Final Exam
A patient admitted with a pulmonary embolism presents with decreased level of conscious and shortness of breath. which proveder order should the nurse question
2 liters 0.9 sodium chloride IV bolus followed by 0.9 sodium cloride @ 150ml/hr
A nurse is caring for a client who is receiving positive pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? SATApositive-pressure
Administer pantoprazole as prescribed perform daily sedation vacations elevate HOB 30' Administer enoxaparin sodium (LOVENOX)as prescribed
A patient arrives to the ER complaining of SOB since last night. Spo2 84% on RA and a RR of 26. The ABG is as follows ph.7.50, PaO2 70, PCO2 25, HCO3 24. The nurse applies a venti mask and completes the assessment while education the patient on deep breathing. An hour later, the patients assess is as follows SpO2 93% on venti mask and RR 22. An ABG is drawn and the results are: pH 7.49, PaO2 75, PCO2 33, HCO3 24. What would you expect the next intervention to be?
Apple BiPAP
a client is being treated in the ICU for obstructive shock secondary to a pulmonary embolus. Despite aggressive interventions the clients mean aterial pressure (MAP) has fallen to 55 mm Hg. the nurse should assess for organ damage related to the lack of perfusion by referring to what laboratory findings? SATA
BUN level Hemoglobin level Creatine level
A client with Cushing syndrome as a result of the pituitary tumor has been admitted for transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery?
Blood glucose
A client is admitted with a brain contusion and is exhibiting, headache, nausea, and vomiting. the nurse receives an order for 150 g of mannitol. the nurse recognizes which assessment related to medication administration should be prioritized.
Blood pressure
A client admitted with acute respiratory distress syndrome (ARDS) is worsening in condition with a mean arterial pressure (MAP) of 55 and a HR of 115 Labs show BUN 30mg, creatinine 3.2 mg/dl, potassium 5.6 mEq/l. Which intervention would be the most appropriate
Continuous renal replacement therapy CRRT
The nurse is caring for a patient with a TBI and notices the following on assessment: Arms abducted and flexed legs extended and internally rotated and wrist flexed on the chest. Because o this assessment, the nurse understands the damage is most likely occurring in
Corticospinal tract
A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. the client has been placed in traction until his femur can be rodded in surgery. For what early complication should the nurse monitor for this client? SATA
Deep vein thrombosis compartment syndrome fat embolism
A client who is being treated for pneumonia reports sudden SOB. An arterial blood gas (ABG) is drawn. The ABG has the following values pH7.21 PaCO2 64mm HG, HCO3=24. What intervention would help to improve the blood gas.
Endotracheal intubation and mechanical ventilation
When CDK patient complains of fatigue and activity intolerance the RN educates that patient that he will receive this medication to simulate bone marrow for RBC production
Ethaprotien
A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should hte nurse review for an indication of a therapeutic effect of the medication?
Hematocrit HCT, Hgb, RBC
A student nurse is caring for a client in the ICU admitted with ARDS from COVID-19. The client has become hypotensive. The student understands theat the cause of this complication of ARDS is from which of the following.
Hypovolemia secondary to leakage of fluid into the interstitial spaces
The nurse is assessing the endocrine system of a client. Which statement indicates to the nurse that the client is experiencing a condition that affects endocrine function? SATA
I have difficulty tolerating heat and hot weather for long periods of time I do not have any energy to do what I normally do I do not know why my skin has gotten so dry lately It seems like the fat on my legs moved to my stomach
A nurse is providing dietary teaching to a client who has CKD, which statement by the client would indicate that the teaching was effective. SATA
I should be cautious of my protein intake eating a lot of calcium-fortified food can help me I need to find recipes that require low amount of salt in my meals
A nurse is caring for a 72 year-old female who collapsed after being outside gardening on a hot summer day. The client has a temperature of 104 degrees F. a BP of 95/50 and a HR of 114. Which priority action will the nurse take first?
Initiate rapid IV fluid administration
A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later the clients urine output suddenly rises above 200ml/hour leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurses suspicion of diabetes insipidus
Low urine osmolality level, high serum osmolality level
A client has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the health care provider to order for the wound?
Mafenide acetate 10% (sulfamylon) hydrophilic-based cream
A patient has a ventriculostomy drain placed for drainage of CSF following a brain injury. Which of the following intervention should the nurse take to avoid complications? SATA
Maintain sterility when setting the system up maintain proper leveling of the drainage system drain the CSF to the ordered amount
A nurse is caring for a client who has a hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
Oliguria (low urine output)
A client is being treated for burns on 25% total body surface area. The nurse knows the client is adequately resuscitated if the following findings are present. SATA
Pulse <100 SBP >90-100 clear mentation
A nurse is caring for a client who has a syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/l. Which of the following prescriptions should the nurse anticipate?
Restrict fluid intake to 1000ml per day
A nurse is caring for a client 1-day after a chest tube was placed for a pneumothorax after a car accident. When assessing the client's three chambers wet drainage system, the nurse notes that there is o bubbling in the suction control chamber. Which of the following actions should the nurse take?
Verify that the suction regulator is on and check the tubing for leaks
An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC?
a client with a blood stream infection requiring vasopressors
A graduate nurse is working in the intensive care unit and watches a physician perform testing to evaluate the likelihood of brain death. The graduate nurse knows which of the following findings may indicate a positive finding indicating brain death. SATA
absence of corneal reflex absence of cough gag reflex
A patient with a diagnosis of meningitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities in the patient plan of care could be designated to an LPN/LVN whom the nurse is surpervising?
administer phenytoin (Dilantin) 200 mg daily
A client has been admitted to the critical care unit with a diagnosis of thyroid storm. What intervention should the nurse include in this client's immediate care?
administering beta blockers to reduce heart rate
A patient is placed in Bucks traction while awaiting surgery to fix a fractured femur head. The nurse knows that with this type of traction it is important to do which of the following? SATA
asses for blister formation and pressure ulcers ensure uniform placement of weights assess for dermatitis and varicose veins prior to placement
As the day progresses, CJ becomes more obtunded. His respirations are more labored and his latest blood gas has worsened. The decision is made to intubate the patient. Immediately after intubation, which action should the nurse take first
assess for symmetrical chest rise and fall with ventilation
A nurse is caring for a patient who had a spinal cord injury 18 months ago. The patient begins to complain of a pounding headache and nausea with profuse sweating. Based on the chief complaint, the nurse understands that this patient may have
autonomic dysreflexia
Patrick is a client with lymphoma being treated with immunotherapy PM presents to the ED with hyponatremia confusion and tremors. The provider mentions a problem with the posterior pituitary gland. The student nurse asks the primary nurse what this means. What is the best explanation the nurse can give?
certain cancers and cancer treatments have a higher risk of ADH hypersecretion
A nurse is caring for a client who came into the emergency department in severe respiratory distress following left-sided blunt chest trauma from a motor vehicle accident. The nurse notes absent breath sounds on the client's left side and tracheal shift to the right. For which of the following procedures should the nurse prepare the client?
chest tube insertion
When direction the role of the various members of rehabilition team the client works with after recovering from shock. Which member would the nurse identify as the one who determines the final outcome of the process?
client
A nurse is reviewing lab results of a lumbar puncture for a client who has manifestations of bacterial meningitis. Which of the following should the nurse expect?
decreased glucose
the intensive care nurse is responsible for the care of a client who is in shock. What signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction?
drop in systolic blood pressure of >_40mm hg from baseline serum lactate >4 mm mean arterial pressure MAP of <65
The nurse in the ED is caring for a client recently admitted with a likely myocardial infarction. The nurse understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. For what health problems should the nurse assess?
dysrhythmias
A rn is caring for a pt with a major burn who is experiencing 3 spaciing. Which of the following imbalance is expected.
elevated Hct
A 11-year-old boy has been brought to the ED by his teacher who reports that the boy may be having a really bad allergic reaction to peanuts after trading lunches with a peer. The triage nurse rapid assessment reveals the presence of respiratory and cardiac arrest. What interventions should the nurse prioritize
establishing a patent airway and beginning cardiopulmonary resuscitation
A patient comes into the ED obtunded and unable to give a history. Labs drawn show a metabolic acidosis with a normal serum anion gap. Which of the following would be considered a cause of acidosis?
excessive diarrhea
A healthcare worker has been exposed to the blood of an HIV-positive client and is awaiting the results of an HIV test in the meantime. What precautions must the healthcare workers take to prevent the spread of the infection.
follow the same sexual precautions as someone who has been diagnosed with HIV
A patient presents to the hospital with profound edema, a large amount of protein in the urine, and a low serum albumin level. The nurse anticipate which of the following orders to be prescribed. SATS
furosemide 20mg IV BID Lisinopril 10 mg PO once daily Atorvastatin 20mg PO daily
A patient comes into the public health clinic and is requesting an HIV test due to her recent onset of symptoms. The nurse knows that which of the following symptoms may be associated with an early presentation of HIV?
generalized rash fatigue sore throat fever
A client with hyperfunction of the adrenal cortex has been admitted to the medical unit.. What would the nurse most likely find when assessing this client?
increased blood pressure
a nurse has been taking care of a client for 3 shifts in a row. the client was admitted with septic shock. when comparing the clients lab results from the previous day, which would indicate the patient's condition is improving.
increasing SCv02 level decreasing lactate level decreasing ALT and AST
A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?
instruct the client to wiggle his toes
A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following priority orders would the nurse anticipate?
intubation and mechanical ventilation
the nurse is caring for a client admitted with cardiogenic shock. The client is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this client?
it dilates blood vessels
A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: SATA
jugular venous distention crackles auscultated in bilateral lung fields
Which set of arterial blood gas (ABG) results requires further investigation?
pH 7.45 PaCO2 49mm hg PaO2 92 mm Hg, and HCO3-32mEq/l
3 hours after arrival a blood gas is drawn on CJ with the following results ph-7.32 paCO2 51 mmHg HCO3 29mEq/l PaO2 77 mmHg O2 89%. What acid-base imbalance does the nurse suspect on the basis of these results?
partially compensated respiratory acidosis
A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should evaluate which lab?
potassium
A client is scheduled for a CT scan of the abdomen with contrast. The client has a baseline creatinine level of 2.3 mg.dl In preparing the client for the procedure the nurse anticipates what order?
provide adequate hydration before procedure
a client who suffered a T4-level spinal cord injury (SCI) 3 years ago is admitted with pneumonia. Upon initial assessment, his blood pressure is 230/110 and he complains of a headache and nasal congestion. The nurse administers and antihypertensive medication as ordered. After administration, the nurse empties the clients bladder and the symptoms go away. Now what is the priority the nurse must watch for?
rebound hypotension
Which nursing intervention is essential in caring for a client with compartment syndrome?
removing all external sources of pressure, such as clothing and jewelry
A nurse is monitoring a client with Guillan-Barre syndrome. Which findings would the nurse anticipate assessing for? SATA
respiratory distress decreased deep tendon reflexes
A nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemotherapy. Which of the following actions should the nurse take?
serve cook fruits with meals
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. the client is oliguric and his blood urea nitrogen BUN and creatinine levels are elevated. The physician will most likely write an order for which treatment.
start IV fluids with a normal saline solution followed by a maintenance dose
A client with endocrine dysfunction who had an adrenal tumor removed is receiving intravenous corticosteroids. When the nurse assesses the client, the client's skin is found to be peeling, the client is weak, and the blood pressure on the monitor is 86/50 mm/hg. How should the nurse interpret these findings?
the client is not receiving enough fluid replacement the corticosteroid is most likely tapered too fast
A home health nurse receives a call from a client on continuous ambulatory peritoneal dialysis. The client reports a weight gain of 2 lbs overnight and a distended abdomen. Which of the following interventions should the nurse instruct the client to perform?
turn from side to side
The provider writes an order to admit Patrick to a medical surgical unit. Which of the following interventions is appropriate for the RN to delegate to non-licensed personnel (nurse attendant to prepare for this client: SATA
zero out the client's bed to obtain an accurate client weight pad the side rails of the client's bed to prevent client injury call the dietary department to notify them of the clients fluid restriction
