Final exam

What signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? (select all) 1.___Tachycardia 2.___Hypertension 3.___Increased CVP 4.___Increased urine output 5.___Jugular vein distention

1, 3, 5 (remember Beck's Triad-JVD, hypotension, and muffled heart sounds)

The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client? 1.10 seconds 2.15 seconds 3.25 seconds 4.30 seconds

1. 10 seconds

A client developed shock after a severe myocardial infarction and has now developed acute renal failure. The client's family asks the nurse why the client has developed ARF. The nurse should base the response on the knowledge that there was 1.A decrease in the blood flow through the kidneys 2.An obstruction of urine flow from the kidneys 3.A blood clot formed in the kidneys 4.Structural damage to the kidney resulting in acute tubular necrosis

1. A decrease in blood flow through the kidneys (think prerenal failure)

Which of the following should the nurse include in the plan of care for a post-op coronary arteriogram client? 1.Assess pedal pulses 2.Assess lung sounds 3.Provide early ambulation 4.Monitor vital signs every 8 hours

1. Assess pedal pulses

When assessing the client with a cord transection above T5 for possible complications, which of the following would the nurse expect as least likely to occur? 1.Diarrhea 2.Paralytic ileus 3.Stress ulcers 4.Intra-abdominal bleeding

1. Diarrhea, constipation would occur

Which of the following signs and symptoms would most likely be found in a client with mitral regurgitation? 1.Exertional dyspnea 2.Confusion 3.Elevated creatine phosphokinase concentration 4.Chest pain

1. Exertional dyspnea (rise in left atrial pressure causes pulmonary congestion)

The nurse is preparing a client for a paracentesis. Which of the following activities would be appropriate before the procedure? 1.Have the client void immediately before the procedure. 2.Place the client in a side-lying position. 3.Initiate an intravenous line to administer sedatives. 4.Place client on NPO status 6 hours before the procedure.

1. Have the client void immediately before the procedure.

A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection? 1.Hematocrit 2.Partial thromboplastin time 3.Hemoglobin concentration 4.Prothrombin time

1. Hematocrit (causes it to rise due to RBC producation, watch BP)

A client should be referred to the pulmonary clinic for suspected tuberculosis when the nurse takes a medical history that includes complaints of: 1.Hemoptysis and night sweats 2.Chest pain and increased cough 3.Weight gain and bilateral crackles Unexplained weight loss and vomiting

1. Hemoptysis (coughing up blood) and night sweats

After open-heart surgery a client develops a temperature of 102 F (38.8 C). The nurse notifies the physician, because elevated temperatures: 1.Increase the cardiac output 2.May indicate cerebral edema 3.May be a forerunner of hemorrhage 4.Are related to diaphoresis and possible chilling

1. Increase the cardiac output

The client with cirrhosis receives 100 mL of 25% serum albumin intravenously. Which finding would best indicate that the albumin is having its desired effect? 1.Increased urine output 2.Increased serum albumin level 3.Decreased anorexia 4.Increased ease of breathing

1. Increased urine output

A nursing is assessing data on a client with the diagnosis of Brown-Sequard syndrome. Which of the following findings should the nurse expect? 1.Ipsilateral paralysis and loss of touch and vibration 2.Bilateral loss of pain and temperature sensation 3.Contralateral paralysis and loss of touch and vibration 4.Complete paraplegia or quadriplegia, depending on the level of injury

1. Ipsilateral paralysis and loss of touch and vibration

The client states she does not understand what causes idiopathic thrombocytopenic purpura (ITP). The nurse provides which of the following explanations? 1.It is believed that the platelets are coated with antibodies and the spleen sees them as foreign bodies 2.It is believed that the liver identifies the platelets as foreign bodies 3.It is now believed that the syndrome is related to an underactive immune system 4.The cause is unknown

1. It is believed that the platelets are coated with antibodies and the spleen sees them as foreign bodies

When caring for a client after a closed renal biopsy, the nurse would plan on implementing which of the following nursing measures? 1.Maintaining the client on strict bed rest in a supine position for 6 hours 2.Inserting an indwelling catheter to monitor urine output 3.Applying a sandbag to the biopsy site to prevent bleeding 4.Administering intravenous narcotics to promote comfort

1. Maintaining the client on strict bed rest in a supine position for 6 hours

If the client who was admitted for MI develops cardiogenic shock, which characteristic signs should the nurse expect to observe? 1.Oliguria 2.Bradycardia 3.Elevated blood pressure 4.Fever

1. Oliguria r/t reduced blood flow to kidneys

A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement by the nurse best explains the procedure to the client? 1.PTCA involves opening a blocked artery with an inflatable balloon located at the end of a catheter 2.PTCA involves cutting away blockages with a special catheter 3.PTCA involves passing a catheter through the coronary arteries to find blocked arteries 4.PTCA involves inserting grafts to divert blood from blocked arteries

1. PTCA involves opening a blocked artery with an inflatable balloon located at the end of a catheter

The nurse administers fat emulsion solution during TPN as order based on the understanding that this type of solution: 1.Provides essential fatty acids 2.Provides extra carbohydrates 3.Promotes effective metabolism of glucose 4.Maintains a normal body weight

1. Provides essential fatty acids (aka Lipids)

In the early stage of shock, the nurse would expect the results of arterial blood gas (ABG) analysis to indicate: 1.Respiratory alkalosis 2.Respiratory acidosis 3.Metabolic alkalosis 4.Metabolic acidosis

1. Respiratory alkalosis due to hyperventilation secondary to hypoxia

The initial treatment plan for a client with pancreatitis most likely would focus on which of the following as a priority? 1.Resting the gastrointestinal tract 2.Ensuring adequate nutrition 3.Maintaining fluid and electrolyte balance 4.Preventing the development of an infection

1. Resting the GI tract (decreases the pancreatic secretion of enzymes)

The nurse should anticipate that which of the following conditions can place a client at risk for ARDS? 1.Septic shock 2.COPD 3.Asthma 4.Heart failure

1. Septic shock

Which of the following respiratory patterns indicate increasing ICP in the brain stem? 1.Slow, irregular respirations 2.Rapid, shallow respirations 3.Asymmetric chest excursion 4.Nasal flaring

1. Slow, irregular respirations-brain stem is affected

After confirming the diagnosis of iron-deficiency anemia through laboratory values, the next essential test is: 1.Stool guaiac x3 2.Liver function 3.Lipid profile 4.Endoscopy

1. Stool guaiac x3

The client with a head injury received mannitol (Osmitrol) during surgery to help decrease intracranial pressure. Which of the following nursing observations would most likely indicate that the drug is having the desired effect? 1.Urine output increases 2.Pulse rate decreases 3.Blood pressure decreases 4.Muscular relaxation increases

1. Urine output increases due to osmotic diuretic effects

When the nurse administers intravenous midazolam hydrochloride (Versed), the client demonstrates signs of an overdose. Which of the following interventions should the nurse be prepared to implement first? 1.Ventilate with an oxygenated Ambu bag 2.Defibrillate 3.Administer 0.5mL 1:1000 epinephrine 4.Administer Flumazenil (Romazicon)

1. Ventilate with an oxygenated Ambu bag

Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug's desired effect? 1.5 to 10 minutes 2.30 to 60 minutes 3.2 to 4 hours 4.6 to 8 hours

1.5 to 10 minutes (peaks 30 min, last 2-4 hours)

Which abnormal laboratory value is most indicative of aplastic anemia? 1.A decreased hemoglobin 2.An elevated white blood cell count 3.An elevated red blood cell count 4.A decreased erythrocyte sedimentation rate

1.A decreased hemoglobin (will also have a decreased RBC count, decreased WBC count, & decreased platelets)

Which of the following is contraindicated for a client diagnosed with DIC? 1.Treating the underlying cause 2.Administering Heparin 3.Administering Coumadin 4.Replacing depleted blood products

1.Administering Coumadin (DIC doesn't respond to oral anticoagulants)

When taking an admission history of a client with right ventricular heart failure, the nurse would expect the client to complain of: 1.Dyspnea, edema, fatigue 2.Fatigue, vertigo, headache 3.Weakness, palpitations, nausea 4.A feeling of distress when breathing

1.Dyspnea, edema, fatigue

The nurse evaluates the client's most recent laboratory data. Which laboratory finding would be consistent with a diagnosis of acute pancreatitis? 1.Hyperglycemia 2.Leukopenia 3.Thrombocytopenia 4.Hyperkalemia

1.Hyperglycemia-pancreas cannot secrete insulin

A nurse is assessing a client who is unable to extend the legs without pain, has a temperature of 103 F, and on flexion of the neck also flexes the hip and knee. Based on this assessment, the nurse suspects the client has (a): 1.Meningitis 2.Brain abscess 3.Brain tumor 4.Epilepsy

1.Meningitis (Brudzinski's sign)

A nurse is performing an admission assessment on a client admitted with newly diagnosed Hodgkin's disease. Which of the following would the nurse expect the client to report? 1.Night sweats 2.Severe lymph node pain 3.Weight loss of 2 kg 4.Headache with minor visual changes

1.Night sweats

The most common symptom associated with bladder cancer is: 1.Painless hematuria 2.Decreasing urine output 3.Burning on urination 4.Frequent infections

1.Painless hematuria

In the oliguric phase of acute renal failure, the nurse should anticipate the development of which of the following complications? 1.Pulmonary edema 2.Metabolic alkalosis 3.Hypotension 4.Hypokalemia

1.Pulmonary edema r/t decreased urine output and fluid retention

The friend of a client brought to the hosital's emergency room states, "I guess she had some bad junk (heroine) today." The client is drowsy and verbally nonresponsive. Which of the following assessment findings would be of immediate concern to the nurse? 1.Respiratory rate of 9 breaths/min 2.Urinary retention 3.Hypotension 4.Reduced pupil size

1.Respiratory rate

The nurse realizes that the client is at risk for autonomic dysreflexia. Which of the following symptoms would indicate this condition? 1.Sudden, severe hypertension 2.Bradycardia 3.Paralytic ileus 4.Hot, dry skin

1.Sudden, severe hypertension (also a headache, "goose bumps" and profuse sweating)

The neurological assessment of a client who had a craniotomy includes the Glasgow Coma Scale. What does the nurse evaluate to assess the client's score on the Glasgow Coma Scale? Check all that apply. 1.___Ability of the client's pupils to react to light 2.___Degree of purposeful movement by the client 3.___Appropriateness of the client's verbal responses 4.___Stimulus necessary to cause the client's eyes to open 5.___Symmetry of muscle strength of the client's extremities

2, 3, 4

The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? 1.Elevated Schilling's test 2.Absent intrinsic factor 3.Sedimentation rate 16mm/hr 4.RBC's 5.0 million/uL

2. Absent intrinsic factor due to atrophy of stomach wall (without intrinsic factor, B12 cannot be absorbed)

The nurse assesses the client to determine the cause of autonomic dysreflexia. The nurse would prioritize assessment based on the knowledge that the most common stimulus for an autonomic dysreflexia episode is: 1.Bowel distention 2.Bladder distention 3.Anxiety 4.Rising intracranial pressure

2. Bladder distention

What is the earliest and most obvious clinical manifestation in a client with acute disseminated intravascular coagulation (DIC)? 1.Severe shortness of breath 2.Bleeding without history of cause 3.Orthopnea 4.Hematuria

2. Bleeding without history or cause

A 15 year old client needs life-saving emergency surgery, but his relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response? 1.Send the client to surgery without the consent 2.Call the family for consent over the telephone and have another nurse listen as a witness 3.No action is necessary in this case because consent is not needed 4.Have the family sign the consent as soon as they arrive

2. Call the family and have another nurse listen as a witness-try and reach the family if able!

A client is receiving a blood transfusion when he begins to complain of difficulty breathing. The nurse notes an elevated blood pressure and cough. Based on these signs, the nurse suspects which of the following complications? 1.Anaphylactic reaction 2.Circulatory overload 3.Sepsis 4.Acute hemolytic reaction

2. Circulatory overload

A client's chest tube accidentally disconnects from the drainage tube when she turns onto her side. Which of the following actions should the nurse take first? 1.Notify the physician 2.Clamp the chest tube 3.Raise the level of the drainage system 4.Reconnect the tube

2. Clamp the chest tube

A nurse ascultates the chest of a client with valvular heart disease every 4 hours. Assessment of which of the following breath sounds indicates a problem with cardiac output? 1.S3 2.Crackles 3.Bronchial 4.Ventricular gallop

2. Crackles

What is the most important nursing action when measuring a pulmonary capillary wedge pressure (PCWP)? 1.Have the client bear down when measuring the PCWP 2.Deflate the balloon as soon as the PCWP is measured 3.Place the client in a supine position before measuring the PCWP 4.Flush the catheter with a heparin solution after the PCWP is determined

2. Deflate the balloon as soon as the PCWP is measured

A 17-year old male is admitted following an automobile accident. He is very anxious, dyspneic, and in severe pain. The chest wall moves in during inspiration and balloons out when he exhales. The nurse understands these symptoms are most suggestive of: 1.Hemothorax 2.Flail chest 3.Atelectasis 4.Pleural effusion

2. Flail Chest

The client asks the nurse what causes a peptic ulcer to develop. The nurse responds that recent research indicates that many peptic ulcers are the result of which of the following? 1.Work-related stress 2.Helicobacter pylori infection 3.Diets high in fat 4.A genetic defect in the gastric mucosa

2. Helicobacter pylori infection

The nurse interprets which of the following as an early sign of ARDS in a client at risk? 1.Elevated carbon dioxide level 2.Hypoxia not responsive to oxygen therapy 3.Metabolic acidosis 4.Severe, unexplained electrolyte imbalance

2. Hypoxia not responsive to oxygen therapy (you keep turning up O2 but pt doesn't get better!)

The nurse would anticipate which of the following arterial blood gas results in a client experiencing a prolonged, severe asthma attack? 1.Decreased paCO2, increased PaO2, and decreased pH 2.Increased PaCO2, decreased PaO2, and decreased pH 3.Increased PaCO2, increased PaO2, and increased pH 4.Decreased PaCO2, decreased PaO2, and increased pH

2. Increased PaCO2, decreased PaO2, and decreased pH (this pt is tired!)

Which of the following signs of symptoms would the nurse expect to see in a client with pancreatitis? 1.Hypertension 2.Left upper quadrant abdominal pain 3.Bradycardia 4.Decreased white blood cell count

2. Left upper quadrant abdominal pain

The most common cause of diabetic ketoacidosis is: 1.Emotional stress 2.Presence of infection 3.Increased insulin dose 4.Inadequate food intake

2. Presence of an infection (insulin cannot be secreted fast enough to keep up with metabolic demands of body)

A nurse should expect a client with an acute myocardial infarction to first manifest which of the following? 1.Abnormal Q wave 2.ST segment elevation 3.T wave depression 4.Elevated serum creatine kinase MB isoenzyme

2. ST segment elevation

A client with bacterial pneumonia is to be started on intravenous antibiotics. Which of the following diagnostic tests must be completed before antibiotic therapy begins? 1.Urinalysis 2.Sputum culture 3.Chest radiograph 4.Red blood cell count

2. Sputum culture

A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. The nurse prepares for cardioversion. To avoid a potential danger of inducing ventricular fibrillation during cardioversion, the nurse should ensure that the: 1.Energy level is set at its maximum level 2.Synchronizer switch is in the "on" position 3.Skin electrodes are applied after the T wave 4.Alarm system of the cardiac monitor is functioning simultaneously

2. Synchronizer switch is in the "on" position

When the client has a cord transection at T4, which of the following is the primary focus of the nursing assessment? 1.Renal status 2.Vascular status 3.Gastrointestinal function 4.Biliary function

2. Vascular status (risk for bradycardia & hypotension due to loss of sympathetic feedback loop

During the period of spinal shock, the nurse would expect the client's bladder function to be which of the following? 1.Spastic 2.Normal 3.Atonic 4.Uncontrolled

3. Atonic-needs catheter

Which of the following laboratory results would be unexpected in a client with chronic renal failure? 1.Serum potassium 6.0 mEq/L 2.Serum creatinine 9mg/dL 3.BUN 15mg/dL 4.Serum phosphate 5.3 mg/dL

3. BUN 15mg/dL

During the first 24 hours after thrombolytic treatment for an ischemic CVA, the primary goal is to control the client's 1.Pulse 2.Respirations 3.Blood pressure 4.Temperature

3. Blood pressure-perfusion!

A nurse is caring for a client who has begun using peritoneal dialysis. The nurse would determine that which of the following manifestations by the client would most likely indicate the onset of peritonitis? 1.Oral temperature of 99.0 F 2.History of GI upset lasting one week 3.Cloudy dialysate fluid 4.Presence of crystals in dialysate output

3. Cloudy dialysate fluid

What assessment data should the nurse anticipate when admitting a client with an extracellular fluid excess? 1.Elevated hematocrit 2.Rapid, thready pulse 3.Distended jugular veins 4.Increased serum sodium

3. Distended jugular veins

Which clinical manifestation does the nurse expect in the client in the postictal phase of grand mal seizure? 1.Inability to move 2.Paresthesia 3.Drowsiness 4.Hypotension

3. Drowsiness

A client is admitted to the surgical floor after having bowel surgery. The nurse observes that the client's urinary output has decreased from 50 to 20mL/hr. Which of the following is the most likely cause? 1.Bowel obstruction 2.Side effect of opioid analgesics 3.Hemorrhage 4.Hypertension

3. Hemorrhage

The nurse recognizes that spinal shock is likely to persist for the first several weeks after the injury. Which of the following symptoms would be unexpected during the period of spinal shock? 1.Tachycardia 2.Rapid respirations 3.Hypertension 4.Dry, warm skin

3. Hypertension (massive vasodilation and pooling of blood in periphery occurs)

A client has the following arterial blood gas values: pH 7.52, PaO2 50 mmHg, PaCO2 28 mmHg, HCO3 24 meq/L. From the client's PaCO2 level, the nurse determines that the client is experiencing which of the following conditions? 1.Hypoxemia 2.Hypoventilation 3.Hyperventilation 4.Oxygen toxicity

3. Hyperventilation

Which of the following is an assessment finding associated with internal bleeding with DIC? 1.Bradycardia 2.Hypertension 3.Increasing abdominal girth 4.Petechiae

3. Increasing abdominal girth

The nurse is caring for an older adult who is being treated for a myocardial infarction. Oxygen is ordered. Administering oxygen to this client is related to which of the following client problems? 1.Anxiety 2.Chest pains 3.Ineffective myocardial perfusion 4.Alteration in heart rate, rhythm, or conduction

3. Ineffective myocardial perfusion

The nurse is reviewing a urinalysis report for a client with acute renal failure (ARF). The results are highly positive for proteinuria. The nurse interprets that this client has which of the following types of renal failure? 1.Postrenal failure 2.Prerenal failure 3.Intrinsic renal failure 4.Atypical renal failure

3. Intrinsic renal failure (post and pre do not have proteinuria)

While assessing a thoractomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. Which of the following should be the nurse's first action? 1.Lower the head of the bed and call the physician. 2.Prepare an aspiration tray. 3.Mark the area with a skin pencil at the outer periphery of the crackling. 4.Turn off the suction of the chest drainage system.

3. Mark the area with a skin pencil at the outer periphery of the crackling.

A client with pneumonia is experiencing pleuritic chest pain. Which of the following describes pleuritic chest pain? 1.A mild but constant aching in the chest 2.Severe midsternal pain 3.Moderate pain that worsens on inspiration 4.Muscle spasm pain that accompanies coughing

3. Moderate pain that worsens on inspiration

During the evening shift of the day of the client's surgery, the nasogastric tube drains 500 mL of green-brown fluid. The nurse should: 1.Call the physician immediately 2.Increase the intravenous infusion rate 3.Record the amount of drainage on the client's chart 4.Irrigate the tube with sterile water solution

3. Record the amount of drainage on the client's chart

A nurse is caring for a client with a spinal cord injury who has spinal shock. The nurse performs an assessment on the client knowing that which assessment will provide the best information about recovery from spinal shock? 1.Blood pressure 2.Pulse rate 3.Reflexes 4.Temperature

3. Reflexes (spinal shock is characterized by areflexia)

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate? 1.Obtain arterial blood gases 2.Lower the tidal volume setting 3.Remove secretions by suctioning 4.Check that the tubing connections are secure

3. Remove secretions by suctioning

A nursing instructor has taught a student about increased intracranial pressure (ICP). The instructor asks the student about the 3 types of noncompressible cranial contents. The student responds correctly by stating that these include the: 1.Ventricles, blood volume, & subarachnoid space 2.Cerebrospinal fluid, brain, & the foramen ovale 3.Semisolid brain, cerebrospinal fluid, & the intravascular blood 4.Gray matter, white matter, & the extrapyramidal tract

3. Semisolid brain, CSF, and the intravascular blood volume

Adequate fluid replacement for a client during the first 24 hours following a burn injury would be indicated by a: 1.Falling CVP readings 2.Urinary output of 15 to 20 mL/hr 3.Slowing of a previous rapid pulse 4.Hematocrit level rising from 50 to 55

3. Slowing of a previously rapid pulse

The nurse is aware that the body's attempts to compensate for excessive fluid losses associated with diarrhea are evident in an increased: 1.Hematocrit 2.Temperature 3.Specific gravity 4.Serum potassium

3. Specific gravity (kidney tries to compensate for fluid loss)

A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? 1.An obstruction is present in the chest tube 2.The client is developing subcutaneous emphysema 3.The chest tube is functioning properly 4.There is a leak in the chest tube system

3. The chest tube system is functioning properly

A client arrives in the emergency department with an ischemic CVA and plans to receive tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? 1.Current medications 2.Complete physical and history 3.Time of onset of current CVA 4.Upcoming surgical procedures

3. Time of onset of current CVA

For a client with a demand pacemaker, the nurse explains that this pacemaker functions by providing stimuli to the heart muscle at which of the following times? 1.When the heart begins to beat irregularly 2.Constantly, resulting in a predetermined heart rate 3.When the heart rate falls below a specified level 4.Whenever ventricular fibrillation occurs

3. When the heart rate falls below a specified level

A client is admitted to the hospital for repair of an unruptured cerebral aneurysm. Before surgery, the nurse performs frequent assessments on the client. Which assessment finding would be noted first if the aneurysm ruptures? 1.Widened pulse pressure 2.Unilateral slowing of pupil responses 3.Unilateral motor weakness 4.A decline in the level of consciousness

4. A decline in the LOC

A client experiences a traumatic brain injury. Which finding indicates damage to the upper motor neurons? 1.Absent reflexes 2.Flaccid muscles 3.Trousseau's sign 4.Babinski response

4. Babinski response (hyperreflexia is found)

A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? 1.Widening pulse pressure 2.Decrease in the pulse rate 3.Dilated, fixed pupil 4.Decrease in LOC

4. Decrease in LOC

The goal of nursing care for a client acute myeloid leukemia (AML) is to prevent: 1.Cardiac arrhythmias 2.Liver failure 3.Renal failure 4.Hemorrhage

4. Hemorrhage (these patients die from bleeding or infection)

Which of the following fluid and electrolyte imbalances would the nurse anticipate that the client would be particularly susceptible to in the emergent phase of burn care? 1.Hemodilution 2.Metabolic alkalosis 3.Hypernatremia 4.Hyperkalemia

4. Hyperkalemia (K+ is released into extracellular fluid)

The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. Which of the following would be ordered to prepare the client for this radiograph? 1.Fluid and food will be withheld the morning of the examination 2.A sedative will be given before the examination 3.An enema will be given before the examination 4.No special preparation is required for the examination

4. No special preparation is required for the examination

The nurse carefully monitors the client with acute pancreatitis for which of the following complications? 1.Congestive heart failure 2.Duodenal ulcer 3.Cirrhosis 4.Pneumonia

4. Pneumonia & respiratory complications

In addition to treatment of the underlying cause, management of acute respiratory distress syndrome (ARDS) includes: 1.Chest tube insertion 2.Aggressive diuretic therapy 3.Administration of beta blockers 4.Positive end expiratory pressure

4. Positive end expiratory pressure

An adult client has undergone a lumbar puncture to obtain a cerebrospinal fluid (CSF) for analysis. A nurse assess for which of the following values that should be negative if the CSF is normal? 1.Protein 2.Glucose 3.White blood cells 4.Red blood cells

4. Red blood cells

After administering naloxone (Narcan), an opioid antagonist, the nurse should monitor the client carefully for which of the following? 1.Cerebral edema 2.Kidney failure 3.Seizure activity 4.Respiratory depression

4. Respiratory depression

Which of the following laboratory tests is the most reliable indicator of renal function? 1.BUN 2.Urinalysis 3.Serum potassium 4.Serum creatinine

4. Serum creatinine

A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following? 1.An intestinal obstruction has developed 2.Additional ulcers have developed 3.The esophagus has become inflamed 4.The ulcer has perforated

4. The ulcer has perforated

A man's blood type is AB and he requires a blood transfusion. To prevent complications of blood incompatibilities, the nurse knows that the client may receive: 1.Type A or B only 2.Type AB blood only 3.Type O blood only 4.Type A, B, AB, or O blood

4. Type A, B, AB, or O blood

In assessing a client in the early stage of chronic lymphocytic lymphoma (CLL), the nurse is aware that the client is prone to experiencing which of the following? 1.Enlarged, painless lymph nodes 2.Headache 3.Hyperplasia of gums 4.Unintential weight loss

4. Unintentional weight loss (also fever, night sweats, large painful LN's)

An adult is diagnosed with disseminated intravascular coagulation (DIC). The nurse should identify that the client is a risk for which of the following nursing diagnoses? 1.Risk for increased cardiac output related to fluid volume excess 2.Disturbed sensory perception related to bleeding into tissues. 3.Alteration in tissue perfusion related to bleeding and diminished blood flow. 4.Risk for aspiration related to constriction of the respiratory musculature.

Alteration in tissue perfusion related to bleeding and diminished blood flow

When the nurse tested an unconscious client for noxious stimuli, the client responded with decorticate rigidity or posturing. This is best described as: 1.Flexion of the upper and lower extremities into a fetal-like position 2.Rigid extension of the upper and lower extremities and plantar flexion 3.Complete flaccidity of both upper and lower extremities and hyperextension of the neck 4.Flexion of the upper extremities, extension of the lower extremities, and plantar flexion

Flexion of the upper extremities, extension of the lower extremities, and plantar flexion

Which of the following assessment findings by the nurse indicates right ventricular failure in a client? 1.Pink frothy sputum 2.Paroxysmal nocturnal dyspnea 3.Jugular venous distention 4.Crackles

Jugular venous distention

A client with a history of a myocardial infarction two days ago reports chest pain that is worse on inspiration but is relieved by sitting forward. Based on this finding, the nurse suspects the client is experiencing the pain of: 1.Endocarditis 2.Angina pectoris 3.Pericarditis 4.Recurrent myocardial infarction.

Pericarditis

Which of the following represents a significant risk immediately after surgery for repair of an aortic aneurysm? 1.Potential alteration in renal perfusion 2.Potential electrolyte imbalance 3.Potential ineffective coping 4.Potential wound infection

Potential alteration in renal perfusion

Two body systems that interact with bicarbonate buffer system to preserve the normal body fluid ph of 7.4 are the: 1.Skeletal and nervous systems 2.Circulatory and urinary systems 3.Respiratory and urinary systems 4.Muscular and endocrine systems

Respiratory and urinary systems