ATI med surge 1 (med admin, surgical aspesis, resp)

you are about to open a sterile pack. place the following steps in the proper sequence for opening the sterile pack

-the flap furthest from your body -the side flaps -the flap closest to your body

A nurse is caring for four clients. Which of the following clients is at greatest risk for a pulmonary embolism? A. A pt who is 48 hr post op total hip arthroplasty B. A pt who is 8 hr post op open surgical appendectomy C. A pt who is 2 hr post op open reduction external fixation of the right radius D. A pt who is 4 hours post op following a laprascopy cholecystectomy

A client who is 48 hr post following a total hip arthroplasty Rationale:The nurse should identify that the client who has undergone a total hip replacement is at greatest risk for a PE due to decreased mobility of the affected extremity and an increased amount of blood clots form in the veins of the thigh following hip surgery. DVTs are most likely to occur 48-72 hours following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devises or antiembolic stockings and by administering anticoagulant medications appendectomy risk for peritonitis OREF radius is at risk for neurovascular compromise

A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. which of the following instructions should the nurse include in the teaching. A- Place the patch on an area of skin away from skin folds and joints B- Apply the new patch to the same site as the previous patch C- Replace the patch at the onset of angina D- Keep the patch on 24 hr per day

A- Place the patch on an area of skin away from skin folds and joints (so the patch has enough room to fit smoothly) pt should rotate patch site to prevent irritation and should wear the patch for 12 hrs per day

persisnte cough is an adverse effect of

ACE inhibitors tendonitis is an adverse effect of fluoroquinolone antibiotics

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) Administer IV fluids to the client evenly over 24hours provide the client a salt substitute assess for pitting edema Encourage the client to rise slowly when standing up Weigh the client every 8hours

Administer IV fluids to the client evenly over 24hours Encourage the client to rise slowly when standing up Weigh the client every 8hours

A nurse is assessing a client who has pulmonary edema related to heart failure. which of the following findings indicates effective treatment of the clients condition A- Decreased Respiratory rate at rest B- Absence of adventitious breath sounds C- Presence of nonproductive Cough D- SaO2 86% on room air

B- Absence of Adventitious breath sounds Adventitious breath sounds indicates fluid in the lungs. the absence of them would indicate pulm edema is resolving resp rate usually decreases at rest so it is not an indicator of effectve treatmennt 86% is expected with pulm edema so it is not an indicator of effective treatment

a nurse is caring for a client who has endocarditis. which of the following findings should the nurse recognize as a potentialcomplication A- Guillain- Barre syndrome B- Valvular Disease C- Ventricular Depolarization D- Myelodysplastic syndrome

B- Valvular Disease ventricular depolarization is a normal part of the cardiac cycle Myelodysplastic syndrome is a disorder of the bone marrow

A nurse is caring for a patient who is dyspneic and slightly cyanotic, with a respiratory rate of 28/min. The nurse determines that the patient has impaired gas exchange during which of the following phases of the nursing process? A. Assessment B. Diagnosis C. Planning D. Evaluation

B. diagnosis (during the assessmen the nurse collects data and findings such as dyspnea and cyanosis. during dx the nurse interperts data)

A nurse is caring for a client following insertion of a permanent pacemaker. which of the following client statements indicates a potential complication of the insertion procedure A- I feel dizzy when I stand B- my incision site stings C- I cant get rid of these Hiccups D- I have a headache

C. i cant get rid of these hiccups hiccups can indicate the pacemaker is stimulating the chest wall or diaphragm which can occur as a reult of lead wire perforation

A nurse should recognize that which of the following is an indication for oxygen therapy? A. Respiratory rate 32/min; anxiety B. Dyspnea; PaO2 90 mm Hg C. Chest pain; FiO2 65% for 4 days D. Tachypnea; SaO2 90%

D. Tachypnea; SaO2 90% a pt who is hyperventalting , does not need more o2 does not need more o2 but more co2 which can be obtained rom inhaling7 exhaing into a paperbag . one of the early signs of o2 toxicity is substernal chest pain. more o2 may damage the pts lungs

For which of the following inhalation medication delivery methods is it important for the nurse to assess the patient's ability to inhale deeply before administering the medication? A. Dry powder inhaler (DPI) B. Nasal spray C. Metered dose inhaler (MDI) with attached spacer D. Use of a nebulizer via a mask

Dry powder inhaler (requires a deep inhalation to trigger release of the medication)

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first? Administer hydralazine via IV bolus. Loosen the client's clothing. Empty the client's bladder. Elevate the head of the client's bed.

Elevate the head of the client's bed .These assessment findings indicate the client is at greatest risk for autonomic dysreflexia and possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from a supine to an upright position, which will result in rapid postural hypotension. The nurse should administer hydralazine, a potent vasodilator, to lower the client's blood pressure. The nurse should loosen the client's clothing because body temperature and tactile stimulation are triggers of autonomic dysreflexia. The nurse should empty the client's bladder because a full bladder or a fecal impaction is a trigger of autonomic dysreflexia. However, there is another action the nurse should take first.

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate (conscious) sedation. Which of the following assessment by the nurse is the priority? A. presence of a gag reflex B. pain level using 0-10 scale C. hydration status D. appearance of the IV insertion site

Gag reflex Rationale:The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.

With which route of drug administration are there no barriers to absorption? IV, IM, SQ, PO

Intravenous * The definition of absorption is the movement of a drug from its site of administration into the blood. With intravenous administration, the drug is injected directly into a vein. Thus any possible barriers to absorption are bypassed, and the drug is completely and instantaneously absorbed.

Teaching AP care of client following total hip arthroplasty. Which of the following instructions should be included? A. avoid applying anti embolic stockings to the affected leg B. have the pt lean forward when moving from sitting to standing C. discourge the pt form sitting in a wheelchair with the back reclined D. Place an abductor pillow between the client's legs when turning the client

Place an abductor pillow between the client's legs when turning the client Want to maintain hip in abduction following surgery to reduce risk of dislocating surgical hip.Place abductor pillow between clients legs when turning the client to keep hips in abduction. do not flex the affected hip more than 90 degrees

A nurse is planning care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care? A. schedule respiratory txs following meals B. have pt sit up in a chair for 2 hr periods tid c. Provide a high calorie diet D. combine activities to allow for longer rest periods between activities

Provide a diet that is high in calories and protein. Rationale:The nurse should provide the client who has COPD with a diet that is high in calories and protein and low in carbohydrates resp txs should be before meals

A nurse is assessing a client who has a serum phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect? Hepatic failure Abdominal pain Slow peripheral pulsations Increase in cardiac output

Slow peripheral pulsationsHypophosphatemia causes slow peripheral pulses that are difficult to detect and can eventually result in cardiac muscle damage. nurse should assess for kidney failure not hepatic fx hypophos can cause muscle weakness and rhabdomylosis , not abd pain would expect decreased cardiac output

A nurse is caring for client who is taking albuterol. For which of the following adverse effects should the nurse monitor the client? Hyperkalmia Dyspnea Tachycardia Candidiasis

Tachycardia Rationale:The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis.

A nurse is caring for a client who has bacterial pneumonia. The nurse should expect which of the following assessment findings? Decreased fremitus SaO2 95% RA temp 101.8 bradypnea

Temperature 38.8 C (101.8 F) Rationale:An elevated temperature is an expected finding for a client who has bacterial pneumonia. increased fremitus is an expected finding of a pt with bacterial pneumonia o2 <95 is expected tachypnea is expected

A nurse is monitoring a client ECG monitor and notes the clients rhythm has change from normal signs rhythm to supraventricular tachycardia. the nurse should prepare to assist with which of the following interventions A- Administration of atropine IV B- Vagal Stimulation C- Defibrillation D- Delivery of precordial Thump

Vagal Stimulation (might temporarily put pt back in NSR but have defibrillator ready bc vagal stimulation can cause dysrhythmias) atropine is used for brady dysrrythmia

A nurse is administering a sub q injection to a pt. Which of the following data should the nurse recognize as the highest priority to prevent potential complications? a) Identify the pts level of knowledge about the medication b) Identify if the pt has allergies to the medicaiton c) Identify a specific site for injection d) identify the rationale for the pt receiving the medication

b) Identify if the pt has allergies to the medication

A nurse is providing instructions to a client on how to use montelukast to treat chronic asthma. Which of the following statements indicates the client understands the teaching? A. "I will monitor my HR every day while taking this med." B. "I will make sure I have this med with me at all times." C. "I will need to rinse my mouth after I take this medication." D. "I will take this medication every night even if I don't have symptoms."

d. I will take this medication every evening, even when I do not have symptoms Rationale:Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening

A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium? 1 large hard bpoiled egg 1 cup bran cereal 1/2 cup almonds 1 cup cooked spinach

1 large hard boiled egg

A nurse is caring for a patient who has been prescribed a fluticasone propinate (Flovent HFA) inhaler with a spacer. The patient asks the nurse why a spacer is needed with the inhaler. Which of the following responses by the nurse is correct? A. "By using a spacer, you can take the medication correctly without any spills." B. "You can inhale five or more puffs in 1 min when using a spacer." C. "By using a spacer, you eliminate the need for mouth rinsing after administration." D. "More medication is delivered to the lungs when you use a spacer."

"More medication is delivered to the lungs when you use a spacer."

A patient drinks 8 oz of water. Which of the following is a correct conversion of the patient's intake?

- 240 mL* One fluid oz equals 30 mL; therefore, 8 fluid oz equals 240 mL.

Which of the following is your highest priority action for ensuring overall safety during medication administration?

- Identify the patient by two acceptable methods.* One of the six rights of medication administration is to identify that you are giving the medication to the correct patient. It is required that you check the medication administration record against the patient's identification bracelet, and use a second method of patient identification, such as asking the patient his birth date.

A nurse is caring for a client who has a serum sodium level of 155 mEq/L. Which of the following IV fluid prescriptions should the nurse anticipate administering? D5 in 0.9% sodium chloride dextrose 5% in LR 0.45 sodium chloride 3% sodium chloride

0.45 sodium chloride the nurse should give a hypotonic solutoin D5 in 0.9% sodium chloride is hypertonic dextrose 5% in LR- LR contains sodium 3% Sodium chlorid is hypertonic

A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? -Sodium polystyrene sulfonate 30 g/day -0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr -Bumetanide 8 mg/day -100 mL of dextrose 10% in water with 10 units of insulin

0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr and not to exceed 20 mEq/hr. The dilution should be 1 mEq to 10 mL of 0.9% sodium chloride. Sodium polystyrene, Bumetanide, D10 in water are given for HYPERkalemia

A nurse preparing a sterile field knows that the field has been contaminated when: select all that apply - A cotton ball dampened with sterile normal saline is placed on the field. - A contaminated instrument touches the outer edge of the sterile field - A sterile instrument is dropped onto the near side of the sterile field. -The nurse turns to address the patients questions concerning the procedure. -The procedure is postponed for 30 minutes to accommodate the patient. - A liquid is poured into a sterile container from a distance of 4 inches.

A cotton ball dampened with sterile normal saline is placed on the field -The nurse turns to address the patients questions concerning the procedure. -The procedure is postponed for 30 minutes to accommodate the patient. (a sterile field becomes contaminated when it comes into contact with moisture) (a 1 inch bored around the sterile field is considered contaminated) (a sterile field becomes contaminated when it is out of visual field and when it is exposed to air for long periods) (recommended pouring distance is 4-6 inches)

Administering oxygen therapy with a nonrebreather mask has which of the following advantages? A. Offers the highest oxygen concentration of the low-flow systems B. Provides oxygen concentrations of 40% to 60% C. Incorporates a design that requires minimal monitoring of the patient D. Is designed for safety once the mask's valves and flaps are sealed

A. Offers the highest oxygen concentration of the low-flow systems A nonrebreather mask delivers oxygen concentrations of 60% to 80%. Thus, it provides a higher fraction of inspiredoxygen (FiO2) than a nasal cannula (also low-flow, but delivering about 24% to 44%) or a simple mask (low-flow, but delivering40% to 60%).

A nurse is assisting with a thoracentesis. Which of the following actions is appropriate for the nurse to take when assisting with this procedure? SELECT ALL THAT APPLY A. wear goggles and mask during the procedure B. cleanse the procedure area with antiseptic solution C. instruct the pt to take deep breaths during the procedure D. position the client laterally on the affectged side before the procedure E. apply pressure to the site after the procedure

A. Wear goggles and mask during the procedure B. Cleanse the area with an antiseptic solution C. Apply pressure to the site after the needle is withdrawn the nurse should instruct the pt to remain as still as possible

A nurse receives prescriptions from the provider for performing nasopharyngeal suction on four clients. Which of the follow clients should the nurse clarify the providers prescription? A. pt with epitaxis B. amyotrophic lateral sclerosis C. penumonia D. emphysema

A. epitaxis nurse should avoid nasopharyngeal suction for a pt with nasal bleding

A patient has been receiving oxygen PRN via nasal cannula for 4 hr. Which of the following assessment findings helps indicate that oxygen therapy has been effective? A. Respiratory rate 14/min B. SaO2 90% C. Cardiac output 5.6 L/min D. PaCO2 68 mm Hg

A. resp rate 14 (cardiac output does not provide sufficient information to determine effectiveness of o2 terpay

A nurse is caring for a client who is 72 hour postop following an above the knee amputation and reports phantom limb pain. Which of the following actions should the nurse take remind the pt the surgery removed the limb changethe dressing on the residual limb

Administer an oral dose of gabapentin (dressing change does not address pain) the residual imb should only be elevated above the level of the heart the first 48 hours after surgery , after that time doing so can cause hip contracture

A nurse is caring for a client who has active tuberculosis. Which of the following isolation precautions should the nurse implement? A. Airborne B. Neutropenic C. Contact D. Droplet

Airborne Rationale:The nurse should initiate airborne precautions for the client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure filtered through a high-efficiency particulate air (HEPA) filter. Members of the healthcare team should not enter the client's room without wearing an N95 respirator mask MRSA would need contact precations influenza- droplet

Which of the following should a nurse assess before administering meds through a ng tube A. Amount of residual volume left in the stomach B. correct tube placement by inserting air into tube C. ability of pt to cooperate with instructions D. areas of tympany and dullness by percussion

Amount of residual volume left in the stomach (checking residual volume prevents putting meds into an already full stomach) (checking ph will also determine if the tube is properly placed) (tympany and dullness are used to assess for constiption and trapped gas)

A nurse in the emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? A. Apply supplemental o2 B. increase the rate of IV fluids C. administer pain medication D. initiate cardiac monitoring

Apply supplemental oxygen Rationale:When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen. increasing iv fluids will increase cardiac output but there is another priority

A nurse is caring fora client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the priority for the nurse to use to evaluate the effectiveness of the mechanical ventilation? A. blood pressure B. capillary refill C. ABGs D. heart rate

Arterial blood gases Rationale:When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance bp, capillary refill and hr assess circulation

A nurse in the Ed is assessing a client who has myasthenia graves. The client reports recent increasing muscle weakness and the nurse suspects the client is experiencing a myasthenic crisis. Which of the following actions is the nurses priority: adminsiter artifical tears Assist with tensilon test administer immunosupressants assist with plasmaparesis

Assist with tensilon test (this will determine if the pt is having a myesthenia crisis or a cholenergic crisis) pt pay have dry eyes but there is another action the nurse should take first immunosupressants should be adminsitered plasmaparesis removes antibodies from plasma and reduces manifestations but there is another actoin the nurse should take first

A nurse is assessing a client who has Left-Sided heart failure. which of the following manifestations should the nurse expect to find A- Increased Abdominal Girth B-Weak Peripheral Pulses C- Dependent Edema D- Jugular Venous Neck Distention

B- Weak Peripheral Pulses abdominal girth, dependent edema and jvd is s/s of R sided heart fx

A nurse in an emergency department is caring for a client who had an anterior MI . the clients history reveals she Is 1 week postoperative following an open cholecystectomy . the nurse should recognize that which of the following interventions is contraindicated. A- administering IV Morphine Sulfate B- Assisting with thrombolytic therapy C- administering oxygen at 2 L/min via nasal cannula D-helping the client to the bedside commode

B- assisting with thrombolytic therapy

A nurse is caring for a patient receiving 0.9% sodium chloride (normal saline) at 75 ml/hr through a triple lumen central venous catheter. The pump is alarming that there is an occlusion. Which of the following is the first thing the nurse should do? A. call the provider who inserted the catheter B. flush with 10mL syringe of heparin C. check the line at or above the hub for kinked tubing that is creating a resistance to flow D. reposition the patient

B. check the line at or above the hub for kinked tubing that is creating a resistance to flow

A nurse administers the first dose of a patient's prescribed antibiotic via IV piggyback. During the first 10 to 15 min of administration of the medication, the nurse gives priority to which of the following assessments? A. IV site redness and swelling B. patient for systemic allergic reaction C. IV dressing for signs of leakage D. limb for signs of discomfort

B. patient for systemic allergic reaction

a patient is starting to take amitriptyline. Which of the following should the nurse instruct the patient to monitor and report?(choose all that apply) Blurred Vision Urinary hesistancy Diarrhea Joint pain Tachycardia

Blurred Vision, Urinary hesistancy & tachycardia amitriptyline an antidepressant can cause blurred vision, urinary hesistancy, dry mouth, constipation, sedation and tachycardia it is more likely to cause constipation than diarrhea

A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? inceased urine specific gravity hypoactive bowel sounds bounding peripheral pulses decreased respiration

Bounding peripheral pulsesFluid overload results in increased vascular volume and places a greater workload on the heart. increased urine specific gravity, increased GI motility @ tachypnea indicates dehydration not FVO

A nurse is caring for a client who had an onset of chest pain 24hr ago. the nurse recognize that an increase in which of the following is diagnostic of myocardial infarction (MI) A- C Reactive protein B- Myoglobin C- Creatine Kinase- MB D-Homocysteine

C- Creatine Kinase- MB (is specfic to the myocardium) Homocysteine is alway present in the blood an increased level may be indicate CV disease Myoglobin is elevsted after MI but not spefici to cardiac muscle C Reactive protein incresed with inflammtion but usually RA

A nurse is preparing to administer an intradermal injection. Which of the following should the nurse do to ensure proper technique? a) Rub the injection site after withdrawing the needle b) Pinch 1/2 in of skin and administer the injection at 45 degree angle c) Use a tuberculin syringe with a 3/8-5/8 in, 25- to 27- gauge needle d) choose a site at least 2 in from the umbilicus

C. use a TB syringe with 3/8 needle

A nurse is caring for a pt who is receiving mechanical ventilation when the low pressure alarm sounds. Whoch of the following situations should the nurse recognize as a possible cause of the alarm? A. Excess secretions B. Kinks in tubing C. Artificial airway cuff leak D. Biting on the endotracheal tube

C. Artifical airway cuff leak Artigical airway cuff leak interferes with oxygenation and causes the low pressure alarm to sound excess secretions in the airway cause the high pressure alarm to sound kinks in the tubing can cause obstruction which causes the high pressure alarm to sound biting on the endotracheal tube causes the high pressure alarm to sound

A patient admitted with community-acquired pneumonia has been receiving oxygen therapy for several days. Which of the following assessment findings indicates an adverse effect of oxygen therapy? A. Poor skin turgor B. Copious respiratory secretions C. Cracks in the oral mucosa D. Elevated heart rate

C. Cracks in the oral mucosa (poor skin tugor is s/s of dehydration) (o2 , esp when used long term without sufficent humidifation is extremly drying and can cause cranks in the nasal/oral mucosa)

A nurse is providing discharge teaching to a pt with a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? A. "I should dip a cotton tipped applicator into a full strength hydrogen peroxide to cleanse around my stoma." B. " I should cut a 4 inch gauze dressing and place it around my tracheostomy tube to absorb drainage." C. "I should remove the old twill ties after the new ties are in place." D. "I should apply suction while inserting the catheter into my tracheostomy tube."

C. I should remove the old twill ties after the new ties are in place. As a safety measure the nurse should teach the pt to wait until the new ties are in place to remove the old ties to prevent accidental decannulation. Rationale: Pt should use gauze moistened with NS to cleanse around the stoma, or if prescribed half strength hydrogen peroxide. The pt should use a split gauze trach dressing

A nurse is caring for a critically ill patient with COPD who requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery device is indicated for this patient? A. Simple face mask B. Nasal cannula C. Venturi mask D. Face tent

C. venturi mask (a simple face mask is appriopriate for pts who require moderate flow rate for a short period of time. bc it fits loosely, the o2 concentration varies

A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? deep tendon reflexes bowel sounds cardiac rhythm peripheral sensation

Cardiac rhythm.(ABC approach, 8.1 is below range. Hypocalcemia can cause ECG changes, Brady, Tachy) nuse should assess dtr, parasthesias and bowel sounds for hypermotility(bc hypocalcemia can cause increased parastelsis) but there is another priority

A nurse is caring for a client who has a full arm cast and reports pain of 8 on a scale from 0 to 10 that is unrelieved by pain medication. Which of the following actions should the nurse plan to take first? Administer additional pain medication. Check the circulation of the affected extremity. Document the findings .Reposition the affected extremity.

Check the circulation of the affected extremity. The GREATEST risk to the client is neuromuscular injury resulting from compartment syndrome. The FIRST action the nurse should take is to check for impaired circulation of the affected extremity. The nurse might need to reposition the client's arm to promote venous return and comfort. or The nurse should document the findings to maintain professional standards. or The nurse might need to administer additional pain medication to control the client's pain. However, there is another action the nurse should take first

A nurse is caring for a client in balanced suspension skeletal traction who reports intermittent muscle spasms. Which of the following actions should the nurse take FIRST? Reposition the client.Provide distraction. Administer a muscle relaxant. Check the position of the weights and ropes.

Check the position of the weights and ropes. The first action the nurse should take using the nursing process is to assess the client. The nurse should first check the position of the weights and ropes to determine the cause of the muscle spasms. The weights might be too heavy, or the nurse might need to realign the client.The nurse should reposition the client to realign him and try to relieve his muscle spasms. However, there is another action the nurse should take first. The nurse should administer a muscle relaxant to minimize the client's muscle spasms. However, there is another action the nurse should take first. The nurse should provide sensory stimulation to help the client keep his focus away from the pain of the spasms. However, there is another action the nurse should take first.

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider? Glasgow Coma Scale score of 15 Intracranial pressure reading of 15 mm Hg Ecchymosis at base of skull Clear drainage from nose

Clear drainage from nose Clear drainage from the nose indicates cerebral spinal fluid is leaking from the skull fracture. This places the client at risk for meningeal infection because micro-organisms have access to the cranium through the nose and the tear in the dura.The nurse should report this finding to the provider. A Glasgow Coma Scale score of 15 indicates intact neurologic functioning. An intracranial pressure reading of 15 mm Hg is at the upper limit of the expected reference range. A client who has a basilar skull fracture is likely to have ecchymosis at the base of the skull from a contusion.

A nurse is caring for a client following the insertion of a chest tube following a lobectomy. The nurse should plan to have which of the following items in the clients room? A. extra drainage system B. suture removal set C. container of sterile water D. nonadherent pads

Container of sterile water Rationale:The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected in order to prevent a pneumothorax.

A nurse is assessing a client with a chest tube in place following thoracic surgery. For which of the following findings should the nurse notify the provider? A. Fluctuation of driange in the tubing with inspiration B. Continous bubbling in the water seal chamber C. Drainage of 75mL in the first hour after surgery D. Several small, dark red blood clots in tubing

Continuous bubbling in the water seal chamber. Rationale:Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while she is waiting for instructions from the provider fluctuation of drainage in the tubing with inspiration is an expected finding drainage and small clots are expecting findings

A nurse is providing teaching for a client who is 2 days postoperative following a heart transplant. which of the following statements should the nurse include in the teaching A- " your level of activity intolerance will not change" B- " you will be able to stop taking immunosuppressant's after 12 months C- " after 6 months you will no longer need to restrict your sodium intake" D- "You might no longer be able to feel chest pain"

D- "You might no longer be able to feel chest pain" (Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart) (activty tolerance should improve, pt will permentatly need ot be on low sodium diet and low fat , will have to be on immunosupresants for life after transplant)

A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. the nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer. A- ask if the client has had a recent infection B- Explore the clients family history of peripheral vascular disease C- Note the presence of absence of pain at the ulcer site D- inquire about the presence or absence of claudication

D- Inquire about the presence or absence of claudication (both arterial and peripheral ulcers can cause pain and both have the potential to become infected)

A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. the client is experiencing weakness and an irregular hear rate. which of the following actions should the nurse take first? A- obtain clients current weight B-Determine the time of the last digoxin dose C- Check the clients urine output D- Review serum electrolyte Values

D- Review serum electrolyte Values (weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. the first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias for hypokalemia)

a nurse is assessing a client who has dilated cardiomyopathy. which of the following findings should the nurse expect A-weight loss B- pericardial rub C- tracheal deviation D- dyspnea on exertion

D- dyspnea on exertion (due to ventricular compromised and decreased caridac output) tracheal deviation is r/t pneumothorax pericardial rub is r/t pericarditis would expect wieight gain not loss

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? Decreased muscle strength Decreased gastric motility Increased heart rate Increased blood pressure

Decreased muscle strength Hyperkalemia can cause muscle weakness. The nurse should monitor the client's muscle strength. pt would have increased

An uncommon, unexpected, or individual drug response thought to result from a genetic predisposition is called a

Idiosyncratic effect * An idiosyncratic effect is an uncommon, unexpected, or individual drug response thought to result from a genetic predisposition.

A nurse is assessing a client who has emphysema. The nurse should report which of the following assessment findings? A. Rhonchi on inspiration B. Elevated temperature C. Barrel shape chest D. Diminished breath sounds

Elevated temperature Rationale:The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infection. Rhonchi, barrel chest and diminished breath sounds are expected with a pt with emphysema

Caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take? Assess for hourly spike in BP Keep PT on BR Keep padded tongue blade at bed side Eastblish IV access

Establsih IV access with a large bore cathater and give sodium chloride if seizures are imminent. If pt is stable nurse should administer a saline lock. do not place anything in the pts mouth

A nurse is caring for a client who has a retinal detachment. Which of the following reports about the affected eye should the nurse expect? Photophobia Complete blindness Flashes of bright light Pain

Flashes of bright light During retinal detachment, the client can experience flashes of bright light or floating dark spots in the affected eye as the retinal layers SEPARATE. A retinal detachment does not typically cause photophobia. More likely, clients who have this disorder will report a sensation of a curtain or a shade blocking the vision of one eye. He or she can have some visual field loss in the area of the detachment but should not have complete blindness. Clients who have a retinal detachment should not have pain, because there are NO pain fibers in the retina.

A nurse is positioning a client who has emphysema to promote effective breathing. The nurse should place the client in which of the following positions? A. Lateral position with a pillow at the back and over the chest to support the arm B. high fowlers with the arms supported on the over bed table C. Semi fowlers with pillows supporting both arms D. Supine with the HOB at 15 degrees

High-Fowlers position with arms supported on the overbid table. Rationale:The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the over-bed table.

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? hyperactive DTR increased bowel sounds drowsiness decreased bp

Hyperactive deep-tendon reflexes Hyperactive DTRs are an expected finding for a client who has hypomagnesemia, along with muscle cramps, numbness, and tingling. DEcreased bowel sounds, insomnia, and INcreased bp are all expected findings with hypomagnesia

Reviewing postop instructions following cataract surgery. Which of the following statements should the nurse identify as indication that client understands instructions? I should call my doctor if vision gets worse I should take aspirin for the pain I can blow my nose to clear out any drainage I can life objects up to 20 lbs

I should call my doctor if vision gets worse. (there should be improvement in vision) avoid aspirin bc of bleeding in the eye avoid blowing nose bc could cause ocular pressure avoid lifting can cause increased ocular pressure

teaching a client who has parkinson's disease about taking carbidopa-levodopa.which of the following statements should the nurse identify as an indication that the client understands teaching? I should expect a slight increase in BP while taking this med I should take my med with high protein food I should expect my urine to be a dark color I should expect it to take up to a week for this med to work

I should expect my urine to be a darker color.Saliva, urine, and sweat can darken in color -- a harmless adverse effect. orthostatic hypotension is an adverse affect of carbadoplevopdepa high protein foods can reduce the absorption of carvadoplevodopa i can take several months for the med to take effect

While reviewing a client's laboratory results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take? Implement seizure precautions. Administer phosphate .Initiate diuretic therapy. Prepare the client for hemodialysis.

Implement seizure precautions. The client is at risk for seizures due to low excitation threshold as a result of the client's decreased calcium level. The nurse should initiate seizure precautions to prevent injury. Administer phosphate, diuretics can further decrease the Ca level hemodylasis is used to treat hypercalemia

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect aphasia right side neglect inability to read Impulsive behavior

Impulsive behavior inmability to read associated with left hemispheric stroke aphasia assocaited with left hemispheric stroke

A nurse is caring for a client who is experiencing respiratory distress as a result of acute pulmonary edema. Which of the following actions should the nurse take first? Assist with intubation. Initiate high-flow oxygen therapy. Administer a rapid-acting diuretic. Administer morphine IV.

Initiate high-flow oxygen therapy. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%. if less invasive measures are ineffective the nurse should prepare to assist md with intubatoin the nurse should adminsiter IV bolus diuretic but there is a more important measure to take 1st the nurse should provide cardiac montioring bc PVCs are common with pulm edema but there is a more important action to take 1st

Caring for a client who has multiple sclerosis. Which of the following finds should the nurse expect? Hypoactive DTR ascending paralysis intention tremors increased lacrimation

Intention tremors -- pts with MS are at risk for motor dysfunction, also poor coordination, and loss of balance pts with MS have hyperactive DTRs pts with guillan barre have ascending paralysis increased lacrimation is tearing of the eyes and is expected with myesthania gravsis during a cholenergirc crisis

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider? A Decreased bowel sounds B. o2 sat 92% C. co2 is 24 mEq/L D. Intercostal retractions

Intercostal retractions Rationale:The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS

A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority? -Maintain a PaCO2 of approximately 35 mm Hg. -Provide small doses of fentanyl via IV bolus for pain management .-Monitor body temperature every 1 to 2 hr. -Reposition the client every 2 hr.

Maintain a PaCO2 of approximately 35 mm Hg. The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority action is to maintain the PaCO2 at approximately 35 mm Hg to prevent hypercarbia and subsequent vasodilation effects that lead to increase in intracranial pressure. The nurse should administer opiate pain medications to reduce agitation and restlessness during mechanical ventilation and to manage pain. Fentanyl does not affect vital signs as much as morphine does, so it is a safer choice for this client. The nurse should monitor the client's body temperature because clients who have head injuries commonly develop a fever due to the body's response to the trauma or hypothalamic damage. The nurse should reposition the client at least every 2 hr to help prevent skin breakdown. However, this is not the nurse's priority.

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? -skin turgor -urine output -mental status -weight

Mental status The greatest risk to this client is injury from declining mental status or a fall from worsened dehydration. Therefore, assessing the client's mental status is the priority. these are all assessments of dehydration but mental status is the priorty

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take? neuro assessment q 8 hours initate droplet prescautions check capillary refill q 4 hours place pt in a well lit environment

Monitor capillary refill at least every 4 hours neuro assessment should be checked every 2-4 hours standard precatoins for viral (droplet for bacterial) minimize exposure to light

A nurse is developing a teaching plan for a client who has Ménière's disease. Which of the following instructions should the nurse include? Move head slowly to decrease vertigo. Apply warm packs to the affected ear during acute attacks. Increase intake of foods and fluids high in salt. Administer corticosteroids during acute attacks.

Move head slowly to decrease vertigo.The client should use slow head movements decrease the stimulation of vertigo. Applying warm packs to the affected ear does not relieve the manifestations of Ménière's disease. Helpful interventions include drinking PLENTY of water, decreasing salt intake, and not smoking. PT should avoid consuming foods and fluids that have a HIGH Sodium content because they cause fluid retention, which exacerbates the manifestations of Ménière's disease. Taking corticosteroids will not relieve the manifestations of Ménière's disease and can actually worsen them because these medications cause fluid retention. The client should take an AntiHistamine, such as meclizine, to minimize or stop the attack.

A nurse is caring for a client who is in respiratory distress. Which of the following devises should the nurse use to provide the highest level of oxygen via a low flow system? A. nasal cannula B. nonrebreather mask C. simple face mask D. partial rebreather mask

Nonrebreather mask Rationale:The nurse should use a non-rebreather mask for a client in respiratory distress to provide the highest oxygen level. A non-rebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2 NC provides o2 at concentrations of 24-44% simple face mask delivers o2 at concentrations of 40-60% partial rebreather delivers o2 at concentrations of 60-75%

A nurse in the emergency department is assessing a client who reports sudden, severe eye pain with blurred vision. The provider determines the client has primary angle-closure glaucoma. Which of the following medications should the nurse administer? Osmotic diuretics via IV bolus Mydriatic ophthalmic drops Corticosteroid ophthalmic drops Epinephrine via IV bolus

Osmotic diuretics via IV bolus The nurse should administer osmotic diuretics (such as mannitol) to rapidly reduce intraocular pressure and prevent damage to the eye. Clients who have primary angle-closure glaucoma should not receive mydriatic ophthalmic drops because they cause pupillary dilation. Instead, the nurse should administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor. Corticosteroid ophthalmic drops are used for inflammatory conditions of the eye, such as conjunctivitis. There is no indication for clients who have primary angle-closure glaucoma to receive corticosteroid ophthalmic drops. Instead, the nurse should administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor. Clients who have primary angle-closure glaucoma should not receive epinephrine-containing medications because they cause vasoconstriction. Instead, the nurse should administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor.

A nurse is in the emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect? Arterial pH 7.5 PaCO2 25mmHg SaO2 92% PaO2 58 mmHg

PaO2 58 mm Hg Rationale:The nurse should expect the client who has acute respiratory failure to have lower partial pressures of oxygen resp fx would cause decreased pH due to resp acidosis co2 would rise with acute resp fx

A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding? A. pallor B. insertion site pain C. persistent cough D. temp 99.1

Persistent cough Rationale: Use ABC approach, the priority finding is persistent cough because this indicates a tension pneumothorax, which is a medical emergency

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding? Sodium 152 mEq/L Chloride 102 mEq/L Magnesium 1.8 mEq/L Potassium 6.1 mg/L

Potassium 6.1 mg/L Hyperkalemia can cause a prolonged PR interval; a wide QRS complex; flat or absent P waves; and tall, peaked T waves. Sodium 152 mEq/L is abnomrla but could not affect PR interval but it can cause cerebral dysfunction chloride is normal Mg is normal

A nurse is caring for a client who has COPD. Which of the following findings should the nurse report to the provider? A. Increased anterior-posterior chest diameter B. Productive cough with green sputum C. Clubbing of the fingers D. Pursed-lip breathing with excretion

Productive cough with green sputum Rationale:When using the urgent vs non-urgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection. Increased chest diametes (barrel chest) is an expected nonurgent finding Clubbing and pursed lip breating with excretion is an expected finding

A nurse in the emergency department is caring for a client after suddenly losing consciousness and falling in her home. The provider determines the client had an embolic stroke. Which of the following medications should the nurse administer? Recombinant tissue plasminogen activator Recombinant factor VIII Nitroglycerin Lidocaine

Recombinant tissue plasminogen activator Recombinant tissue plasminogen activator is a thrombolytic administered to DISSOlve the blood clot that caused the stroke. Recombinant factor VIII helps manage the manifestations of hemophilia. Nitroglycerin is a coronary and venous vasodilator that treats angina. Lidocaine is an antidysrhythmic agent that treats ventricular dysrhythmias.

A nurse is providing teaching for a client who is prescribed alendronate for osteoporosis. Which of the following information should the nurse include in the teaching? Take this medication with 240 mL (8 oz) of milk. Remain upright for 30 min after taking this medication. Expect this medication to increase serum calcium levels. Increase vitamin D intake to promote medication absorption.

Remain UPright for 30 min after taking this med .To prevent Esophagitis or Esophageal ulcers that can result from alendronate therapy, the client should sit up for 30 min after taking this medication and remain sitting until after eating the first meal of the day. instruct the client to take alendronate with 240 mL (8 oz) of WATER, not milk. Foods or beverages containing calcium can reduce medication absorption. Vitamin C intake does not increase alendronate absorption and some sources, such as orange juice, decrease absorption. However, the nurse should encourage the client to take Vitamin D, which promotes calcium absorption. Alendronate does not cause insomnia. Headache is a common adverse effect of alendronate.

A nurse is caring for a client who is recovering from a stroke and has right sided homonymous hemianopsia. To help the client adapt, the nurse should take which of the following actions: check pts cheek after he eats to be sure no food remains there Remind the client to look consciously at both sides of his meal tray encourage pt to sit upright and head tilted forward during meals provide pt with utensils that have large handels

Remind the client to look consciously at both sides of his meal tray. (pt with homonymous hemianopsia have lost visual fields of right eyes and may not be able to see all the food on the plate) homonymous hemianopsia does not cause the pt to pocket food, does not cause dysphasia and does not impair fine motor skills

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mm Hg, PaCO2 56 mm Hg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances? respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis

Respiratory acidosis Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis.

assessing a client who has a head injury following a motor-vehicle crash. the nurse should identify that which of the following findings indicates increasing intracranial pressure? restlessness fever hypotension dizziness

Restlessness. behavioral changes such as restlessness and irritability are early manifestations (dizziness oculd be present after head trama but it is not a s/s of increased icp) hypotension would be present in shock but not with increased ICP cushings triad (HTN, bradycardia, widening pulse pressure) is a late manifestation of increased ICP

Planning to teach client who has epilepsy and is to start phenytoin. Which of the following instructions should the nurse include in the med teaching plan? A. rinse with antiseptic mouth wash in place of using dental floss B. use OTC antihistamine if rash develops C. slower taper the med after 6 months of no seizure activity D.Take meds at a consistent time each day to maintain therapeutic blood levels and achieve maximum effect.

Take meds at a consistent time each day to maintain therapeutic blood levels and achieve maximum effect. phentynonin can cause gingerval hyperplasia so the pt should floss and brush after each meal an adverse effect of penytonin is measles like rash and should be reported to the provider immediately pt should not stop taking med

A nurse is discharging a client who has pulmonary tuberculosis and is to start therapy with rifampin. The nurse should plan to include which of the following in the clients discharge teaching plan? A. "Ringing in the ears is an adverse effect of this medication." B. "Have your skin test repeated in 4 months to show a positive result." C. "expect your urine and other secretions to be orang while taking this medication." D. "Remember to take this medication with a sip of water just before your first bite of each meal."

Urine and other secretions will be orange Rationale:The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur including jaundice, fatigue or malaise

A nurse is caring for a postoperative client 1 hr following an aortic aneurysm repair. which of the following findings can indicate shock and should be reported to the provider A- urine output of 20ml/hr B- Severe pain with coughing C- Serosanguineous drainage on dressing D- increase in temperature from 98.2 to 99.5

Urine output of 20ml/hr (urine output of <30 is an manifestation of shock, urine output is decreased due to decreased blood flow to the kidneys)

A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse take? A. Use clean technique when suctioning the clients endotracheal tube B. Use a rotating motion when removing the suction catheter C. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube D. Suction the pts endotracheal tube q 2 hours

Use a rotating motion to remove the suction catheter Rationale:The nurse should rotate the suction catheter during withdrawal to reduce the risk of tissue trauma. the nurse should use sterile technique when performing ET suction (not clean technique) the nurse should suction the sterile ET tube prior to suctioning the nonsterile oropharyngeal cavity the nurse should suction the ET tube only prn (not q 2) because routine suction can cause hypoxia, tissue damage, bronchospasm

A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect?

a pt with FVE would expect can have HCT that is low a pt with dehydratoin would expected an elevated HGB FVE would cause BUN increase FVE would cause decrease in specific gravity

A nurse is preparing to administer an insulin injection to a pt. Which of the following is appropriate? a) Rotate injection sites to avoid tissue injury b) Administer no more than 2 mL per injection c) Use the nondominant hand to displace the skin and subq tissue at the site about 1-1 1/2 in d) Inject the medication after aspirating the syringe

a) rotate Rotating prevents damage from repeated injection sites at the same site

Oxygen therapy is prescribed for a patient who is brought to an emergency department in the early stages of hypoxia. When assessing the patient, the nurse should expect to find which of the following clinical indicators? A. Elevated blood pressure B. Decreased respiratory rate C. Cyanosis D. Peripheral edema

a. elevated bp (in EARLY stages, HTN is common (unless r/t shock) (decreased resp rate occurs in later stages of hypoxia) (cyanosis occurs in late stages of hypoxia) (peripherial edema is a s/s of chronic hypoxia)

A nurse is about to administer an intravenous medication directly into the vein. The nurse should understand that a disadvantage of parenterally administered medications is that they:

are irreversible

Which of the following terms indicates a medication is given by injection? a) enteral b) sublingual c) transdermal d) pareneteral

d. parenteral

A nurse in an emergency room is assessing a client who has bradydysrhythmia. which of the following findings should the nurse monitor for? A- Friction Rub B- Confusion C-Dry Skin D-Hypertension

b. confusion (brady dysrhythmia can cause decreased cardiac output causing confusion) (would have disphoresis not dry skin, would have hypotension not hyper)

A home health nurse is instructing a patient who has just started receiving oxygen therapy via mask. The nurse should emphasize that the patient must A. clean the mask with soapy water every other day B. reposition the elastic band frequently C. apply petroleum jelly around and inside the nares D. make sure there is adequate condensation in the tubing.

b. reposition the elastic band frequently

nurse is caring for a patient who has a tracheostomy. Which of the following must the nurse use when administering oxygen to this patient? A. Distilled water for humidification B. A tracheostomy collar C. An inner tracheostomy cannula D. An aerosol mask

b. trach collar (sterile water , not distilled, is used for humidifation) (a tach collar is desinged to provide humidity

A nurse is preparing to give an intramuscular injection into the left ventrogluteal muscle. Which of the following should the nurse do to locate the appropriate site? a) Measure two fingerbreadths below the acromion process b) Measure a handbreadth above the knee and a handbreadth below the greater trochanter c) With the heel of the hand on the greater trochanter, point the index finger up toward the anterior superior iliac spine, extending the other fingers back against the iliac crest. d) divide the buttock into four quadrants and give the injection in the upper, outer quadrant

c) With the heel of the hand on the greater trochanter, point the index finger up toward the anterior superior iliac spine, extending the other fingers back against the iliac crest.

The nurse is assessing a client with new diagnosis of osteoarthritis. which of the following findings should the nurse expect? SATA crepitus with joint movement decreased ROM low grade temp spongy tissue over joints joint pain the resolves with rest

crepitus with joint movement (a grating sound) due to loosened bone and cartilage moving around in fluid inside the joint. decreased range of motion of the affected joint because pain limits movement .joint pain that resolves with rest and increased pain with activity.\ spongy tissue is associated with RA

A patient is to receive his daily isoniazid (INH) dosage for tuberculosis. He states he is feeling nauseated with this medication and refuses to take it. The nurse knows that the correct way to indicate this refusal is to: A. document the reason for refusal along with the date and time in the patient's medical record. B. circle the scheduled time of medication administration on the medication record. C. initial the scheduled time of medication administration on the medication record. D. notify the primary care provider that the patient refused to take the medication.

document the reason for refusal along with the date and time in the patient's medical record

A nurse in an emergency department s caring for a client who has a blood pressure of 254/139 mm hg. the nurse recognizes that the client is in a hypertensive crisis. which of the following actions should the nurse take first. A- tell the client to report vision changes B- elevate the head of the clients bed C- Start a peripheral IV D- Initiate Seizure precautions

elevate HOB. the pt is at risk for tissue injury . nurse should elevate HOb to reduce bp and promote oxygenation

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? PaO2 PaCo2 Sodium Bicarbonate

expected decreased PaCo2 in a pt with resp alkalosis due to hyperventalation PaO2, Soidum and Bicarbonate should be in expected range with resp alkalosis

A nurse will be administering several medications to a patient who is receiving enteral feedings through a small bore nasogastric tube. The nurse administers the medications correctly by: A. adding crushed medications to the enteral tube feedings and infusing via an electronic pump. B. infusing each medication by gravity and flushing with water before and after instillation. C. administering medications through a large bulb syringe. D. lowering the syringe to promote instillation of medication.

infusing each medication by gravity and flushing with water before and after instillation.

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority? -Provide for frequent rest periods throughout the day. -Medicate for pain on a regular schedule. -Monitor pulse oximetry findings. -Administer baclofen for spasticity.

monitor pulse oximetry findings. The greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles. Therefore, the priority intervention is to monitor o2 sat to identify respiratory compromise as soon as possible. The nurse should provide for frequent rest periods throughout the day because the client's fatigue will increase as the disease progresses. The nurse should administer pain medication on a regular schedule to keep the client's pain level under control. The nurse should give baclofen to manage spasticity that can interfere with self-care. However, this is not the priority intervention.

A nurse is planning care for a client who has a serum potassium level of 3.0mEq/L. The nurse should plan to monitor the client for which of the following findings? hyperactive dtr orthostatic hypotension rapid depp respiration strong bound pulse

orthostatis hypotenson is a manifestation of hypokalemia

A nurse is caring for a client who is 4 hr postoperative following a total laryngectomy for laryngeal cancer. Which of the following assessments is the priority? A. bleeding at the surgical site B. decreased o2 saturation C. urinary retention D. increased pain level

oxygen saturation Using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia due to airway obstruction

A nurse is caring for a patient who is postoperative and has a respiratory rate of 9 secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis? A. ph 7.5, PO2 95 mmHg, PaCo2 25mm Hg, HCO 22 mEq B. ph 7.5, PO2 87 mmHg, PaCo2 35 mmhg, HCO 30 mEq C. ph 7.3, PO2 90mmHg, PaCO2 35 mmHg, HCO3 20 mEq D. ph 7.3, PO2 80mmHg, PaCO2 55 mmHg, HCO 22 mEq

pH 7.30, PO2 80mm Hg, PaCO2 55mm Hg, HCO3 22mEq/L Rationale:These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis. A. indicates respiratory alkalosis B. indicates metabolic alkalosis B. indicates metabolic acidosis

A nurse is caring for a client who requires nasogastric suctioning. Which of the following set of laboratory results indicates that the client has metabolic alkalosis? pH 7.51, Pa02 94 mm Hg, PaC02 36 mm Hg, HCO3- 31 mEq/L pH 7.48, Pa02 89mm Hg, PaC02 30 mm Hg, HCO3- 26mEq/L pH 7.31, Pa02 77mm Hg, PaC02 52mm Hg, HCO3- 23 mEq/L pH 7.26, Pa02 84 mm Hg, PaC02 38 mm Hg, HCO3- 20mEq/L

pH 7.51, Pa02 94 mm Hg, PaC02 36 mm Hg, HCO3- 31 mEq/L An elevated pH and HCO3- with a PaCO2 within the expected reference range indicates metabolic alkalosis. HCO3 is elevated in metabolic alkalosis

during an assessment of a patient taking chlorproamazine , the provider notes shuffling gait, rigid facial expression, and fine tremor. the provider recgonizes this as which of the following? acute dystonia tardive dyskinesia parkinsons akathisia

parksinsons is an adverse affect of antipsychotics acute dystoniais muscle spasm of the face and neck tardive dyskinesia is involuntary smaking of lips/tongue akathisia is constant uncontrolled movement

prior to entering the surgical scrub area, which of the following personal protective equipment (PPE) items do the team members don? (select all that apply) gown-protective eyewear-shoe cover-hair cover-mask

protective eyewear shoe cover hair cover mask not gown bc gown is considered sterile and not donned unless sterile procedure is being performed

A nurse is assessing a patient receiving IV normal saline at 125 ml/hr. Which of the following should the nurse recognize as a possible complication related to the intravenous therapy? A. petechiae B. skin is cool over IV site C. pt reports cough & SOB D. pts BP lower than usual

pt reports cough and sob (indicated fvo) (the iv site is usually cool as th fluids you are flushing with are cooler than body temp)

A nurse is caring for client who is receiving heparin therapy and develops hematuria. which of the following actions should the nurse take if the clients aPTT is 96 seconds A- Request a Prothrombin time (PT) B- Stop the heparin infusion C- Continue to monitor the heparin infusion as prescribed D- Increase the heparin infusion flow rate by 2ml/h

stop the drip. 96 is critial lab value

A nurse is caring for a client who has spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition valsalva maneuver crede maneuver administer a diuretic

stroke the clients inner thigh (other manuvers include pinching the skin above the groin and providing digital and anal stimulation) valsalva manuver is whe na pt hwoles their breath and bears down. this is perform to express urine from a flaccid bladder and is not effective with spastic bladder ddue to the spasticity of the externa spinchter crede manuver is applying direct pressure over the pts bladderto express urine from a flaccid bladder, it is not effective with a spastic bladder due to the spasticity of the externa spinchter antispasmaotics would be effective not diuretics

A nurse is caring for a patient who is recieving D5W with 20 mEq of KCL at 75 ml/hr. The provider has prescribed 1 g ceftriaxone (Rocephin) IV. When preparing to administer this medication by IV piggyback, which of the following data is the highest priority for the nurse to collect? A. vital signs B. LOC C. the medication's compatibility with the primary IV solution. D. amt of solution n the primary bag

the medication's compatibility with the primary IV solution.

A nurse is working in the emergency department is caring for a client following a chest trauma. Which of the following findings indicates a tension pneumothorax? A. Collapsed neck veins on the affected side B. Collapsed neck veins on the unaffected side C. Tracheal deviation to the affected side D. Tracheal deviation to the unaffected side

tracheal deviation to the unaffected side. Rationale:The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side pt will not have collapsed neck veins. distended neck veins are an expected finding

PICC line

using a syringe <10mL to flush causes pressure and the picc line to ruptre no syringe smaller than 10ml should be used to flush or introduce meds into a picc line

A nurse is providing discharge teaching for a client who has a heart failure. the nurse should instruct the client to report which of the following findings immediately to the provider A- increase of 10 mm/hg in systolic blood pressure B- dizziness when rising quickly C- weight gain of 0.9KG or 2lb in 24 hr D- dyspnea with exertion

weight gain of 2 lbs (indicated fluid retention)

while waiting for a sterile procedure to begin, how do you position your hands and arms

with hands clasped together infront of your body at waist level