HURST Mod 1

The client presents to the emergency department with nausea, vomiting and anorexia for the last few days. As the nurse connects the client to a cardiac monitor, the client becomes unresponsive, without a pulse. The nurse the rhythm. What action should the nurse take first? 1. Defibrillate at 200 joules 2. Administer amiodarone IV 150 mg over 10 minutes 3. Infuse 500 mL NS with 40 mEq KCL (40 mmol/L) at 100 mL/hour 4. Begin 2 person cardiopulmonary resuscitation

1. Correct: The client has become unresponsive and does not have a pulse. The monitor is showing Ventricular tachycardia. The first action with pulseless V-tach is defibrillation.

A client arrives at the emergency department after being removed from a burning building. The nurse suspects carbon monoxide poisoning when the client exhibits which signs and symptoms? 1. Almond odor to breath 2. Blurred Vision 3. Dull headache 4. Excess salivation 5. Respirations 10

2.,3. & 5. Correct: Not enough oxygen is getting to the vital organs, such as the brain and heart, so blurred vision, a dull headache and respiratory depression can occur. 1. Incorrect: An almond odor to the breath is a manifestation of cyanide poisoning. 4. Incorrect: Excessive salivation can be seen with ingestion of acids or alkalis.

What should the nurse monitor for when caring for a client receiving an IV of 0.9% Normal Saline at 150 mL/hr? 1. Hypotension 2. Fluid volume deficit 3. Hyponatremia 4. Pulmonary edema

4. Correct: NS is an isotonic solution which causes fluid to stay in the vascular space. Too much fluid in the vascular space will put too much work on the heart. If the heart cannot keep up with the workload, fluid will back up from the heart to the lungs. Pulmonary edema is a complication to monitor for with rapid NS infusion.

Based on the results of the arterial blood gases (ABGs), what imbalance does the nurse understand the client to be exhibiting? 1. Respiratory acidosis compensated 2. Respiratory acidosis partially compensated 3. Metabolic acidosis compensated 4. Metabolic acidosis partially compensated

1. Correct: The pH is normal but is on the acidic side of normal. The PaCO2 is elevated, causing acid formation. The HCO3 is alkalotic and is increased to buffer the acid. The pH and PaCO2 match, so the original problem was respiratory acidosis, but compensation has occurred since the pH is now normal.

The community health nurse has been educating a group of college students living in a dormitory about receiving an immune globulin (IG) injection for hepatitis A virus (HAV). Which statement made by the students would indicate to the nurse that further teaching is necessary? 1. Immune globulin contains antibiotics that destroy the HAV, preventing infection. 2. Immune globulin protection is permanent, so no other injection is required. 3. Common side effects of the injection include soreness and swelling around the injection site. 4. The sooner you get a shot of IG after being exposed to HAV, the greater the likelihood of protection from the virus. 5. Crowded living environments such as dormitories place people at risk for HAV.

1., & 2. Correct: Immune globulin contains antibodies that destroy the HAV, preventing infection. IG protection is only temporary, lasting about 3 months.

How should the nurse interpret this arterial blood gas (ABG) report? pH - 7.34 PaO2 - 94% PaCO2 - 30 HCO3 - 20 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

1., & 6. Correct: This set of ABGs reflects partially compensated metabolic acidosis. The pH, bicarb, and carbon dioxide are all abnormal, so compensation is beginning. Since the pH is not normal yet, total compensation has not occurred. There is only partial compensation. 2. Incorrect: The pH remains low (acidic) so acidosis rather than alkalosis is occurring. 3. Incorrect: This set of ABGs reflects partially compensated metabolic acidosis. The pH, bicarb, and carbon dioxide are all abnormal, so compensation is beginning. Since the pH is not normal yet, total compensation has occurred. The pH and bicarb match indicating a metabolic problem initially. The lungs are attempting to compensate by blowing off CO2. 4. Incorrect: This set of ABGs reflects partially compensated metabolic acidosis. The original problem is not a lung problem, but a metabolic problem. 5. Incorrect: With uncompensated metabolic acidosis, the lungs have decreased the CO2 (acid) level in the blood yet. 7. Incorrect: Full compensation occurs when the pH has reached within the normal range.

A client has been admitted with advanced Cirrhosis. The nurse's assessment of the abdominal girth verifies an increase in 5 inches (12.7 cm) and an increase in 6 lbs. (2.72 kg) since yesterday's measurements. Which interventions would the nurse expect to see in this client's plan of care? 1. Administer spironolactone 100 mg by mouth once daily. 2. Ask client about food intake over past 24 hours. 3. Maintain client in supine position. 4. Obtain weight daily. 5. Provide 3 small meals throughout the day.

1., 2., & 4. Correct: Spironolactone is used in the management of edema in cirrhosis of the liver unresponsive to fluid and sodium restriction. This diuretic blocks actions of aldosterone and is potassium sparing. The initial dose for treatment of ascites in 100 mg by mouth once daily. The nurse should ask about the client's diet to determine if the client is eating foods high in sodium. Too much sodium causes fluid retention. Obtain daily weight. The nurse needs to monitor the effectiveness or ineffectiveness of treatment. The goal is to get rid of fluid. Diuretics are used, so we expect weight to go down.

The nurse is caring for a client admitted to the unit with heart failure. Upon entering the room, the nurse notes that the client is agitated, gasping for air, and attempting to sit up. The client states "I can't get my breath". What actions should the nurse take? 1. Elevate the head of the bed to sitting position 2. Dangle client's legs over side of the bed 3. Initiate oxygen at 2 liters per nasal cannula 4. Initiate IV of lactated ringers 5. Administer morphine 2 mg IV

1., 2., 3., & 5. Correct: What are you worried about? The client has heart failure and is now agitated, gasping for air and trying to sit up. The client is in acute distress, likely from pulmonary edema. The first thing the nurse should do is to sit the client up. This allows for better chest expansion, thereby improving pulmonary capacity. By dangling the legs, blood is pooling in the periphery. This decreases the circulating blood volume so that the heart does not have to work as hard and blood will then go in a forward direction rather than going backward to the lungs. Oxygen increases available oxygen for myocardial uptake to combat effects of hypoxia. Morphine decreases vascular resistance and venous return, reducing myocardial workload, especially when pulmonary congestion is present. Allays anxiety and breaks the feedback cycle of anxiety to catecholamine release to anxiety.

A nurse is caring for a client who was admitted with severe dehydration due to excessive vomiting. Which data noted by the nurse validates this diagnosis? 1. Flat neck veins when supine 2. Lethargy 3. Hematocrit 36% 4. Orthopnea 5. Tachycardia 6. Urine specific gravity - 1.036

1., 2., 5., & 6. Correct: These are signs and symptoms indicating that a client is dehydrated (fluid volume deficit).

The nurse is caring for a client 8 hours post colectomy who is receiving 40% humidified oxygen. ABG results are: pH= 7.30, pO2= 91, pCO2= 50, HCO3= 24. Based on this information, which nursing action should the nurse initiate? 1. Reposition the client every 2 hours. 2. Request respiratory therapy to perform postural drainage and percussion. 3. Increase oxygen percentage. 4. Initiate incentive spirometry. 5. Assess mental status.

1., 4., & 5. Correct: If you had just a colectomy, would you be taking nice deep breaths? No. So what would you be retaining? CO2, which makes your pCO2 go up and your pH go down. These interventions will help improve gas exchange. 2. Incorrect: Requesting postural drainage and percussion form respiratory therapy would not be the best nursing action to address the problem of retaining CO2. 3. Incorrect: How is oxygen going to help this client? It's not until they get rid of what? CO2. And the only way to rid of the CO2 is coughing and deep breathing.

Which client would the nurse monitor for the development of anaphylactic shock? 1. Admitted with pericardial tamponade 2. Allergic reaction to penicillin administration 3. Diagnosed with Cushing's Disease 4. A 10 year old with 40% Total body surface area (BSA) burns 5. Admitted with multiple wasp stings

2. & 5. Correct: These clients are at risk for anaphylactic shock. 1. Incorrect: I would worry about cardiogenic shock with this client. 3. Incorrect: I would worry about fluid volume excess with this client. 4. Incorrect: This child is at risk for hypovolemic shock.

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education was successful when a nurse selects which set of ABGs as compensated respiratory alkalosis? 1. pH - 7.35, PaCO2 - 45, HCO3 - 22 2. pH - 7.45, PaCO2 - 32, HCO3 - 20 3. pH - 7.46, PaCO2 - 34, HCO3 - 26 4. pH - 7.48, PaCO2 - 44, HCO3 - 28

2. Correct: This set of ABGs indicate compensated respiratory alkalosis. The pH is normal, but on the alkalotic side of normal (normal 7.35-7.45; perfect is 7.4). Both the PaCO2 is low, indicating alkalosis, so it matches the alkalotic pH. The bicarb are abnormal at 20 which indicates acidosis. The bicarb is low to get rid of base. Compensation has occurred.

A nurse is caring for a client that is lethargic and has the following ABGs: pH = 7.33, PaCO2 = 49, HCO3 = 26, O2 = 92%. What medication could have contributed to these blood gases? 1. Furosemide 2. Chloral hydrate 3. Heroin 4. Methadone 5. Methylphenidate 6. Tramadol

2., 3., 4., & 6. Correct: Yes. These medications typically decrease the respiratory rate, causing respiratory acidosis.

The charge nurse is evaluating a new nurse who is performing a linear wound dressing change on a surgical client. Which action by the new nurse requires intervention by the charge nurse? 1. Hand hygiene is done prior to the dressing change. 2. Dressing tape is removed in the direction opposite of the hair growth. 3. The soiled dressing is discarded in a biomedical waste bag. 4. Clean gloves are donned in order to clean the wound. 5. The center of the wound is cleaned first, then the wound area farthest from the nurse, then the area closest to the nurse. 6. New sterile dressing is applied to the wound.

2., & 4. Correct: Tape on the dressing is pulled parallel with the skin in the direction of hair growth. Most dressing changes following surgery are sterile and require that the nurse use standard precautions and wear sterile gloves to clean the incision and apply sterile dressings. Clean gloves can be used to remove the old dressing. Dressings are never touched by ungloved hands.

A client arrives at the emergency department (ED) after sustaining a high-voltage electrical injury. Which interventions should the nurse initiate in the ED? 1. Determine body surface area injured using the Lund and Browder Method. 2. Draw blood for cardac enzymes. 3. Infuse Lactated Ringers to maintain hourly urine output between 75-100 mL/hr. 4. Obtain 12 lead electrocardiogram (EKG). 5. Remove nonadherent clothing.

2., 3., 4 & 5. Correct: These are correct interventions for the nurse to initiate when caring for a client who has sustained a high-voltage electrical injury. Remember, electricity kills vessels, nerves, and organs. So the heart can be damaged. We need to assess damage by drawing blood for cardiac enzymes, and by obtaining a 12 lead EKG. Large-bore IV access and large-volume fluid resuscitation is important in patients with anything more than a very minor low-voltage injury. Fluids should be titrated to produce adequate urine output (75 to 100 mL/hr in adults or 1 mg/kg/hr in children). Remove nonadherent clothing so that proper inspection and care can be provided.

A client was admitted 24 hours ago in septic shock. Treatment included oxygen at 40% per ventimask, IV therapy of Lactated Ringer's (LR) at 150 mL/hr, vancomycin 1 gram IV every 8 hours, and methylprednisolone 40 mg IVP twice a day. Which clinical data indicates to the nurse that further treatment is necessary? 1. Blood pressure 96/68; HR 98; RR 20 2. WBC 12,000/mm3 (12 x 10^9)/L 3. CVP- 3 mmHg 4. pH- 7.30; pCO2- 44; pO2 -92; HCO3- 20 5. Urinary output of 150 mL/8 hours

2., 4., & 5. Correct: The client's white blood cell count is elevated. This means the client is still sick and needs further therapy. The client is still in metabolic acidosis, so no improvement. Urinary output should be adequate if treatment is successful. The urinary output should be 30 mL/hr for an adult. What is it for this client? 150 mL over 8 hours or 18.75 mL/hr. 1. Incorrect: The systolic BP should be greater than 90 if not told what the BP has been. The client is perfusing vital organs with this BP. 3. Incorrect: This is a normal CVP. It would be low if the client was still in a fluid volume deficit.

The nurse is reviewing morning laboratory results for multiple clients. Which client laboratory results should the nurse immediately report to the Healthcare provider? 1. Client with chronic obstructive pulmonary disease (COPD) and a PCO2 of 50 mm Hg. 2. Diabetic client with fasting blood sugar of 145 mg/dL (8.0 mmol/L). 3. Cardiac client on furosemide with potassium of 3.1mEq/L (3.1 mmol/L). 4. Client with sepsis and total white blood cell count of 16,000 mm3. 5. Client following a thyroidectomy with calcium level of 8.0 mg/dL (2 mmol/L).

3. & 5. Correct: Although all the laboratory results are outside of standard accepted levels, two particular clients are the most concerning. The cardiac client's potassium level of 3.1 is extremely concerning, since normal potassium levels should be between 3.5-5.0 mEq/L. Hypokalemia can cause muscle weakness and heart arrhythmias, such as PVC's. Secondly, after the client's thyroidectomy, their calcium level is 8.0 mg/dl (normal 9.0-10.5 mg/dl), indicating possible removal of parathyroid glands. Because hypocalcemia places the client at risk for seizures or laryngospasms as well as arrhythmias, the primary healthcare provider needs to be notified immediately so that corrective therapy can be initiated. 1. Incorrect: While this client's PCO2 of 50 is elevated (normal is 35-45 mm Hg), this is neither unexpected or unusual for an individual with COPD. This client will frequently experience elevated levels of PCO2; therefore, the nurse should just continue monitoring for any changes in respiratory status. 2. Incorrect: This diabetic client has a fasting blood sugar of 145, which is elevated above normal levels of 70-110. However, it is not uncommon for diabetics to occasionally have elevated glucose levels, even early in the morning. The nurse can address this issue by referring to the sliding scale for insulin administration. This does not need to be reported immediately to the primary healthcare provider. 4. Incorrect: It is expected that clients diagnosed with sepsis will have extremely elevated white blood cell counts. Despite the fact that this lab result is outside of normal values (4,500 - 10,000 mm3), this level is not concerning enough to immediately contact the primary healthcare provider.

An elderly, confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the LPN? 1. Perform a physical assessment. 2. Start an IV of NS with KCL 20 mEq at 50 mL/hr. 3. Insert a urinary catheter. 4. Weigh the client.

3. Correct: The LPN can insert a urinary catheter.

What clinical manifestation does the nurse expect to see in a client suspected of having hypercalcemia? 1. Tachycardia 2. Positive Chvostek 3. Lethargy 4. Tachypnea 5. Decreased deep tendon reflexes

3., & 5. Correct: Hypercalcemia is a condition in which the calcium level in blood is above normal. Too much calcium in blood can weaken bones, create kidney stones, and interfere with heart and brain function. Hypercalcemia is usually a result of overactive parathyroid glands. Other causes include cancer, some medications, and taking too much of calcium and vitamin D supplements. Signs and symptoms of hypercalcemia range from nonexistent to severe. Lethargy and decreased deep tendon reflexes are two manifestations of hypercalcemia. 1. Incorrect: Bradycardia rather than tachycardia is seen with hypercalcemia. Remember - muscles are sedated. 2. Incorrect: A Negative Chvostek will be seen with hypercalcemia. It will be positive in hypocalcemia. 4. Incorrect: Hypercalcemia will result in a decreased, rather than increased respiratory rate.

An intubated client has been admitted to the emergency department via ambulance with sustained burns to the upper torso, face, and neck as a result of a steam injury. Which intervention is the nurse's priority? 1. Administer 1000mL of lactate ringers (LR) over 1 hour. 2. Connect endotracheal tube to a ventilator. 3. Elevate head of bed to 35 degrees. 4. Connect to cardiac monitor

3. Correct: What happens with burn injuries. Swelling. Elevating the head of the stretcher will help to decrease swelling. Since the client is already intubated, this would be the nurse's first action on arrival. 1. Incorrect: Fluid resuscitation is needed, however, it takes no time to elevate the head of the stretcher so do that first. The client will need IV fluids to replace the transfer of plasma to interstitual tissue. 2. Incorrect: The client can be connected to a ventilator if needed, but at present the airway is being protected by the ET tube. Nothing was said to indicate that ventilation assistance is needed at present. 4. Incorrect: Connect to a cardiac monitor after elevating the client's head.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? pH - 7.46 PaCO2 - 32 HCO3 - 22

4., & 5. Correct: The blood gases confirm respiratory alkalosis. Why? The pH is 7.46 (normal 7.35-7.45). This pH indicates alkalosis since it is high. Which other chemical says alkalosis? The PaCO2 of 32 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that the client is in uncompensated respiratory alkalosis.

A client is being treated for fluid volume deficit with D5W, oral hydration, and management of viral symptoms. Which client data would indicate to the nurse that treatment has been successful? 1. BP 120/70 lying; 98/68 standing 2. Bounding pulses 3. One day weight gain of 5 kg 4. Urine specific gravity of 1.010 5. Serum sodium 145 mEq (145 mmol/L)

4., & 5. Correct: With fluid volume deficit, the specific gravity can be expected to be abnormally high. This urine specific gravity is normal. This is a normal sodium level.

An adult client has partial and full thickness burns over the anterior trunk, the anterior and posterior aspect the left leg, and the anterior aspect of the right leg. Utilizing the rule of nines, what percentage of the body surface area is burned? Round your answer to the nearest whole number.

45 The anterior trunk counts for 18% of the body; entire left leg counts 18%; anterior right leg counts 9%. Body surface on this client is 45%.

A nurse arrives at the scene of a home fire along with local emergency medical services (EMS) to find a client lying in the front yard. Burns are noted to the face, neck and chest. In what order should the nurse care for this client at the scene?

Establish airway patency Assess breathing Administer 100% humidified oxygen Soak burned area with cool water. Remove restrictive objects

A client weighing 132.3 pounds (60 kg) is admitted to the burn unit with second and third degree burns covering 40% total body surface area. Normal Saline IV fluid resuscitation is ordered at 4 mL/kg per percentage of total body surface area burned over the first 24 hours. How much fluid does the nurse calculate the client will receive in 24 hours? Provide your answer using numbers and decimal points only.

4 mL x 60 kg= 240 240 mL x 40 tbsa= 9,600 mL in the first 24 hours