Final Nursing Concepts

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?

Speak at a normal volume

What is the normal QRS duration?

0.06-0.10 seconds

Osteoarthritis is defined as the loss of which of the following?

Articular Cartilage

What would you expect to see in a patient diagnosed with systemic lupus erythematosus (SLE)? SAA

Butterfly Rash Raynaud's phenomenon Fatigue Joint pain

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which manifestation of peritonitis?

Nausea and vomiting

A nurse is teaching a client who has chronic kidney failure about planning a low-protein diet. The client states, "Why do I have to be concerned about protein?" Which response should the nurse make?

"A low protein diet reduces the risk for uremia."

What is the normal PR interval?

0.12-0.20 seconds

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?

0.9% normal saline IV at 50 ml/hr continuous

A client with gastrointestinal (GI) bleeding suddenly develops diaphoresis with a rapid and thready pulse, and the nurse finds it difficult to hear a blood pressure. Which of the following intravenous (IV) fluids does the nurse anticipate the physician will order STAT?

0.9% sodium chloride (normal saline)

A 17 year old client who sustained a head injury in a motorcycle collision 2 days ago is responsive only to pain. Which intravenous (IV) fluid order would the nurse question because it could increase the risk of complications?

5% dextrose in water (D5W)

The nurse is evaluating a client with CAD. What is an expected patient outcome that demonstrates hemodynamic stability?

Blood pressure and pulse within range for adequate metabolic demands.

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?

Breathlessness

A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which action should the nurse take first?

Check the tubing for kinks

What occurs to the specific gravity of urine in a person with diabetes insipidus?

Decreases

A nurse is planning care for a client who has urolithiasis. Which action should the nurse take?

Encourage intake of at least 3L of fluids per day

Elevation of the ST segment indicates what?

MI

After years of pain Mr. F elected to have a total knee replacement to his left knee. As his primary nurse you know to assess for the following complications. Select all that apply.

Pulmonary Embolism Dislocation Infection Nerve Injury

While observing a patient in the ED with chest pain, the nurse suspects MI instead of Angina when she notes which EKG changes?

S-T segment elevation

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?

Troponin I

CHD may be asymptomatic, or may lead to angina pectoris, acute coronary syndrome, MI, dysrhythmias, heart failure, and even sudden death.

True

Which patient is at the highest risk for developing hyponatremia?

Young adult male with fever, severe vomiting, and diarrhea.

Medication is the only way to decrease hypertension.

False

SIADH is caused by a decrease in ADH secretion.

False

A nurse is reviewing the laboratory results from a client who has prerenal acute kidney injury. Which electrolyte imbalance should the nurse expect?

Hyperkalemia

What does the p wave measure?

Atrial regularity

Which of the following is a contraindication for a total joint arthroplasty surgery?

recent infection

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed?

Administer corticosteroids as prescribed for inflammation.

Which of the following are modifiable risk factors for coronary heart disease (CHD)? Select all that apply.

Diet Cigarette Smoking Activity Level

A patient returns following a heart cath in which the femoral artery was used for access. Which of the following is contraindicated following a heart cath?

Early ambulation to prevent DVT

An elderly patient was hydrated with lactated ringers solution in the emergency room for the last hour. During the most recent evaluation of the patient by the nurse, a finding of a rapid bounding pulse and shortness of breath were noted. Reporting this episode to the physician, the nurse suspects that the patient now shows signs of:

Hypervolemia, and needs the fluids adjusted.

Infusion of ______________ tonic intravenous solutions promotes movement of water into cells, thus making the cells swell.

Hypo

Chvostek's and Trousseau's signs are implemented to assess for what?

Hypocalcemia

A patient admitted for diabetic ketoacidosis is now hydrated and has a normal blood sugar. During assessment, the patient presents with a weak pulse, shallow breathing, and an ashen color. Which of the following imbalances is the cause?

Hypoglycemia

A patient reports being awakened at night by a "creepy-crawly" feeling in the legs that is only relieved by frequent position changes. What medical condition are they most likely suffering from?

Restless Leg Syndrome

Miss E., presents to her primary physician with complaints of fever, abdominal pain, nausea, vomiting, and a board like abdomen. Which of the following orders by Dr. P. is inappropriate for ruling out Peritonitis?

Troponin

Which lab is the most indicative indicator that an MI is occurring (most commonly used to dx MI because it elevates almost immediately) ?

Troponin 1

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? Select all that apply.

Troponin T CPK Myoglobin Troponin I

A nurse is performing discharge teaching with a client about the care of a newly created ileal conduit. The nurse should instruct the client to empty the appliance how often?

When the bag is 2/3 full

Which patient is at the highest risk for developing hyponatremia?

Young male adult with fever, severe vomiting, and diarrhea.

Urine specific gravity will be decreased with hyponatremia.

false

A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which assessment should the nurse view to be an indication of a postoperative complication?

Output of burgundy colored urine

A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate?

Pallor of toes with cold exposure

A nurse is providing dietary teaching to a client who has chronic kidney disease. The nurse should instruct the client to limit which nutrients? Select all that apply.

Phosphorous Sodium Protein

_________________ is a systemic connective tissue disorder characterized by inflammation of connective tissue and muscle fibers leading to muscle weakness and atrophy.

Polymyositis

Match the labs to their normal values.

Serum osmolality: 285-295 Urine specific gravity: 1.010-1.030 pH: 7.35-7.45 pCo2: 35-45 HCO3: 22-26 Na: 135-145 K: 3.5-5.0

A patient who exhibits xerophthalmia and xerostomia is most likely diagnosed with what autoimmune condition?

Sjogren Syndrome

A patient was found to have obstructive sleep apnea (OSA), but does not wish to use a continuous positive airway pressure (CPAP) device. The nurse will suggest which alternative measures to decrease OSA? (SAA)

Weight loss if the patient is obese Use of a device to prevent back-sleeping

The nurse provides home care instructions to a client with systemic lupus erythmatosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction?

"I should take hot baths because they are relaxing"

A nurse is teaching a client who has a new diagnosis of urge incontinence. Which pieces of information should the nurse include in the teaching? Select all that apply.

"You should limit fluids in the evening." "You should restrict your intake of caffeine." "Your provider might prescribe anticholinergic medications."

The hemodilution of body fluids that can cause hyponatremia includes which of the following causes? (Select all that apply)

Hypervolemia due to heart failure. SIADH Drinking excessive amounts of plain water.

Which of the following are manifestations of a fat or pulmonary embolism? Select all that apply.

Altered mental status Decreased SaO2 Increased Respirations Increased pulse Chest pain

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching?

"You need to limit your housekeeping activities"

Mr. C has a parent that has just been diagnosed with Colorectal Cancer. As you obtain his medical history you know Mr. C may be at risk for developing Colorectal Cancer as well due to the following statements made by Mr. C. Select all that apply.

"I have been trying to lose about 50 pounds, but I find it is hard to give up fast food with my busy schedule". "I still smoke 1 pack of cigarettes a day, but I am thinking about trying the new e-cigarettes". "I just had my 55th birthday and I wonder if I should slow down on drinking".

A nurse is providing discharge teaching for a client who is to perform peritoneal dialysis at home. Which of the following information should the nurse include?

"You should anticipate pain the first week during the inflow of dialysate."

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem?

A sense of a curtain falling across the field of vision.

When caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH), the nurse plans to do which of the following to correct the fluid and electrolyte imbalance associated with this disorder?

Administration of ordered loop diuretics.

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

Atrial fibrillation

When self recognition is impaired and immune defenses are directed against normal host tissue, the result is what?

Autoimmune Disorder

A nurse is developing a plan of care for a client who has a new ileal conduit. The nurse should include that the client is at risk for which of the following? Select all that apply.

Infection Impaired skin integrity Disturbed body image Anxiety

A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? Select all that apply.

Bananas Tomatoes Raisins

A nurse is carving for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which urinary alteration?

Bladder infection

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation?

Blurred Vision

A patient reports difficulty sleeping. Which suggestions will the nurse provide? (Select all that apply).

Exercise every day Put electronic devices away 1 to 2 hours before bedtime.

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

Irregular

Match the correct electrolyte imbalances with the cause.

NG Suctioning: Hyponatremia Overhydration with IV 1000mL NS: Hypernatremia Use of diuretics, such as furosemide: Hypokalemia Renal failure: Hyperkalemia

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply)

Nausea Diaphoresis Tachycardia

A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which lab result should the nurse review for an indication of a therapeutic effect of the medication?

The hematocrit (Hct)

Coronary Arteries main job is to supply blood to the heart, this will include the nodes (or electrical system) of the heart.

True

The general treatment goal related to angina is to reduce oxygen demand and increase oxygen supply in the body.

True

What class of medications is usually the first line of treatment in a hypertensive crisis?

Vasodilators

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which findings associated with urinary retention should the nurse expect? Select all that apply.

Voiding 30mL frequently Report of feeling pressure Distended bladder Tenderness over the symphysis pubis

Which of the following are examples of bowel obstructions: Pick all that apply.

Volvulus Incarcerated hernia Impaction Intussusception

The nurse is teaching a patient with heart failure about signs and symptoms that suggest the conditioning is worsening. Which of the following DO NOT suggest worsening of heart failure?

Weight loss of 3 pounds or more in 2 days

_________ macular degeneration is less common and is caused by the new growth of blood vessels that have thin walls that leak blood and fluid.

Wet

After a scope procedure a client is difficult to arouse. The priority action for the nurse to perform at this time is to:

assess the client's airway.

A 55 year-old client is scheduled for a total hip arthroplasty. The nurse is preparing a teaching plan for the client including activity restrictions after the surgery. Which of the following should the nurse include in the teaching plan? (Select all that apply)

avoid hip flexion greater than 90 degrees. use an abduction pillow while lying on your side in bed. continue isometric exercises.

A client is scheduled for a colonoscopy this morning, and the nurse notes the client is continuing to have stool in the last output after the prescribed phosphor-soda enema. The appropriate action for the nurse to take is to:

notify the provider