End game
A client in the oliguric phase of acute kidney injury has a 24-hour fluid output of 100 ml emesis and 200 ml urine. The nurse plans a fluid replacement for the following day of ml. 750 ml 900 ml 1000 ml 1400 ml
900 ml
A client in respiratory distress is admitted to the medical unit. During the initial assessment of the client, the nurse should obtain a comprehensive health history complete a full physical examination. delay the physical assessment and obtain more history. ask specific questions about this episode.
ask specific questions about this episode.
A client with severe heart failure develops a decrease to normal level of sodium. The nurse plans care for the client based on the knowledge that collaborative care of the client will be directed toward the goal of preventing hypertension. decreasing fluid volume diluting nephrotoxic substances. maintaining cardiac output.
maintaining cardiac output.
A nurse is providing care to four clients. Which of the clients is at risk of developing sepsis? (Select all that apply). A 35-year old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place A 55-year old male who is a recent kidney transplant recipient A 78-year-old female with diabetes mellitus who is recovering from colon surgery A 65-year-old male recovering from right lobectomy for treatment of lung cancer
A 35-year old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place A 55-year old male who is a recent kidney transplant recipient A 78-year-old female with diabetes mellitus who is recovering from colon surgery A 65-year-old male recovering from right lobectomy for treatment of lung cancer
After receiving a change-of-shift report about these four clients, which client should the nurse assess first? A client with SIADH with a serum sodium level of 126 mEq/L. A client with Cushing's syndrome and blood glucose of 300 mg/di. A client with Addison's disease with a regular pulse of 112, and irritable. A client who is on levothyroxine has an irregular pulse of 118.
A client who is on levothyroxine has an irregular pulse of 118.
The nurse starts an intravenous nitroglycerin drip on a client as per CCU protocol. Which outcome does the nurse expect from ad, inistration of the drug? An increase in myocardial oxygen demand Absence of cardiac arrhythmias Control of hypotension Relief of anxiety
Relief of anxiety
A client has acute pancreatitis. To assess for the most systemic complication of the disease is it most important for the nurse to monitor Serum lipase Abdominal CT scan Serum amylase Arterial blood gas
Abdominal CT scan
A client admitted with sepsis and severe hypotension. Laboratory results indicate BUN 30 mg.dl, serum creatinine 1.8mg/dl (177mmol/L), urine sodium 45 mEq/L , urine specific gravity 1.010. The nurse knows these finding are consistent with Chronic renal insufficiency Pre-kidney injury Post kidney injury Acute tubular necrosis
Acute tubular necrosis
A client who has end stage renal disease (ERSD) is on hemodialysis and complaining of muscle cramps. The nurse anticipates taking which action? Massage the extremities Administer muscle relaxer Discontinue dialysis Administer hypertonic glucose
Administer hypertonic glucose
A COPD client is short of breath and the nurse identifies a nursing diagnosis of ineffective breathing pattern related to obstruction of airflow and anxiety. What interventions will the nurse include in the plan of care ? select all that apply Administer ordered bronchodilator Perform chest physiotherapy Adminster oxygen at 5 L/min Position the client upright with elbows resting on the over the bed table
Administer ordered bronchodilator Perform chest physiotherapy Position the client upright with elbows resting on the over the bed table
For a terminally ill client experiencing continuous and severe pain, the nurse will plan to administer Opioid on which of the time schedule? Administer enough of the pain medication to keep the client sedated Provide PRN doses of the medication whenever the client requests. Administer the medication around-the-clock Administer analgesic doses that provide pain control with normal respiratory.
Administer the medication around-the-clock
A client with cirrhosis who is being treated with spironolactone (Aldactone) and furosemide (Lasix) has a serum sodium level of 135 mEq/L (135 mmol/L) and serum potassium 3.2 mEq/L (3.2 mmol/L). Before notifying the health care provider, the nurse should administer the furosemide and withhold the spironolactone. give both drugs as scheduled. Administer the spironolactone. withhold both drugs until after talking with the health care provider.
Administer the spironolactone.
Which of these nursing actions included in the care of a mechanically ventilated client with acute respiratory distress syndrome (ARDS) is most appropriate for the RN to delegate to an experienced LPN/LVN working in the intensive care unit? Place the client in the prone position. Assessment of client breath sounds. Administration of enteral tube feedings. Obtain pulmonary artery pressures.
Administration of enteral tube feedings.
The nurse recognizes a client with a full thickness burn over the lower half of the body is in acute phase when the client has Dyspnea Shivering Severe pain Altered mental status
Altered mental status
A client is in the diuretic phase acute kidney injury (AKI). the nurse will assess the client for (select all that apply) Tachycardia Rapid respirations Poor skin turgor Dysrhythmia
Tachycardia Poor skin turgor Dysrhythmia
A client is admitted with a diagnosis of endocarditis. Which client teaching regarding his diagnosis should the nurse include in his plan of care? Complications are rare once antibiotics have been started. Short courses of antibiotics are needed to treat this condition. Avoid excessive fatigue and plan rest periods. Clients with this condition have a high risk for coronary artery occlusions.
Avoid excessive fatigue and plan rest periods.
A client approaching death is displaying Cheyne-stokes respiration. The nurse describes this breathing as: kussmaul respiration gasping lat ed breathing apnea and deep rapid breathing intermittent and shallow breathing
apnea and deep rapid breathing
The nurse identifies that a client who has thyrotoxicosis is showing symptoms of thyroid storm. What should the nurse do next? Elevate the heard of the bed Administer methimazole(antithyroid) Notify the health care provider Place cold packs on the eyes
Notify the health care provider
After noting increasing QRS intervals in a client with AKI, which actions should the nurse take first? Notify the clients health care provider Check the chart for the most recent blood potassium level Look at the client's current BUN and creatinine levels Document the QRS interval
Check the chart for the most recent blood potassium level
A client with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? Notify the client's health care provider. Check the temperature Give the ordered antiemetic. Assess for a fecal impaction.
Check the temperature
The nurse has received a change of shift report about these four clients. Which one will the nurse plan to assess first? Client with cystic fibrosis coughing up thick greenish sputum Client with bacterial pneumonia and has a temperature of 102.2F Client with diaphragmatic breathing after a thoracentesis Client with fulminating TB and coughing incessantly
Client with diaphragmatic breathing after a thoracentesis
A client had a right sided CVA and has homonymous hemianopsia. Which nursing intervention takes priority ? Activities of daily living Peripheral vision care Range of Motion Alternate communication methods
Peripheral vision care
Which of these tasks is appropriate for the registered nurse to delegate to a licensed vocational nurse (LVN)? Emptying a foley catheter bag Changing central line dressing Teaching a client how to self administer inulin Changing an abdominal wound dressing
Emptying a foley catheter bag
Combination therapy of &- interferon and ribavirin (Ribatol) is being used to treat hepatitis C in a client with human immunodeficiency virus (HIV). One effect of this drug regimen the nurse must monitor in the client is? Increased blood glucose Decreased platelet count Decreased CD4 cell counts Increased BUN and serum creatinine
Decreased CD4 cell counts
A kidney transplant has been performed on a client. Four days postoperatively, what manifestations by the client are suggestive of acute graft rejection. Anorexia and high serum calcium. Polydipsia and collapsing neck veins. Increasing creatinine clearance and urinary hesitancy. Decreased urine output and elevated creatinine.
Decreased urine output and elevated creatinine.
A client with multiple trauma and intracranial lesions from an automobile accident was brought to the hospital with manifestations of Cushing's triad. Which of these signs will the nurse expect to find during the assessment? Heart rate 48, blood pressure 128/88 respiratory rate 16. Heart rate 59, blood pressure 140/70, respiratory rate 14. Heart rate 66, blood pressure 156/90, respiratory rate 12. Heart rate 114, blood pressure 132/60, respiratory rate 22
Heart rate 59, blood pressure 140/70, respiratory rate 14.
The nurse is caring for a client with an addisonian crisis. What action by the client requires the nurse to intervene? Select all that apply Eating a banana brought from the kitchen Requesting to ambulate in the hall Eating a low salt diet from the hospital kitchen Requesting to have his blood pressure taken
Eating a banana brought from the kitchen Eating a low salt diet from the hospital kitchen
A client with pneumonia has a nursing diagnosis of ineffective airway clearance related to thick secretions. The nurse anticipates the expectation for this client to be? Sp02 is 99% Effective cough Tolerates activities of daily living Has adequate hydration
Effective cough
The nurse assesses a burn injury client's output and documents that the client's urine is bloody. Based on the bloody urine, the nurse suspects that the client has which kind of burn injury? Thermal Chemical Electrical Smoke
Electrical
The nurse is caring for a client who has severe acute pancreatitis. When the client requests food, how should the nurse address this? Administer ordered total parenteral nutrition Offer the client ice chips Enforce NPO status Given the client hard candy
Enforce NPO status
A client with congestive heart failure (CHF) is being discharged home on spironolactone. The client should be instructed to report which of these side effects is most prominent in men? Lightheadedness, palpitations or feeling faint. Fatigue, muscle weakness or feeling faint. Nausea, vomiting or memory loss Enlargement of the and tissue of the breasts
Enlargement of the and tissue of the breasts
When providing client care using evidence-based practice, the nurse uses clinical judgment based on experience. evidence from a clinical research study. Evidence based guidelines coupled with clinical expertise. Evaluation of data showing that the client outcomes are met.
Evidence based guidelines coupled with clinical expertise.
The nurse has finished checking the groin catheter insertion site of a client one hour post cardiac catheterization. The client begins to raise the head of his bed. The initial nursing action will be to Explain that he must not move his leg for 3 hours, thus the head of the bed may not be elevated Elevate his affected leg on a pillow and allow him to raise the head of the bed to position of comfort Check the pedal pulse and dressing Explain that the head of the bed should be elevated at 30 degrees
Explain that he must not move his leg for 3 hours, thus the head of the bed may not be elevated
Diagnostic criteria for sepsis include Temperature of 36.5 C (97.7 F) Heart rate greater than 90 bpm Respiratory rate less than 20 bpm Leukocyte count between 5,000 and 11,000 cells/mm3
Heart rate greater than 90 bpm
A client who is breathing on room air has the following arterial blood gas (ABG) results: Ph 7.40, Pa02: 74, Sa02: 92%, PaCo2: 40. What is the most appropriate action by the nurse? Document the results in the client's record Repeat the ABGs within an hour to validate findings Encourage deep breathing and coughing Initiate pulse oximetry for continuous monitoring
Initiate pulse oximetry for continuous monitoring
A healthcare provider who has been effectively immunized for hepatitis B is exposed to the hepatitis B virus (HBV) through a needle's stick from an infected client. The infection control nurse informs that individual that treatment for the exposure should include Baseline hepatitis B antibody testing now and in 2 months Active immunization with Hepatitis B vaccine Hepatitis B immune globulin (HBIG) injection Both the hepatitis B vaccine and HBIG injection
Hepatitis B immune globulin (HBIG) injection
The nurse is planning care for a client who is scheduled to begin peritoneal dialysis. What condition, if present, would disqualify the client as a "good" candidate for peritoneal dialysis? History of confusion. Client verbalizes to the nurse that she is upset. History of cesarean section and laparotomy for ruptured uterus. History of multiple knee surgeries and confusion.
History of cesarean section and laparotomy for ruptured uterus.
A client is trying to determine the difference between Hospice care and Palliative care? Which response by the nurses to the clients is correct? Select all that apply Hospice care is provide when the person decide to forego curative treatments Palliative care does not all a person to receive curative and palliative together Hospice care is provided at an institution with 24 hour nursing being present Family members are not required for palliative care
Hospice care is provide when the person decide to forego curative treatments Hospice care is provided at an institution with 24 hour nursing being present
The nurse is caring for a client who has septic shock. Which of these should the nurse administer to the client first? Corticosteroids to treat underlying inflammation Antibiotics to treat underlying inflammation Vasopressors to increase blood pressure IV fluids to increase intravascular volume
IV fluids to increase intravascular volume
A client has heart failure and is receiving palliative care. The nurse understands that the purpose of palliative care is (are)? Select all that apply Client and family teaching about heart failure Improve his quality of life Provide relief from symptoms Hasten nor postpone death
Improve his quality of life Provide relief from symptoms
The nurse is caring for a client following a right sided CVA. Clients with damage to the right side are most likely to have greater problems with (select all that apply) Aphasia, speech and language Impulsive behavior Spatial perceptual deficits Cognition, memory deficits
Impulsive behavior Spatial perceptual deficits Cognition, memory deficits
The client was diagnosed with pneumothorax. Which statement explains the nurse's understanding of tracheal deviation? Accumulation of air in the pleural space, the lung collapses Increase intrathoracic pressure, the lung collapses Increases intrathoracic secretion of pus, the lung collapses Pleural pressure leakage increases, the lung collapses
Increase intrathoracic pressure, the lung collapses
A nurse taking care of a client with septic shock understand that the pathophysiology of septic shock includes all of the following, EXPECT Increased capillary permeability Increased systemic vascular resistance Increased clot formation Increased serum lactate level
Increased systemic vascular resistance
A client with diabetes insipidus is given a dose of aqueous vasopressin during a water deprivation test. The nurse should monitor the client for? Decrease body weight Increased urine osmolality Decreased blood pressure Increased urine output
Increased urine osmolality
Which condition would change a client's diagnosis from SIRS to sepsis? Decreased platelet count Difficulty breathing Heart rate greater than 90 beats per minute Infection documented by culture
Infection documented by culture
To inflate the cuff of an endotracheal tube (ET) when the client is on mechanical ventilation, The nurse Uses the minimal occluding volume technique by inflating the cuff with 10 ml of air Injects air into the cuff until a barometer indicate a pressure of 15 mmHg Injects air into the cuff until no leak is heard at the peak inspiratory pressure Inflate the cuff until the pilot balloon cannot be easily compressed with the fingers
Injects air into the cuff until no leak is heard at the peak inspiratory pressure
A client is on a lasix 40 mg bid for CHF. What food would you advise him to eat to maintain his electrolyte balance and to prevent cardiac dysrhythmia? Grapes Mango Kiwi Oranges
Kiwi
In caring for a patient with burn injury, the nurse understands that hypovolemia occurs during the emergency phase of burn injury as a result of which of the following? (select all that apply) Decreased capillary permeability Loss of sodium to the interstitium Decreased vascular osmotic pressure Fluid accumulation from denuded skin surfaces
Loss of sodium to the interstitium Decreased vascular osmotic pressure
On admission to the intensive care unit after a craniotomy, the nursing assessment revealed serosanguinous drainage on the client's heart dressing. The initial action by the nurse should be to Document the finding Notify the neurosurgeon Measure and mark the drainage Reinforce or change the dressing
Measure and mark the drainage
A client with CKD brings all home medications to the client to be reviewed by the nurse. Which medication being used by the client indicated teaching is required? Milk of magnesia 30 ml administered orally Oral acetaminophen (tylenol) 650 mg Multivitamin with iron Calcium phosphate (PhosLo)
Milk of magnesia 30 ml administered orally
During treatment of a client with a minnesota balloon tamponade for bleeding esophagus varices, which nursing action will be included in the plan of care Encourage the client to cough and deep breathe Insert the tube and notify its position q4hr Monitor the client for shortness of breath Deflate the gastric balloon q8-12hr
Monitor the client for shortness of breath
The nurse is caring for a newly admitted client who had a myocardial infarction. Which nursing actions should receive priority during the first 72 hours post IM? Pain relief measures, oxygen therapy, and complete bed rest. Arrhythmia recognition and treatment per protocol. Hemodynamic monitoring, anxiety relief measures, and low fat, low salt diet. Intake and output monitoring, daily weight, and client teaching on CAD.
Pain relief measures, oxygen therapy, and complete bed rest.
The nurse determines that the teaching has been effective when the hepatic encephalopathy clients choose foods from the menu? An omelet with cheese and mushrooms and milk Pancakes with fried eggs and orange juice Baked beans, cornbread, potatoes, and coffee Baked chicken with french fries and tea
Pancakes with fried eggs and orange juice
A client with hypertension and stage 2 chronic kidney disease is receiving captopril (capoten). Before administration of the medication, the nurse will check the clients Creatinine Glucose Phosphate Potassium
Potassium
To promote compliance in a client with the treatment of hyperthyroidism, which treatment will the nurse recommend to the physician? lodine (SSKI). Methimazole. Propylthiouracil. Carbimazole.
Propylthiouracil.
Two days after undergoing chest surgery, a client develops marked dyspnea and anxiety. What action(s) should the nurse take (select all that apply) Raise the head of the bed to ten degrees Administer anti-anxiety medication Take the client's pulse and blood pressure Determine the client = SpO2
Raise the head of the bed to ten degrees Take the client's pulse and blood pressure Determine the client = SpO2
The ventilation/perfusion scan strongly suggests pulmonary embolism in a client with a history of immobility due to left femur fracture. The most common complaints that are found in pulmonary embolism are: Rapid irregular heartbeat, excessive cough Chest pain, with diarrhea, elevated blood glucose. Headache, with high blood pressure. Feelings of tiredness, and high fever.
Rapid irregular heartbeat, excessive cough
Sepsis and septic shock can cause various abnormal blood, which of the following occurs during cell death? Overactivity of the cells' sodium- potassium pump. Increased intracellular potassium levels. Increased loss of water from the cells Release of cellular digestive enzymes
Release of cellular digestive enzymes
The nurse expects endotracheal intubation as immediate management of the airway for the client with which kind of burn injury: Carbon monoxide poisoning Electrical burns with cardiac dysrhythmias Thermal burn injuries to the neck and upper chest region Respiratory distress with eschar formation around the chest.
Respiratory distress with eschar formation around the chest.
A client had a myocardial infarction that progressed to cardiogenic shock. Which parameters would indicate that cardiogenic shock is developing? Restlessness Slow respiratory rate Brady arrhythmia Increasing pulse pressure
Restlessness
The nurse will monitor for clinical manifestations of hypoxemia when a client in the emergency department has A chest trauma and multiple rib fracture Carbon monoxide poisoning after a house fire Left sided ventricular failure and acute pulmonary edema Tachypnea and acute respiratory distress syndrome (ARDS)
Tachypnea and acute respiratory distress syndrome (ARDS)
A client has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action if included in the plan of care by the nurse will require the charge nurse to intervene? Decrease assessments during the night to allow uninterrupted sleep. Administer prescribed sedatives or opioids at bedtime to promote sleep. Silence the alarms on the cardiac monitors to allow 30-to 40-minute naps. Cluster nursing activities so that the client has uninterrupted rest periods.
Silence the alarms on the cardiac monitors to allow 30-to 40-minute naps.
A client with damaged nerve fibers as well as other tissues ask the nurse to explain the extent of the nerve damage. The best response from the nurse should be Nerve cells do not regenerate Normal motor and sensory function will return Weak sensation and movement will come back Some sensory and motor function may return
Some sensory and motor function may return
A client is admitted to the unit following a head injury. The nurse assesses deep-tendon reflexes and other reflexes frequently for which of the following reasons? Muscle and skeletal damage Spinal cord damage Cranial nerve damage Tendon and ligament damage
Spinal cord damage
A 26 year old client with C8 spinal cord injury tells the nurse " My wife and I have always had a very active sex life and am worried that she may leave me if i cannot function sexually". The most appropriate response by the nurse to the client comment is to Advise the client to talk to his wife to determine how she feels about his sexual function Tell the client that silken (diagram) helps to decrease erectile dysfunction in clients with spinal cord injury Inform the client that most clients with upper motor neuron injuries have reflex erections Suggest that the client and his wife work with a nurse specialty trained in sexual counseling
Suggest that the client and his wife work with a nurse specialty trained in sexual counseling
The nursing action contradicted when a client returns to the surgical nursing unit following a thyroidectomy is to Check the dressing for bleeding Assess respiratory rate and effort Support the clients head with pillows Take the blood pressure and pulse
Support the clients head with pillows
A Client had a subdural hematoma two months ago and is in rehabilitation. Which medication below is given for a long term complication associated with head injuries? Solumedrol (Methylprednisolone) Baclofen (Liofen) Tegretol (Carbamazepine) Valium (Diazepam)
Tegretol (Carbamazepine)
A Client with acute respiratory failure is receiving assist control mechanical ventilation with peak end expiratory pressure (PEEP) of 10 cm H20 and has an arterial line and pulmonary artery catheter in place. Which information indicates that a change in the ventilator settings may be required? The pulmonary artery pressure (PAP) is decreased The arterial line shows a blood pressure of 90/46 The pulmonary artery wedge pressure is (PAWP) is increased The cardiac monitor shows a heart rate of 58 bpm
The arterial line shows a blood pressure of 90/46
A nurse student questions the nurse about her client who sustained chemical burns. The nurse's best response to the student is that chemical burns have which characteristics (select all that apply)? Metabolic acidosis occurs immediately following burns The visible skin injury often represents the full extent of tissue damage The burning process stops when the injury is flushes with large amount of water Tissue damage continues even after being neutralized
The burning process stops when the injury is flushes with large amount of water Tissue damage continues even after being neutralized
Which information obtained when caring for a client who has just been admitted for evaluation of diabetes insipidus will be of least concern to the nurse? The client has a urine output of 800 ml/hr The client's urine specific gravity is 1.003 The client has a recent head injury The client is confused and lethargic
The client's urine specific gravity is 1.003
The nurse explained chest tube removal to the client. Which statement by the client will give the nurse concern? A chest X-ray is done immediately before the chest tube is removed I will take a deep breath, exhale, and bear down while the tube is removed An airtight dressing will be placed on the skin after the chest tube is removed The drainage system will be clamped before the chest tube is removed
The drainage system will be clamped before the chest tube is removed
A post MI client has been pain free for three days. He asks the nurse why his activity is restricted. Which information about controlling activity in post MI clients is correct? Any additional activity at this time will result in life threatening complication The injured area in the heart is not capable of responding to an increase in bodily activity Minimal activity promotes the effect of the medication used to control the force of heart muscle contractions Activity is restricted because the heart requires complete physical rest for at least 5 days after an MI
The injured area in the heart is not capable of responding to an increase in bodily activity
A client has a mitral valve replacement with a mechanical valve. The discharge teaching plan for the client on coumadin should include Monitoring intake and output Avoid removing established clots The effects of job related stress The significance of decrease activity
The significance of decrease activity
Which data obtained when assessing a client who had a kidney transplant 8 years ago and who is receiving the immunosuppressants tacrolimus (Prograf). Cyclosporine (Sandimmune), and prednisone (Deltasone) will be of most concern to the nurse? The blood glucose is 144 mg/dl The client has a round, moonlike face There is non tender lump in the axilla The client's blood pressure is 150/92
There is non tender lump in the axilla
A client is in the emergency room with a complaint of chest pain. He tells the nurse that his chest pain occurs at night and is unrelated to activity. The nurse knows that the client has: Myocardial infarction Unstable angina Variant angina Stable angina
Unstable angina
The nurse is auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is characterized by Occasional coupled beats with irregular rhythm. Long pauses in an otherwise irregular rhythm. Variable loudness of S1 and irregular rhythm. Premature QRS complex with irregular rhythm.
Variable loudness of S1 and irregular rhythm.
The nurse assessed a burn client to have rapid changes in his assessment. What evidence based finding may indicate the client is in early sepsis? Vital signs Urinary output Gastrointestinal function Burn wound appearance
Vital signs
Impaired gas exchange related to excess fluid in the lungs is added to a patient's plan of care. The nurse anticipates that the implementation has been effective when the client exhibits. Walks to the end of the hall Effective cough Bilateral rales to lung auscultation nonproductive cough with thin secretions.
Walks to the end of the hall
A client with severe cirrhosis of the liver has an episode of bleeding esophageal varices. To detect the possible complication of bleeding, it is important for the nurse to monitor prothrombin time. bilirubin levels. ammonia levels. complete blood count (CBC) levels.
ammonia levels.
A client with cirrhosis as octreotide (sandostatin) ordered. The nurse teaches the client rationale for this medication is that acts to decrease the risk of bleeding. aids in the formation and maturation of red blood cells. inhibits reabsorption of sodium and secretion of potassium. inhibits the synthesis and production of clotting factors.
acts to decrease the risk of bleeding.
The nurse is caring for a client with an extensive burn injury. The initial action by the nurse should be to: initiate oxygen through a non-rebreather mask. administer intravenous isotonic solution. Include Morphine Sulfate in the intravenous solution. insert a feeding tube and give 20 ml/hr enteral feedings.
administer intravenous isotonic solution.
A client needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the graft is that it can accommodate larger needles. increases client mobility. is much less likely to clot. can be used sooner after surgery.
can be used sooner after surgery.
The nurse is doing an assessment of a client with mitral stenosis. Which finding by the nurse supports decreased cardiac output and coronary perfusion? chest pain hypotension Shortness of breath and friction rub Bradycardia and syncope
chest pain
An elderly, emaciated client is admitted to the intensive care unit (ICU). The nurse plans a 2-hourly turning schedule to prevent skin breakdown. In this case, the nursing action is dependent. cooperative. codependent collaborative.
collaborative.
In planning care for a client with acute pancreatitis, the nurse must recognize that the priority problem for this client is: complications. respiratory disorder. inadequate pain control. fluid and electrolyte imbalance.
inadequate pain control.
A nursing student asks the nurse why she must wear a gown, mask and gloves when taking care of her burn injury client. Which explanation by the nurse would be appropriate? Bone marrow protection decrease in immunoglobulin levels Increased function of white blood cells (WBCs) Overwhelmed microorganisms
decrease in immunoglobulin levels
A client in acute kidney jury (AKI) has a gradual increase in urinary output to 3400 ml a day with a BUN of 92 mg/di (33 mmol/L) ant serum creatinine of 4.2 mg (371 mmol/L). The nurse should plan to use a urine dipstick to monitor for proteinuria. auscultate the lungs to assess for pulmonary edema. take the blood fissure to check for hypertension. draw blood to monitor for hypokalemia.
draw blood to monitor for hypokalemia.
A client contracts hepatitis from a contaminated needle. During the acute (icteric) phase of the client's illness, the nurse would expect serologic testing to reveal hepatitis B surface antigen (HBAg). anti-hepatitis B core immunoglobulin M (anti-HBc IgM). anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). anti-hepatitis A virus immunoglobulin M (anti-HAV)
hepatitis B surface antigen (HBAg).
To prevent the development of heart failure in a client with stage 1 hypertension, which information that is likely to improve compliance with antihypertensive therapy will the nurse include in the teaching plan? (select all that apply) hypertensive crisis may lead to development of acute heart failure in some clients hypertension eventually will lead to heart failure by overworking the heart muscle. high BP decreases risk for rheumatic heart disease. high systemic pressure precipitates papillary muscle rupture.
hypertensive crisis may lead to development of acute heart failure in some clients hypertension eventually will lead to heart failure by overworking the heart muscle. high systemic pressure precipitates papillary muscle rupture.
A client has been diagnosed with acute kidney injury after having a CT scan with contrast media. The nurse recognizes that the client's renal failure is : pre-renal post renal intra renal sepsis
intra renal
A client with adrenocortical adenoma is scheduled for laparoscopic surgery to remove the tumor. What non-pharmacological intention is the most appropriate before the surgery? monitor blood glucose level every 2 hours. place the client in a room at the end of the hall. monitor the blood pressure every 2 hours. Perform abdominal assessment.
monitor the blood pressure every 2 hours.
A thrombolytic agent was administered to a client with an acute myocardial infarction within 4 hours following the onset of symptoms. The nurse should assess the client for neurologic changes cool, clammy skin. ankle edema. Gl bleeding and diarrhea.
neurologic changes
A client with acute kidney injury (AKI) requires hemodialysis, and temporary vascular access is obtained by placing a catheter in the left femoral vein. After the catheter placement the nurse will plan to restrict the client's oral protein intake. discontinue the retention catheter. place the client on bed rest. start continuous pulse oximetry.
place the client on bed rest.
A client is being taught about dietary regulation due to his myocardial infarction (MI) and coronary artery disease (CAD). what food section by the client would indicate that the client needs more teaching according to the american heart association's diet pork chop. pickled cabbage fruit salad toast with jelly.
pork chop.
A client with Cushing's syndrome returns to the surgical unit following an adrenalectomy. During the initial postoperative period, the nurse gives the least priority to monitoring for infection. Administering pain medication maintaining fluid and electrolyte status. preventing severe emotional disturbances.
preventing severe emotional disturbances.
The nurse is caring for a client receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for acute heart failure with severe orthopnea. When evaluating the client's response to the medications, the best indicator that the treatment has been effective is weight loss of 2 pounds overnight. ate 100% of the meal. reduction in systolic BP. decreased heart rate
reduction in systolic BP.
A client has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of impaired physical mobility related to right hemiplegia. risk for injury related to denial of deficits and impulsiveness. impaired verbal communication related to speech-language deficits. ineffective coping related to depression and distress about disability.
risk for injury related to denial of deficits and impulsiveness.
When caring for a client with infective endocarditis, the nurse should assess for striae and splinter hemorrhage decreased blood pressure. temperature. alteration in consciousness.
striae and splinter hemorrhage
The nurse working is working with a heart failure client in the clinic. Which action by the client indicates the need for further teaching by the nurse? (Select all that apply) takes his blood pressure every other day. calls when the weight increases from 124 to 128 pounds in a week. takes his furosemide (Lasix) daily. eats six regular meals daily.
takes his blood pressure every other day. eats six regular meals daily.
o check the correct placement of an endotracheal tube (ET) after insertion, the action for the nurse to take is to use an end-tidal CO monitoring auscultate for the presence of bilateral breath sounds. obtain a portable chest radiograph confirm arterial blood gas test
use an end-tidal CO monitoring