complex exam 2

A nurse is preparing to administer medications to a patient with increased intracranial pressure. Which of the following medications would be expected? Select all that apply

Mannitol 3% saline dexamethasone

A nurse is caring for a client experiencing Cushing's triad following a subdural hematoma. Which manifestation should a nurse prepare to administer to decrease cerebral edema?

Mannitol 25%

The nurse is preparing a client for placement of a catheter for arterial pressure monitoring. What is the best way for the nurse to assess ulnar circulation prior to catheter insertion?

Occlude the radial artery.

The nurse is caring for a newly admitted client diagnosed with acute kidney injury. The nurse understands that the acute kidney injury is Most likely related to a history of which condition?

Sepsis

The nurse anticipates that a client with which type of shock would be most likely to develop systemic inflammatory response syndrome (SIRS)?

Septic shock

A nurse in the emergency department is caring for a client injured in a motor vehicle accident. The client reports dyspnea and severe pain. The nurse notes that the clients chest moves inward during inspiration and bulges out during expiration. How does the nurse interpret these findings?

flail chest -the affected (flail) area moves in the opposite direction with respect to the intact part of the chest. During inspiration, the affected part is sucked in, and during expiration, it bulges out. This paradoxical chest movement prevents adequate ventilation and increases the work of breathing.

A nurse is reviewing information with a client about the risk factors associated with heart failure. What information does the nurse provide to the client?

heart attack can increase the risk of developing heart failure.

A nurse in an emergency department is caring for a client that had a seizure and became unresponsive after stating she had sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure 198/110 mmHg, pulse 82/min, respirations of 24/min, and a temperature of 38.2 C(100.8 F) which of the following neurologic disorders should the nurse suspect?

hemorrhagic stroke

A nurse is reviewing the laboratory test results from a client with prerenal kidney injury(AKI). Which of the following electrolyte imbalances should the nurse expect?

hyperkalemia

following an earthquake, a client rescued from a collapsed building is seen in the emergency department. has a blunt trauma to the thorax and abdomen. which nursing observation most suggest the client is bleeding?

hypotension

A client with acute renal failure is undergoing dialysis for the first time. The nurse monitors the client closely for dialysis disequilibrium syndrome. A complication that's most common during the first few dialysis sessions. Typically, dialysis disequilibrium syndrome causes:

hypotension, tachycardia, and tachypnea

Intrarenal

include conditions that cause direct damage to the kidney tissue, resulting in impaired nephron function. -Acute tubular necrosis (ATN) is the most common intrarenal cause of AKI in hospitalized patients.

A nurse is assessing a client following a craniotomy. Which assessment finding requires immediate action by the nurse?

intracranial pressure (ICP) 18 mm Hg

Herniation

occurs as the brain tissue is forcibly shifted from the compartment of greater pressure to a compartment of lesser pressure.

is caused by air entering the pleural cavity.

pneumothorax

A nurse is providing instructions to a client scheduled for a computed tomography (CT) scan of the head with contrast. Which statement by the client indicates a need for further instructions?

"I can take my mornings dose of metformin the day of the CT scan."

Which statement by the client is most important for the nurse to communicate to the physical therapist when planning discharge care for a client who is recovering from an acute myocardial infarction?

"I used to be active when I was younger, but now I just get so weak."

The nurse is caring for a client with hypovolemic shock. The family member asks why the fluids are being warmed. What is theBest response by the nurse?

"to prevent complications from hypothermia"

A client comes to the emergency department (ED) with diaphoresis, nausea, and shoulder pain. What assessment data should the nurse obtain first ?

12-lead ECG

A nursing instructor is preparing a lecture on cerebral perfusion for a group of nursing students. The nursing instructor relates which cerebral perfusion pressure (CPP) result is needed to prevent inadequate cerebral oxygenation?

70 mm Hg

A nurse is caring for a client with an epidural hematoma. Which of the following manifestations should the nurse expect?

A lucid period followed by an immediate loss of consciousness.

A nurse in a long-term care facility is caring for an older adult client who had a brain injury four weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

A redded area over the sacrum

A nurse is caring for a client with a central venous catheter (CVC) in the left subclavian vein. Which assessment finding requires immediate action by the nurse?

Absent breath sounds on left side

A nurse notes increasing edema in the calf of a client with multiple fractures of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications?

Acute compartment syndrome

A client diagnosed with supraventricular tachycardia (SVT) has a heart rate of 140 beats per minute, and a blood pressure of 98/50 mm Hg. Which priority intervention should the nurse implement?

Administer Adenosine 6 mg IV push ?

A client arrives to the emergency room following a fall with a neck injury. A cervical collar is in place and adequate oxygenation is observed. BP 80/40, HR 30, RR 16. Which action would the nurse determine is the first priority?

Administer Atropine

A nurse in the emergency department is assessing a newly admitted client who has facial trauma. Which of the following assessments is the nurse's priority?

Altered respirations

A nurse on the medical surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

An older adult client who is confused and has urinary frequency

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse?

Ankle -picture

A nurse is caring for a client who has just experienced a 90 second tonic, colonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mmHg, PaCO2 60mmHG, and HCO3-22 mEq/L. What action will the nurse take first?

Applying oxygen by mask or nasal cannula

Which action should the nurse take to prevent complications in a client with arterial pressure monitoring?

Assess extremity every 2 hours

The nurse is caring for a client with a newly inserted pulmonary artery (PA) catheter. Which nursing interventions are appropriate? Select all that apply

Assess the site for signs and symptoms of infection level the transducer to the phlebostatic axis add multiple stockcocks

When providing care for an older adult who has undergone cardiac catheterization and angiography, which action is most important for the nurse to implement?

Bedrest with the head-of-bed elevation no higher than 30 degrees

The nurse is evaluating a client who is being treated for shock. Which findings indicates an improvement in the client's condition?

Blood pressure 120/70 Bun of 12 mg/dL

A nurse is caring for a client with autonomic dysreflexia. The nurse should monitor the client for which condition?

Bradycardia

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?

Brief loss of consciousness

The nurse is caring for a client in hypovolemic shock. The nurse should anticipate which central venous pressure (CVP) reading for this client?

CVP reading of 1 mmHg

Which nursing care responsibility is most important for a client immediately after a craniotomy?

Check the dressing for yellow-brown drainage and change prn.

A nurse received shift report on multiple clients in the emergency room. Which client should the nurse assess first?

Client complaining of sudden "sharp" and "worst ever" upper back pain

A clinic nurse is assessing a client with a history of a myocardial infarction for an annual health visit. What assessment data would the nurse follow up on in regards to the possibility of heart failure?

Client states they get short of breath walking to their mailbox

The nurse is caring for four clients with a traumatic brain injuries. Which client would the nurse assess first?

Client who has a temperature of 102°

A client with shock has been upgraded to critically ill. What information should be discussed with the family?

Client's wishes Cultural preferences Presence of a living will Usual coping strategies Life sustaining therapies

A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?

Continuous bubbling in the water seal chamber

The nurse is evaluating a client who is being treated for shock. When evaluating a client being treated for shock, what finding indicated an improvement in the client's condition?

Creatinine 2.6mg/dL that's too high -normal level is: 0.6 to 1.6mg/dL

A nurse is performing a neurological assessment for a client who has had head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Instruct the client to look up and down without moving his head

A nurse is assessing a client with chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?

Daily Weight

The nurse is teaching a client about the clinical manifestations of increased fluid retention secondary to heart disease. Which clinical manifestation(s) require the client to contact the healthcare provider?

Decrease in urine output. Bilateral pitting pedal edema. Noticeable shortness of breath

A nurse is caring for a client with ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?

Defibrillation

A client is admitted to the intensive care unit with supraventricular tachycardia (SVT) at a rate of 200 beats per minute (bpm). Which assessment finding(s) would the nurse expect to see with the client? (Select all that apply)

Dyspnea, Decreased mental status, hypotension, increased urine output

The nurse is monitoring a client on hemodialysis. The nurse understands that which lab value has the highest potential to be abnormal and cause complications as a result of fluid imbalance?

Electrolytes

Nurse is performing a neurological assessment on a client following head trauma. Which test will give the nurse information about the function of cranial nerve III?

Instruct the client to look up and down without moving his head.

A client with Meniere's disease is having an attack of vertigo. Which nursing intervention is the priority?

Instruct the client to remain in bed

A client is diagnosed with pyelonephris. Which nursing acon is a priority for care now?

Ensure sucient hydraon.

A client is in the clinic for a follow up visit after a moderate traumatic brain injury. The client spouse is very frustrated, stating that the client's personality has changed, and the situation is intolerable. What action by the nurse is best?

Explain that personality changes are common following brain injuries.

A nurse is caring for a client with polycystic kidney disease (PKD). Which of the following findings should the nurse expect?

Flank Pain

The nurse is rounding on clients at the beginning of the shift. Which observation requires immediate action when caring for a client with a percutaneous catheter for dialysis?

Gauze dressing over insertion site

A nurse is caring for a client starting to take cyclosporine following a kidney transplant. The nurse should instruct the client that which of the following foods can have an adverse interaction with this medication?

Grapefruit Juice

A client with a paraplegic resulting from T9 spinal cord injury has a neurologic reflexic bladder. Which action should the nurse include in the plan of care?

Instruct the client how to self-catheterize.

A nurse is evaluating the central venous pressure (CVP) of client who has sustained multiple traumas. Which of the following interpretations of a low cvp pressure should the nurse make?

Hypovolemia

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?

Implement a schedule to include periods of rest

The nurse is caring for a client with shock who is receiving dobutamine. To evaluate the effectiveness of dobutamine, the nurse should assess for what outcome?

Increased heart rate

When caring for a client with pleural chest tube following a coronary artery bypass graft, what assessment finding would require further assessment?

Increased output

Which nursing assessment finding in an elderly client with sepsis requires immediate intervention?

Increasing oxygen requirements

The nurse is caring for a client diagnosed with kidney failure who is undergoing hemodialysis. The nurse is aware the client is at risk for complications. Which complications should the nurse be aware of when caring for this client?

Infection Hypertension Hypervolemia

A nurse Is caring for a client 4 hrs. Following a craniectomy for an evacuation of a subdural hematoma. Which of the following assessments should be the nurse's priority?

Intracranial pressure (ICP)

A client with a central line catheter has an increase in central venous pressure (CVP). Which additional assessment findings would indicate to the nurse that the client is developing cardiogenic shock?

Jugular venous distention

A nurse is caring for a client in the intensive care unit (ICU) who sustained a traumatic brain injury following a motor vehicle crash. The client has increased intracranial pressure. When positioning the client, which action has the highest priority?

Keep the head alignment to prevent blockage of cerebral spinal fluid (CSF) flow.

When planning care for a client with a history of coronary artery disease, which assessment finding(s) would the nurse beMost concerned about?

Last dose of nitroglycerin tablet Location of new onset pain Quality of pain

The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which diet would be most appropriate?

Low Protein, Low sodium, Low potassium

A nurse is caring for a client who is in buck's traction. Which of the following actions should the nurse take? (Select all that apply)

Monitor peripheral pulses in the affected extremity, assess the temperature of the affected extremity, examine the skin under the traction splint

A nurse is caring for a client with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action?

Numbness and tingling in the left hand

After the insertion of a mediastinal chest tube. Which action is most important for the nurse to implement?

Observe the color and consistency of fluid in the drainage system.

The nurse is caring for a client with cardiogenic shock. Which clinical manifestation indicates the client has progressed to multiple organ dysfunction syndrome (MODS)?

Petechia

A nurse enters the room of a client experiencing a seizure. What is the nurse's priority action?

Position the client on their side.

Postrenal

Postrenal causes of AKI involve mechanical obstruction in the outflow of urine. With the flow of urine obstructed, urine refluxes into the renal pelvis, impairing kidney function. The most common postrenal causes are benign prostatic hyperplasia (BPH), prostate cancer, stones, trauma, and extrarenal tumors.

Client is admitted with a massive gastrointestinal bleed. The nurse should monitor the client for what type of acute kidney injury?

Prerenal -causes of AKI are factors that reduce systemic circulation, causing a reduction in renal blood flow. The decrease in blood flow leads to decreased glomerular perfusion and filtration of the kidneys.

After the initial phase of the burn injury. What goals should the nurse establish with the client?

Preventing Infection

A client, that's a sustained a spinal cord at the C4 level one week ago. Is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?

Provide oral care per protocol.

Which of the following nursing action can prevent airway obstruction in the postoperative client who is unconscious?

Put the client and a side-laying position.

When developing the plan of care for an older adult client with acute kidney injury, the nurse understands that it is essential to consider which factor in the client's history?

Recent use of antibiotics

The nurse is assessing a client during hemodialysis. Which finding should the nurse report to the health care provider immediately ?

Redness at insertion site

What is the priority nursing intervention for a client and a neural surgical ICU, who is experiencing anxiety and sensory overload caused by being in the ICU environment?

Reduce unnecessary alarms and overhead paging.

One of the roles of the nurse in caring for clients with chronic renal failure is to help them learn to minimize and manage potential complications this would include:

Restricting sources of potassium

The nurse is caring for a client with coronary artery disease (CAD). Which long term outcome is most important for the nurse to consider?

Risk factor modification.

In addition to ambulation, which nursing intervention could be implemented to prevent what tree at the postoperative complication of syncope?

Slow progress to ambulation with slow changes in position

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

Stridor

occurs when air enters the pleural space but cannot escape.

Tension pneumothorax -may result from either an open or a closed pneumothorax. -manifestations include severe dyspnea, marked tachycardia, tracheal deviation, decreased or absent breath sounds on the affected side, neck vein distention, cyanosis, and profuse diaphoresis.

A client with diabetes mellitus is scheduled for an cholecystectomy. Which information is important to obtain before the procedure to prevent acute kidney injury?

Urinary output Use of NSAIDS Use of diuretics Mean arterial pressure Trough levels of aminoglycosides

A nurse is caring for a client on a cardiac unit and is interpreting the cardiac rhythm below. How should the nurse document the interpretation of the rhythm?

Ventricular Fibrillation

A nurse is caring for a client with a mild traumatic brain injury (TBI). Which selected manifestations should the nurse immediately report to the healthcare provider?

a decrease in the Glasgow coma scale score from 13 to 11

Common causes of increased ICP

a mass (hematoma, contusion, abscess, tumor) and cerebral edema (from brain tumors, hydrocephalus, head injury, brain inflammation).

Interstitial cerebral edema

a result of hydrocephalus. Hydrocephalus is a buildup of fluid in the brain. It is manifested by ventricular enlargement. It can be due to excess CSF production, obstruction of flow, or an inability to reabsorb the CSF.

a nurse in the emergency department is caring for a client with a 30% burn injury to the lower extremities. which of the following interventions should the nurse perform first?

administer iv fluids

which condition is a postrenal cause of acute kidney injury?

benign prostatic hyperplasia (BPH)

a 19 year old women is brought to the emergency department with a knife handle protruding from her abdomen. what should the nurse do during the initial assessment of the client?

check for circulation and tissue perfusion

a client with a blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. if the lavage returns brown fecal drainage, which action will the nurse plan to take next?

prepare the client for surgery

Cytotoxic cerebral edema

results from disruption of the integrity of the cell membranes. It develops from destructive lesions or trauma to brain tissue, resulting in cerebral hypoxia or anoxia and syndrome of inappropriate antidiuretic hormone (SIADH) secretion. In this type of edema, the blood-brain barrier stays intact.

The emergency department nurse admits a client who presents with penetrating abdominal trauma. on exam, the client is agitated, disorientated, and cannot remember how they got to the hospital. what is the priority action by the nurse?

stabilize the penetrating object

Vasogenic Cerebral Edema

the most common type of cerebral edema, occurs mainly in the white matter. It is characterized by leakage of large molecules from the capillaries into the surrounding extracellular space.

which assessment data is the most important for the nurse to review when calculating the fluid needs for a client in the oliguric phase of acute renal failure?

total amount of output