

Pushing force of fluid against vessel walls. Higher at arterial end. Lower at venous end.

"A postoperative patient rapidly present with hypotension; rapid, thread pulse; oliguria, and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be nurses first action?"

Quickly attempt to determine the cause of hemorrhage.

Operates under supervision of surgeon. Anticipate surgeon and team needs

RN First assistant

Anesthesia injected near a nerve or nerve pathway or around operative site i.e. epidural, spinal, local conduction block

Regional

Surgery that is scheduled and needed but not right away

Required

Declomycin treats __________ and cannot be given with foods containing _________________

SIADH - Calcium

EKG changes of hypokalema

ST Depression Shallow, flat, or inverted T wave Prominent U wave

RN, LPN, or surgery tech that counts sponges, prepares tools, etc

Scrub Role

Values for hypernatremia

Serum sodium greater than 145 mEq/L

Values for hyponatremia

Serum sodium less than 135 mEq/L

Stages of General Anesthesia

Stage 1—Beginning of anesthesia; client is drowsy and dizzy; pain sensation is depressed Stage 2—Excitement stage; client has irregular breathing, involuntary motor movements; avoid stimulating client, which can trigger vomiting, holding the breath, and increased activity; ensure client safety by proper use of safety straps. Patient will fight. Stage 3—Stage of anesthesia appropriate for surgical procedures; client has skeletal muscle relaxation, constricted pupils, absence of eyelid reflex Stage 4—medullary depression; client is NEAR DEATH; pupils are fixed and dilated, respirations are weak, pulse is rapid and thready. This is an unplanned stage. Too much anesthesia has been given. Emergence—recovery from anesthesia

Everyone in the OR stops and team double checks that they have correct patient, correct body part, etc

Surgical time out

EKG changes of hyperkalemia

Tall peaked T wave Flat P wave Widened QRS complex Prolonged PR interval

The PACU nurse is caring for a patient who has been deemed ready to go to the postsurgical floor after her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select all that apply.

The patients preoperative level of consciousness The presence of family and/or significant others The patients full name

Surgery that needs to be done within 24-30 hours

Urgent

The nurse determines that which of the following patients is at highest risk for developing a fluid volume deficit? a. A 76-year-old patient who has a nasogastric (NG) tube to low suction following surgery for colon cancer b. A thin 55-year-old patient who smokes and takes glucocorticoids for chronic lung disease c. A 1-year-old child being treated in the clinic for a runny nose and ear infection d. A 30-year-old patient jogging in 50-degree weather

a. A 76-year-old patient who has a nasogastric (NG) tube to low suction following surgery for colon cancer

How does Trousseau Syndrome (Migratory Thrombophlebitis) present?

adducted thumb, flexed wrist and metacarpophalangeal joints

A father telephones the clinic nurse asking what he should do for his 3-year-old son who developed fever, vomiting, and diarrhea today. Which of the following would be an appropriate recommendation by the nurse? A. "Have him drink as much water as you can get him to swallow." b. "Give small sips of commercial oral rehydration fluids frequently." c. "Provide frequent sips of fruit juice and commercial sports drinks." d. "Have him eat only bananas, rice, applesauce, and toast (BRAT diet)."

b. "Give small sips of commercial oral rehydration fluids frequently."

A client admitted to the emergency department with chest injuries following a motor vehicle accident complains that it hurts to breathe. The client's respiratory rate is 12 and very shallow. The nurse would anticipate which of the following results on arterial blood gases (ABGs)? a. pH 7.42, PaCO2 41mmHg, HCO3 23 mEq/L, SaO2 96% b. pH 7.31, PaCO2 49mmHg, HCO3 24 mEq/L, SaO2 87% c. pH 7.49, PaCO2 34mmHg, HCO3 30 mEq/L, SaO2 89% d. pH 7.38, PaCO2 38mmHg, HCO3 22 mEq/L, SaO2 90%

b. pH 7.31, PaCO2 49mmHg, HCO3 24 mEq/L, SaO2 87%

Autonomic nervous system agent- used to treat emergent malignant hyperthermia

dantrolene (Dantrium)

It is important to ask about _______________ prior to surgery.

family history of malignant hyperthermia, death during surgery. (can be prevented is surgeon knows of this history)

pH normal, PCO2 and/or HCO3 abnormal

fully compensated

Hypotonic solution

has fewer particles per volume as plasma. Half strength saline: 0.45% solution

Isotonic solution

has the same number of particles per volume as plasma. Just adds to the volume. Lactated ringer and normal saline (0.9% NaCl)

Primary classification of hemmorhage

hemorrhage occurs at the time of the surgery

The nurse is assessing the patient for presence of a Chvostek's sign. What electrolyte imbalance would a positive Chvostek's sign indicate?

hypocalcemia

"You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?"

hypovolemia

"The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply."

i. Provide all discharge instructions in writing ii. Provide the nurses or surgeons contact information iii. Give prescriptions to the patient

"A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply."

i. Stable blood pressure ii. Sufficient oxygen saturation iii. Adequate respiratory function

Phase I of post-op

immediate recovery phase. Intensive nursing care

The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patient's medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery?

infection

SIADH

is a condition in which the body makes too much antidiuretic hormone (ADH). This hormone helps the kidneys control the amount of water your body loses through the urine. SIADH causes the body to retain too much water

Diabetes insipidus

is an uncommon disorder that causes an imbalance of fluids in the body. This imbalance makes you very thirsty even if you've had something to drink. It also leads you to produce large amounts of urine.

Normal Saline

is the only thing/fluid that can be given with blood products.

Reverses the neuromuscular blocking agents

neostigmine (Prostigmin)

"A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do?"

notify the physician and continue to monitor the hourly urine output closely

Intermediary classification of hemorrhage

occurs during the first few hours after surgery when the rise of BP to its normal level dislodges insecure clots from untied vessels

Loop diuretics waste __________

potassium

Phase III of post-op

prepared for discharge

Antidote to heparin

protamine sulfate

Values for hypercalcemia

serum calcium greater than 10.5 mg/dL

Values for hypocalcemia

serum calcium less than 8.5 mg/dL

Values for hyperchloremia

serum chloride greater than 108 mEq/L

Values for hypochloremia

serum chloride less than 96 mEq/L

Values for hypermagnesemia

serum magnesium greater than 3.0 mg/dL

Values for hypomagnesemia

serum magnesium less than 1.8 mg/dL

Values for hyperphosphatemia

serum phosphorus greater than 4.5 mg/dL

Values for hypophosphatemia

serum phosphorus less than 2.5 mg/dL

Values for hyperkalemia

serum potassium greater than 5.0 mEq/L

Values for hypokalemia

serum potassium less than 3.5 mEq/L

Electrolytes

solutes that break down into ions

pH abnormal, and either PCO2 or HCO3 normal

uncompensated