LAST FINAL!

Notify the provider of the findings immediately.

A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?

"DKA can be caused by taking too little insulin."

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

Frequent swallowing OR Infection

A client with hyperthyroidism is being treated with radioactive iodine therapy. After receiving the dose of radioiodine, the nurse would assess the client for

Difficulty breathing, Cardiovascular overload, Pulmonary edema

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

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would 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

B. pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hgc.

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this client? A. pH 7.38, HCO3 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hgb. B. pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hgc. C. pH 7.48, HCO3 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hgd. D. pH 7.32, HCO3 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

B) Initiate intravenous fluid resuscitation

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

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

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?

Fowlers

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

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

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

c. Has clear lung sounds on auscultation.

A client experiences impaired swallowing after a stroke and has worked with speech- language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met? a. Chooses preferred items from the menu. b. Eats 75 to 100% of all meals and snacks. c. Has clear lung sounds on auscultation. d. Gains 2 lb (1 kg) after 1 week.

a. "Increased pressure from the tumor can cause seizures."

A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct? a. "Increased pressure from the tumor can cause seizures." b. "Preventing febrile seizures with a tumor is important." c. "Seizures always occur in clients with brain tumors." d. "This drug is used to sedate with a brain tumor."

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

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

c. Ensure a patent airway.

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%. 248 b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.

Assist in finding one change the client can control.

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best?

C) Hypocalcemia

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? A) Hyponatremia B) Hypophosphatemia C) Hypocalcemia D) Hypokalemia

a. Epoetin alfa (Epogen)

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer? a. Epoetin alfa (Epogen) b. Filgrastim (Neupogen) c. Mesna (Mesnex) d. Oprelvekin (Neumega)

c. Report of chest heaviness

A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr

Maintain airway patency.

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority?

a. Hypotension b. Increased urinary output e. Poor skin turgor

A client is admitted with a possible diagnosis of diabetes insipidus (DI). What assessment findings would the nurse expect? Select all that apply. a. Hypotension b. Increased urinary output c. Concentrated urine d. Decreased thirst e. Poor skin turgor f. Bradycardia

Evidence of hemorrhagic stroke

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what?

Hypovolemic shock

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?

B. Glycosuria C. Dehydration D. Hypernatremia E. Hyperglycemia

A client is brought to the emergency department. 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. A. Leukocytosis B. Glycosuria C. Dehydration D. Hypernatremia E. Hyperglycemia

Tell the client that anxiety is common and that you can help.

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best?

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

A client is on mechanical ventilation and the client's spouse wonders why ranitidine 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."

a. Alert and oriented, answering questions

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

b. Determine if the client can switch to a nasal cannula during the meal.

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. Assess the client's oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during themeal. c. Have the client lift the mask off the face when taking bites offood. d. Turn the oxygen off while the client eats the meal and then restart it.

Absolute bed rest in a quiet, non stimulating environment

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client?

B. Excess fluid volume

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

d. Time of symptom onset

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

c. Provide frequent oral care per protocol.

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

Slurred speech and confusion

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?

a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia

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.)

This can be manifested by a decrease in urine output to below 30 mL/hr.

A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?

c. Palpate the bladder for distention.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next? a. Initiate oxygen via a nasal cannula. b. Recheck the client's blood pressure. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

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

A nurse assesses a patient on the medical-surgical unit. Which statement made by the patient alerts the nurse to assess the patient for hypothyroidism? a. My sister has thyroid problems. b. I seem to feel the heat more than other people. c. Food just doesnt taste good without a lot of salt. d. I am always tired, even with 12 hours of sleep.

Univocal PVC

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

c. I will help you identify a support system.

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.

b. Provide a low-sodium diet.

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.

c. Omelet, soft whole wheat bread

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client? a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole wheat bread d. Pasta salad, custard, orange juice

b. Lorazepam

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse anticipate to prepare for administration? a. Atenolol b. Lorazepam c. Phenytoin d. Lisinopril

Assess the client for airway patency

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first?

d. Assess the client for airway patency.

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? a. Sedate the client to prevent tube dislodgement. b. Maintain balloon pressure at 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Assess the client for airway patency.

a. "Diarrhea is expected; that's how your body gets rid of ammonia."

A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, "I do not want to take this medication because it causes diarrhea." How should the nurse respond? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take Kaopectate liquid daily for loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory."

b. "Viral hepatitis is not spread through casual contact."

A nurse cares for a client with hepatitis C. The client's brother states, "I do not want to contract this infection, so I will not go into his hospital room." How should the nurse respond? a. "If you wear a gown and gloves, you will not get this virus." b. "Viral hepatitis is not spread through casual contact." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."

d. Administration of intravenous insulin

A nurse cares for a patient experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take? a. Administration of oxygen via face mask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

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

A nurse cares for a patient who has hypothyroidism as a result of Hashimoto's thyroiditis. The patient asks, "How long will I need to take this thyroid medication?" How does 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. Highly dilute urine

A nurse caring for a patient with diabetes insipidus 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

Cells lack an adequate blood supply and are deprived of oxygen and nutrients

A nurse in the ICU is planning the care of a client who is being treated for shock. What statement best describes the pathophysiology of this client's health problem?

Stridor

A nurse is assessing a client for a suspected anaphylactic reaction following a a scan with contrast media. For which of the following client findings should the nurse intervene first?

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

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 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 primary health care provider immediately

A. Petechiae

A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect? A. Petechiae B. Hypertension C. Osteoarthritis D. Peripheral ulcers

C. Bloody stools

A nurse is assessing a client who has cirrhosis. Which of the following findings is a priority for the nurse to report to the provider? A. Spider angiomas B. Peripheral edema C. Bloody stools D. Jaundice

Spider Angiomas

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

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

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?

c. Interrupt the procedure to give oxygen.

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

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

A nurse is caring for a client in acute respiratory failure who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client's bedside. b. Ensure that the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

B. Muffled heart sounds

A nurse is caring for a client in the critical care unit following a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following findings supports this suspicion? A. widening pulse pressure B. Muffled heart sounds C. Elevating systolic bp D. decreasing venous pressure

a. Assess the cause of the agitation.

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

Dysphagia

A nurse is caring for a client receiving external radiation to the neck for cancer of the larynx; during a pre-treatment exam, the nurse explains to the client that the most likely side effect would be which of the following?

Ham Sandwhich

A nurse is caring for a client who has cirrhosis and has a prescription for bumetanide. When delivering the client's lunch tray, which of the following items should the nurse identify as contraindicated for the client?

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 caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, 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 the correct 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 enjoy it." C. "Exercise is good for you and good for your heart." D. "Your doctor is the expert here, and I'm sure he would only recommend what is best for you.

A. Elevated blood urea nitrogen (BUN)

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

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

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I don't understand the need for rehabilitation; the paralysis will not go away and it will not get better." How would the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let your primary health care provider know." b. "Rehabilitation programs have helped many patients 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."

b. Administer oxygen via face mask

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 100/min, respiratory rate 40/min, and blood pressure 140/80 mmHg, HCO₃ mEq/L, and SaO₂ 86%. Which of the following is the priority nursing intervention? a. Prepare for mechanical ventilation b. Administer oxygen via face mask c. Prepare to administer a sedative d. Assess for indications of pulmonary embolism

A) Monitoring for infection

A nurse is caring for a patient who has a diagnosis of acute leukemia. What assessment most directly addresses the most common cause of death among patients with leukemia? A) Monitoring for infection B) Monitoring nutritional status C) Monitor electrolyte levels D) Monitoring liver function

D. Inability of the liver to use vitamin K.

A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient's increased risk of bleeding. The nurse recognizes that this risk is related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K.

Regular Insulin

A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?

Client with a new spinal cord injury on a rotating bed Older client who is 1-day post hip replacement surgery Young obese client with a fractured femur

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)

Client with a Glasgow Coma Scale score that was 10 and is now is 8

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first?

b. Lactate: 5.4 mg/dL (6 mmol/L)

A nurse is caring for several patients at risk for shock. Which laboratory value requires the nurse to communicate with the healthcare provider. a. Creatinine: 0.9 mg/dL (68.6 mcmol/L) b. Lactate: 5.4 mg/dL (6 mmol/L) c. Sodium: 150 mEq/L (150 mmol/L) d. White blood cell count: 11,000/mm3 (11 109/L)

a. Applying suction while inserting the catheter

A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Pre Oxygenating 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

Active substance abuse user

A nurse is discussing liver transplant with a client who has end stage liver failure. Which of the following should the nurse identify as a contraindication for this treatment?

Perform neurovascular checks with vital signs

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?

Administer furosemide Implement a low-sodium diet Measure the client's abdominal girth

A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply)

Fresh Flowers Raw vegetables

A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?

b. Ensuring that there is a bag-valve-mask in the room

A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure from the emergency department. What action does the nurse take first? a. Assessing that the ventilator settings are correct b. Ensuring that there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room

a. A 27-year-old heavy-cocaine user.

A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the highest risk for a stroke? a. A 27-year-old heavy-cocaine user. b. A 30-year-old who drinks a beer a day. c. A 40-year-old who uses seasonal antihistamines. d. A 65-year-old who is active and on no medications

B. "The medication can take up to 15 minutes to take effect."

A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include? A. "Place the tablet under your tongue, and then take a small sip of water." B. "The medication can take up to 15 minutes to take effect." C. "Avoid taking medication prior to exercising." D. "Stop taking the medication and notify your provider if you develop a headache."

A. exertion and anxiety can trigger the pain

A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain? A. exertion and anxiety can trigger the pain B. the pain often radiates to the jaw or the back C. the pain usually lasts more than 20 min D. the pain persists with rest and organic nitrates

Decreased platelet count Decreased WBC Decreased RBC

A nurse is reviewing the laboratory data of a client who has acute leukemia and received aggressive chemotherapy treatment 10 days ago. Which of the following abnormalities should the nurse expect to see? (SATA)

Amylase

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 lab values?

B. DIC is caused by abnormla coagulation involving fibrinogen

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? A. DIC is controllable with lifelong heparin usage B. DIC is caused by abnormal coagulation involving fibrinogen C. DIC is a genetic involving a vitamin K deficiency D. DIC is characterized by an elevated platelet count

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

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding 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."

D. Nosebleeds

A nurse is treating a client who is receiving treatment for metastatic colorectal cancer about the adverse effects of bevacizumab. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? A. Weight gain B. Mild hearing loss C. Temporary loss of smell D. Nosebleeds

d. Call the Rapid Response Team.

A nurse on the general medical-surgical unit is caring for a client in shock and assesses the following: Respiratory rate: 10 breaths/min Pulse: 136 beats/min Blood pressure: 92/78 mm Hg Level of consciousness: responds to voice Temperature: 101.5° F (38.5° C) Urine output for the last 2 hours: 40 mL/hr. What action by the nurse is best? a. Transfer the client to the Intensive Care Unit. b. Continue monitoring every 30 minutes. c. Notify the unit charge nurse immediately. d. Call the Rapid Response Team.

c. Depression and withdrawal

A nurse plans care for a client with hypothyroidism. Which priority problem does the nurse address first for this client? a. Heat intolerance b. Body image problems c. Depression and withdrawal d. Obesity and water retention

C). "Tell me more about your concerns about the test."

A nurse prepares a patient for coronary cardiac catheterization surgery. The patient states, "I am afraid I might die." What is the nurse's best response? A). "What support systems do you have to assist you?" B). "This is a routine test and the risk of death is very low." C). "Tell me more about your concerns about the test." D). "Would you like to speak with a chaplain prior to the test?"

The client should increase intake of fish and increase omega-3 fatty acids to reduce the risk for prostate cancer.

A nurse provides an education program about dietary interventions to reduce the risk for prostate cancer. What information should the nurse include?

a. Maintain tight glycemic control and prevent hyperglycemia

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications? a. Maintain tight glycemic control and prevent hyperglycemia. b. Restrict your fluid intake to no more than 2 liters a day. c. Prevent hypoglycemia by eating a bedtime snack. d. Limit your intake of protein to prevent ketoacidosis.

a. Do not share utensils, plates, and cups with anyone else. d. Wash your clothing separate from others in the household. e. Take a laxative 2 days after therapy to excrete the radiation.

A nurse teaches a client who is prescribed an unsealed radioactive isotope. Which statements should the nurse include in this clients education? (Select all that apply.) a. Do not share utensils, plates, and cups with anyone else. b. You can play with your grandchildren for 1 hour each day. c. Eat foods high in vitamins such as apples, pears, and oranges. d. Wash your clothing separate from others in the household. e. Take a laxative 2 days after therapy to excrete the radiation.

27

A nurse uses the rule of nines to assess a patient with burn injuries to the entire back region and left arm. How would the nurse document the percentage of the patient's body that sustained burns?

C) A 39-year-old man with chronic alcoholism

A nurse who provides care in a walk-in clinic assesses a wide range of individuals. The nurse should identify which of the following patients as having the highest risk for chronic pancreatitis? A) A 45-year-old obese woman with a high-fat diet B) An 18-year-old man who is a weekend binge drinker C) A 39-year-old man with chronic alcoholism D) A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day

A. Fluid status

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

C) Mannitol (Osmitrol) (diuretic) E) Hypertonic saline? F) Steroid

A patient is being admitted to the neurologic ICU following an acute head injury that has cerebral edema. When planning this patient's care, the nurse would expect to administer what priority medication? A) Hydrochlorothiazide (HydroDIURIL) (Thiazide diuretic) B) Furosemide (Lasix) (Loop diuretic) C) Mannitol (Osmitrol) (diuretic) D) Spironolactone (Aldactone) E) Hypertonic saline? F)Steroid

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

A patient is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. (11.6 mmol/L). The spouse asks why the patient needs insulin as the patient 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 patient presents to the ER conscious with NO alterations in mental status. patients only abnormalities on physical exam are ascites and jaundice. Which of these would you anticipate the physician ordering?

D) The patients urinary catheter became occluded.

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

A) Check the patients indwelling urinary catheter for kinks to ensure patency.

A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? A) Check the patients indwelling urinary catheter for kinks to ensure patency. B) Lower the HOB to improve perfusion. C) Administer analgesia. D) Reassure the patient that headaches are expected after spinal cord injuries.

Diabetic Ketoacidosis

A patient with a history of type 1 diabetes is admitted to the ED with nausea and abdominal pain. He is responsive but difficult to arouse. His respiratory rate is 34 breaths per minute but deep. His breath is fruity. The student nurse asks why the patient is breathing rapidly and deeply. What is the best response?

Hold the insulin and inform doctor of potassium level

A patients admitted with diabetic ketoacidosis. The physician orders intravenous fluids of 0.9% Normal Saline and 10 units of intravenous regular insulin IV bolus and then to start an insulin drip per protocol. The patient's labs are the following: pH 7.25, Glucose 455, potassium 2.5. Which of the following is the most appropriate nursing intervention to perform next?

b. Lower blood volume lowers MAP.

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. "You should go to the hospital immediately to have your new liver checked out."

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I am experiencing right flank pain and have a temperature of 101° F." How should the nurse respond? a. "The anti-rejection drugs you are taking make you susceptible to infection." b. "You should go to the hospital immediately to have your new liver checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen (Tylenol) every 4 hours until you feel better."

c. "I take sodium bicarbonate after every meal to prevent heartburn."

After providing discharge teaching, a nurse assesses the client's understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching? a. "I don't drink milk because it gives me gas and diarrhea." b. "I have been taking digoxin every day for the last 15 years." c. "I take sodium bicarbonate after every meal to prevent heartburn." d. "In hot weather, I sweat so much that I drink six glasses of water each day."

b. I need to avoid protein in my diet.

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. I cannot drink any alcohol at all anymore. b. I need to avoid protein in my diet. c. I should not take over-the-counter medications. d. I should eat small, frequent, balanced meals.

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 client's 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'll keep food on upper shelves so I do not have to bend over."

After teaching a client who is recovering from an endoscopic transsphenoidal hypophysectomy, the nurse assesses the client's 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. "I'll keep food on upper shelves so I do not have to bend over." c. "I must wash the incision with saline and redress it daily." d. "I should cough and deep breathe every 2 hours while I am awake."

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

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

a. "The lower abdomen is the best location because it is closest to the pancreas."

After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "The lower abdomen is the best location because it is closest to the pancreas." b. "I can reach mythigh the best, so I will use the different areas of my thighs." c. "By rotating the sites in one area, mychance of having a reaction is decreased." d. "Changing injection sites from the thigh to the arm will change absorption rates."

b. After surgery, I wont need to take thyroid medication.

After teaching a patient who is recovering from a complete thyroidectomy, the nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional instruction? a. I may need calcium replacement after surgery. b. After surgery, I wont need to take thyroid medication. c. Ill need to take thyroid hormones for the rest of my life. d. I can receive pain medication if I feel that I need it.

a. Assess the client's lung sounds.

An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best? a. Assess the client's lung sounds. b. Assign a different AP to the client. c. Report the AP to the manager. d. Request thicker liquids for meals.

a. Electrocardiogram (ECG)

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

a. Increased rate and depth of respiration

An emergency department nurse assesses a patient with ketoacidosis. Which clinical manifestation would the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension

a. Administer dexamethasone (Decadron).

An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement? a. Administer dexamethasone (Decadron). b. Complete a minimental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.

Severe, crushing chest pain

An emergency department nurse triages patients who present with chest discomfort. Which patient would the nurse plan to assess first?

C. Radial pulse in the left arm

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

B. The difference is the timing of the delivery of the electric current.

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructors best response? A. Cardioversion is done on a beating heart; defibrillation is not B. The difference is the timing of the delivery of the electric current. C. Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not. D. Cardioversion is always attempted before defibrillation because it has fewer risks.

a. Assess that the client is breathing adequately.

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.

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

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.

Hypotension

Patient is at risk for shock. What is the earliest indication?

a. Adherence to proper hand hygiene b. Administering antiulcer medication c. Elevating the head of the bed d. Providing oral care per protocol f. Turning and positioning the client at least every 2 hours

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) ? not sure if its same question a. Adherence to proper hand hygiene b. Administering antiulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule f. Turning and positioning the client at least every 2 hours

a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition f. Use of diuretics

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 f. Use of diuretics

a. Client with a blood pressure change of 128/74 to 110/88 mm Hg

The nurse gets the hand-off report on four clients. Which client would the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

A. Syncope B. Dizziness C. Palpitations Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats per minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Hypertension and flat neck veins are not associated with the loss of cardiac output.

The client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. Which associated findings would the nurse anticipate in the assessment? Select all that apply. A. Syncope B. Dizziness C. Palpitations D. Hypertension E. Flat neck veins

red with a yellow halo ring

The emergency room nurse is assessing a patient recently brought in from a motor vehicle crash. The nurse would correctly interpret the fluid coming out of the patients left ear as "blood and csf" if it appears

A) Contractures C) Pressure ulcers D) Venous thromboembolism E) Pneumonia

The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply. A) Contractures B) Hemorrhage C) Pressure ulcers D) Venous thromboembolism E) Pneumonia

d. Client who has a temperature of 102° F (38.9° C)

The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first? a. Client with amnesia for the incident b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg and on a ventilator d. Client who has a temperature of 102° F (38.9° C)

D. "Prolonged, equal PR intervals indicate first-degree heart block." Rationale: Prolonged and equal PR intervals indicate first-degree heart block. The development of Q waves indicates myocardial necrosis. Tall, peaked T waves may indicate hyperkalemia. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block. An electrocardiogram (ECG) taken during a pain episode is intended to capture ischemic changes, which also include ST segment elevation or depression.

The nurse has completed an educational course about first-degree heart block. Which statement by the nurse indicates that teaching has been effective? A. "Presence of Q waves indicates first-degree heart block." B. "Tall, peaked T waves indicate first-degree heart block." C. "Widened QRS complexes indicate first-degree heart block." D. "Prolonged, equal PR intervals indicate first-degree heart block."

d. Evaluate respiratory status

The nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status

Get the ultrasound machine

The nurse is assessing her patient that has an altered level of consciousness and does not speak or move. if the nurse discovered that the patients left calf is red and warm to touch, the nurse would do which of the following?

Hyperkalemia

The nurse is caring for a client in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate?

c. Dehydration

The nurse is caring for a client who is diagnosed with diabetes insipidus (DI). For what common complication will the nurse monitor? a. Hypertension b. Bradycardia c. Dehydration d. Pulmonary embolus

Frequent monitoring of vital signs

The nurse is caring for a client who is in shock in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What assessments and interventions should the nurse prioritize?

C. Muscle weakness

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

a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. e. Obtain blood cultures. f. Administer rapid bolus of IV crystalloids.

The nurse is caring for a client with suspected septic shock. What does the nurse prepare to do within 1 hour of the client being identified as possibly having sepsis? Select all that apply. a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures. f. Administer rapid bolus of IV crystalloids.

b. The need to report chest pain and dyspnea when starting the drug.

The nurse is planning health teaching for a client starting on levothyroxine. What health teaching about this drug would the nurse include? a. The need to take the drug when the client feels fatigued and weak. b. The need to report chest pain and dyspnea when starting the drug. c. The need to check blood pressure and pulse every day. d. The need to rotate injection sites when giving self the drug.

C) Take antihypertensive medication as ordered.

The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A) Mild, intermittent seizures can be expected. B) Take ibuprofen for complaints of a serious headache. C) Take antihypertensive medication as ordered. D) Drowsiness is normal for the first week after discharge.

c. Rapid-onset hypernatremia

The nurse is preparing to give tolvaptan for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). For which potentially life-threatening adverse effect would the nurse monitor? a. Increased intracranial pressure b. Myocardial infarction c. Rapid-onset hypernatremia d. Bowel perforation

C. Monitor for any rhythm change. Rationale: Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats per minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the primary health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action would the nurse take? A. Check vital signs B. Check laboratory test results. C. Monitor for any rhythm change. D. Notify the primary health care provider. Submit

a. WBC 2300 mm3

The nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which finding should the nurse report to the healthcare provider? a. WBC 2300 mm3 b. Hemoglobin 12 g/dL c. Platelets 150,000 mm3 d. RBC 5 million mm3

a. Have suction equipment with an airway at the bedside. d. Have oxygen administration set at the bedside. f. Ensure that the client has IV access.

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

Bulging Eyes

The nurse reads on a client's chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis?

c. Turn the client's head to the side.

The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first? a. Start fluids via a large-bore catheter. b. Administer IV push diazepam. c. Turn the client's head to the side. d. Prepare to intubate the client.

B. IV calcium gluconate

The nurses assessment of a patient with thyroidectomy suggests tetany and a a review of the most recent blood work corroborate this finding. The nurse should prepare to administer what intervention? A. Oral calcium chloride and vitamin D B. IV calcium gluconate C. STAT levothyroxine D. Administration of parathyroid hormone (PTH)

C. Atenolol

The patient is to have hemodialysis this morning. Which drug should be held until after the dialysis treatment? A. Calcium B. Multivitamin C. Atenolol D. Glyburide

Widening pulse pressure bradycardia irregular RR

What are the 3 signs of cushing triad (SATA):

Eye opening Verbal response Motor response

What are the sections that are being evaluated in the glasgow coma scale?

Normal Sinus Rhythm

What does the monitor read?

The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is SO severe that the patient does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the patient and helping them to understand the irreversible stage of shock is the best intervention. Informing the patients family early that the patient will likely not survive does allow the family to make plans and move forward, but informing the family too early will rob the family of hope and interrupt the grieving process. The chance of surviving the irreversible (or refractory) stage of shock is very small, and the nurse needs to help the family cope with the reality of the situation. With the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing the end-of-life issues

What occurs during the refractory stage of shock

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

When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client 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.

a. Lethargy c. Low body temperature e. Slowed speech f. Weight gain

When caring for an older client who has hypothyroidism, what assessment findings will the nurse expect? (Select all that apply.) a. Lethargy b. Diarrhea c. Low body temperature d. Tachycardia e. Slowed speech f. Weight gain

After the initial treatment

When is the patient most at risk for developing tumor lysis syndrome?

A. primary

While reviewing a client's medical record, the nurse notes that the client has hypothyroidism resulting from dysfunction of the thyroid gland itself. The nurse identifies this as which type of hypothyroidism? A. primary B. central C. secondary D. tertiary

C) Client receiving TPA who has a change in in respiratory pattern and rate

a nurse is caring for four patients in the neurologic intensive care unit.which patient does the nurse see first? A) A client who has been diagnosed with meningitis with a fever of 101 B) Client who has a TIA and is waiting for teaching on clopidogrel C) Client receiving TPA who has a change in in respiratory pattern and rate D) Client who is waiting for a subarachnoid bolt insertion with the consent already signed

Continuous venovenous hemodialysis (CVVHD)

A client is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the client develops acute kidney injury. The client is hemodynamically unstable, and renal replacement therapy is needed to manage the client's hypervolemia and hyperkalemia. Which of the following therapies will the client's hemodynamic status best tolerate?

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

A 80-year-old patient with chronic kidney disease and a history of diabetes had surgery two weeks ago to place vascular graft access for hemodialysis. Which precaution will the nurse follow to ensure the function of the AV graft? A. The nurse will insert an IV and run saline at 10mL/hr to keep the graft site clean and free of infection 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.

a. Apply direct pressure to the bleeding.

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.

a. Apply personal protective equipment.

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.

Atrial depolarization

A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave?

C. A 62 year old with a simple fracture of the left arm A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?" A. A 44 year old with chest pain and diaphoresis B. A 50 year old with chest trauma and absent breath sounds C. A 62 year old with a simple fracture of the left arm D. A 79 year old with a temperature of 104° F (40.0° C)

b. The poison control center

A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate? a. The facility's neurologist b. The poison control center c. The physical therapy department d. A herpetologist (snake specialist)

Do CPR.

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?

Checks the patient/Check for pulse

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?

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

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?

C. Changes in the level of consciousness

The nurse is caring for a patient 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 the level of consciousness D. Skin flushing

D. Headache, deteriorating level of consciousness, and twitching.

The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for: A. Hypertension, tachycardia, and fever. B. Hypotension, bradycardia, and hypothermia. C. Restlessness, irritability, and generalized weakness. D. Headache, deteriorating level of consciousness, and twitching.

A patient with diabetes mellitus and poorly controlled hypertension

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. Maintain aseptic technique when administering dialysate.

The nurse has identified the nursing diagnosis of "risk for infection" in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk? A. Maintain aseptic technique when administering dialysate. B. Wash the skin surrounding the catheter site with soap and water prior to each exchange. C. Add antibiotics to the dialysate as ordered. D. Administer prophylactic antibiotics by mouth or IV as ordered.

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

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.

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

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

C. Ventricular Tachycardia Rationale: Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140 and 180 impulses per minute. The rhythm is regular.

The nurse is watching the cardiac monitor and notices that a client's rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats per minute. The nurse determines that the client is experiencing which dysrhythmia? A. Sinus Tachycardia B. Ventricular Fibrillation C. Ventricular Tachycardia D. Premature Ventricular Contractions

Second-Degree AV Block: Mobitz Type 1 (Wenckebach)

What does this monitor read?

Clean the skin and clip hairs if needed

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure?

2.Assess for airway patency. 3.Administer oxygen as prescribed. 5.Elevate extremities if no fractures are present.

A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1.Restrict fluids. 2.Assess for airway patency. 3.Administer oxygen as prescribed. 4.Place a cooling blanket on the client. 5.Elevate extremities if no fractures are present. 6.Prepare to give oral pain medication as prescribed.

a.Administer analgesics. b.Prevent wound infections. c.Provide fluid replacement.

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? Select all that apply. a.Administer analgesics. b.Prevent wound infections. c.Provide fluid replacement. d.Decrease core temperature. e.Initiate physical therapy.

A. Assess the client's respiratory status.

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? A. Assess the client's respiratory status. B. Draw blood to assess the client's serum electrolytes. C. Administer intravenous furosemide (Lasix). D. Ask the client about current medications.

Excess fluid volume

A patient is being treated for AKI and the patient daily weights have been ordered. The nurse notes a weight gain of 3 (1.4 kg) pounds over the past 48 hours. What nursing diagnosis is suggested by this assessment finding?

a. Assess the clients 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.

Providing education to the client and family Rationale: Client and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the client is still in the acute phase of burn recovery.

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. Assess the client's lung sounds and oxygenation.

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse 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. Atrial fibrillation Rationale: Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombus formation.

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

D. Place a heparin or heparin/saline dwell after hemodialysis.

A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse? A. Use the catheter for the next laboratory blood draw. B. Monitor the central venous pressure through this line. C. Access the line for the next intravenous medication. D. Place a heparin or heparin/saline dwell after hemodialysis.

Third Degree Block

What is the monitor reading?

A. Sinus Tachycardia Rationale: Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats per minute.

A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats per minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How would the nurse interpret this rhythm? A. Sinus Tachycardia B. Sinus Bradycardia C. Sinus Dysrhythmias D. Normal Sinus Rhythm

B. Administer oxygen via a nonrebreather mask. The client is exhibiting signs of AMS with high-altitude pulmonary edema (HAPE). Cyanosis indicates hypoxia and must be treated immediately. A complete pulmonary assessment and ABG analysis are indicated but the priority is oxygen administration. Acetazolamide is used to prevent AMS.

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.

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. F. Be willing to be flexible working during a crisis situation.

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.

B. "My shoes fit really tight lately"

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."

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

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. Cardiopulmonary status

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

d. Place the client in an upright position.

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.

B. Night sweats C. Cardiac murmur E. Osler's nodes

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.) A. Weight gain B. Night sweats C. Cardiac murmur D. Abdominal bloating E. Osler's nodes

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

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."

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

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.Administer the prescribed intravenous morphine sulfate.

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

A nurse cares for a client with right-sided heart failure. 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."

Check for pulse/Assess

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?

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

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.

The P wave is before the 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?

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 collaborates with unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (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. Dyspnea C. Jugular vein distention D. Confusion

A nurse id preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestationd should the nurse monitor to prevent fluid volume overload? Select all that apply. A. Dyspnea B. Gastrointestinal bloating C. Jugular vein distention D. Confusion E. Hypotension

B. Increased urine output

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective? A. Increased heart rate B. Increased urine output C. Decreased blood pressure D. Decreased blood glucose level

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

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 required 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

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

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. A 34-year-old on NPO status who is receiving intravenous D5W

A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia? a. A 34-year-old on NPO status who is receiving intravenous D5W b. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic c. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin) d. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)

D. Reduction of T wave amplitude

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. Which of the following ECG results should indicate to the nurse that the medications has been effective?​ A. Restoration of QRS complex amplitude​ B. Widening of the QRS complex C. Reduction of P wave duration​ D. Reduction of T wave amplitude

pH 7.26 HCO3 14 Paco2 30

A nurse is caring for a client who has acute kidney injury. Which of the following arterial blood gas values would the nurse expect this client to have?

a. Apply oxygen by mask or nasal cannula.

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The client's arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3- 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the client's nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin

b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W

A nurse is caring for a client who is experiencing excessive diarrhea. The client's arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3- 16 mEq/L. Which provider order should the nurse expect to receive? a. Furosemide (Lasix) 40 mg intravenous push b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W c. Mechanical ventilation d. Indwelling urinary catheter

A. Hypokalemia-muscle weakness with respiratory depression B. Hypermagnesemia-_ bradycardia and hypotension C. Hyponatremia-decreased level of consciousness E. Hypomagnesemia-_-hyperactive deep tendon reflexes F. Hypernatremia-_weak peripheral pulses

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? Select all that apply. A. Hypokalemia-muscle weakness with respiratory depression B. Hypermagnesemia-_ bradycardia and hypotension C. Hyponatremia-decreased level of consciousness D. Hypercalcemia- positive Trousseau and Chvostek signs E. Hypomagnesemia-_-hyperactive deep tendon reflexes F. Hypernatremia-_weak peripheral pulses

Alcohol Use Disorder

A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?

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

A nurse is discussing laboratory values associated with the renal system with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the value? 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

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

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

d. Multiple fractured ribs and shortness of breath

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

A. Serum creatinine 1.8mg/dL

A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury. Which of the following findings should the nurse identify as indicating an increased risk of acute kidney injury (AKI) ? A. Serum creatinine 1.8mg/dL B. Serum osmolality 290 mOsm/kg H2O C. Blood urea nitrogen (BUN) 20mg/dL D. Magnesium 2.0 mEq/L

C. Reduce the client's intake of protein.

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level? A. Administer diuretics. B. Restrict the client's intake of fluids. C. Reduce the client's intake of protein. D. Administer vitamin K.

C. Ensure that informed consent has been obtained from the client.

A nurse is preparing to administer a blood transfusion. What is the first action the nurse would do? A. Establish intravenous access with a 22-gauge needle. B. Prime an infusion set with lactated Ringer's solution. C. Ensure that informed consent has been obtained from the client. D. Suggest that the client consider autologous transfusion.

Dyspnea Jugular vein distention Confusion

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? Select all that apply

c. IV

A nurse is preparing to administer fentanyl to a client who was admitted 24 hours ago with deep partial thickness and full thickness burns over 60% of his body. The nurse should plan to use which of the following routes to administer the medication. a. subcutaneous b. IM c. IV d. transdermal

d. decreased urine specific gravity

A nurse is taking care of a client who had severe burns. Which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation adequacy? a. decreased skin turgor b. decreased pulse pressure c. decreased core body temperature d. decreased urine specific gravity

D. Urine output < 400 mL / 24 hours

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. BUN and serum creatinine levels decreased C. Glomerular filtration rate (GFR) recovers D. Urine output < 400 mL / 24 hours

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 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.Provide at least 5000 kcal/day. c. Administer a diet high in protein. d.Collaborate with a registered dietitian. e.Offer frequent high-calorie snacks.

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this client's plan of care to ensure adequate nutrition? Select all that apply. a.Provide at least 5000 kcal/day. b.Start an oral diet on the first day c. Administer a diet high in protein. d.Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.

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

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.

c.Serum potassium: 6.5 mEq/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

B. Control ventricular rate

A patient converts from normal sinus rhythm at 80 beats/min to atrial fibrillation with a ventricular response at 166 beats/min. Blood pressure is 162/74. Respiratory rate is 20/min with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the primary goal of treatment is what? A.Decrease SA node conduction B. Control ventricular rate C. Improve oxygenation D. Maintain anticoagulation

A. Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis

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

D. Full-thickness

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm? A. Superficial partial-thickness B. Deep partial-thickness C. Full partial-thickness D. Full-thickness

A. Inform the physician and assess the patient for signs of infection.

A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurses most appropriate action? A. Inform the physician and assess the patient for signs of infection. B. Flush the peritoneal catheter with normal saline. C. Remove the catheter promptly and have the catheter tip cultured. D. Administer a bolus of IV normal saline as ordered.

b. Don personal protective equipment.

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.

a.Apply oxygen and continuous pulse oximetry.

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a.Apply oxygen and continuous pulse oximetry. b.Provide small quantities of ice chips and sips of water. c.Request a prescription for an antitussive medication. d.Ask the respiratory therapist to provide humidified air.

c. a 26 year old male who has pale, cool, clammy skin and a heart rate of 160

An emergency room nurse is triaging victims of a multi-casualty event. Which client should the receive care first? a. 48 year old female with a compound fracture of the lower leg b. a 30 year old distraught mother holding her crying child c. a 26 year old male who has pale, cool, clammy skin and a heart rate of 160 d. a 65 year old conscious male with a head laceration

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

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. Contact the provider and prepare for intubation.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? a. Contact the provider and prepare for intubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowler's position. d. Ask the client to perform deep-breathing exercises.

B. Risk for electrolyte imbalance

You're developing a nursing care plan for a patient in the diuresis stage of AKI. What nursing diagnosis would you include in the care plan? A. Excess fluid volume B. Risk for electrolyte imbalance C. Urinary retention D. Acute pain

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

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 ofresources 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, anddomestic violence e. Paramedic—provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

b. Brought in unconscious by roommate after opioid overdose. Opioid medications can cause respiratory depression, so this client is most at risk for gas exchange problems. Diminished respirations will allow a buildup of carbon dioxide in the blood. The clients with asthma and COPD have the potential for gas exchange problems but this is not indicated in answer option as he or she is being discharged. The client with a broken femur does not have information suggesting gas exchange problems.

The nurse in the emergency department (ED) is caring for four clients. Which client does the nurse assess for gas exchange abnormalities first? a. Involved in motor vehicle crash, has broken femur. b. Brought in unconscious by roommate after opioid overdose. c. Asthmatic client being discharged after bronchodilator therapy. d. History of COPD, presents to ED after being bitten by a dog.

c."Sometimes I wake up at night and smoke."

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a."I get my chimney swept every other year." b."My hot water heater is set at 120 degrees." c."Sometimes I wake up at night and smoke." d."I use a space heater when it gets below zero."

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

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.

Atrial Flutter

What would the nurse document this as?