final exam cm4

A nurse is caring for a client in acute respiratory failure who is on mechanical ventilation. What action will promote comfort in this client? (SATA)

- Allow visitors at the client's bedside - Ensure the client can communicate if awake. - Provide back and hand massages when turning. -Turn the client every 2 hours or more.

the nurse is preparing to administer furosemide to a patient with heart failure. which actions will the nurse perform prior to administering this medication. select all that apply - Encourage water and fruit juices intake - Restrict intake of green, leafy vegetables - Checking apical pulse before administering medication - Monitor hemoglobin and hematocrit - Monitor serum electrolytes

- Encourage water and fruit juices intake - Restrict intake of green, leafy vegetables - Checking apical pulse before administering medication - Monitor hemoglobin and hematocrit - Monitor serum electrolytes

which of the following are characteristics of sinus rhythm with second degree AV block type 1 -wenckbach select all that apply

- Progressively lengthening PR intervals - QRS dropped - Ventricular rhythm is irregular

After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) 1. "I'll read the nutritional labels on food items for salt content." 2. "I will drink at least 3 L of water each day." 3. "Using salt in moderation will reduce the workload of my heart." 4. "I will eat oatmeal for breakfast instead of ham and eggs." 5. "Substituting fresh vegetables for canned ones will lower my salt intake." 6. "Salt substitutes are a good way to cut down on sodium in my diet."

1. "I'll read the nutritional labels on food items for salt content." 4. "I will eat oatmeal for breakfast instead of ham and eggs." 5. "Substituting fresh vegetables for canned ones will lower my salt intake."

A client develops an anaphylactic reaction after receiving Vancomycin. The nurse should plan to institute which actions? Select all that apply. 1. administer oxygen 2. quickly assess the client's respiratory status 3. document the event, interventions, and client's response 4. leave the client briefly to contact a health care provider 5. keep the client supine regardless of the blood pressure readings 6. start an IV infusion of D5W and administer a 500-mL bolus

1. administer oxygen 2. quickly assess the client's respiratory status 3. document the event, interventions, and client's response

The nurse is caring for clients in the emergency department of an acute care facility. Four clients have been admitted in the last 20 minutes. Which of the following admissions should the nurse see FIRST ? 1. A client reporting chest pain that is unrelieved by nitroglycerin 2. A client with third-degree burns to the face 3. A client with a fractured left hip 4. A client reporting epigastric pain

2. A client with third-degree burns to the face

A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. which of the following clients should the nursing tag to be the priority care? A client who has severe head injuries, respiratory rate 6/min and is unresponsive A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around

A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site

Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A) A patient with a blunt chest trauma with some difficulty breathing B) A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar C) A patient with a possible fractured tibia with adequate pedal pulses D) A patient with an acute onset of confusion

A) A patient with a blunt chest trauma with some difficulty breathing

The triage nurse is working in the ED. A homeless person is admitted during a blizzard with complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2C (91.8F). The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurses priority in the care of this patient? A) Addressing the patients hypothermia B) Addressing the patients frostbite in his lower extremities C) Addressing the patients alcohol intoxication D) Addressing the patients malnutrition

A) Addressing the patients hypothermia

A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of circulatory shock should the nurses identify? Select all that apply. A) Anaphylactic B) Hypovolemic C) Cardiogenic D) Septic E) Neurogenic

A) Anaphylactic D) Septic E) Neurogenic

The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patient's risk of developing pulmonary emboli (PE)?

A) Early ambulation

A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? A) Evidence of hemorrhagic stroke B) Blood pressure of 180/110 mm Hg C) Evidence of stroke evolution D) Previous thrombolytic therapy within the past 12 months

A) Evidence of hemorrhagic stroke

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this? A) Maintaining a patent airway B) Preventing the need for suctioning C) Maintaining the sterility of the patients airway D) Increasing the patients lung compliance

A) Maintaining a patent airway

A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients who are being treated for shock. What intervention should be specified in the patients plan of care while the patient is ventilated? A) Performing frequent oral care B) Maintaining the patient in a supine position C) Suctioning the patient every 15 minutes unless contraindicated D) Administering prophylactic antibiotics, as ordered

A) Performing frequent oral care

The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids? A) Presence of a cough and gag reflex B) Absence of nausea C) Ability to demonstrate deep inspiration D) Oxygen saturation of 92%

A) Presence of a cough and gag reflex

A patient is admitted to the critical care unit (CCU) with a diagnosis of cardiomyopathy. When reviewing the patient's most recent laboratory results, the nurse should prioritize assessment of which of the following? A) Sodium B) AST, ALT, and bilirubin C) White blood cell differential D) BUN

A) Sodium

The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A) Stable vital signs and ABGs B) Pulse oximetry above 80% and stable vital signs C) Stable nutritional status and ABGs D) Normal orientation and level of consciousness

A) Stable vital signs and ABGs

The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurses assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurses analysis of these data should lead to what preliminary conclusion? A) The patient is in the compensatory stage of shock. B) The patient is in the progressive stage of shock. C) The patient will stabilize and be released by tomorrow. D) The patient is in the irreversible stage of shock.

A) The patient is in the compensatory stage of shock.

A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? A)Assess pulse of affected extremity every 15 minutes at first. B)Palpate the affected leg for pain during every assessment. C)Assess the patient for signs and symptoms of compartment syndrome every 2 hours. D)Perform Doppler evaluation once daily.

A)Assess pulse of affected extremity every 15 minutes at first.

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patients care? A)Fluid status B)Risk of infection C)Nutritional status D)Psychosocial coping

A)Fluid status

A new graduate nurse has started working on a medical-surgical unit. What actions would the nurse take to be prepared for a disaster? (Select all the apply) a. Know the institution's Emergency Response Plan. b. Participate in the institution's disaster drill. c. Develop a personal preparedness plan. d. Understand that nurses play a role in every phase of a disaster. e. Be prepared to report immediately to the emergency department. f. Be willing to be flexible working during a crisis situation.

A,B,C,D,F

A patient has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The physicians choice of antibiotics would be primarily based on what diagnostic test? A) Echocardiography B) Blood cultures C) Cardiac aspiration D) Complete blood count

B) Blood cultures

A nurse is planning care for a client who has quadriplegia. Which of the following nursing actions are most essential for prevention of pulmonary emboli (PE)? (Select all that apply.) A. Assess legs for redness B. Apply elastic compression stockings C. Perform passive range of motion exercises D. Monitor INR results E. Massage calves every shift

A. Assess legs for redness B. Apply elastic compression stockings C. Perform passive range of motion exercises D. Monitor INR results

A client's cardiac rhythm suddenly changes on the monitor. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How would the nurse interpret the rhythm? A. Atrial fibrillation B. Sinus tachycardia C. Ventricular fibrillation D. Ventricular tachycardia

A. Atrial fibrillation

A client is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the client's mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should assess for the onset of acute kidney injury by referring to what laboratory findings? (Select all that apply.) A. Blood urea nitrogen (BUN) level B. Urine specific gravity C. Alkaline phosphatase level D. Creatinine level E. Serum albumin level

A. Blood urea nitrogen (BUN) level B. Urine specific gravity D. Creatinine level

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first? A. Check the client's indwelling urinary catheter for kinks to ensure patency. B. Lower the HOB to improve perfusion. C. Administer PRN analgesia as prescribed. D. Reassure the client that headaches are expected during recovery from spinal cord injuries.

A. Check the client's indwelling urinary catheter for kinks to ensure patency.

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood? A. Elevated blood urea nitrogen (BUN) B. Elevated HbA1c C. Decreased chloride D. Decreased bilirubin

A. Elevated blood urea nitrogen (BUN)

A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what findings? A. Hyperkalemia, hyponatremia, elevated hematocrit B. Hypokalemia, hypernatremia, decreased hematocrit C. Hyperkalemia, hypernatremia, decreased hematocrit D. Hypokalemia, hyponatremia, elevated hematocrit

A. Hyperkalemia, hyponatremia, elevated hematocrit

A nurse is assessing a client with hypovolemic shock. Which of the following symptoms can be found during the compensatory and progressive stages of A. Hypotension B. Anuria C. Rapid weak pulse D. Edematous skin E. Hyperkalemia F. Lethargy G. Loss of reflexes

A. Hypotension C. Rapid weak pulse D. Edematous skin E. Hyperkalemia

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increase hematocrit E. Increased temperature

A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate

The nurse is caring for a patient who has had an ECG. The nurse notes that leads I, II, and III differ from one another on the cardiac rhythm strip. How should the nurse best respond? A. Recognize that the view of the electrical current changes in relation to the lead placement. B. Recognize that the electrophysiological conduction of the heart differs with lead placement. C. Inform the technician that the ECG equipment has malfunctioned. D. Inform the physician that the patient is experiencing a new onset of dysrhythmia.

A. Recognize that the view of the electrical current changes in relation to the lead placement

A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning the patient's continuing care, the nurse should prioritize which of the following risk diagnoses? A. Risk for infection related to immunosuppressant use B. Risk for injury related to decreased hemostasis C. Risk for unstable blood glucose related to impaired gluconeogensis D. Risk for contamination related to accumulation of ammonia

A. Risk for infection related to immunosuppressant use

A 37-year-old client presents at the emergency department (ED) reporting nausea and vomiting and severe abdominal pain. The client's abdomen is rigid, and there is bruising to the client's flank. The client's spouse states that the client was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the client for what health problem? A. Severe pancreatitis with possible peritonitis B. Acute cholecystitis C. Chronic pancreatitis D. Acute appendicitis with possible perforation

A. Severe pancreatitis with possible peritonitis

A nurse is caring for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team? A. Stridor B. Coughing C. Hoarseness D. Extensive oral secretions

A. Stridor

The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient? A. Taking a BP reading on the affected arm can damage the fistula. B. The patient feels best immediately after the dialysis treatment. C. Using a stethoscope for auscultating the fistula is contraindicated. D. The patient should not feel pain during initiation of dialysis.

A. Taking a BP reading on the affected arm can damage the fistula.

The occupational health nurse is assessing an employee who has just had respiratory exposure to a toxin. What should the nurse assess? Select all that apply. A. Time frame of exposure B. Type of respiratory protection used C. Immunization status D. Breath sounds E. Intensity of exposure

A. Time frame of exposure B. Type of respiratory protection used D. Breath sounds E. Intensity of exposure

A homeless person is admitted the ED during a blizzard, and is unable to feel his feet and lower legs. Core temperature is noted at 33.2°C (91.8ºF). The client is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurse's priority in the care of this client? Addressing the client's alcohol intoxication Addressing the client's malnutrition Addressing the client's hypothermia Addressing the client's frostbite in his lower extremities

Addressing the client's hypothermia

A nurse in the emergency department is caring for a patient who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60, a weak pulse rate of 118 and a respiratory rate of 40. Which of the following actions should the nurse take first?

Administer Oxygen via nasal cannula

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? Administration of prophylactic antibiotics Administration of pneumococcal vaccine to vulnerable individuals Obtaining culture and sensitivity swabs from all newly admitted patients Administration of antiretroviral medications to patients over age 65

Administration of pneumococcal vaccine to vulnerable individuals

A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patients increased risk forwhat complication?

Atelactasis

The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD? A) A patient with a history of polycystic kidney disease B) A patient with diabetes mellitus and poorly controlled hypertension C) A patient who is morbidly obese with a history of vascular disorders D) A patient with severe chronic obstructive pulmonary disease

B) A patient with diabetes mellitus and poorly controlled hypertension

A 37-year-old male is admitted with a severely abscessed tooth, BP 90/42, HR 136, RR 28, Spoz 90% on room air, temperature 38.7° C. The nurse suspects that the pavent has developed sepsis. whats the pnonty nursing intervention? A) Administer prescribed antibiotics prior to blood cultures B) Initiate intravenous fluid resuscitation C) Obtain a complete chemistry for laboratory analysis D) Insert an indwelling urinary catheter.

B) Initiate intravenous fluid resuscitation

A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply. A) Coping B) Level of consciousness C) Oral intake D) Arterial blood gases E) Vital signs

B) Level of consciousness D) Arterial blood gases E) Vital signs

The nurse is caring for a patient who is scheduled to undergo mechanical valve replacement. Patient education should include which of the following? A) Use of patient-controlled analgesia B) Long-term anticoagulant therapy C) Steroid therapy D) Use of IV diuretics

B) Long-term anticoagulant therapy

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

B) Neurogenic shock

The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock? A) The patient admitted with acute renal failure B) The patient admitted following an MI C) The patient admitted with malignant hypertension D) The patient admitted following a stroke

B) The patient admitted following an MI

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? A)Fluid intake for the last 24 hours B)Baseline arterial blood gas (ABG) levels C)Prior outcomes of weaning D)Electrocardiogram (ECG) results

B)Baseline arterial blood gas (ABG) levels

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? A. "I sleep with four pillows at night." B. "My shoes fit really tight lately" C. "I wake up coughing every night" D. "I have trouble catching my breath."

B. "My shoes fit really tight lately"

A pulmonary nurse cares for patients who have chronic obstructive pulmonary disease (COPD). Which patient would the nurse assess first? A. A 46-year-old with a 30-pack-year history of smoking B. A 52-year-old in a tripod position using accessory muscles to breathe C. A 68-year-old who has dependent edema and clubbed fingers D. A 74-year-old with a chronic cough and thick, tenacious secretions

B. A 52-year-old in a tripod position using accessory muscles to breathe

An 11-year-old client has been brought to the emergency department by their parent, who reports that the client may be having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. Which interventions should the nurse prioritize? A. Establishing central venous access and beginning fluid resuscitation B. Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR) C. Establishing peripheral intravenous (IV) access and administering IV epinephrine D. Performing a comprehensive assessment and initiating rapid fluid replacement

B. Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)

A client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. What is the priority nursing diagnosis for a cent with this condition? A. Risk for peripheral neurovascular dysfunction B. Excess fluid volume C. Hypothermia D. Ineffective airway clearance

B. Excess fluid volume

A nurse is preparing to administer a blood transfusion to a client. Which action should the nurse take before initiating the transfusion? A. Confirm the client's identity and blood type with the client's family member. B. Obtain informed consent from the client and ensure the client has a signed consent form. C. Warm the blood unit to body temperature in a microwave oven to prevent hypothermia. D. Administer a rapid bolus of normal saline to prime the client's veins.

B. Obtain informed consent from the client and ensure the client has a signed consent form.

A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A. Monitoring fluid and electrolyte imbalances B. Providing education to the client and family C. Treating infection D. Promoting thermoregulation

B. Providing education to the client and family

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client? A. Moist skin B. Spider angiomas C. Tarry stools D. Blood in the urine

B. Spider angiomas

Which teaching point is most important for the client with a peritonsillar abscess? A. Gargle with warm salt water. B. Take all antibiotics as directed. C. Let us know if you want liquid medications. D. Wash hands frequently.

B. Take all antibiotics as directed. Any client on antibiotics must be instructed to complete the entire course of antibiotics. Not completing them can lead to complications or drug-resistant strains of bacteria. The other instructions are appropriate, just not the most important.

The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance does a positive Chvostek's sign indicate? A) Hypermagnesemia B) Hypercalcemia C) Hypocalcemia D) Hyperkalemia

C) Hypocalcemia

Which type of chest configuration is typical of a client with COPD?

Barrel Chest

Several patients who have been involved in a bombing are extremely unlikely to survive. Which color coded tag are these patients given during triage?

Black tag

A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

Breathing ranging from very deep to very shallow with periods of apnea

The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive what? A) Pleurisy B) Emphysema C) Asthma D) Pneumonia

C) Asthma

The nurse is creating a plan of care for a patient with a cardiomyopathy. What priority goal should underlie most of the assessments and interventions that are selected for this patient? A) Absence of complications B) Adherence to the self-care program C) Improved cardiac output D) Increased activity tolerance

C) Improved cardiac output

The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? A) Ineffective breathing pattern related to decreased cardiac output B) Anxiety related to fear of death C) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) D) Impaired skin integrity related to CAD

C) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)

The nurse is caring for a patient with a diagnosis of Addisons disease. What sign or symptom is most closely associated with this health problem? A) Truncal obesity B) Hypertension C) Muscle weakness D) Moon face

C) Muscle weakness

The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurses plan of care should include which of the following interventions? A) Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good B) Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS patients may last for several months C) Promoting communication with the patient and family along with addressing end-of-life issues D) Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea

C) Promoting communication with the patient and family along with addressing end-of-life issues

A patient diagnosed with diabetes mellitus is being discharged home and you are teaching them about preventing DKA. What statement by the patient demonstrates they understood your teaching about this condition? A. "I will hold off taking my insulin while I'm sick." B. "It is normal for my blood sugar to be 250-350 mg/dL while I'm sick." C. "It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids." D. "I should not be alarmed if ketones are present in my urine because this is expected during illness."

C. "It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids."

A patient has a pulmonary embolism and is started on oxygen. The student nurse asks why the patient's oxygen saturation has not significantly improved. What response by the nurse is best? A. "Breathing so rapidly interferes with oxygenation." B. "Maybe the patient has respiratory distress syndrome." C. "The blood clot interferes with perfusion in the lungs." D. "The patient needs immediate intubation and mechanical ventilation."

C. "The blood clot interferes with perfusion in the lungs."

A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values? A. Calcium B. Magnesium C. Amylase D. RBC count

C. Amylase

A patient is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the patient develops acute kidney injury. The patient is hemodynamically unstable, but renal replacement therapy is needed to manage the patient's hypervolemia and hyperkalemia. Which of the following therapies will the patient's hemodynamic status best tolerate? A. Hemodialysis B. Peritoneal dialysis C. Continuous venovenous hemodialysis (CVVHD) D. Plasmapheresis

C. Continuous venovenous hemodialysis (CVVHD)

A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? A. Assessment of blood pressure and assessment for headaches and visual changes. B. Assessments for signs and symptoms of venous thromboembolism. C. Daily weights and abdominal girth measurement. D. Blood glucose monitoring q4h

C. Daily weights and abdominal girth measurement.

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. Perform range-of-motion exercises B. Place suction equipment at the bedside C. Encourage the use of an incentive spirometer D. Administer an expectorant

C. Encourage the use of an incentive spirometer

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. C. Ensure a patent airway d. Start two large-bore IV lines.

C. Ensure a patent airway

A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding? A. glucose in the urine B. albumin in the urine C. highly dilute urine D. leukocytes in the urine

C. Highly dilute urine

The nurse is caring for a client in acute kidney injury (AKI). Which complication would most clearly warrant the administration of polystyrene sulfonate? A. Hypernatremia B. Hypomagnesemia C. Hyperkalemia D. Hypercalcemia

C. Hyperkalemia

A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness and full-thickness burns over 60% of the body 24 hours ago. The nurse should plan to use which of the following routes to administer the medication? A. Subcutaneous B. Oral C. Intravenous D. Transdermal

C. Intravenous

A nurse cares for a patient who is infected with Burkholderia cepacia. What action would the nurse take first when admitting this patient to a pulmonary care unit? A. Instruct the patient to wash his or her hands after contact with other people. B. Implement droplet precautions and don a surgical mask. C. Keep the patient isolated from other patients with cystic fibrosis. D. Obtain blood, sputum, and urine culture specimens.

C. Keep the patient isolated from other patients with cystic fibrosis.

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate? A. Brachial pulse in the left arm B. Brachial pulse in the right arm C. Radial pulse in the left arm D. Radial pulse in the right arm

C. Radial pulse in the left arm

The nurse is caring for a patient on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, what action would the nurse take next?

DO CPR

A patients plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy? A) Administer the treatment with the patient in a high Fowlers or semi-Fowlers position. B) Perform the procedure immediately following the patients meals. C) Apply percussion firmly to bare skin to facilitate drainage. D) Assist the patient into a position that will allow gravity to move secretions.

D) Assist the patient into a position that will allow gravity to move secretions.

The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurses rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm? A) Pulseless electrical activity (PEA) B) Ventricular fibrillation C) Ventricular tachycardia D) Asystole

D) Asystole

A 23-year-old patient with a history of type 1 diabetes is admitted to the ED with nausea and abdominal pain. His respiratory rate is 34/min with deep breaths and a fruity smell to his breath. He is responsive, but difficult to arouse.What does the nurse suspect is happening with this patient?

Diabetic Ketoacidosis

An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patient's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient's risk of septic shock? A) Apply an antibiotic ointment to the patient's mucous membranes, as ordered. B) Perform passive range-of-motion exercises unless contraindicated C) Initiate total parenteral nutrition (TPN) D) Remove invasive devices as soon as they are no longer needed

D) Remove invasive devices as soon as they are no longer needed

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment? A) To prevent the formation of infarcts of emboli B) To limit stroke volume and cardiac output C) To prevent pulmonary and peripheral edema D) To maintain adequate mean arterial pressure

D) To maintain adequate mean arterial pressure

When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this goal? A) Provide a detailed diagnosis and plan of care in order to promote the patients and familys coping. B) Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. C) Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on blood pressure and skin temperature. D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.

D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.

A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI. The nurse's plan of care calls for the patient to walk for 10 minutes 3 times a day. The patient questions the relationship between walking and heart function. How should the nurse best reply? A)"The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue." B)Walking increases your heart rate and blood pressure. Therefore your heart is under less stress." C)"Walking helps your heart adjust to your new arteries and helps build your self-esteem." D)"When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."

D)"When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."

A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A)Pain B)Fluid balance C)Anxiety and fear D)Airway management

D)Airway management

A nurse cares for a patient who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take? A. Ambulate the patient in the hallway to promote deep breathing. B. Auscultate the patient's anterior and posterior lung fields. C. Encourage the patient to take shallow breaths to help with the pain. D. Administer pain medication and encourage the patient to take deep breaths.

D. Administer pain medication and encourage the patient to take deep breaths.

A workplace explosion has left a 40-year-old client with full thickness burns over 75% of the body. Despite these injuries, the client is conscious. How would this person be triaged? A. Green B. Yellow C. Red D. Black

D. Black

A nurse is discussing lab values associated w/ the renal system w/ a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the values? A. Potassium levels are increased in clients who have polyuria. B. Specific gravity is decreased in clients who have hypovolemia. C. BUN is decreased in clients who have dehydration. D. Creatinine levels are increased in clients who have acute kidney injury

D. Creatinine levels are increased in clients who have acute kidney injury

What should the nurse suspect when hourly assessment of urine output on a postcraniotomy patient exhibits a urine output from a catheter of 1,500ml for 2 consecutive hours? A. Cushing's syndrome B. Syndrome of inappropriate antidiuretic hormone C. Adrenal crisis D. Diabetes insipidus

D. Diabetes Insipidus

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible B. Administering oxygen via nasal cannula at 2 L/min C. Helping the client select a low-salt diet D. Encouraging the client to drink 2 to 3 L of water daily

D. Encouraging the client to drink 2 to 3 L of water daily

An adult client has tested positive for tuberculosis (TB). While providing client teaching, what information should the nurse prioritize? A. The need to work closely with the occupational and physical therapists B. The fact that TB is self-limiting, but can take up to 2 years to resolve C. The fact that the disease is a lifelong, chronic condition that will affect ADLs. D. The importance of adhering closely to the prescribed medication regimen.

D. The importance of adhering closely to the prescribed medication regimen.

A nurse is teaching a patient who has been diagnosed with acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching? A. Renal function is reestablished B. Blood urea nitrogen & serum creatinine levels decrease C. The glomerular filtration rate (GFR) recovers D. Urine output is less than 400 ml in 24 hours

D. Urine output is less than 400 ml in 24 hours

A nurse cares for a patient who has a chest tube. When would this patient be at highest risk for developing a pneumothorax? A. When the insertion site becomes red and warm to the touch B. When the tube drainage decreases and becomes sanguineous C. When the patient experiences pain at the insertion site D. When the tube becomes disconnected from the drainage system

D. When the tube becomes disconnected from the drainage system

A 68-year-old woman has chronic kidney disease and a history of type 2 diabetes. Two weeks ago, she had surgery to place a vascular graft access for hemodialysis. Which precaution will the nurse follow to ensure the function of the AV graft? A.Insert an IV and run saline at 10 mL/hr. B.Keep the patient's arm elevated on two pillows. C.Monitor blood pressure and radial pulses in both arms. D.Check for a bruit and thrill by auscultation and palpation over the site.

D.Check for a bruit and thrill by auscultation and palpation over the site.

What should the nurse suspect when hourly assessment of urine output on a post craniotomy patient exhibits a urine output from a catheter of 1,500 mL for 2 consecutive hours? A.Cushing's syndrome B.Syndrome of inappropriate antidiuretic hormone (SIADH) C.Adrenal crisis D.Diabetes insipidus

D.Diabetes insipidus

A client with diabetes is asking the nurse what causes diabetic ketoacidosis (DKA). Which of the following is a correct statement by the nurse?

DKA can be caused by taking too little insulin

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?

Ensuring a bag-valve mask is in the room

The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED? Controlling hemorrhage. Establishing an airway. Obtaining consent for treatment. Restoring cardiac output.

Establishing an airway.

A client admitted to the hospital with a right femur fracture is placed in balanced suspension traction. During the first 48 hours, the nurse should assess the client for which of the following complications?

Fat embolism

A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted?

Glasgow Coma Scale score is unchanged

A client is brought to the emergency department by the paramedics. The client is a type 2 diabetic and is experiencing hyperglycemic hyperosmolar syndrome (HHS). The nurse should identify what components of HHS? Select all that apply.

Glycosuria Dehydration Hypernatremia Hyperglycemia

A client has returned to the floor after having a thyroidectomy for thyroid cancer. What laboratory finding may be an early indication of parathyroid gland injury or removal?

Hypocalcemia

After teaching a client who is recovering from an endoscopic trans-nasal hypophysectomy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will wear dark glasses to prevent sun exposure. b. Ill keep food on upper shelves so I do not have to bend over. c. I must wash the incision with peroxide and redress it daily. d. I shall cough and deep breathe every 2 hours while I am awake.

I'll keep food on upper shelves so I do not have to bend over. After this surgery, the client must take care to avoid activities that can increase intracranial pressure. The client should avoid bending from the waist and should not bear down, cough, or lie flat. With this approach, there is no incision to clean and dress. Protection from sun exposure is not necessary after this procedure.

After teaching a client who is recovering from pancreas transplantation, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional education? If I develop an infection, I should stop taking my corticosteroid. If I have pain over the transplant site, I will call the surgeon immediately. I should avoid people who are ill or who have an infection. I should take my cyclosporine exactly the way I was taught. If I develop an infection, I should stop taking my corticosteroid.

If I develop an infection, I should stop taking my corticosteroid.

The triage nurse in the ED assesses an adult client who presents with reports of midsternal chest pain that has lasted for the last 5 hours. If the client's symptoms are due to an MI, what will have happened to the myocardium?

It may have developed an increased area of infarction during the time without treatment

A nurse is field-triaging clients after an industrial accident. What client condition should the nurse triage with a red tag?

Multiple fractured ribs and shortness of breath.

There is a mass casualty event as a building has collapsed. Upon arriving on scene you are asked to triage patients and place tags on the patient. Which patient would get a red tag?

No answer

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

Perform pre-oxygenation prior to suctioning Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. . In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen.

A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?

Preoxygenate the client with 100% oxygen for up to 3 min

A student shows up at the school Nursing office significantly agitated and diaphoretic. She has no history of illness but states that in the middle of her Biology final exam, she started feeling like her heart was pounding out of her chest. The school nurse instructs the student to sit down and breathe into a paper bag as slowly as she can. The nurse recognizes that the student is likely to develop the following condition:

Respiratory alkalosis

A patient who involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this patients care? Restoration of adequate gas exchange Attainment of effective coping Self-management of oxygen therapy Facilitation of long-term intubation

Restoration of adequate gas exchange

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. which of the following interventions should the nurse take to reduce the risk for ventilator associated pneumonia?

Rinse the client's mouth with an antimicrobial solution every 4 hour. Rationale: The nurse should brush the client's teeth every 8 hour and rinse the client's mouth with an antimicrobial rinse every 2 hour to reduce the growth of bacteria.

What does this monitor read?

Second degree AV block: Mobitz 1 (wenchkkebach)

Which one is included in the irreversible stage of shock?

Shock will not respond to therapy

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? The client received a blood transfusion. The client's analgesia regimen was recently changed. The client was not repositioned during the night shift. The client's urinary catheter became occluded.

The client's urinary catheter became occluded.

A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate?

The poison control center.

The nurse is caring for an older adult client who has been involved in a motor vehicle accident. The client's labs indicate minimally elevated serum creatinine levels. The nurse should assess for signs of what change? a) substantially reduced renal function b) acute kidney injury c) decreased cardiac output d) alterations in ratio of body fluids to muscle mass

a) substantially reduced renal function

A client who has had a significant myocardial infarction receives a referral to the cardiac rehabilitation unit. During his first visit to the unit, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do as the damage is done. Which of the following is an appropriate nursing response? a. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." b. "It's not unusual to feel that way at first, but once you learn the routine, you'll be fine." c. "You are probably right and I agree with you, but I still think you should go." d. "Your doctor is the expert here, and I'm sure he would only recommend what is best for you."

a. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely."

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) a. "Chemo" gloves b. Face mask c. Impervious gown d. N95 respirator e. Shoe covers f. Eye protection

a. "Chemo" gloves b. Face mask c. Impervious gown f. Eye protection

A nurse supervises an unlicensed assistive personal apply electrocardiographic monitoring. Which statement would the nurse provide to the UAP related to this procedure a. "Clean the skin and clip hairs if needed." b. "Add gel to the electrodes prior to applying them." c. "Place the electrodes on the posterior chest." d. "Turn off oxygen prior to monitoring the client."

a. "Clean the skin and clip hairs if needed."

A 45-year-old man with diabetic nephropathy has end-stage renal disease and is starting dialysis. What should the nurse teach the client about hemodialysis? a. "Hemodialysis is a treatment option that is usually required three times a week." b. "Hemodialysis is a program that will require you to commit to daily treatment." c. "This will require you to have surgery and a catheter will need to be inserted into your abdomen." d. "Hemodialysis is a treatment that is used for a few months until your kidney heals and starts to produce urine again."

a. "Hemodialysis is a treatment option that is usually required three times a week."

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic.

a. "High glucose is common in shock and needs to be treated."

The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information? a. "I will be careful if I need enemas for constipation." b. "I will use an electric shaver instead of a razor." c. "I should only eat soft food that is either cool or warm." d. "I won't be able to play sports with my grandkids."

a. "I will be careful if I need enemas for constipation."

A nurse triages clients arriving at the hospital after a mass casualty. What clients are correctly classified? a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag

a. A 35 year old female with severe chest pain; red tag. d. A 60 year old male with an open fracture with distal pulses; yellow tag.

An emergency department nurse cares for a middle-age mountain climber who is confused, ataxic, and exhibits impaired judgement. After administering oxygen, which intervention would the nurse implement next? a. Administer dexamethasone. b. Complete a mini mental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.

a. Administer dexamethasone.

A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions would the nurse include in the plan? SATA a. Administer furosemide b. Administer warfarin c. Implement a low-sodium diet d. Measure the client's abdominal girth e. Encourage weightlifting during physical therapy

a. Administer furosemide b. Administer warfarin c. Implement a low-sodium diet

A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours

a. Alert and oriented, answering questions

A nurse works on an oncology unit and delegates personal hygiene to assistive personnel (AP). What action by the AP requires intervention from the nurse? a. Allowing a very tired client to skip oral hygiene and sleep b. Assisting clients with washing the perianal area every 12 hours c. Helping the client use a soft-bristled toothbrush for oral care d. Reminding the client to rinse the mouth with water or saline

a. Allowing a very tired client to skip oral hygiene and sleep

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication would the nurse being most beneficial? a. Alteplase b. Enoxaparin c. Unfractionated heparin d. Warfarin sodium

a. Alteplase

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration

a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition

A client receiving radiation therapy reports severe skin itching and irritation. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.) a. Apply approved moisturizers to dry skin. b. Apply steroid creams to the skin. c. Bathe the client using mild soap. d. Help the client pat skin dry after a bath. e. Teach the client to avoid sunlight. f. Make sure no clothing is rubbing the site

a. Apply approved moisturizers to dry skin. c. Bathe the client using mild soap. d. Help the client pat skin dry after a bath. f. Make sure no clothing is rubbing the site

A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first? a. Apply personal protective equipment. b. Notify local law enforcement officials. c. Obtain universal donor blood. d. Prepare the client for emergency surgery.

a. Apply personal protective equipment.

A client has thrombocytopenia. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.) a. Apply the client's shoes before getting the client out of bed. b. Assist the client with ambulation. c. Shave the client with a safety razor only. d. Use a lift sheet to move the client up in bed. e. Use a water pressure device be set on low for oral care.

a. Apply the client's shoes before getting the client out of bed. b. Assist the client with ambulation. d. Use a lift sheet to move the client up in bed.

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

a. Applying suction while inserting the catheter

A client's family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.) a. Ask the family to describe their concerns more fully. b. Consult with a social worker, chaplain, or ethics committee. c. Explain the client's right to know and ask for their assistance. d. Have the unit manager take over the care of this client and family. e. Tell the family that this secret will not be kept from the client.

a. Ask the family to describe their concerns more fully. b. Consult with a social worker, chaplain, or ethics committee. c. Explain the client's right to know and ask for their assistance.

A client receiving chemotherapy has a white blood cell count of 1000/mm3 (1 109/L). What actions by the nurse are most appropriate? (Select all that apply.) a. Assess all mucous membranes every 4 to 8 hours. b. Do not allow the client to eat meat or poultry. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance hourly. e. Take and record vital signs every 4 to 8 hours. f. Encourage activity the client can tolerate.

a. Assess all mucous membranes every 4 to 8 hours. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance hourly. e. Take and record vital signs every 4 to 8 hours.

A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below: What action by the nurse is most important? a. Assess blood pressure and pulse. b. Attach the client to a pulse oximeter. c. Have the client rate his or her pain. d. Facilitate urgent radiation therapy

a. Assess blood pressure and pulse

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.

a. Assess that the client is breathing adequately.

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? . a. Assess the cause of the agitation b. Reassure the client that he or she is safe. c. Restrain the client's hands. d. Sedate the client immediately.

a. Assess the cause of the agitation

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? a. Assess the client's gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the client's job risks

a. Assess the client's gait and balance

A patient with a history of heart failure and hypertension is in the clinic for a follow up visit. The patient is on lisinopril and warfarin. The client reports a new onset of cough. What action is most appropriate? a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil

a. Assess the client's lung sounds and oxygenation.

A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the clients neck. What action by the nurse takes priority? a. Assess the clients oxygenation b. Facilitate a STAT chest x-ray c. Prepare for immediate surgery d. Start two large-bore IVs.

a. Assess the clients oxygenation

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? a. Assessing the IV site and blood return every hour b. Educating the client on side effects c. Monitoring the client for nausea d. Providing warm packs for comfort

a. Assessing the IV site and blood return every hour

A client has mucositis. What actions by the nurse will improve the client's nutrition? (Select all that apply.) a. Assist with rinsing the mouth with saline frequently. b. Encourage the client to eat room-temperature foods. c. Give the client hot liquids to hold in the mouth. d. Provide local anesthetic medications to swish and spit. e. Remind the client to brush teeth gently after each meal. f. Offer the client fluids to drink each hour.

a. Assist with rinsing the mouth with saline frequently. b. Encourage the client to eat room-temperature foods. d. Provide local anesthetic medications to swish and spit. f. Offer the client fluids to drink each hour.

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

a. Assisting the client to pre-plan for this event

The nurse cares for a client with a dysrhythmia and understands that the P wave on an electrocardiogram (ECG) represents which phase of the cardiac cycle? a. Atrial depolarization b. Early ventricular repolarization c. Ventricular depolarization d. Ventricular repolarization

a. Atrial depolarization

A client is receiving rituximab. What assessment by the nurse takes priority? a. Blood pressure b. Temperature c. Oral mucous membranes d. Pain

a. Blood pressure

A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best? a. Call the client at home the next day to review teaching. b. Give the client information about a cancer support group. c. Provide all the preoperative instructions in writing. d. Reassure the client that surgery will be over soon.

a. Call the client at home the next day to review teaching.

A client admitted to the emergency department following a lightning strike. What is the priority assessment the nurse focuses on? a. Cardiopulmonary b. Integumentary c. Peripheral vascular d. Renal

a. Cardiopulmonary

The nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.) a. Clotting abnormalities from thrombocythemia b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits f. Increased risk of bone fractures

a. Clotting abnormalities from thrombocythemia b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits f. Increased risk of bone fractures

The nurse working with oncology clients understands that which age-related change increases the older client's susceptibility to infection during chemotherapy? a. Decreased immune function b. Diminished nutritional stores c. Existing cognitive deficits d. Poor physical reserves

a. Decreased immune function

A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which assessment findings would the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension

a. Deep and fast respirations c. Tachycardia e. Orthostatic hypotension

What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department? a. Determine the acuity of the client's condition to determine priority of care. b. Assess the status of the airway, breathing, circulation, or presence of deficits. c. Determine whether the client is responsive enough to provide needed information. d. Evaluate the emergency department's resources to adequately treat the patient.

a. Determine the acuity of the client's condition to determine priority of care.

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL (61 mmol/L). The client is symptomatic but refuses blood transfusions. What medication does the nurse prepare to administer? a. Epoetin alfa b. Filgrastim c. Mesna d. Dexrazoxane

a. Epoetin alfa

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

a. Have suction equipment at the bedside.. d. Keep bed rails up at all times. f. Ensure that the client has IV access.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

a. Heart rate of 34 beats/min c. Urine output less than 30 mL/hr d. Decreased level of

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

a. Heart rate of 34 beats/min c. Urine output less than 30 mL/hr d. Decreased level of consciousness

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Music as a distraction b. Tactile stimulation c. Massage to injury sites d. Cold compresses e. Increasing client control

a. Music as a distraction b. Tactile stimulation e. Increasing client control

The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition? a. Pneumothorax b. Cardiac ischemia c. Acute bronchitis d. Aspiration

a. Pneumothorax

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

a. Provide a calm location for the family to cope and discuss needs.

The complex care provided during an emergency requires interprofessional collaboration. Which team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse—interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner—performs rapid assessments to ensure that clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse—provides basic life support interventions such as oxygen, basic wound care, splinting, spinal motion restriction, and monitoring of vital signs d. Emergency medical technician—obtains client histories, collects evidence, and offers counseling and follow up care for victims of rape, child abuse, and domestic violence e. Paramedic—provides prehospital advanced life support, including cardiac monitoring,

a. Psychiatric crisis nurse—interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis e. Paramedic—provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

A nurse collaborates with an unlicensed assistive personal to provide care for a patient with congestive heart failure. Which instructions would the nurse provide to the UAP when delegating care for this patient? Select all that apply a. Reposition the client every 2 hours. b. Teach the client to perform deep-breathing exercises. c. Accurately record intake and output. d. Use the same scale to weigh the client each morning. e. Place the client on oxygen if the client becomes short of breath

a. Reposition the client every 2 hours. c. Accurately record intake and output. d. Use the same scale to weigh the client each morning.

A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 18 to 14 breaths/min d. A decrease in the client's weight by 6 kg

a. Urine output via indwelling urinary catheter is 20 mL/hr

A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) a. Wear synthetic clothing instead of cotton to keep your skin dry. b. Drink plenty of fluids. Brandy can be used to keep your body warm. c. Remove your hat when exercising to prevent the loss of heat. d. Wear sunglasses to protect skin and eyes from harmful rays. e. Know your physical limits. Come in out of the cold when limits are reached.

a. Wear synthetic clothing instead of cotton to keep your skin dry. d. Wear sunglasses to protect skin and eyes from harmful rays. e. Know your physical limits. Come in out of the cold when limits are reached.

A nurse cares for a client with right-sided HF. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond? a. Weight is the best indication that you are gaining or losing fluid b. Daily weights will help us make sure that you're eating properly c. The hospital requires that all clients be weighed daily d. You need to lose weight to decrease the incidence of heart failure

a. Weight is the best indication that you are gaining or losing fluid

An emergency department nurse assesses a client admitted after a lightning strike. The client is awake but somewhat confused. Which assessment would the nurse complete first? a. Electrocardiogram (ECG) b. Wound inspection c. Creatinine kinase d. Computed tomography of head

a. electrocardiogram

nurse is caring for a client admitted for Non-Hodgkin's lymphoma and chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nurse is most important? a. Request an order for serum electrolytes and uric acid b. Increase the client's IV infusion rate. c. Instruct assistive personnel to strain all urine. d. Administer an IV antiemetic

a. request an order for serum electrolytes and uric acid

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the client's pain? a.Administer the prescribed intravenous morphine sulfate. b.Apply ice to skin around the burn wound for 20 minutes. c.Administer prescribed intramuscular ketorolac (Toradol). d.Decrease tactile stimulation near the burn injuries.

a.Administer the prescribed intravenous morphine sulfate.

What is this ECG reading (GET PIC)

atrial fibrilation

What would the nurse document this as?

atrial flutter

A critical care nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client? Select all that apply. a- Hypoglycemia b- Cardiovascular overload c- Pulmonary edema d- Hypovolemia e- Difficulty breathing

b- Cardiovascular overload c- Pulmonary edema e- Difficulty breathing

After teaching a client who is recovering from a complete thyroidectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional instruction? a. "I may need calcium replacement after surgery." b. "After surgery, I won't need to take thyroid medication." c. "I'll need to take thyroid hormones for the rest of my life." d. "I can receive pain medication if I feel that I need it."

b. "After surgery, I won't need to take thyroid medication."

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? a. "Avoid getting salt water on the radiation site." b. "Do not expose the radiation area to direct sunlight." c. "Have a wonderful time and enjoy your vacation!" d. "Remember you should not drink alcohol for a year."

b. "Do not expose the radiation area to direct sunlight"

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate? a. "Are you getting adequate rest and sleep each day?" b. "It is normal to be fatigued even for months afterward." c. "This is not normal and I'll let the primary health care provider know." d. "Try adding more vitamins B and C to your diet."

b. "It is normal to be fatigued even months afterward."

A nurse is teaching the partner of a client who has a acute MI about the reason blodd was drawn from the client. Which of the following statements shouls dht nurse make regading cardiac enzymes studies? a. "Cardiac enzymes will identify the location of the MI" b. "These tests help determine the degree of damage to the heart tissues." c. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." d. "These tests will enable the provider to determine the heart structure and mobility of the heart valves."

b. "These tests help determine the degree of damage to the heart tissues."

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) Select one or more: a. Hypertension b. Abdominal bloating c. Increased ejection fraction d. Shortness of breath e. New-onset bradycardia

b. Abdominal bloating d. Shortness of breath e. New-onset bradycardia

A middle-age mountain hiker is admitted to the emergency department exhibiting a cough with pink, frothy sputum and cyanosis of lips and nail beds. What priority action would the nurse implement? a. Administer acetazolamide. b. Administer oxygen via a nonrebreather mask. c. Complete a thorough pulmonary assessment. d. Obtain arterial blood gas (ABG) specimen for analysis.

b. Administer oxygen via a nonrebreather mask.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

b. Don personal protective equipment.

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters

b. Ensure the client has a patent airway.

A client is having a catheter placed to deliver chemotherapy beads into a liver tumor via the femoral artery. What action by the nurse is most important? a. Assessing the client's abdomen beforehand b. Ensuring that informed consent is on the chart c. Marking the client's bilateral pedal pulses d. Reviewing client teaching done previously

b. Ensuring that informed consent is on the chart

A client with cancer has anorexia and mucositis, and is losing weight. The client's family members continually bring favorite foods to the client and are distressed when the client won't eat them. What action by the nurse is best? a. Explain the pathophysiologic reasons behind the client not eating. b. Help the family show other ways to demonstrate love and caring. c. Suggest foods and liquids the client might be willing to try to eat. d. Tell the family the client isn't able to eat now no matter what they bring.

b. Help the family show other ways to demonstrate love and caring.

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.) a. Genetic predisposition b. Hypercholesterolemia c. Hypertension d. Obesity e. Smoking

b. Hypercholesterolemia c. Hypertension d. Obesity e. Smoking

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. Some medications have been known to cause hepatitis A. b. I may have been exposed when we ate shrimp last weekend. c. I was infected with hepatitis A through a recent blood transfusion. d. My infection with Epstein-Barr virus can co-infect me with hepatitis A

b. I may have been exposed when we ate shrimp last weekend.

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. Some medications have been known to cause hepatitis A. b. I may have been exposed when we ate shrimp last weekend. c. I was infected with hepatitis A through a recent blood transfusion. d. My infection with Epstein-Barr virus can co-infect me with hepatitis A.

b. I may have been exposed when we ate shrimp last weekend.

A nurse cares for a patient who has 80% blockage of the right coronary artery RCA with a heart rate of 45 and is scheduled for bypass surgery. Which intervention would the nurse be prepared to assist in while the patient waits for surgery a. Administration of IV furosemide (Lasix) b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

b. Initiation of an external pacemaker

A client has a platelet count of 9800/mm3 (9800 109/L). What action by the nurse is most appropriate? a. Assess the client for calf pain, warmth, and redness. b. Instruct the client to call for help to get out of bed. c. Obtain cultures as per the facility's standing policy. d. Place the client on protective Isolation Precautions.

b. Instruct the client to call for help to get out of bed.

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3

b. Lactate: 6 mmol/L

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I - Located within remote areas and provides advanced life support within resource capabilities b. Level II - Located within community hospitals and provides care to most injured clients c. Level III - Located in rural communities and provides only basic care to clients d. Level IV - Located in large teaching hospitals and provides a full continuum of trauma care for all clients

b. Level II - Located within community hospitals and provides care to most injured clients

A student is caring for a patient who suffered massive blood loss after trauma. How does the student correlate the blood loss with the patient's mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.

b. Lower blood volume lowers MAP.

A nurse is caring for a client in a critical care unit who has suffered a knife wound to the chest. The nurse suspects the clients is developing a cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion. a. Sudden legarthy b. Muffled heart sounds c. Flattened neck veins d. Bradycardia

b. Muffled heart sounds

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take? a. Instruct the client to perform range-of-motion exercises to his lower extremities. b. Perform neurovascular checks with vital signs. c. Ambulate the client 1 hr following the procedure. d. Restrict the client's fluid intake.

b. Perform neurovascular checks with vital signs.

A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily.

b. Provide a low-sodium diet.

A client with long-standing heart failure being treated for cancer has received a dose of ondansetron for nausea. What action by the nurse is most important? a. Assess the client for a headache or dizziness. b. Request a prescription for cardiac monitoring c. Instruct the client to change positions slowly. d. Weigh the client daily before eating

b. Request a prescription for cardiac monitoring

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1 F (40.1 C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assess in 15 minutes.

b. Start an intravenous line and infuse 0.9% saline solution.

A nurse in a long-term care facility is caring for a 83 year old client who has a history of heart failure and peripheral arterial disease. at present, the client is unable to stand or ambulate. the nurse should implement measures to prevent which complication? a. aortitis b. deep vein thrombosis c. thoracic aortic aneurysm d. raynaud disease

b. deep vein thrombosis

A nurse assesses a patient who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse (select all that apply) a. blood pressure of 140/88 b. serum potassium 2.9 c. warmth and redness at the site d. expanding groin hematoma e. rhythm changes on the cardiac monitor

b. serum potassium 2.9 d. expanding groin hematoma e. rhythm changes on the cardiac monitor

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a.Increase intravenous fluids by 100 mL/hr. b.Administer furosemide (Lasix) 40 mg IV push. c.Continue to monitor urine output hourly. d.Draw blood for serum electrolytes STAT.

b.Administer furosemide (Lasix) 40 mg IV push.

A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider? a.The patient has an outflow volume of 1800 mL. b.The patient's peritoneal effluent appears cloudy. c.The patient has abdominal pain during the inflow phase. d.The patient's abdomen appears bloated after the inflow.

b.The patient's peritoneal effluent appears cloudy.

The nurse preceptor tells the novice nurse that one of the late signs of increased ICP is the Cushing trad. The novice nurse asks what Cushing triad is. The preceptor would correctly

bradycardia hypertension bradypnea

A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, "All of my family hates me." How should the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous

c. "I will help you identify a support system."

A client is receiving rituximab and asks how it works. What response by the nurse is best? a. "It causes rapid lysis of the cancer cell membranes." b. "It destroys the enzymes needed to create cancer cells." c. "It prevents the start of cell division in the cancer cells." d. "It sensitizes certain cancer cells to chemotherapy."

c. "It prevents the start of cell division in the cancer cells."

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How should the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let the provider know." b. "Rehabilitation programs have helped many clients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability."

A nurse cares for a client who has hypothyroidism as a result of Hashimoto's thyroiditis. The client asks, "How long will I need to take this thyroid medication?" How should the nurse respond? a. "You will need to take the thyroid medication until the goiter is completely gone." b. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication." c. "You'll need thyroid pills for life because your thyroid won't start working again." d. "When blood tests indicate normal thyroid function, you can stop the medication."

c. "You'll need thyroid pills for life because your thyroid won't start working again."

A nurse is admitting a client who has acute heart failure following MI. The. Nurse recognizes which of the following prescriptions by the provider requires clarification.. a. Morphine sulfate 2mg IV bolus every 2hr PRN pain b. Laboratory testing of serum potassium upon admission c. 0.9% Normal saline IV at 50ml/hr continuous d. Bumetanide 1mg IV bolus every 12 hr (loop diuretic)

c. 0.9% Normal saline IV at 50ml/hr continuous

An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48 year old with a simple fracture of the lower leg

c. A 26-year-old male who has pale, cool, clammy skin

A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first? a. Unilateral peripheral swelling b. Clotting times c. Cardiopulmonary status d. Electrocardiogram rhythm

c. Cardiopulmonary status

The nurse is caring for a client who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac output? a. Increased blood pressure b. Bounding peripheral pulses c. Changes in level of consciousness d. Skin flushing

c. Changes in level of consciousness

A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate? a. Administer a dose of allopurinol. b. Assess the client's serum potassium level. c. Gently inquire about advance directives. d. Prepare the client for emergency surgery.

c. Gently inquire about advance directives.

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. I have been drinking more water than usual b. I am awakened by the need to urinate at night c. I must stop halfway up the stairs to catch my breath d. I have experienced blurred vision on several occasions

c. I must stop halfway up the stairs to catch my breath

A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond? a. To do the greatest good for the greatest number of people, it is necessary to sacrifice some. b. Not everyone will survive a disaster, so it is best to identify those people early and move on. c. In a disaster, extensive resources are not used for one person at the expense of many others. d. With black tags, volunteers can identify those who are dying and can give them comfort care.

c. In a disaster, extensive resources are not used for one person at the expense of many others.

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? a. Ensure the client has adequate sedation. b. Find another provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client's oxygen saturation.

c. Interrupt the procedure to give oxygen.

A nurse is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent? a. Chest pain and diaphoresis b. Decreased breath sounds due to chest trauma c. Left arm fracture with palpable radial pulses d. Sore throat and a temperature of 104° F

c. Left arm fracture with palpable radial pulses

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.

c. Provide frequent oral care per protocol.

Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients would the nurse assess first? a. Dry, itchy, peeling skin b. Serum calcium of 9.2 mg/dL (2.3 mmol/L) c. Serum potassium of 2.8 mEq/L (2.8 mmol/L) d. Weight gain of 0.5 lb (1.1 kg) in 1 day

c. Serum potassium of 2.8 mEq/L (2.8 mmol/L)

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L

c. Serum potassium: 6.5 mEq/L

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

c. Slurred speech and confusion

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity.

c. Transfer the client to a negative-pressure room.

A patient was brought into the ED after sustaining injuries due to an explosion while welding. The patient is breathing but has an oxygen saturation of 90%, a respiratory rate of 32, and is coughing. What is the priority action by the nurse? a) Start an IV of normal saline solution at 125 mL/h. b) Obtain a chest x-ray. c) Administer oxygen at 2 L/min via nasal cannula. d) Administer oxygen with a nonrebreather mask.

d) Administer oxygen with a nonrebreather mask.

A nurse assesses a client on the medical-surgical unit. Which statement made by the client should alert the nurse to the possibility of hypothyroidism? a. "My sister has thyroid problems." b. "I seem to feel the heat more than other people." c. "Food just doesn't taste good without a lot of salt." d. "I am always tired, even with 12 hours of sleep."

d. "I am always tired, even with 12 hours of sleep."

A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best? a. "It will increase the motility of the gastrointestinal tract." b. "It will keep the gastrointestinal tract functioning normally." c. "It will prepare the gastrointestinal tract for enteral feedings." d. "It will prevent ulcers from the stress of mechanical ventilation."

d. "It will prevent ulcers from the stress of mechanical ventilation."

The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed? a. "I should take my temperature daily and when I don't feel well." b. "I will discard perishable liquids after sitting out for over an hour." c. "I won't let anyone share any of my personal toiletries." d. "It's alright for me to keep my pets and change the litter box."

d. "It's alright for me to keep my pets and change the litter box."

Using the Rule of Nines to assess a client with burn injuries to the entire back region and all of the left arm, how should the nurse document the percentage (TBSA) of the patient's body that sustained burns? a. 18% b. 36% c. 9% d. 27%

d. 27%

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position

d. Place the client in an upright position

A nurse is assessing a female client who is taking hormone therapy for breast cancer. What assessment finding requires the nurse to notify the primary health care provider immediately? a. Irregular menses b. Edema in the lower extremities c. Ongoing breast tenderness d. Red, warm, swollen calf

d. Red, warm, swollen calf

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are being noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately.

d. Stay with the client and have someone else call the provider immediately.

A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority? a. Helping clients adjust to their appearance b. Reassuring clients that this change is temporary c. Referring clients to a reputable wig shop d. Teaching measures to prevent scalp injury

d. Teaching measures to prevent scalp injury

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy

d. Visiting Nurses for directly observed therapy

A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate? a. Crush the medications if the client cannot swallow them. b. Give one medication at a time with a full glass of water. c. No special precautions are needed for these medications. d. Wear personal protective equipment when handling the medications.

d. Wear personal protective equipment when handling the medications.

A client is brought to the emergency department bleeding profusely from a stab wound in the left chest area. Vital signs are blood pressure 80/50 mm Hg, pulse 110 beats/minute, and respiratory rate 28 breaths/minute. The nurse should expect which of the following potential problems? a. septic shock b. cariogenic shock c. neurogenic shock d. hypovolemic shock

d. hypovolemic shock

.A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action by the nurse is best? a. Ensure the client is placed in protective isolation. b. Have pregnant visitors stay 6 feet from the client c. No special action is necessary to care for this client. d. Read the policy on handling radioactive excreta.

d. read the policy on handling radioactive excreta

A nurse cares for a client who has burn injuries. The client's wife asks, "When will his high risk for infection decrease?" How should the nurse respond? a."When the antibiotic therapy is complete." b."As soon as his albumin levels return to normal." c."Once we complete the fluid resuscitation process." d."When all of his burn wounds have closed."

d."When all of his burn wounds have closed."

A patient is being brought into the emergency room. The patient is stiff with plantar flexion, legs internally rotated, shoulders adducted, and elbow and wrists flexed. The nurse would know this position as

decorticate

which statement by the patient who has undergone coronary artery bypass graft surgery identifies a need for further instruction

this will cure my atherosclerosis

you have identified your patient as suddenly going into third degree heart block. which of the following would be nursing interventions you would do (select all that apply)

· As a nursing priority, assess the patient for possible causes and monitor blood pressure, pulse, and other vital signs. Assess for syncope, palpitations, or shortness of breath. · Hypotension may occur due to a low ventricular rate. For patient safety, lie your patient down to prevent syncope and potential falls.

A nurse cares for a patient who is on a cardiac monitor. The monitor displayed the rhythm shown below:Which action does the nurse take first?

· Check for pulse/assess

The nurse is caring for a patient on the medical-surgical unit who suddenly shows this on the monitor. The cardiac monitor shows the rhythm below:The nurse runs into the patient's room. What action does the nurse take first?

· Check the patient/check for pulse

What is the refractory (irreversible) stage of shock?

· During this stage, vital organs have failed and the shock can no longer be reversed · Exacerbation of anaerobic metabolism · Profound acidosis · Profound hypotension and hypoxemia · Tachycardia worsens · Failure of one organ system affects others · Brain damage and cell death have occurred · Recovery unlikely · Death will be imminent→ end organ dysfunction

The nurse is analyzing a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm as which of the following?

· Normal sinus rhythm

What does the monitor read?

· Normal sinus rhythm

Which of the following characteristics of Sinus Rhythm with Second degree AV block Type I- Wenckebach. Select all that apply

· Progressive lengthening of the PR interval, with a dropped QRS complex

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

· The P wave is before the QRS complex

A nurse assesses a patient's electrocardiogram (ECG) and observes the reading shown below: How would the nurse document this patient's ECG strip?

• Univocal PVC