ALPHA 3 FOXTROT

A patient receiving chemotherapy is anemic. Which medication will the nurse anticipate giving?

Epoetin alpha

A patient with a history of ventricular tachycardia is taking amiodarone and Ondansetron for nausea. A nurse assesses the client's electrocardiogram (ECG) and observes the reading shown below: TORSADES IMAGE The nurse anticipates which drug regime to be initiated?

NOT SURE ON ANSWER OPTIONS BUT CORRECT ANSWER WAS MAGNESIUM

A patient is taking furosemide. What values indicated that the treatment has been therapeutic? Urine output of 10ml is now 85ml potassium 3.8 is now 3.6 BNP...... NO IDEA ON THE OTHER OPTION FOR THIS PATIENT

URINE OUTPUT THIS IS WHAT I SAID ON EXAM

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.

a, b, e

A client has symptomatic bradycardia that is not responsive to atropine. The provider order the client to be started on a dopamine infusion at 5 mcg/kg/min. The dopamine infusion is mixed 400 mg in 250 mL of D5W. The client weighs 84 kg. How many gtt/min will the nurse begin the infusion at?

16 gtt

A patient suffered a brain injury, a sternal rub was placed on him. I cant remember the exact question but I know that patient was dead!!! No reaction to stimuli, response, movement, nothing. What interventions will the nurse implement? SATA · Contact organ procurement organization (OPO) · Intubate · CT scan · Assess neurologic status every 2 hours. · Apply a cervical collar. · Maintain proper head and neck alignment.

???

Another question with the same answer choices but this time the patient was dead.... yet. He was not in the best condition, but he did react to stimuli, and he was awake. (I will remediate and ask about the answers) SATA. · Contact organ procurement organization (OPO) · Intubate · CT scan · Assess neurologic status every hour. · Apply a cervical collar. · Maintain proper head and neck alignment.

???

A RN is working with an LPN and UAP. Which task is the most appropriate for the RN to delegate to the LPN? A. administer ordered metoprolol 25 mg by mouth to a client B. complete an admission assessment on a client C. collect a stool specimen from an incontinent client D. obtain vital signs on a client newly admitted to the unit

A

A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A. Applying a protective eye shield at night B. Chewing on the affected side to prevent unilateral neglect C. Avoiding the use of analgesics whenever possible D. Avoiding brushing the teeth

A

A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? A) Assess the client for support systems B) Determine if a clergy member would help. C) Explain legal requirements to tell sex partners. D) Offer to tell the family for the client.

A

A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important? A) Consult with the provider about obtaining stool cultures. B) Delegate frequent perianal care to unlicensed assistive personnel. C) Place the client on NPO status until the diarrhea resolves. D) Request a prescription for an anti-diarrheal medication

A

A client is undergoing preoperative teaching before his cardiac surgery and the nurse is aware that a temporary pacemaker will be placed later that day. What is the nurse's responsibility in the care of the client's pacemaker? A. Monitoring for pacemaker malfunction or battery failure B. Determining when it is appropriate to remove the pacemaker C. Making necessary changes to the pacemaker settings D. Selecting alternatives to future pacemaker use

A

A client who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse's best response? A. "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia." B. "To detect and treat bradycardia, which is an excessively slow heart rate." C. "To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently." D. "To shock your heart if you have a heart attack at home."

A

A client with a diagnosis of prostate cancer is scheduled to have an interstitial implant for high-dose radiation (HDR). What safety measure should the nurse include in this client's plan of care? A. Limit pregnant visitor's due client receiving brachytherapy. B. Teach the client to perform all aspects of basic care independently. C. Assign male nurses to the client's care whenever possible. D. Situate the client in a shared room.

A

A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the client for which complication of therapy? A. Immunosuppression B. Agranulocytosis C. Anemia D. Thrombocytopenia

A

A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? A) Consult with the pharmacy about drug interactions. B) Ensure that the client understands the new medications. C) Give the new drugs without considering the old ones. D) Schedule all medications at standard times.

A

A community is affected by a tornado. Emergency medical service (EMS) providers alert the local ED that there are currently 20 victims accounted for in this weather-related disaster, with potential for more. Which leadership style is most appropriate for this scenario? A. authoritarian B. democratic C. Laissez-faire D. participative

A

A critically ill patient has a living will in his chart. His condition has deteriorated. His wife says she wants everything done, regardless of the patient's wishes. Which ethical principle is the wife violating? (ANSER WAS DIFFERENT: The nurse did not slap the patient but instead gently brushed nail beds.) A. Autonomy B. Beneficence C. Justice D. Nonmaleficence

A

A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate? A) Ensure that the radiology department is aware of the isolation precautions. B) Plan to travel with the client to ensure appropriate precautions are used. C) No special precautions are needed when this client leaves the unit. D) Notify the physician that the client cannot leave the room for the CT scan.

A

A med-surg nurse is floated to the burn unit. Which of the following clients is most appropriate for the charge nurse to assign to the med surg nurse? A. a client recovering from a partial-thickness burn who has a weight loss of 15% from admission and requires tube feeding B. a client who has just come back to the unit after having a cultured epithelial autograft to the chest C. a client who has blebs under the autograft on the thigh and has an order for bleb aspiration D. a client who has twice a day burn debridement and dressing changes to a partial-thickness facial burns

A

A new graduate nurse comes to work and complains of being tired all the time. The nurse states "All clients are liars and you can't trust anything that a client tells you." What phase of reality shock is the client in? A. shock and rejection B. anger C. recovery D. honeymoon

A

A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders

A

A nurse delegates care for a client with Parkinson disease to unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care? a. Allow the client to be as independent as possible with activities. b. Assist the client with frequent and meticulous oral care. c. Assess the clients ability to eat and swallow before each meal. d. Schedule appointments early in the morning to ensure rest in the afternoon.

A

A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? A) I don't need to go to the hospital after using it. B) I must carry two EpiPens with me at all times. C) I will write the expiration date on my calendar. D) This can be injected right through my clothes

A

A nurse is triaging clients in the ED. Which client will the nurse see first? A. a client with chest trauma and absent bilateral breath sounds B. a client with a simple fracture of the left arm C. a client with chest pain and diaphoresis D. a client with a temperature of 104 F (40 C) and tachycardic

A

A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem? A) Assisting the client to pre-plan for this event B) Reassuring the client that alopecia is temporary C) Teaching the client ways to protect the scalp D) Telling the client that there are worse side effects

A

A patient has arrived to the emergency room with left sided weakness, slurred speech, and complains of a severe headache. What diagnostic tests should be implemented? a. CT without contrast, 12 lead EKG, capillary blood glucose b. MRI, 12 lead EKG, capillary blood glucose c. MRI, CT with and without contrast, 12 lead EKG

A

A patient has been prescribed nitroglycerin (NTG) in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications before admission for: a. erectile dysfunction. b. prostate enlargement. C. asthma .d. peripheral vascular disease.

A

A patient is admitted to the emergency department with clinical indications of an acute myocardial infarction. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient? A. Administer thrombolytic therapy unless contraindicated b. Diurese aggressively and monitor daily weight c. Keep oxygen saturation levels to at least 88% d. Maintain heart rate above 100 beats/min

A

A patient on Airborne Precautions asks the nurse to leave his door open. What is the nurse's best reply? A) "I have to keep your door shut at all times. I'll open the curtains so that you don't feel so closed in." B) "I'll keep the door open for you, but please try to avoid moving around the room too much." C) "I can open your door if you wear this mask." D) "I can open your door, but I'll have to come back and close it in a few minutes."

A

A postsurgical patient is on a ventilator in the critical care unit. The patient has been tolerating the ventilator well and has not required any sedation. On assessment, the nurse notes the patient is tachycardic and hypertensive with an increased respiratory rate of 28 breaths/min. The patient has been suctioned recently via the endotracheal tube, and the airway is clear. The patient responds appropriately to the nurse's commands. The nurse should: a. Assess the patient's level of pain b. Decrease the ventilator rate. c. Provide sedation as ordered. d. Suction the patient again

A

ASYSTOLE IMAGE he nurse sees the rhythm below. What should the do first? A. Check the pulse, check if the patient is breathing. B. Start an 18-gauge intravenous line C. Initiate cardiopulmonary resuscitation (CPR). D, Transcutaneous pacemaker

A

An intra-aortic balloon pump (IABP) has been placed in a client with cardiogenic shock. What do you monitor? A. Urine output B. Heart rate C. Blood pressure D. Capillary refill

A

An older client is hospitalized with Guillain-Barr syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best? a. Assess the clients oxygen saturation. b. Check the medication list for interactions. c. Place the client on a bed alarm. d. Put the client on safety precautions

A

During rounds, the primary care provider (PCP) alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse should have what understanding about the benefit of proning? A. It is an optional treatment if the PaO2/FiO2 ratio is less 100. B. It presents less of a risk for skin breakdown because the patient is face down. C. It is possible with minimal help from co-workers. D. It is used to provide continuous lateral rotational turning.

A

During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is: a. an optional treatment to improve ventilation. b. less of a risk for skin breakdown because the patient is face down. c. possible with minimal help from coworkers. d. used to provide continuous lateral rotational turning.

A

Once an endotracheal tube is placed how is placement initially assessed? A. Auscultation of breath sounds B. End tidal CO2 C. Chest Xray D. Arterial blood gas

A

THIS WAS A TYPE IN ANSWER: The nurse is caring for an athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? a. The patient is developing neurogenic shock. b. The patient is experiencing an allergic reaction. c. The patient most likely has an elevated temperature. d. The vital signs are normal for this patient.

A

The cardiac nurse is caring for a client who has been diagnosed with dilated cardiomyopathy (DCM). Echocardiography is likely to reveal what pathophysiological finding? A. Decreased ejection fraction B. Decreased heart rate C. Ventricular hypertrophy D. Mitral valve regurgitation

A

The charge nurse is reviewing the status of patients in the critical care unit. Regarding which patient should the nurse notify the organ procurement organization to evaluate for possible organ donation? a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram (ON TEST said "Patient with a Glasgow Coma Scale score of 3, with hepatitis) b. A 68-year-old patient admitted with unstable atrial fibrillation who has suffered a strokec. c. A 40-year-old brain-injured patient with a history of ovarian cancer and a Glasgow Coma Scale score of 7 d. A 53-year-old diabetic with a history of unstable angina status postresuscitation.

A

The clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. The client has begun treatment with pyridostigmine bromide. What change in status would most clearly suggest a therapeutic benefit of this medication? A. Increased muscle strength B. Decreased pain C. Improved GI function D. Improved cognition

A

The most important nursing intervention for patients who receive neuromuscular blocking agents is to? a. Administer sedatives in conjunction with the neuromuscular blocking agents. b. Assess neurological status every 30 minutes. c. Avoid interaction with the patient, because he or she won't be able to hear. d. Restrain the patient to avoid self-extubation.

A

The most important nursing intervention for patients who receive neuromuscular blocking agents is to? a. administer sedatives in conjunction with the neuromuscular blocking agents b. assess neurological status every 30 minutes. c. avoid interaction with the patient, because he or she won't be able to hear. d. restrain the patient to avoid self-extubation.

A

The nurse gets the hand-off report on four clients. Which client should the nurse assess first? A. Client with a blood pressure change of 128/74 to 110/88 mm Hg B. Client with oxygen saturation unchanged at 94% C. Client with a pulse change of 100 to 88 beats/min D. Client with urine output of 40 mL/hr for the last 2 hours.

A

The nurse has admitted a client to the ED following a fall from a second-floor hotel balcony. The client smells of alcohol and begins to vomit in the ED. Which of the following interventions is most appropriate? A. prepare to suction the oropharynx while maintaining cervical spine immobilization B. offer the client an emesis basin so that the amount of emesis can be measured C. insert an oral airway to prevent aspiration and protect the airway D. immediately insert a nasogastric tube to prevent aspiration

A

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? A. Disorientation and restlessness B. Decreased pulse and respirations C. Projectile vomiting D. Loss of corneal reflex

A

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? A. Fluid restriction B. Transfusion of platelets C. Transfusion of fresh frozen plasma (FFP) D. Electrolyte restriction

A

The nurse is caring for a client who is to receive IV daunorubicin, a chemotherapeutic agent. The nurse starts the infusion and checks the insertion site as per protocol. During the most recent check, the nurse observes that the IV has infiltrated so the nurse stops the infusion. What is the nurse's priority concern with this infiltration? A. Extravasation of the medication B. Discomfort to the client C. Blanching at the site D. Hypersensitivity reaction to the medication

A

The nurse is caring for a client who sustained rib fractures after hitting the steering wheel of the car during a motor vehicle crash. The client is spontaneously breathing and receiving oxygen. via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The client's BP dropped from 128/76 to 84/60. The nurse assesses the breath sounds are absent throughout the left lung fields. The nurse notifies the provider and anticipates which order? A. obtain supplies for needle thoracostomy and chest tube insertion B. obtain supplies for endotracheal intubation and mechanical ventilation C. administration of lactated Ringers' solution (1 liter) wide open D. Chest X-Ray study to determine the etiology of the symptoms

A

The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention? a. Dobutamine b. Furosemide c. Phenylephrine d. Sodium nitroprusside

A

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of central line associated bloodstream infection (CLABSI)? a. Review daily the necessity of the central venous catheter. b. Cleanse the insertion site daily with isopropyl alcohol. c. Change the pressurized tubing system and flush bag daily. d. Maintain a pressure of 300 mm Hg on the flush bag.

A

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? a. Diminished breath sounds over left lung field b. Localized pain at catheter insertion site c. Measured central venous pressure of 5 mm Hg d. Slight bloody drainage around insertion site

A

The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? a. Cardiac index (CI) of 2.5 L/min/m2 b. Pulmonary artery diastolic pressure of 26 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg d. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm−5

A

The nurse is caring for a patient in cardiogenic shock being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP? a. "The action of the machine will improve blood supply to the damaged heart." b. "The machine will beat for the damaged heart with every beat until it heals." c. "The machine will help cleanse the blood of impurities that might damage the heart." d. "The machine will remain in place until the patient is ready for a heart transplant."

A

The nurse is caring for a patient who is being evaluated clinically for brain death. Which assessment finding supports brain death? a. Absence gag/mouth reflex b. Unequal, reactive pupils c. Withdrawal from painful stimuli d. Core temperature of 100.8° F

A

The nurse is caring for a patient who is receiving vincristine (Oncovin), a plant alkaloidchemotherapeutic agent, to treat non-Hodgkin lymphoma. The nurse observes that the patienthas difficulty walking. What action will the nurse take? a. Ask about numbness or tingling in the fingers and toes. b. Assess heart rate and blood pressure to evaluate for orthostatic hypotension. c. Assess the temperature to evaluate for infection. d. Request an order for a complete blood count and electrolytes.

A

The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head injury. When working with this patient and family, what mutual goal should be prioritized? A) Achieve as high a level of function as possible. B) Enhance the quantity of the patient's life. C) Teach the family proper care of the patient. D) Provide community assistance.

A

The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the client to avoid? A. Washing the face B. Exposing the skin to sunlight C. Using artificial tears D. Drinking large amounts of fluids

A

The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? A. Change the client's position frequently. B. Provide a high-protein diet. C. Provide light massage at least daily. D. Teach the client deep breathing and coughing exercises.

A

The nurse is preparing to admit clients who have been the victim of a blast injury. The nurse will expect to treat a large number of clients who have experienced what type of injury? A. tympanic membrane rupture B. spinal cord injury C. meningeal tears D. chemical burns

A

The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which provider prescription should the nurse institute first? a. Mannitol 1 g intravenous b. Portable chest x-ray c. Seizure precautions d. Ancef 1 g intravenous

A

The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic- clonic seizure. What is the best nursing action? a. Assist the patient to the floor and provide soft head support. b. Insert a nasogastric tube and connect to continuous wall suction. c. Open the patient's mouth and insert a padded tongue blade. d. Restrain the patient's extremities until the seizure subsides.

A

The nurse working with oncology clients understands that which age-related change increases the older clients susceptibility to infection during chemotherapy? A) Decreased immune function B) Diminished nutritional stores C) Existing cognitive deficits D) Poor physical reserves

A

The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? EXAM HAD PT EJECTED IN MVA A) Ensure that the player is not moved. B) Obtain the players vital signs, if possible C) Perform a rapid assessment of the players range of motion. D) Assess the players reflexes.

A

Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal cord injury at the C5 dermatome level (ON TEST it was C4) b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg

A

While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action? A) Stopping the administration of the drug immediately B) Notifying the patients physician C) Continuing the infusion but decreasing the rate D) Applying a warm compress to the infusion site

A

You are caring for a patient who has just been told that her stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the patient the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer? A) Palliative B) Reconstructive C) Salvage D) Prophylactic

A

the nurse is coordinating the care of victims who arrive at the ED after a radiation leak at a nearby nuclear plant. What will be the first intervention initiated when the victims arrive at the hospital? A. survey the victims using a radiation survey meter B. irrigate the victims' open wounds C. administer prophylactic antibiotics D. perform soap and water decontamination

A

Brachytherapy question, select all that apply: A. Placing the client in a private room with a private bath. B. No pregnant patients allowed in the room C. Nurses should protect themselves by wearing a lead shield. D. Nurses should spend as much time with the patient due to isolation

A, B, C

The nurse is preparing to administer 100 mg of phenytoin to a patient in status epilepticus. To prevent patient complications, what is the best action by the nurse? a. Ensure patency of intravenous (IV) line. b. Check Blood Pressure c. Check Heart rated. d. Mix drug with 0.9% normal saline. e. Evaluate serum K+ level. f. Obtain an IV infusion pump.

A, B, C

The patient tells the nurse, "I didn't think I was having a heart attack because the pain was in my neck and back." The nurse explains: (Select all that apply.) a. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." d. "You need to make sure it's a heart attack before you call the emergency response personnel." e. "Often symptoms can be treated with nitroglycerin, so be sure to take several before calling 911."

A, B, C

A patient is taking a chemotherapy agent and the site infiltrates. What should the nurse do? Select all that apply? A. Stop infusion immediately B. Notify the healthcare provider C. Administer antidotes D. Apply heat or ice to the site

A, B, C, D

A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply. A) Current medication regimen B) Identification of patients support system C) Immune system function D) Genetic risk factors for HIV E) Dietary history and difficulty with oral intake

A, B, C, E

A nurse is providing an in service on best practice for implementing family presence during resuscitation. Which of the following will the nurse list as benefits of having the family present during resuscitation? (SATA) A. provide a sense of closure B. facilitates the grief process C. sustains client-family relationships D. allows the staff easy access to ask for tissue/organ donation E. allows the family see that everything is being done

A, B, C, E

Which interventions can the nurse use to facilitate communication with patients and families who are in the process of making decisions regarding end-of-life care options? (Select all that apply.) a. Communication of uniform messages from all health care team members b. An integrated plan of care that is developed collaboratively by the patient, family, and health care team c. Facilitation of continuity of care through accurate shift-to-shift and transfer reports d. Limitation of time for families to express feelings in order to control family grief. e. Reassuring the patient and family that they will not be abandoned as the goals of care shift from aggressive treatment to comfort care

A, B, C, E

A nurse is caring for a client that presented to the ED in cardiac arrest. The client has return of spontaneous circulation (ROSC) in the ED. Which of the following goals will the nurse prioritize in the immediate post resuscitation phase? (SATA) A. identify and treat cause of cardiac arrest B. maintain adequate blood pressure C. early ambulation D. control dysrhythmias E. wean off oxygen

A, B, D

Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED. (Select all that apply.) a. Administration of morphine b. Administration of nitroglycerin (NTG) c. Dopamine infusion d. Aspirin e. Transfusion of packed red blood cells

A, B, D

The nurse is conducting a first aid session and discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that priority interventions in the event of this occurrence include which of the following (select all that apply) A. cleanse the wound and cover with a dressing B. remove jewelry and constricting clothing from the victim C. apply a tourniquet above the level of the bite D. immobilize the affected extremity E. apply ice to the bite

A, B, D

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client plan of care? (Select all that apply.) ANSWERS WERE DIFFERENT a. Tape a halo wrench to the clients vest (screwdriver on test) b. Assess the pin sites for signs of infection (on test) c. Loosen the pins when sleeping. d. Decrease the clients oral fluid intake e. Fall Precautions

A, B, E

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (Select all that apply.) a. Until your incision is healed, do not submerge your pacemaker. Only take showers. b. Report any pulse rates lower than your pacemaker settings. c. If you feel weak, apply pressure over your generator. d. Have your pacemaker turned off before having magnetic resonance imaging (MRI). e. Do not lift your left arm above the level of your shoulder until physician says otherwise

A, B, E

The family of a critically ill patient has asked to discuss organ donation with the patient's nurse. When preparing to answer the family's questions, the nurse understands which concern(s) most often influence a family's decision to donate? (Select all that apply.) a. Donor disfigurement influences on funeral care b. Fear of inferior medical care provided to donor c. Age and location of all possible organ recipients d. Concern that donated organs will not be used e. Fear that the potential donor may not be deceased

A, B, E

The nurse is caring for a client with mitral valve prolapse. Which symptoms would be consistent with this diagnosis? Select all that apply. A. Anxiety B. Fatigue C. Shoulder pain D. Tachypnea E. Palpitations

A, B, E

The nurse is working on a burn unit. Which of the following infection control strategies will the nurse implement to decrease the risk of infection in the burn-injured client? (SATA) A. apply topical antibacterial wound ointments/dressings B. restrict family visitation C. daily assess the need for central IV catheters D. maintain strict aseptic technique during burn wound management E. change indwelling urinary catheter every 7 days

A, C, D

The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. A. Contractures B. Hemorrhage C. Pressure ulcers D. Venous thromboembolism E. Pneumonia

A, C, D, E

The nurse providing care for a client post PTCA knows to monitor the client closely. For what complications should the nurse monitor the client? Select all that apply. A. Abrupt closure of the coronary artery B. Venous insufficiency C. Bleeding at the insertion site D. Retroperitoneal bleeding E. Arterial occlusion

A, C, D, E

The nurse providing care for a patient post percutaneous transluminal coronary angioplasty (PTCA) knows to monitor the patient closely. What does the nurse know to monitor for? Select all that apply. A) Abrupt closure of the coronary artery B) Venous insufficiency C) Bleeding at the insertion site D) Retroperitoneal bleeding E) Arterial occlusion

A, C, D, E

A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.) A) Admit the client to a negative-airflow room. B) Maintain a distance of 3 feet from the client at all times. C) Order specialized masks/respirators for caregiving. D) Other than wearing gloves, no special actions are needed. E) Perform hand hygiene before leaving the room

A, C, E

A nurse collaborates with unlicensed assistive personnel (UAP) to provide care for a client. Which instructions should the nurse provide to the UAP when delegating care for this client? (select all that apply.) A. obtain daily weights on the client each morning B. administer oxygen if the client becomes short of breath C. feed the client that is unable to feed himself D. teach the client to perform deep-breathing exercises E. accurately record intake and output

A, C, E

A nurse is participating in secondary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.) A) Demonstrating breast self-examination methods to women B) Instructing people on the use of chemo prevention C) Providing vaccinations against certain cancers D) Teaching patients about colonoscopy screenings.. (It was something about colonoscopy) E) Teaching teens the dangers of tanning booths

A, D

A nurse triages clients arriving at the hospital after a mass casualty event. Which clients are correctly classified? (SATA) A. a client with a shortness of breath and tracheal deviation: red tag B. a client with full-thickness burns to the chest and abdomen: yellow tag C. a client with an open femur fracture with absent distal pulses: yellow tag D. a client with a laceration to the left forearm: green tag E. a client with a head injury, pupils fixed and dilated: black tag

A, D, E

What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? A. Serum calcium level of 14 mg/dL (3.0 mmol/L) B. Weight loss of 6 kg in 1 month (I don't know if this is right or not) C. Serum Sodium level of 135 D. Numbness and tingling of the lower extremities. E. Facial edema and ineffective breathing pattern ANSWER: SUPERIOR VENA CAVA SYNDROME, NUMBNESS/TINGLING OF EXTREMETIES, HYPERCALCEMIA

A, D, E

What treatments will be included for a patient with a STEMI. Select all that apply! A. clopidogrel B. morphine C. Heparin D. Nitro E. aspirin

A, D, E

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

A, D, F

RHYTHM OF PAC IMAG

ANSWER IS TO DECREASE CAFFEINE INTAKE

THIS WAS A TYPE IN QUESTION: A nurse is triaging clients in a mass casualty situation. How will the nurse correctly triage the following client: a client with first degree burn to the left forearm?

Ans: Green

A RN is working with a LPN and an unlicensed assistive personnel. Which task is the most appropriate for the RN to delegate to the UAP? A. administer oxygen via nasal cannula for a hypoxic client B. collect a stool specimen from an incontinent client C. teach a client to do self-catheterization D. monitor the client's response to a dose of morphine

B

A client diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should anticipate what therapeutic response? A. Permanent improvement after 4 to 6 months of treatment B. Symptom improvement that lasts a few weeks after TPE ceases C. Permanent improvement after 60 to 90 treatments D. Gradual improvement over several months

B

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly .b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.

B

A client hospitalized for chemotherapy is taking Epoetin alfa. What findings should the nurse notify the provider before administering the next dose of Epoetin alfa? What medication should the nurse prepare to administer? A) Blood pressure of 102/60 B) Hemoglobin of 14.2 mg/dL C) Platelets of 160,000 D) WBC of 6,000

B

A client is admitted to the ED complaining of a racing heart rate. The ED nurse places the client on the monitor in the room. The client is in a regular, wide complex rhythm with a rate of 190 bpm and a BP of 114/68. What will the nurse prepare to do first? A. administer adenosine B. administer amiodarone C. cardioversion D. administer diltiazem

B

A client is being treated in the ED following a terrorist attack. The client is experiencing visual disturbances, nausea, vomiting, and behavioral changes. The nurse suspects this client has been exposed to what chemical agent? A. blood agent B. Nerve agent C. pulmonary agent D. vesicant

B

A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects? A. Nervousness or paresthesia B. Throbbing headache or dizziness C. Drowsiness or blurred vision D. Tinnitus or diplopia

B

A client with polymyositis is experiencing challenges with activities of daily living as a result of proximal muscle weakness. What is the most appropriate nursing action? A. Initiate a program of passive range of motion exercises B. Facilitate referrals to occupational and physical therapy C. Administer skeletal muscle relaxants as prescribed D. Encourage a progressive program of weight-bearing exercise

B

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? A. Pain upon ankle dorsiflexion of the foot B. Neck flexion produces flexion of knees and hips C. Inability to stand with eyes closed and arms extended without swaying D. Numbness and tingling in the lower extremities

B

A director of an ED comes in and immediately goes to the office. The director only leaves their office to attend meetings. The director communicates with staff through email only. What type of management style does this director demonstrate? A. afraid to decide B. emotionally remote C. know-it-all D. pure mean

B

A nurse assesses a client after administering prescribed levetiracetam. Which laboratory tests should the nurse monitor for potential adverse effects of this medication? a. Serum electrolyte levels b. BUN and Creatine c. Complete blood cell count d. Antinuclear antibodies.

B

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, Why will I need to take anticoagulants for the rest of my life? How should the nurse respond? a. The prosthetic valve places you at greater risk for a heart attack. b. Blood clots form more easily in artificial replacement valves. c. The vein taken from your leg reduces circulation in the leg. d. The surgery left a lot of small clots in your heart and lungs

B

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)

B

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse do first? a. Administer intravenous diltiazem (Cardizem).b. Assess vital signs and level of consciousness. c. Turn patient on left sided. Assess capillary refill and temperature.

B

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse take first? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness, c. Turn the patient to the left sided. d. Assess capillary refill and temperature.

B

A nurse evaluates prescriptions for a client with chronic atrial fibrillation taking diltiazem.. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

B

A nurse in the intensive care unit (ICU) receives a report from the nurse in the emergency department (ED) about a new client being admitted with a neck injury received while diving into a lake. The ED nurse reports that the client's blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU nurse recognize that the client is probably experiencing? A. Anaphylactic shock B. Neurogenic shock C. Septic shock D. Hypovolemic shock

B

A nurse is assessing a client with HIV who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority? A. Oral temperature of 37.2°C (99°F) B. Tachypnea and restlessness C. Frequent loose stools D. Weight loss of 0.45 kg (1 lb) since yesterday

B

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

B

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? A. Prevent complications of immobility. B. Maintain and improve cerebral tissue perfusion. C. Relieve anxiety and pain. D. Relieve sensory deprivation

B

A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

B

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

B

A nurse is teaching a patient about neutropenia. What statement indicates that the client understands teaching about neutropenia? A. "No visitors are allowed in my home" B. "I will call my doctor if I have an increase in temperature." C. "I need to use a soft toothbrush." D. "My grandchildren may get an infection from me."

B

A nurse is triaging in the ED. Which client will the nurse see first? A. an immunosuppressed client with a cough and a temperature of 102 F B. a client with a blunt chest trauma with labored breathing C. a client with an acute onset of confusion D. a client with a possible fractured tibia with pedal pulses

B

A nurse responds to a building collapse at a local store after a weather-related event. The nurse triages victims at the site of the building collapse, what is the nurse's priority? A. call in additional staff to assist with care of the victims B. perform a rapid assessment of clients to determine priority of care C. provide psychological support to staff and family members D. splint fractures and clean and dress lacerations

B

A patient decided to have genetic testing done and has the BRCA1 gene mutation. What should the nurse teach the client about their risk for breast cancer? A. You have a higher risk of getting breast cancer than the general population B. You have an increased risk of developing breast cancer C. You will most likely get breast care ID. think there was an answer about 50 % chance of getting breast cancer

B

A patient has a concentration of S. aureus located on his skin. The patient is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which of the following stages? A) Infection B) Colonization C) Disease D) Bacteremia

B

A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy? A) Promoting appropriate use of complementary therapies B) Addressing possible barriers to adherence C) Educating the patient about the pathophysiology of HIV D) Teaching the patient about the need for follow-up blood work

B

A patient is receiving the antitumor antibiotic doxorubicin (Adriamycin) to treat lung cancer.The patient is experiencing shortness of breath and palpitations. The nurse is concerned that the patient has developed which condition? a. Anemia b. Cardiotoxicity c. Hypersensitivity d. Pulmonary infection

B

A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? A) Right-sided heart failure B) Acute pulmonary edema C) Pneumonia D) Cardiogenic shock

B

A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize which of the following interventions? A) Lifestyle actions that improve immune function B) Educational programs that focus on control and prevention C) Appropriate use of standard precautions D) Screening programs for youth and young adults

B

After receiving the hand-off report, which client should the oncology nurse see first? A) Client who is afebrile with a heart rate of 108 beats/min B) Older client on chemotherapy with mental status changes C) Client who is neutropenic and in protective isolation D) Client scheduled for radiation therapy today

B

An ED charge nurse receives a telephone call from emergency medical services providers that a tornado has hit a local residential area and reports numerous casualties have occurred. The victims will be brought to the ED. What is the charge nurse's priority action? A. prepare the triage rooms B. activate the emergency response plans C. obtain additional supplies from the central supply department D. call in additional nursing staff to assist in treating casualties

B

An ED nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How will the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A. administer IV potassium chloride B, Administer IV fluids C. Administer IV morphine D. Administer broad-spectrum antibiotics

B

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

B

An essential aspect of teaching that may prevent recurrence of heart failure is? a. notifying the provider if a 2-lb weight gain occurs in 24 hours. b. compliance with diuretic therapy. c. taking nitroglycerin if chest pain occurs. d. assessment of an apical pulse.

B

An industrial site has experienced a radiation leak and workers who have been potentially affected are en route to the hospital. Which action is essential to minimize the risk of contaminating the hospital? A. Place hospital staff on abbreviated shifts of no more than 4 hours B. establish triage outside the hospital C. have hospital staff put on PPE D. place all potential victims on reverse isolation

B

Emergency medical technicians arrive at the ED with an unresponsive client who has an oxygen mask in place. What action should the nurse take first? A. place the client on a cardiac monitor and obtain a blood pressure B. Assess the client's breathing and respiratory effort C. Insert two large-bore intravenous lines D. Assess for the client's neurological response

B

Family members have a need for information. Which interventions best assist in meeting this need? A. Handing family members a pamphlet that explains all of the critical care equipment. B. Providing a daily update of the patients progress and facilitating communication with the intensivist. C. Telling them that you are not permitted to give them a status report but that they can be present at 4:00 PM for family rounds with the intensivist. D. Writing down a list of all new medications and doses and giving the list to family members during visitation.

B

The ED nurse is caring for clients that presented to the ED for treatment. Which client will the nurse see first? A, a client with a minor laceration on the index finger sustained while cutting a zucchini B. a client with chest pain, complaining of some nausea, and denies shortness of breath C. a client who twisted her ankle when rollerblading and is requesting medication for pain D. a client complaining of muscle aches, a headache, and history of seizures

B

The ED nurse is treating a client admitted with a pH of 7.22 PaCO2 of 30. PaO2 of 90, and HCO3 of 14. What is the best intervention to treat this client? A. supplemental oxygen B. sodium bicarbonate administration C. effective ventilation D. epinephrine administration

B

The client's monitor shows a heart rate of 35 beats/min with a measured blood pressure of 82/48. The nurse anticipates the provider will order which medication first? A. continuous dopamine infusion B. Atropine 1 mg IV push C. continuous norepinephrine infusion D. continuous epinephrine infusion

B

The clinic nurse caring for a patient with Parkinsons disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect of Sinemet would the nurse assesses this patient? A) Pruritus B) Dyskinesia C) Lactose intolerance D) Diarrhea

B

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? A. Position the client supine. B. Maintain head of bed (HOB) elevated at 30 to 45 degrees. C. Position client in prone position. D. Maintain bed in Trendelenburg position.

B

The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? This was a select all that apply a. Keep the neck in the hyperextended position. b. Maintain proper head and neck alignment. c. Prepare for immediate endotracheal intubation. d. Remove cervical collar upon arrival to the ED.

B

The nurse has just completed administration of a 500 mL bolus of 0.9% normal saline in a patient with hypovolemic shock. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/ min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? a. Patient response to therapy is appropriate. b. Additional interventions are indicated. c. More time is needed to assess response. d. Values are normal for the patient condition.

B

The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium 3.8 mEq/L d. Sodium 140 mEq/L

B

The nurse is admitting an oncology client to the unit prior to surgery. The nurse reads in the electronic health record that the client has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem? A. Cognitive deficits B. Delayed wound healing C. Cardiac tamponade D. Tumor lysis syndrome

B

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath

B

The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? A. Taking a hot bath at least once daily B. Resting in an air-conditioned room whenever possible C. Increasing the dose of muscle relaxants D. Avoiding naps during the day.

B

The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which prescription by the provider should the nurse implement first? a. Obtain stat serum electrolytes. b. Administer lorazepam c. Obtain stat portable chest x-ray. d. Administer phenytoin.

B

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/ min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a. Administer acetaminophen as ordered for the headache. b. Assess for a kinked urinary catheter c. Encourage the patient to take slow, deep breaths. d. Notify the provider of the patient's blood pressure

B

The nurse is caring for a patient with an advanced stage of breast cancer and the patient has recently learned that her cancer has metastasized. The nurse enters the room and finds the patient struggling to breath and the nurses rapid assessment reveals that the patients jugular veins are distended. The nurse should suspect the development of what oncologic emergency? A) Increased intracranial pressure B) Superior vena cava syndrome (SVCS) C) Spinal cord compression D) Metastatic tumor of the neck

B

The nurse is educating an 80-year-old client diagnosed with heart failure about the medication regimen. Which instruction would the nurse give this client about the use of furosemide? A. Avoid drinking fluids for 2 hours after taking the diuretic. B. Take the furosemide in the morning to avoid interfering with sleep. C. Avoid taking the medication within 2 hours consuming dairy products. D. Take the diuretic only on days when experiencing shortness of breath.

B

The nurse notes the following rhythm on the heart monitor. The patient is unresponsive and not breathing. The nurse should? a. treat with intravenous amiodarone or lidocaine. b. provide emergent basic and advanced life support. c. provide electrical cardioversion. d. ignore the rhythm because it is benign.

B

The nurse notices ventricular tachycardia on the heart monitor. When the patient is assessed, the patient is found to be unresponsive with no pulse. The nurse should a. treat with intravenous amiodarone or lidocaine. b. begin cardiopulmonary resuscitation and advanced life support. c. provide electrical cardioversion. d. ignore the rhythm because it is benign.

B

The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring the patient from the stretcher to the bed. Before obtaining a cardiac output, which action is most important for the nurse to complete? a. Document a pulmonary artery catheter occlusion pressure. b. Zero reference the transducer system at the phlebostatic axis. c. Inflate the pulmonary artery catheter balloon with 1 mL air. d. Inject 10 mL of 0.9% normal saline into the proximal port.

B

The patient is admitted with a fever and rapid heart rate. The patient's temperature is 103° F (39.4° C). The nurse places the patient on a cardiac monitor and finds the patient's atrial and ventricular rates are above 105 beats per minute. P waves are clearly seen and appear normal in configuration. QRS complexes are normal in appearance and 0.08 seconds wide. The rhythm is regular, and blood pressure is normal. The nurse should focus on providing: (This question was worded different) a. medications to lower heart rate. b. treatment to lower temperature. c. treatment to lower cardiac output. d. treatment to reduce heart rate.

B

Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized? A) Assessing skin and mucous membranes B) Consistently using appropriate hand hygiene C) Monitoring daily white blood cell counts D) Teaching visitors not to visit if they are ill

B

Which vasopressor is commonly used in the treatment of septic shock? A) Dopamine B) Norepinephrine C) Epinephrine D) Isoproterenol

B

While caring for a client with an endotracheal tube, the nurse should normally provide suctioning how often? A. Every 2 hours when the client is awake B. When adventitious breath sounds are auscultated C. When there is a need to prevent the client from coughing D. When the nurse needs to stimulate the cough reflex

B

While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention? A. Diuretics B. Intravenous fluids C. Negative inotropic agents D. Vasopressors

B

a client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would the nurse's immediate, priority concern when planning this client's risk? A. risk of infection B. fluid status C. psychosocial coping D. nutritional status

B

client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? A) Ask the client about travel to any foreign countries. B) Assess the client for adherence to the drug regimen. C) Determine if the client has any new sexual partners. D) Request information about new living quarters or pets.

B

it is determined that the client needs a transcutaneous pacemaker until the transvenous pacemaker can be inserted. What is the most appropriate nursing intervention? A. apply conductive gel to the skin B. Provide adequate sedation and analgesia C. set a milliamperes to 2mA below the capture level D. recheck leads to make sure the rhythm is asystole

B

A client with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The client is admitted to the cardiac critical care unit after the PTCA. The complications for which the nurse should monitor the client include which of the following? A. Peripheral edema B. Bleeding at insertion site C. Left ventricular hypertrophy D. Pulmonary edema

B THERE WAS AN ANSWER FOR "ASSESS FOR BLEEDING" -- NOT SURE IF THIS WAS THE QUESTION

A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A) Assessing the clients fluid and electrolyte status B) Assisting the client to get out of bed to prevent falls C) Obtaining a bedside commode if the client is weak D) Providing gentle perianal cleansing after stools E) Apply a perianal cream medication

B, C, D

The nurse educator is discussing emerging diseases with a group of nurses. The educator should cite what causes of emerging diseases? Select all that apply. A) Progressive weakening of human immune systems B) IV drug use C) Increase in urban population D) Increased global travel E) Globalization of food supplies

B, C, D, E

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Ethnic background. f. inactivity

B, C, D, F

A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A) Assess the patients ability to swallow food and water B) Assist the client with oral care every 2 hours. C) Offer the client frequent sips of cool drinks. D) Provide the client with alcohol-based mouthwash. E) Give the client only a soft toothbrush.

B, C, E

The nurse is planning and providing the care of a patient with heart failure (HF). What will be the overall goals of management for this patient? Select all that apply. A. Increase cardiac contractility B. Relieve patient symptoms C. Extend survival D. Decrease pulmonary venous pressure E. Improve functional status

B, C, E

A client has been successfully converted for ventricular tachycardia with a pulse to a sinus rhythm. Upon further assessment, it is noted that the client is hypotensive. What medication(s) will the nurse anticipate that the provider will order to treat the client's hypotension? (SATA) A. sodium bicarbonate infusion B. dopamine infusion C. normal saline bolus D. norepinephrine infusion E. magnesium

B, C., D

A nurse manager is educating the nursing staff about clients that the nurse will call the rapid response team. Which clients will the nurse manager include in her teaching? (SATA) A. a client with apnea admitted with a severe head injury B. a client experiencing an anaphylactic reaction with stridor C. a client admitted with chest pain, unresponsive with no palpable pulse D. a client admitted with a pulmonary embolism in severe respiratory distress E. a client with a heart rate of 40 bpm and BP of 82/48

B, D, E

An ER nurse is caring for a trauma client. Which interventions might the nurse perform during primary survey? (SATA) A. turn the client and assess the client's back B. manually ventilate a client that has poor respiratory effort C. obtain the client's past medical history D. Place a nasopharyngeal airway on a client with agonal respirations E. Insert two large bore peripheral intravenous catheters

B, D, E

A nurse is teaching a nursing student about fluid resuscitation of a trauma client. Which of the following statements is true regarding fluid resuscitation during the care of a trauma client? (SATA) a. 5% dextrose is recommended for rapid crystalloid infusion B. IV fluids may need to be warmed to prevent hypothermia C. hypertonic saline solutions are often used during initial resuscitation D. massive transfusions are standard for all trauma clients E. Crossmatched blood products are preferred but O negative can be administered in an emergency

B, E

A RN is at the nurses' station reading her work email. Multiple call lights go off at once and the nurse asks the UAP to answer the call lights and only notify the RN if the client is asking for medication. What type of delegation is the RN demonstrating? A. under delegation B. proper delegation C. over delegation D. improper delegation

C

A client admitted to the ED after falling into a frozen pond while ice skating. What priority action will the nurse perform while rewarming the client? A. assessing the client's oral temperature frequently B. massaging the client's skin surfaces to promote circulation C. ensuring continuous electrocardiogram (ECG) monitoring D. administering bronchodilators by nebulizer

C

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown

C

A client is admitted to the ED after being involved in a MVA. The client has multiple injuries with a large laceration to the lower extremity and is hypotensive. After establishing an airway and adequate ventilation, the ED will prioritize what aspect of care next? A. splint the client's fractures B. Obtain laboratory studies C. Control the client's hemorrhage D. Assess the client's neurological status

C

A client is admitted to the ED complaining of a racing heart rate, is pale, and diaphoretic. The ED nurse places the client on the monitor in the room. The client is in SVT with a rate of 200 beats per minute and a blood pressure of 78/46. What will the nurse prepare to do first? A. administer amiodarone B. Administer adenosine C. cardioversion D. perform vagal maneuvers

C

A client is admitted to the critical care unit with a diagnosis of acute myocardial infarction. Suddenly, the monitor alarms and the screen shows asystole. Upon assessment the nurse finds the client unresponsive, apnic, and pulseless; what action will the nurse take next? A. administer 300 mg of amiodarone by IV push B. administer 1 mg of epinephrine by IV push C. begin chest compressions D. defibrillate the client

C

A client is admitted with Guillain-Barr syndrome (GBS). What assessment takes priority? a. Bladder control b. Cognitive perception c. Respiratory system d. Sensory functions

C

A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care? A. Monitoring of pulse oximetry B. Administration of a low-protein diet C. Administration of thorough oral hygiene D. Fluid restriction as prescribed

C

A client who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action? A. Document the client's low urine output and monitor closely for the next several hours. B. Contact the dietitian and suggest the need for increased oral fluid intake. C. Contact the client's health care provider and continue to assess fluid balance and renal function. D. Increase the infusion rate of the client's IV fluid to prompt an increase in renal function

C

A client with Myasthenia gravis becomes increasingly weak. The health care provider prepares to identify whether the client is reacting to an over dose of the medication (cholinergic crisis) or increasing severity of the disease (Myasthenic crisis). An injection of edrophonium (Enlon) is administered. Which of the following indicates that the client is in Myasthenic crisis? WORDED DIFFERENT A. No change in the condition B. Complaints of muscle spasms C. An improvement of the weakness D. A temporary worsening of the condition

C

A client with acquired immunodeficiency syndrome (AIDS) is suspected of having cutaneous Kaposi's sarcoma. The nurse prepares the client for which test that will confirm the presence of this type of sarcoma? a) sputum culture b) liver biopsy c) punch biopsy of the lesion d) white blood cell count

C

A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3. What action should the nurse take first? (CD4 COUNT WAS DIFFERENT) A) Initiate Droplet Precautions for the client. B) Notify the provider about the CD4+ results. C) Place the client under Airborne Precautions. D) Use Standard Precautions to provide care.

C

A client with increased intracranial pressure (ICP) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? A. Encephalitis B. Cerebral spinal fluid leak C. Meningitis D. Catheter occlusion

C

A client, brought to the clinic by the client's spouse and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease? A. Metastasis B. Risk for stroke C. Emotional and personality changes D. Pathologic bone fractures

C

A hospital unit is participating in a bioterrorism drill. A "client" is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the "client"? A. droplet B. airborne C. standard D. contact

C

A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first? (Answer was worded different) a. Notify the provider b. Initiate external pacing. c. Assess the client's medications (On test it said "Assess the patient's blood pressure") d. Administer 1 mg of atropine.

C

A nurse is planning care for a client with Sjogren's syndrome. At what point does the nurse determine that priority outcomes have been met? A) The client states that he or she is not as fatigued as previously. B) The client dresses attractively despite gaining a large amount of weight. C) The oral mucosa is intact and no systemic signs of infection are present. D) The client is able to complete activities of daily living with minimal shortness of breath.

C

A nurse is teaching a nursing student about defibrillation. Which statement by the nurse is correct concerning defibrillation? A. "All models of defibrillation are the same for standardization." B. "It is not necessary to ensure that personnel are clear of the client if hands-off defibrillation is used." C. "Early defibrillation (if indicated) is recommended before other actions." D. "You must synchronize defibrillation shocks."

C

A nurse receives shift change report. Which client will the nurse see first? A. a client admitted with abdominal pain the previous night. The last set of vital signs are heart rate of 96, BP of 106/54, respiratory rate of 20, and temperature of 99.4 F B. a client admitted with pneumonia two days ago and requiring 2 LPM of 02 via nasal cannula C. a client admitted the previous night with chest pain. The client was diagnosed with a pulmonary embolus and is having increased oxygen requirements and is currently on a 50% Venturi mask D. a client that was admitted with Flu A three days ago and is planning discharge that day

C

A patient has increased intracranial pressure due toa head injury. What vital signs will the nurse anticipate? Answer was the only opening that said widening pulse pressure! A. Increased respirations decreased systolic and decreased diastolic blood pressure. B. Decreased pulse, decreased respirations, increased systolic and increased diastolic blood pressure. C. Decreased pulse, irregular respirations, increased systolic and decreased diastolic blood pressure (widening pulse pressure) D. Increased pulse, normal respirations, increased systolic and decreased diastolic blood pressure.

C

A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzyme (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process? a. Myocardial stunning b. Hibernating myocardium c. Myocardial remodeling d. Tachycardia

C

A patient is receiving bone marrow transplantation for cancer and receives filgrastim (Neupogen). The patient reports abdominal pain in the left upper quadrant. The nurse will perform which action? a. Administer acetaminophen 650 mg. b. Administer an antiemetic medication. c. Notify the provider and report a potentially life-threatening event. d. Request an order for cardiac enzyme levels.

C

A patient is undergoing diagnostic testing for mitral stenosis. What statement by the patient during the nurse's interview is most suggestive of this valvular disorder? A) "I get chest pain from time to time, but it usually resolves when I rest." B) "Sometimes when I'm resting, I can feel my heart skip a beat." C) "Whenever I do any form of exercise I get terribly short of breath." D) "My feet and ankles have gotten terribly puffy the last few weeks."

C

A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in patients at risk for thrombocytopenia? A) Interrupted sleep pattern B) Hot flashes C) Epistaxis D) Increased weight

C

A patient with mitral stenosis exhibits new symptoms of a dysrhythmia. Based on the pathophysiology of this disease process, the nurse would expect the patient to exhibit what heart rhythm? A) Ventricular fibrillation (VF) B) Ventricular tachycardia (VT) C) Atrial fibrillation D) Sinus bradycardia

C

A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action will the nurse take prior to starting this treatment? A. massage the frostbitten areas B. assess the limb for compartment C. administer ordered intravenous morphine D. wrap the limb with a compression dressing

C

A public health nurse has formed an interdisciplinary team that is developing an educational program entitled Cancer: The Risks and What You Can Do About Them. Participants will receive information, but the major focus will be screening for relevant cancers. This program is an example of what type of health promotion activity? A. Disease prophylaxis B. Risk reduction C. Secondary prevention D. Tertiary prevention

C

After a hospital's ED has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to "stand down" from the emergency plan. Which question will the incident commander ask the nursing supervisor at this time? A. "Does the chief medical officer agree this disaster is under control?" B. "Are all the hospital administrators in the building?" C. "Do all areas of the hospital have the supplies and personnel they need?" D. "Have all ED staff had the chance to eat and rest recently?"

C

An ED nurse is triaging victims of a multi-casualty event. Which client will receive care first? A. a client with partial thickness burns to the client's left lower extremity only B. A client with full thickness burns over 80% of the client's body C. An unconscious client with a head laceration, thready pulse, and respiratory rate of 30 breaths/min D. a client who is pale with no respirations and without a pulse

C

An immunosuppressed patient is receiving chemotherapy treatment at home. What infection-control measure should the nurse recommend to the family? A) Family members should avoid receiving vaccinations until the patient has recovered from his or her illness. B) Wipe down hard surfaces with a dilute bleach solution once per day. C) Maintain cleanliness in the home but know that the home will not be sterile. D) Avoid physical contact with the patient unless absolutely necessary.

C

Four hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and normal arterial blood gases (ABGs), and is placed on a T-piece for ventilatory weaning. The following information pertains to the 1900 assessment. Assessments and Vital Signs: Restless Increased to 110 beats/min Respirations 36 breaths/min Blood pressure 156/98 mm Hg Sinus tachycardia 10 PVCs/min Elevated pulmonary artery pressure Loud crackles throughout New ABGs: pH: 7.28, PaCO2: 46 mm Hg, Bicarbonate: 22 mEq/L , aO2: 58 mm Hg, O2 saturation: 88% Nursing Action: Performs complete assessment Suctions patient for pink, frothy secretions Obtains prescriptions from provider for ABGs, electrolyte levels, and portable chest x-ray What action by the nurse is best? a. Prepare for rapid intubation. b. Increase the patient's oxygen. c. Prepare to administer a diuretic. d. Change the ventilator settings.

C

The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first? a. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour b. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform c. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula d. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula

C

The critical care nurse is caring for 25-year-old admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? A. Maintaining the client's functional independence B. Providing health education C. Monitoring neurologic status closely D. Promoting mobility

C

The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications, such as infection. Based on these care priorities, the client is in what phase of burn care? A. emergent B. immediate resuscitative C. acute D. rehabilitation

C

The family of your critically ill patient tells you that they have not spoken with the physician in over 24 hours and they have some questions that they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange for her to meet with the family at 4:00 PM in the conference room. Which competency of critical care nursing does this represent? A. Advocacy and moral agency in solving ethical issues B. Clinical judgment and clinical reasoning skills C. Collaboration with patients, families, and team members D. Facilitation of learning for patients, families, and team members

C

The infectious control nurse is presenting a program on West Nile virus for a local community group. To reduce the incidence of this disease, the nurse should recommend what action? A) Covering open wounds at all times B) Vigilant hand washing in home and work settings C) Consistent use of mosquito repellants D) Annual vaccination

C

The nurse is assessing a patient who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurses most recent assessment reveals that the patients left pedal pulses are not palpable and that the right pedal pulses are rated at +2. What is the nurses best response? A) Document this expected assessment finding during the initial postoperative period. B) Reposition the patient with his left leg in a dependent position. C) Inform the patients physician of this assessment finding. D) Administer an ordered dose of subcutaneous heparin.

C

The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine. The physician's order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2. The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the nurse? (ANSWER ON TEST: Increase the rate of dobutamine) A. Obtain a stat serum potassium level. B. Order a stat 12-lead electrocardiogram. C. Reduce the rate of dobutamine. D. Assess the patient's hourly urine output.

C

The nurse is participating in the care conference for a client with ACS. What goal should guide the care team's selection of assessments, interventions, and treatments? A. Maximizing cardiac output while minimizing heart rate B. Decreasing energy expenditure of the myocardium C. Balancing myocardial oxygen supply with demand D. Increasing the size of the myocardial muscle SIMILAR QUESTION TO THIS -- NOT EXACT

C

The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6° F. What is the best action by the nurse? a. Administer blood transfusion over at least 4 hours. b. Notify the physician of the elevated temperature. c. Titrate rate of blood administration to patient response. d. Notify the physician of the patient's heart rate.

C

The nurse notes that the patient's arterial blood gas levels indicate hypoxemia. The patient is not intubated and has a respiratory rate of 22 breaths/min. what is the nurse's first intervention to relieve hypoxemia? A. Call the physician for an emergency intubation procedure B. Obtain an order for bilevel positive airway pressure (BiPAP). C. Provide for oxygen administration. D. Suction secretions from the oropharynx.

C

The nurse receives report on four clients. Which will the nurse assess first? A. a client post operative day 1 admitted with a ruptured appendix B. a client admitted the previous night with pneumonia on 5 LPM O2 NC and complaining of shortness of breath C. a client admitted with COPD exacerbation and mild shortness of breath on exertion D. a client admitted three days ago with pulmonary embolus on 1 LPM 02 NC

C

What is a key nursing intervention for managing anaphylactic shock? A) Immediate fluid resuscitation B) Administering a sedative C) Administration of epinephrine and maintaining airway D) Cooling the patient

C

Which medication is the first-line treatment for anaphylactic shock? A) Corticosteroids B) Broad-spectrum antibiotics C) Epinephrine D) Atropine

C

While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? a. Have the patient blow the nose until clear. b. Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears

C

he nurse is creating a plan of care for a client with cardiomyopathy. Which goal would be a priority for the client? A. Absence of complications B. Adherence to the self-care program C. Improved cardiac output D. Increased activity tolerance

C

While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? THIS WAS A SATA AND SLIGHTLY DIFFERENT ANSWER OPTIONS, picture of patient a. Have the patient blow the nose until clear. b. Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears. e. Tell the patient to not blow nose

C, E

Which statements are true regarding the symptoms of an AMI? (Select all that apply.) a. Dysrhythmias are not common occurrences. b. Men have more atypical symptoms than women. c. Midsternal chest pain is a common presenting symptom. d. All patients present with symptoms e. Patients may complain of jaw or back pain.

C, E,

A client has a cardiac arrest while visiting his family. Resuscitation measures are initiated while the family is still in the room. What is the best initial action for the nurse to take? A. have the family wait outside the client room with a designated staff member to provide emotional support B. keep the family in the room and assign a member of the team to explain the care given and answer questions C. advise the family members that clients are comforted by having family members presents during resuscitation efforts D. ask the family members whether they would prefer to remain in the client room or wait outside the room

D

A client has just been diagnosed with Parkinson disease and the nurse is planning the client's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the client's family? A. Risk for infection B. Impaired spontaneous ventilation C. Unilateral neglect D. Risk for injury

D

A client is admitted to the ED after becoming lost in the snow and developing hypothermia and frostbite. How will the nurse best manage the client's frostbite? A. gently massage the client's frozen extremities in between water baths B. immediately perform passive range-of-motion exercises to the affected extremities to promote circulation C. immerse affected extremities in room temperature water for 1-2 hours at a time D. Immerse affected extremities in water slightly above normal body temperature

D

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? A. fluid balance B. pain C. anxiety and fear D. airway management

D

A client is scheduled for a skin test. The client informs the nurse that the client used a corticosteroid earlier today to alleviate allergy symptoms. Which nursing intervention should the nurse implement? A. Note the corticosteroid use in the electronic health record and continue with the test B. Modify the skin test to check for grass, mold, or dust allergies only. C. Administer sodium valproate to reverse the effects of corticosteroid usage. D. Cancel and reschedule the skin test when the client stops taking the corticosteroid

D

A client on a medical-surgical floor receiving a levofloxacin suddenly becomes extremely anxious and complains of itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which are the priority nursing actions for this client? A. administer diphenhydramine and epinephrine and continue the infusion B. administer oxygen and diphenhydramine IVP C. slow the rate of infusion and sit the client up in bed D. slop the infusion and call for the rapid response team (RRT)

D

A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? A) Chooses high-protein food B) Has decreased oral discomfort C) Eats 90% of meals and snacks D) Has a weight gain of 1 kg in 2 weeks

D

A client with multiple injuries is brought to the ED by ambulance. The client has an intact airway and has adequate spontaneous respirations. The ED nurse does not see any active bleeding, but will suspect internal hemorrhage based on which assessment finding? A. absence of bruising at contusion sites B. sudden diaphoresis C. increased blood pressure with narrowed pulse pressure D. rapid pulse and decreased capillary refill

D

A hospital prepares to receive large numbers of casualties from a community disaster. The charge nurse is instructed to identify clients appropriate for discharge. Which of the following clients will the charge nurse identify as appropriate for discharge or transfer to another facility.? A. client on a cardiac floor admitted with chest pain an hour ago and awaiting cardiac testing B. Client that is requiring a 50% Venturi mask admitted with pneumonia C. client admitted with urosepsis that day requiring intravenous antibiotic therapy D. client admitted with diabetic ketoacidosis with a closed anion gam and tolerating a diabetic diet

D

A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first? a. Sleepy but arouses to voice b. Dry and cracked oral mucosa c. Pain present in lower back d. Bladder palpated above pubis

D

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

D

A nurse is assessing a client admitted with a heart rate of 120, WBC of 100, and respiratory rate of 28. Which action should the nurse perform first? A) Administer antibiotics. B) Give an antipyretic. C) Place the client in isolation. D) Obtain specified cultures.

D

A nurse is caring for a client who has allergic rhinitis. What intervention would be most likely to help the client meet the goal of improved breathing pattern? A. Teach the client to take deep breaths and cough frequently. B. Use antihistamines daily throughout the year .C. Teach the client to seek medical attention at the first sign of an allergic reaction. D. Modify the environment to reduce the severity of allergic symptoms.

D

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement? a. Apply an ice pack to the clients chest. b. Provide a neck rub, especially on the left side. c. Allow the client to lie in bed with the lights down. d. Sit the client up with a pillow to lean forward on.

D

A nurse is providing care for a client who has a recent diagnosis of giant cell arteritis (GCA). Which aspect of physical assessment should the nurse prioritize? A. Subtle signs of bleeding disorders B. The metatarsal joints and phalangeal joints C. Thoracic pain that is exacerbated by activity D. Headaches and jaw pain

D

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this clients discharge teaching? a. Avoid drinking more than 3 quarts of liquids each day. b. Eat six small meals daily instead of three larger meals. c. When you feel short of breath, take an additional diuretic. d. Weigh yourself daily while wearing the same amount of clothing.

D

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a. The assessed values are within normal limits. b. The patient is at risk for developing cardiogenic shock. c. The patient is at risk for developing fluid volume overload. d. The patient is at risk for developing hypovolemic shock.

D

A patient is prescribed an antiretroviral therapy medication called Bictegravir-emtricitabine-tenofovir-alafenamide. What side effect does the nurse tell the patient to see immediate attention? A. Headache and rash B. Insomnia and diarrhea C. Weird dreams and flatulence D. Jaundice and dark color urine

D

A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. An important nursing intervention for the patient is to A) teach about the importance of nutrition during treatment. B) have the patient eat large meals when nausea is not present. C) offer dry crackers and carbonated fluids during chemotherapy. D) administer prescribed ondansetron 1 hour before the treatments

D

After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. To prevent complications, I will drink at least 2 liters of water daily. b. This medication will stop me from getting an aura before a seizure. c. I will not drive a motor vehicle while taking this medication. d. Even when my seizures stop, I will continue to take this drug.

D

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

D

ED staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members will remove the client's clothing and then perform what action? A. rinse the client with hydrogen peroxide B. wash the client with a dilute bleach solution C. wash the client with chlorhexidine D. wash the client with soap and water

D

On a hot, humid day, an ED nurse is caring for a client who is confused and has these vital signs: temperature 104.1 F (40.1 C), pulse 132 bpm, respirations 26 bpm, BP 106/66. Which of the following will the nurse complete first? A. encourage rest and re-assess in 15 minutes B. encourage the client to drink cool water or sports drinks C. administer acetaminophen 650 mg orally D. start an IV line and infuse 0.9% saline solution

D

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify? A. Absence of infarcts or emboli B. Reduced stroke volume and cardiac output C. Absence of pulmonary and peripheral edema D. Maintenance of adequate mean arterial pressure.

D

The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? a. Assess for the presence of a headache. b. Assess the patient's general orientation. c. Determine the patient's drug allergies. d. Determine the time of symptom onset.

D

The nurse has been administering 0.9% normal saline intravenous fluids in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? (ANSWERS WERE DIFFERENT) a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output (on test it was cap refill and Urine Output)

D

The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping? OPTIONS WERE DIFFERENT A. Help the family understand that the client could have died. B. Emphasize the importance of accepting the client's new limitations. C. Have the members of the family plan the client's inclient care. D. Assist the family in setting appropriate short-term goals.

D

The nurse is caring for a client with a chemical burn injury. What is the priority nursing intervention for the nurse to perform when the client presents to the ED? A. remove all jewelry B. apply saline compresses C. Contact a poison control center for directions on neutralizing agents D. Remove the client's clothes and flush the area with water

D

The nurse is caring for a mechanically ventilated patient and notes the high-pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the patient's oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurse's priority action is to: a. ask the respiratory therapist to get a new ventilator. b. call the rapid response team to assess the patient. c. continue to find the cause of the alarm and fix it. d. manually ventilate the patient while calling for a respiratory therapist

D

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a. Hyperoxygenate during endotracheal suctioning. b. Elevate the patient's head of the bed 30 degrees. c. Apply bilateral heel protectors after repositioning. d. Provide rest periods between nursing interventions.

D

The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a. Stimulate the patient hourly. b. Continue to monitor the patient. c. Elevate the head of the bed. d. Notify the provider immediately.

D

The nurse is caring for a patient with a left radial arterial line and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines? (THIS WAS A SATA) a. Document all waveform values. b. Limit the pressure tubing length. c. Zero reference the system daily. d. Ensure alarm limits are turned on.

D

The patient's heart rate is 165 beats per minute. The cardiac monitor shows a rapid rate with narrow QRS complexes. The P waves cannot be seen, but the rhythm is regular. The patient's blood pressure has dropped from 124/62 mm Hg to 78/30 mm Hg. The patient's skin is cold and diaphoretic, and the patient is complaining of nausea. The nurse prepares the patient for a. administration of beta blockers. b. administration of atropine. c. transcutaneous pacemaker insertion. d. emergent cardioversion.

D

To support family members of clients in critical care staff should encourage? A. limit visitation hours B. discussion of patient status only when there is a decline. C. restrict visitors under the age of 18. D. family presence during rounds

D

What should the nurse suspect when hourly assessment of urine output on a client post craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? A. Cushing syndrome B. Syndrome of inappropriate antidiuretic hormone (SIADH) C. Adrenal crisis D. Diabetes insipidus

D

While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? a. Ensure adequate periods of rest between nursing interventions. b. Insert an oral airway and monitor respiratory rate and depth. c. Maintain neutral head alignment and avoid extreme hip flexion. d. Reduce ambient room temperature and administer antipyretics.

D

While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action? A. Increase supplemental oxygen and notify respiratory therapy. B. Notify the provider immediately of the assessment findings. C. Obtain a stat chest x-ray film to verify proper catheter placement. D. Zero reference and level the catheter at the phlebostatic axis.

D

a victim of a weather-related mass casualty is brought to the ED with a partial amputation of the left lower extremity, a pulse of 128 beats/min, blood pressure of 82/46, and respiratory rate of 32 breaths/min. The nurse assesses shortness of breath and diaphoresis. Which color tag does the nurse use when triaging this client? A. green B. yellow C. black D. red

D

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this clients teaching? (Signs of Digoxin toxicity) a. Avoid taking aspirin or aspirin-containing products. b. Increase your intake of foods that are high in potassium. c. Hold this medication if your pulse rate is below 80 beats/min. d. Blurred vision, Nausea, Vomiting

D on test, it said signs of toxicity -- pt was experiencing nausea and vomiting