MED SURG ATI

A nurse is caring for a client who has a new diagnosis of hypertension and a new prescription for spironolactone (Aldactone) 25 mg/day. Which of the following statements by the client indicates a need for further teaching?

"I should eat a lot of fruits and vegetables, especially bananas and potatoes."

A nurse is screening a client for hypertension. Which of the following actions by the client increase his risk for hypertension?

- Eating popcorn at the movie theater - Consuming 36 oz of beer daily

A nurse if preparing to administer morphine 2.5 mg IV bolus to a client who has a pneumothorax. Available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth)

0.3 mL

A patient with a spinal cord injury is prescribed pantoprazole (Protonix). According to best practices, why is this medication prescribed for the patient? 1. Prevents stress-related gastric ulcers 2. Encourages healing of gastric nerves 3. Promotes digestion of enteral feedings 4. Supports healthy bacteria in the GI tract

1

The nurse assesses a depressed gag reflex in an unconscious patient. Which nursing diagnosis should the nurse use to guide this patient's care? 1. Risk for aspiration 2. Ineffective breathing pattern 3. Decreased intracranial adaptive capacity 4. Imbalanced nutrition: less than body requirements

1

The nurse is assessing a patient's cranial nerve function. What equipment should the nurse use to assess function of cranial nerve V, the trigeminal nerve? 1. cotton ball and safety pin 2. measuring tape and pencil 3. scents such as coffee and vanilla 4. stethoscope with bell and diaphragm

1

The nurse is monitoring the neurologic status of a patient in a coma. Which command should the nurse use to accurately identify changes in mental status? 1. Squeeze my hand 2. Tell me your name 3. Are you having trouble breathing 4. Look at this light when I shine it in your eyes

1

The nurse is preparing a teaching session on the neurologic system for a group of nursing students. What should the nurse include about the purpose and function of cerebrospinal fluid? (Select all that apply) 1. Cushions the brain 2. Helps nourish the brain 3. Prevents glucose from entering brain cells 4. Protects the brain and spinal cord from trauma 5. Removes waste products of cellular metabolism

1, 2, 4, 5

An industrial nurse is conducting a class for manufacturing plant employees on methods to prevent back pain. What should the nurse include in this teaching? (Select all that apply) 1. Use large leg muscles to push when lifting 2. Bend from the waist to lift articles from the floor 3. Spread the feet apart to broaden the base of support 4. Work as closely as possible to the object to be moved 5. Always lift articles rather than rolling or pushing them

1, 3, 4

The nurse is determining which patients should have corneal reflex assessments completed during morning care. For which patients would assessing this reflex be appropriate? (Select all that apply) 1. an unconscious patient 2. anyone over the age of 50 3. a patient with a head injury 4. a patient who wears contact lenses 5. a patient with spinal cord trauma

1, 3, 4

The nurse is instructing a patient on ways to prevent a stroke. What should the nurse emphasize as being the greatest risks for a stroke? (Select all that apply) 1. Diabetes 2. Head trauma 3. Heart disease 4. Hypertension 5. High cholesterol levels

1, 3, 4

Laboratory tests are being prescribed for a patient with altered level of consciousness. Which tests should the nurse expect to be prescribed for this patient? (Select all that apply) 1. Blood glucose 2. Urine for WBCs 3. Serum electrolytes 4. Spinal fluid osmolarity 5. Blood and urine toxicology

1, 3, 5

The nurse is planning care for a patient with an acute SCI. According to best practices, which medications should the nurse prepare to administer to this patient? (Select all that apply) 1. Analgesics 2. Antibiotics 3. Vasopressors 4. Antihistamines 5. Corticosteroids

1, 3, 5

The nurse is planning care for a patient with acute hypernatremia. What should the nurse include in this patient's plan of care? (Select all that apply) 1. Maintain IV access 2. Limit length of visits 3. Restrict fluids to 1500 mL per day 4. Conduct frequent neurologic checks 5. Orient to time, place, and person every 2 hours.

1, 4, 5 Frequent neurologic checks are necessary as hypernatremia draws water out of brain cells, causing them to shrink. As the brain shrinks, tension is placed on cerebral vessels, which may cause them to tear and bleed. Hypernatremia affects mental status and brain function including orientation to time, place, and person. Fluid replacement is the primary treatment for hypernatremia.

The nurse is assessing a patient with damage to the lower motor neurons. Which findings should the nurse expect to assess in this patient? (Select all that apply) 1. loss of reflexes 2. increased muscle tone 3. decreased coordination 4. decreased muscle strength 5. muscle atrophy and fasciculations

1, 5

A patient diagnosed with a suspected heroin overdose has a respiratory rate of 5 to 6 per minute. Which additional data should the nurse expect to collect on this patient? (Select all that apply) 1. pH 7.29 2. PaCO2 54 mmHg 3. HCO3 32 mEq/L 4. alert and oriented 5. skin warm and flushed

1,2,5 The slow respiratory rate leads to inadequate alveolar ventilation. As a result, carbon dioxide is not effectively eliminated from the blood, causing it to accumulate. This increases carbonic acid levels, leading to respiratory acidosis, as indicated by the low pH and high PaCO2. The bicarbonate level is initially unchanged in acute respiratory acidosis because the compensatory response of the kidneys occurs over hours to days. Excess carbon dioxide causes vasodilation, leading to warm, flushed skin, particularly in acute respiratory acidosis. The increased carbon dioxide level will affect neurologic function and the patient will not be alert and oriented.

The nurse notes that a patient with a systemic illness is not demonstrating signs of neurologic involvement. Which physiologic mechanism should the nurse recall that protects the brain from harmful substances? 1. Blood-brain barrier 2. Structure of neurons 3. Large oxygen demand 4. Circulation of cerebrospinal fluid

1.

A patient's arterial blood gas results are pH 7.21 PaO2 98 mmHg, PaCO2 32 mmHg, and HCO3 17 mEq/L. Which acid-base imbalance do these results indicate to the nurse? 1. metabolic acidosis 2. metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. pH <7.35 indicates acidosis. The bicarbonate level is less than 22 Meq/L which indicates a deficit of bicarbonate because of acidosis. The PaCo2 of 32 is less than 35 mmHg. This indicates respiratory compensation for excess acid.

A nurse is assessing a patient recovering from a posterior cervical laminectomy for manifestations of spinal cord compression. How should this assessment be conducted? 1. Ask the patient to wiggle his or her toes 2. Ask the patient to grip the nurse's hands 3. Use a stethoscope to auscultate heart sounds 4. Use a reflex hammer to assess Babinski's reflex

2

A patient is admitted to the emergency department with a cervical SCI following an automobile crash. What should the nurse explain to the family as the reason for the patient being placed on mechanical ventilation? 1. The accident injured the patient's lungs 2. The nerves that control lung function have been injured 3. The patient is unable to breathe because of being unconscious 4. The ventilator is temporary to ensure the patient receives adequate oxygen until recovery

2

A patient is demonstrating manifestations of autonomic dysreflexia. What will the nurse most likely assess as the reason for this health problem? 1. Diarrhea 2. Distended bladder 3. Elevated blood pressure 4. Respiratory wheezes and stridor

2

A patient with a thrombotic stroke is prescribed to receive tissue plasminogen activator. Why should the nurse ensure this medication is provided within the first 3 hours after the thrombotic stroke? 1. To increase platelet aggregation 2. To cause fibrinolysis of the clot 3. To reduce the risk of vasospasm 4. To dcrease the risk of infection

2

Following a motorcycle crash, a patient is diagnosed with damage to the posterior spinal roots. What should the nurse expect to assess in this patient? 1. flaccid paralysis of the legs 2. loss of sensation to dull and sharp 3. decreased sense of smell and taste 4. changes in peripheral vision in both eyes

2

The nurse is concerned that a patient is experiencing a transient ischemic attack. What did the nurse most likely assess in this patient? (Select all that apply) 1. Sudden severe pain over the left eye 2. Visual disturbances of one or both eyes 3. Loss of sensation and reflexes in both legs 4. Complete paralysis of the right arm and leg 5. Numbness and tingling in the corner of the mouth

2, 5

A patient is demonstrating confusing, hallucinations, and a positive Chvostek's sign. Which medications should the nurse prepare to provide to this patient? 1. calcium chloride 2. magnesium sulfate 3. insulin and glucose 4. sodium bicarbonate

2. A positive Chvostek's sign indicates increased neuromuscular excitability, commonly associated with both hypomagnesemia and hypocalcemia. Hypomagnesemia also causes confusion, hallucinations, and possible psychoses.

The nurse instructs a patient on calcium supplement therapy. Which statement indicates that the patient understands how to take calcium supplementation? 1. I will take the calcium with meals 2. I will take the calcium with a full glass of water 3. I will take these supplements as need for tremulousness 4. I will take these supplements all at one time in the morning.

2. Calcium should be taken with full glass of water. Calcium supplements should actually be taken 1-1.5 hours after meals and at bedtime.

The nurse is caring for a patient undergoing gastric decompression. For which potential acid-base balance should the nurse plan interventions? 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis

2. Gastric suctioning removes highly acidic gastric secretions, increasing the risk of metabolic alkalosis. Respiratory alkalosis is caused be hyperventilation.

A patient's serum potassium level is 2.2 mEq/L. Which nursing action is the highest priority for this patient? 1. Start oxygen at 2 L/min 2. Initiate cardiac monitoring 3. Initiate seizure precautions 4. Keep the patient on bed rest

2. Hypokalemia affects nerve impulse transmission, including the transission of cardiac impulses. May develop ECG changes

A patient being mechanically ventilated after a severe chest wall injury and flail chest complains of chest tightness, anxiety, and air hunger. The patient fears that a heart attack is pending. What should the nurse do first? 1. Notify the physician 2. Obtain arterial blood gases 3. Administer prescribed analgesic 4. Contact respiratory therapy to evaluate ventilator settings

2. These are classic manifestations of respiratory alkalosis, a potential complication of mechanical ventilation when the rate or volume of ventilation is too high. ABGs provide data necessary to confirm and treat this problem. The nurse should obtain an ABG to validate the patient's manifestations before contacting the respirator therapist to change to evaluate the ventilator settings.

A nurse is planning a seminar for city public health workers on ways to reduce the onset of central nervous system infections in the community. On which topic should the nurse focus in this seminar? 1. Garbage pickup 2. Sanitation services 3. Mosquito spraying 4. Washing fruits and vegetables

3

A nurse is planning care for a patient with a lumbar metastatic spinal cord tumor. Which assessment finding indicates that pain control is needed? 1. Fever 2. Diarrhea 3. Increased heart rate 4. Urinary incontinence

3

A patient reports narrowly missing having an automobile crash while merging onto the freeway while driving to see the healthcare provider for a routine appointment. Which division of the autonomic nervous system should the nurse recall as causing body responses to stress? 1. adrenergic 2. cholinergic 3. sympathetic 4. parasympathetic

3

A patient with a thoracic spinal cord injury is experiencing spinal shock. How should the nurse explain this pathophysiologic process to the patient? 1. There is damage to the lower motor neurons 2. There is an exaggerated sympathetic response 3. There is a loss of control of cardiovascular mechanisms 4. There is a temporary loss of reflex function below the level of injury

3

The nurse is document that a patient is demonstrating decorticate posturing. What does this statement indicate about the patient's physical posture? 1. in supine position, spine extended, legs extended 2. in prone position with arms, and knees sharply flexed 3. arms close to sides, elbows and wrists flexed, legs extended 4. neck extended, arms extended and pronated, feet plantar flexed

3

A patient with meningitis is drowsy and confused. What should the nurse explain to the patient's family as being the cause for these mental status changes? 1. Decreased intracranial pressure 2. Bleeding in the central nervous system 3. Elevated serum white blood cell count 4. Sluggish flow of cerebrospinal fluid

4

The nurse is assessing the breathing pattern of a patient with a head injury who has a change in level of consciousness. Which pathophysiologic event causes an irregular respiratory pattern as level of consciousness decreases? 1. Pressure on the meninges 2. Reflexive motor responses 3. Loss of the oculocephalic reflex 4. Brainstem responses to changes in PaCO2

4

The nurse is caring for a patient with altered levels of consciousness. On which laboratory value should the nurse focus as the most accurate indicator of hydration status in the patient? 1. CBC 2. Urinalysis 3. Blood culture 4. Serum osmolarity

4

The nurse is caring for a patient with increased intracranial pressure. Why should the nurse expect osmotic diuretics to be prescribed for this patient? 1. To treat hyperthermia 2. To prevent the onset of seizures 3. To reduce the risk for gastrointestinal hemorrhage 4. To draw edematous fluid into the vascular system

4

The nurse is planning to assess a patient's gag reflex. What equipment should the nurse use to test this reflex? 1. safety pin 2. cotton ball 3. stethoscope 4. tongue depressor

4

The nurse is preparing to assess a patient's neurologic system. Which assessment technique is not a part of this physical assessment? 1. palpation 2. percussion 3. inspection 4. auscultation

4

The nurse is providing care for a patient who has had an acute ischemic stroke of a left cerebral vessel. The medical record includes information that the patient has contralateral deficits. What does this information suggest to the nurse? 1. Both sides of the body are involved 2. Deficits will be present below the level of the stroke 3. The patient will have neurologic deficits on the left side of the body 4. The patient will have neurologic deficits on the right side of the body

4

Which manifestation should the nurse expect to assess in a patient with fluid volume deficit? 1. Headache and muscle cramps 2. Dyspnea and respiratory crackles 3. Increased pulse rate and blood pressure 4. Orthostatic hypotension and flat neck veins

4. In fluid volume deficit, there is less volume in the vascular system, which decreases venous return and cardiac output, leading to manifestations of dizziness, orthostatic hypotension, and flat neck veins.

A patient is admitted to the emergency department with hypovolemia. Which IV solution should the nurse anticipate administering? 1. 3% sodium chloride 2. 10% dextrose in water 3. 0.45% sodium chloride 4. lactated Ringer's solution

4. Ringer's solution is an isotonic, balanced electrolyte solution that can expand plasma volume and help restore electrolyte balance. 3% NaCl - hypertonic 0.45% NaCl - maintenance soln 10% dextrose - hypertonic

A patient suffering from dehydration would have the following urine specific gravity: A. Increased B. Decreased C. Normal

A

Which statement made by the client who experienced burns to the head and neck indicates positive adjustment to the injury? A. I am planning on cutting the grass in the mornings when the sun isn't as strong B. I am working with my family so they can do all of the chores I used to do C. I hope the home care nurse can change my dressings so that I do not have to look at my wounds D. My wife and I have decided to go to movies instead of baseball games so that people can't see me

A

A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (select all that apply) A. Impulse control difficulty B. Left hemiplegia C. Loss of Depth perception D. Aphasia E. Lack of awareness

A B C E

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (select all that apply). A. Speak to the client at a slower rate B. Look directly at the client when speaking C. Allow extra time for the client to answer D. Complete sentences that the client cannot finish E. Give Instructions one step at a time

A B C E

A nurse is planning care for a client who has dysphagia and has a new dietary prescription. Which of the following should the nurse include in the plan of care? (select all that apply) A. Have a suction equipment available for use B. Use thickened liquids. C. Place food on the client's unaffected side of her mouth. D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with her neck flexed.

A B C E

The home care nurse is providing direction to a home care aide who is scheduled to care for a patient with cystic fibrosis. Which information should the nurse instruct the aide to report immediately? (Select all that apply) A. Difficulty clearing mucous secretions B. Increasing shorness of breath and fatigue C. Thick, tenacious, milky, and white sputum D. Fever E. Bulky, fatty stools

A, B, C, D Thick, tenacious, milky white sputum and fever indicate possible infection. Difficulty coughing up mucus and increased shortness of breath and fatigue indicate potential early manifestations of respiratory failure. Steatorrhea causing frequent, bulky, foul-smelling stools is a common manifestations as a result of associated pancreatic insufficiency.

A nurse is caring for a client during surgery. The client has been administered dantrolene to treat malignant hyperthermia, and the administration of succinylcholine and other anesthetics has been discontinued. Which of the following additional actions should the nurse take? (Select all that apply) A. Place a cooling blanket on the client B. Administer oxygen at 100% C. Administer iced 0.9% NS D. Administer potassium chloride IV E. Monitor core body temperature

A, B, C, E

A nurse preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply) A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing

A, B, C, E Oxygen should be readily available in case the client develops respiratory distress following chest tube placement. If the chest tube becomes disconnected, the end of the tubing should be placed in sterile water to restore the water seal Hemostat clamps should be available for the nurse to use to check air leaks Immediately place an occlusive dressing over the chest tube insertion site if becomes disconnected. This allows air to escape and reduces the risk for a tension pneumothorax

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (ARDS)? (Select all that apply) A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a hemoglobin of 15.1 mg/dL D. A client who has dysphagia E. A client who experienced a drug overdose

A, B, D, E A client who experienced a near-drowning incident has had trauma to the lungs and cerebral edema A client following coronary artery bypass graft surgery has had trauma to the chest A client who has dysphagia has difficulty swallowing and is at a risk for aspiration A client who experienced a drug overdose has damage to the central nervous system

A nurse is caring for a client who is receiving hemodynamic monitoring readings: PAS 34 mm Hg, PAD 21 mm Hg, PAWP 16 mm Hg, CVP 12 mm Hg. For which of the following is the client at risk? (Select all that apply) A. Heart Failure B. Cor pulmonale C. Hypovolemic shock D. Pulmonary hypertension E. Peripheral edema

A, B, D, E A. Heart failure is associated with left ventricular failure and would be indicated by elevated hemodynamic readings B. Cor pulmonale is associated with the right side of the heart, and pulmonary problems would be indicated by elevated hemodynamic readings D. Pulmonary hypertension is associated with high blood pressure in the pulmonary arteries, affects the right side of the heart, and would be indicated by elevated hemodynamic readings E. Peripheral edema is associated with left ventricular failure and would be indicated by elevated hemodynamic readings

A nurse is beginning a physical assessment of a client who was recently diagnosed with multiple sclerosis (MS). Which of the following findings should the nurse expect? (Select all that apply) A. Areas of paresthesia B. Involuntary eye movement C. Alopecia D. Increased salivation E. Ataxia

A, B, E Areas of loss of skin sensation, nystagmus, and ataxia can occur in a client who has MS

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply) A. Encourage the client to cough every 2 hours B Check for continuous bubbling in the suction chamber C. Strip the drainage tubing every 4 hours D. Clamp the tube once a day E. Obtain a chest x ray

A, B, E Cough every 2 hours to promote oxygenation and lung reexpansion Check for continuous bubbling in the suction chamber to verify that suction is being maintained at an appropriate level A chest x ray is obtained following the procedure to verify chest tube placement

A nurse is assessing a client who has experienced a gun shot wound. Findings include BP 108/55, HR 124/min, RR 36/min, temperature 38.6 (101.4), and SaO2 95% on oxygen 15L/min via non-rebreather mask. The client reports dyspnea and pain. The nurse reassess the client 30 minutes later. Which of the following should the nurse report to the provider? (Select all that apply) A. Distended neck veins B. Tracheal deviation C. Headache D. Nausea E. HR 154/min

A, B, E Distended neck veins indicate that the client's condition is worsening; they are due to impaired gas exchange, which compresses the blood vessels and limits blood return. Tracheal deviation is due to altered intrathoracic pressure, which moves the trachea toward the unaffected side An increased HR is due to impaired cardiac output as a result of trauma

A nurse is assessing a client who is in respiratory distress. The nurse should recognize that which of the following can cause a low pulse oximetry reading? (Select all that apply) A. Nail polish B. Inadequate peripheral circulation C. Hyperthermia D. Increased Hgb level E. Edema

A, B, E Nail polish can affect the accuracy of pulse oximetry and result in an incorrect pulse oximetry level Inadequate peripheral circulation can result in a low reading while obtaining client's pulse oximetry level Edema can result in a low reading while obtaining a client's pulse oximetry level

Which of the following clients have an increased risk for developing pneumonia? (Select all that apply) A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis

A, B, E, F Difficulty swallowing, immunocompromised, invasive procedure, and difficulty clearing secretions

A nurse is reviewing a new prescription to administer 0.9% NaCl IV at 50 ml/hr to a client who is receiving hemodynamic monitoring and has an indwelling IV catheter in the left hand. Which of the following sites can be used for administering this solution? (Select all that apply) A. Peripheral saline lock B. Port on the arterial line C. Port on proximal (CVP) lumen of pulmonary artery (PA) catheter D. Port on distal lumen of PA catheter E. Balloon inflation port

A, C A. IV fluid administration can occur via a lock on a peripheral IV catheter C. The proximal (CVP) lumen of a PA catheter is used for hemodynamic monitoring and can also be used for IV fluid administration.

A nurse is caring for a client who is receiving vecuronium (Norcuron) for acute respiratory distress syndrome (ARDS). Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply) A. Fentanyl (Duragesic) B. Furosemide (Lasix) C. Midazolam (Versed) D. Famotidine (Pepcid) E. Dexamethasone (Decadron)

A, C Fentanyl is a pain medication used to treat clients who has ARDS when a neuromuscular blocking agent us administered Midazolam (Versed) is a sedative medication used when a neuromuscular blocking agent is administered

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply) A. Dysnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the punture site

A, C, D Dyspnea can indicate a pneumothorax or a reaccumulation of fluid. The nurse should notify the provider immediately Fever can indicate an infection. The nurse should notify the provider immediately Hypotension can indicate intrathoracic bleeding. The nurse should notify the provider immediately

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure is in the client's room? (Select all that apply) A. oxygen equipment B. Incentive spirometer C. Pulse oximeter D. Sterile dressing E. Suture removal kit

A, C, D Oxygen equipment is necessary to have in the client's room if the client becomes short of breath following the procedure Pulse oximetry is necessary to monitor the client's oxygen saturation level during the procedure A sterile dressing is necessary to apply to the puncture site following the procedure

A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism? (Select all that apply) A. A client who has a BMI of 30 B. A female client who has postmenopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic atrial fibrillation

A, C, E Obesity, a long bone fracture, and turbulent blood flow in the heart increase the risk for a blood clot

*A nurse is caring for a client who has myasthenia gravis (MG) and has developed drooping eyelids. Which of the following actions should the nurse take? (Select all that apply) A. Apply lubricating eye drops B. Encourage use of sunglasses C. port the head with pillows D. Tape eyes closed at night E. Provide for periods of rest during the day

A, D Lubricating eye drops reduce corneal dryness and irritation caused by weakness of the eyelids Taping the eyes closed prevents corneal dryness

A patient in skeletal traction suddenly develops right-sided chest pain and shortness of breath. What should the nurse do? (Select all that apply) A. Start oxygen per nasal cannula B. Administer the prescribed analgesic C. Check for Homan's sign D. Auscultate heart sounds every 2 to 4 hours E. Place in the high Fowler's position

A, D, E These manifestations may indicate pulmonary embolism. Oxygen should be administered to support gas exchange and tissue oxygenation. The high-Fowler's position facilitates oxygenation. Auscultating heart sounds can help detect cardiac compromise. Checking for Homans' sign would not be beneficial at this time. Pain medication should not be provided until a pain assessment is completed.

A nursing administrator is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which action by the administrator would have the biggest impact on decreasing complications? A. Investigate initiating a dedicated IV team B. Limit IV starts to the most experienced nurses C. Require inservice education for all RNs D. Perform quality control testing on all preparation products.

A.

The client who tripped while carrying an open kettle o hot water received scald burns to the entire chest, the entire anterior section of the right arm, the right half of the abdomen, and the anterior portion of the right left from the groin to the knee. At what percentage of total body surface area does the nurse calculate the injury using the rule of nines? A. 22-23% B. 30-31% C. 39-40% D. 48-49%

A.

The client with 45% burns has a hematocrit of 52% 10 hours after the burn injury and 6 hours after fluid resuscitation was started. What is the nurse's best action? A. Assess the client's blood pressure and urine output B. Notify the physician or the Rapid Response team C. Document the report as the only action D. Increase the IV infusion rate

A.

When an IV pump alarms because of pressure, what action does the nurse take first? A. Check for kinking of the catheter B. Flush the catheter with a thrombolytic enzyme C. Get new infusion pump D. Remove the IV catheter

A.

The nurse is caring for a patient undergoing mechanical ventilation for acute respiratory failure. Which measure should the nurse use to help maintain effective alveolar ventilation? A. Perform endotracheal suctioning as indicated B. Maintain ordered oxygen concentration C. Keep the patient in the supine position D. Increase the tidal volume on the ventilator

A. A patent airway is necessary to maintain effective alveolar ventilation and gas exchange. Endotracheal suctioning as needed will ensure a patent airway for the patient. The supine position will not ensure effective alveolar ventilation. Providing oxygen as prescribed will not ensure effective alveolar ventilation. Increasing the tidal volume on the ventilator could cause lung tissue trauma.

The nurse caring for a patient with COPD is concerned that the patient is developing respiratory failure. What did the nurse assess as an early sign of possible respiratory failure? A. Restlessness and tachypnea B. Deep coma C. Decreased urine output D. Hypotension and tachycardia

A. The manifestations of respiratory failure are caused by hypoxemia and hypercapnia, as well as the underlying disease process. Dyspnea and headache are early signs. Hypoxemia causes dyspnea and neurologic symptoms such as restlessness, apprehension, impaired judgment, and motor impairment. Tachycardia and hypertension develop as the cardiac output increases in an effort to bring more oxygen to the tissues. As hypoxemia progresses, dysrhythmias, hypotension, and decreased cardiac output may develop. Increased carbon dioxide levels depress CNS function and cause vasodilation.

A nurse is teaching a client who has begun taking oral baclofen (Liresal) three times daily to treat muscle spasms caused by a spinal cord injury. Which of the following statements by the client indicates a need for further teaching? A. I will stop taking this medication right away if I develop dizziness B. I know the doctor will gradually increase my dose of medication for awhile C. I'll make sure that I empty my bladder completely while taking this medication D. I won't be able to drink alcohol while I'm taking this medication

A. Abrupt withdrawal from baclofen can result in a number of adverse effects including visu hallucinations and seizures

The nurse is providing care to a patient newly admitted with bacterial pneumonia. Which action should the nurse perform first? A. Apply oxygen per nasal cannula at 5 L/min as prescribed B. Obtain a sputum specimen for culture and sensitivity C. Provide a meal for diet as tolerated D. Insert an IV catheter and start the prescribed antibiotic

A. Adequate oxygenation is a priority for all patients. The nurse should apply the prescribed amount of oxygen to the patient first. The sputum specimen should be obtained before beginning the prescribed antibiotic. The meal tray would be of the least priority.

A nurse in a clinic is caring for a client who was brought to the clinic by her partner. The partner states that the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following is the priority nursing action? A. Obtain baseline vital signs and oxygen saturation B. Obtain a sputum culture C. Obtain a complete history from the client D. Provide a pneumococcal vaccination

A. Assessment is the first step of the nursing process and is essential to patient centered care

During an assessment the nurse learns that a patient has had lower back pain for 9 months. For which type of pain will the nurse plan care? A. Chronic pain B. Somatic pain C. Visceral pain D. Neuropathic pain

A. Chronic pain is defined as pain that has persisted long after the reason for the pain has healed or subsided. Low back pain is the most common cause of chronic pain. Somatic pain arises from nerve receptors originating in the skin, subcutaneous tissues, or deep body structures such as periosteum, muscles, tendons, joints, and blood vessels. Somatic pain may be either sharp and well localized, or dull and diffuse. Visceral pain arises from body organs and is dull and poorly localized because of the low number of nociceptors. Visceral pain may be described as deep cramping, splitting or stabbing pain, intermittent pain, or colicky pain. Neuropathic pain is the result of hyperactive nociceptive stimulation. Neuropathic pain may be acute, is usually chronic, and is associated with conditions such as diabetic neuropathy or postherpetic neuralgia. This pain is described as gnawing, electric shock-like, burning, shooting, or tingling.

A nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy. Which of the following should the nurse recognize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago B. Elevated sedimentation rate C. Incident of exercise-induced asthma 1 week ago D. Elevated platelet count

A. Clients who have undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site.

The nurse is planning care for a patient with a tension pneumothorax. Which diagnoses should the nurse identify as the highest priority for this patient? A. Impaired gas exchange B. Acute pain C. Risk for aspiration D. Ineffective breathing pattern

A. Maintaining or restoring adequate alveolar ventilation and gas exchange is of highest priority for the patient with a pneumothorax. Loss of negative pressure in the pleural cavity and the resulting collapse of lung tissue can cause poor chest expansion and loss of alveolar ventilation. Acute Pain, Risk for Aspiration, and Ineffective Breathing Pattern are not priority diagnoses for this patient.

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table B. Explain the procedure to the client C. Obtain ABGs from the client D. Administer benzocaine pray to the client

A. Positioning the client in an upright position and bent over the bedside table widens the pleural space for the provider to access the pleural fluid

A patient who recently took up running to lose weight asks why she feels better after running when she should be tired and sore. Which nursing response would be the most accurate? A. Natural narcotic-like substances are released during physical activities like running B. Engaging in activities that actively use large muscle groups change pain circuits in the brain, reducing the perception of pain C. Activities such as running activate a natural "gate" in the spinal cord, blocking pain signals D. With repeated stimulation through activities such as running, nociceptors in deep tissues become less sensitive to stimuli

A. Rigorous physical activity such as running prompts the release of endorphins, which are natural opioid-like substances. Endorphins bind with opioid receptors in the CNS, which inhibits the transmission of pain signals. Physical activity does not create a gate in the spinal cord to block pain signals. Physical activity also does not change perception of pain in the brain. Exercise does not reduce the sensitivity of nociceptors in deep tissue.

A patient asks if glucosamine should be taken for knee pain. Which information should the nurse use to base a response to this patient's question? A. When combined with chondroitin, glucosamine has been effective in relieving moderate to severe knee pain in some patients B. Chronic pain such as that associated with osteoarthritis is best treated with NSAIDs and acetaminophen C. There is no evidence that natural products such as glucosamine are effective for treating any type of pain D. Although no studies have shown a benefit from taking glucosamine, other CAM therapies such as acupuncture are effective for treating pain

A. The combination of glucosamine and chondroitin has been shown to reduce pain in patients with moderate to severe knee pain. Other natural products have been studied for the relief of pain associated with migraine and other musculoskeletal conditions with mixed results. The nurse cannot say that there is no evidence that natural products are effective when treating pain. Because the treatment of chronic pain presents additional challenges, a broader range of drug classes may be used such as antidepressant medications, anticonvulsants, and opioids. Acupuncture has been shown to be effective in reducing pain of the neck, lower back, and shoulder but not the knee.

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and states that she is seeing double. The client states that she ran out of her diltiazem (Cardizem) 3 days ago, and she has not been able to purchase more. Which of the following nursing interventions should the nurse expect to perform first?

Administer acetaminophen for headache

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of her body. B. Place the client's bedside table on the right side of the bed. C. Orient the client to the food on her plate using the clock method. D. Place the client's wheelchair on her left side.

B

The nurse observes that a patient, whose blood type is AB-negative, is receiving a transfusion with type O=negative packed red blood cells. Which action does the nurse take first? A. Report the problem to the blood bank B. Assess and record the client's vital signs C. Stop the transfusion and keep the IV open D. Administer prescribed diphenhydramine

B

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 (100 F), respirations 30/min, BP 130/76, HR 100/min, and SaO2 91% on room air. Using a scale of 1 to 4, with 1 being the highest priority, prioritize the following nursing intervention: A. Administer antibiotics as prescribed B. Administer oxygen therapy C. Perform a sputum culture D. Administer an antipyretic medication to promote client comfort

B C A D

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply) A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration D. Exposed sutures without dressing E. Drainage system upright at chest level

B, C Gentle bubbling in the suction control chamber is an expected finding as air is being removed A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicate that the drainage system is functioning properly

A nurse is planning care for a client who is receiving mechanical ventilation. Which mode of ventilation increases the effort of the client's respiratory muscles? (Select all that apply) A. Assist-control B. Synchronized intermittent mandatory ventilaiton C. Continuous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation

B, C, D

A patient with arthritis has been taking over-the-counter NSAIDs for several years. Which questions should the nurse ask the patient while completing the health history? (Select all that apply) A. Do you know that you may become addicted to this drug? B. Tell me how and when you take this drug C. Have you ever vomited blood or had very dark stools? D. Do you have your blood pressure checked regularly? E. Have you noticed any problems with your breathing?

B, C, D NSAIDs are more effective when taken on a scheduled basis for predictable pain rather than prn for occasional pain. These drugs can cause gastrointestinal bleeding and hypertension, necessitating regular follow-up. NSAIDs are not known to affect the respiratory tract and are not addictive.

A nurse in the emergency department is assessing a client with a suspected flail chest. Which of the following clinical findings confirm this diagnosis? (Select all that apply) A. Bradycardia B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxic chest movement

B, C, D, E Tachycardia is a clinical manifestation of flail chest due to inadequate oxygenation

A nurse is caring for a client following a coronary artery bypass graft (CABG). Hemodynamic monitoring has been initiated. Which of the following actions by the nurse facilitate correct monitoring readings? (Select all that apply) A. Place the client in high-Fowler's position B. Level transducer to phlebostatic axis C. Zero transducer to room air D. Observe trends in readings E. Compare readings to physical assessment

B, C, D, E B. The level of the transducer should be at the phlebostatic axis (right atrium) to ensure an accurate reading is obtained C. The transducer is zeroed to room air to ensure an accurate reading is obtained. Hemodynamic pressure lines should be calibrated to read atmospheric pressure as zero. D. The trend of the client's pressure reading assists in providing appropriate medical treatment E. Readings are compared to the client's physical assessment findings to evaluate the client's condition and the appropriate treatment provided.

A nurse in the ED is caring for a client who was admit with an acute asthma attack. Which of the following indicates the client's respiratory status is declining? (Select all that apply) A. SaO2 95% B. Wheezing C. Retraction sternal muscles D. Pink mucous membranes E. Premature ventricular complexes (PVCs)

B, C, E

A nurse is assessing a client who has a pulmonary embolism. Which of the clinical manifestations should the nurse expect to find? (Select all that apply) A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia

B, D, E

A nurse is planning care for a client who has severe acute respiratory distress syndrome (SARS). Which of the following should be included in the plan of care for this client? (Select all that apply) A. Administration of antibiotics B. Providing supplemental oxygen C. Administration of antiviral medications D. Administration of bronchodilators E. Maintaining ventilatory support

B, D, E Oxygen is administered to treat hypoxemia Bronchodilators are given to vasodilate the airway Intubation may be required to maintain a patent airway

A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early clinical manifestations of hypoxemia? (Select all that apply) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

B, E Pale skin and elevated blood pressure are early clinical manifestations of hypoxemia

The nurse caring for a patient following a lobectomy notes 100 mL of red drainage in the chest drainage container since checking it 30 minutes previously. What should the nurse do to help this patient? (Select all that apply) A. Apply pressure to the chest tube insertion site B. Assess vital signs and level of consciousness C. Empty the chest tube drainage system D. Note the finding and reevaluate in 30 minutes E. Notify the surgeon

B, E Chest tube drainage that is red, free flowing, and exceeds 70 mL/h indicates hemorrhage and must be reported. Vital signs and level of consciousness are measured to evaluate cardiac output and hemodynamic stability. The drainage should not be emptied and pressure should not be applied to the chest tube insertion site. The nurse needs to notify the surgeon now and not wait for 30 minutes to reevaluate the patient's drainage.

The RN in the ED tells the student nure to choose this IV solution for a young healthy male trauma patient and explains that it buffers the acidosis in the blood but it is often not a good choice in the elderly patient because it should not be given to patients with liver or kidney disease. A. 0.45 NS B. LR C. 25% albumin D. 5% Dextrose and Water (D5W)

B.

The best definition of preload is: A. the amount of blood ejected from the ventricle per beat B. The amount of tension on the ventricular walls at end-diastole C. The resistance the ventricle must overcome to eject its blood D. The volume of blood returning to the heart

B.

The client with burns to the head, neck, and upper body from a house fire starts drooling uncontrollably about 8 hours after the injury. What is the nurse's best first action? A. Ensure that the client remains NPO B. Notify the Rapid Response team C. Slow the IV infusion rate D. Raise the head of the bed

B.

The nurse is evaluating teaching provided to a patient with lung cancer. Which patient statement indicates that teaching has been effective? A. Having the big C is very scary; I'm just glad it is one of the more curable forms of cancer B. Even though I can't undo the damage caused by cigarette smoking, I will try to quit, preventing further damage to my lungs C. Well, since I'm going to die anyway, I may as well go home, put my affairs in order, and spend the rest of my time in the easy chair D. I understand that because the cancer has already spread I will be undergoing aggressive cancer treatment for the next several years to beat this thing

B.

To prevent infection when infusing an intermittent "piggyback" IV line, which intervention does the nurse implement? A. Detaching and capping the secondary line after use B Backpriming the secondary container from the primary line C. Using a new secondary container with each drug infused D. Using sterile gloves when administering medication

B.

Which assessment does the nurse perform first on the client just admitted after an electrical injury with contact sites on the left hand and left foot? A. Core body temperature B. Electrocardiography C. Depth of burn injury D. Urine Output

B.

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the client's chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Place the tubing in sterile water to restore the water seal B. Apply sterile gauze to the insertion site C. Place tape around the insertion site D. Assess the client's respiratory status

B. Using ABC priority framework, the application of a sterile gauze to the site should be the first action for the nurse to take. This allows the air to escape and reduces the risk of the tension pneumothorax

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following statements by the client indicates the teaching was effective? A. This medication can decrease my immune response B. I take this medication to prevent asthma attacks C. I need to take this medication with food D. This medication has a slow onset to treat my symptoms

B. A bronchodilator prevents asthma attacks from occuring

A nurse is caring for a client who has dyspnea and is to receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask

B. A venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered to the client

A nurse is reviewing the prescriptions for a client who has pneumothorax. Which of the following actions should the nurse perform first? A. Assess the client's pain B. Obtain a large-bore IV needle for decompression C. Administer lorazepam (Ativan) D. Prepare for chest tube insertion

B. According to ABCs, establishing and maintaining the client's respiratory function is the priority. Therefore, obtaining a large-bore needle for decompression is the priority action by the nurse.

Mr. Gibson is in the ICU with CHF exacerbation. His heart rate is 83 and his BP is 102/66. He is tachypneic and dyspneic. He has a CVP=11 and PCWP=16. His cardiac output is 5 L/min. What is his stroke volume? A. 55 mL B. 60 mL C. 65 mL D. 70 mL

B. CO = HR x SV

A nurse is assessing a client with asthma. Which of the following is a risk factor associated with the disease? A. Gender B. Environmental allergies C. Alcohol Use D. Race

B. Environmental allergies are a risk factor associated with asthma. A client with environmental allergies typically has other allergic problems such as rhinitis or a skin rash

A nurse is teaching a group of clients about influenza. Which of the following statements by a client requires clarification? A. I should wash my hands after blowing my nose to prevent spreading the virus B. I need to avoid drinking fluids if I develop symptoms C. I need a flu shot every year because of the different flu strains D. I should sneeze into my elbow rather than my hands

B. Fluid intake should be increased if findings develop

A nurse is orienting a newly licensed nurse who is caring for a client that is receiving mechanical ventilation, which has been placed on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse demonstrates an understanding of PSV? A. It keep the alveoli open and prevents atelectasis B. It permits spontaneous ventilation to decrease the work of breathing C. It is used with clients who have difficulty weaning from the ventilator D. It delivers a preset ventilatory rate and tidal volume to the client

B. PSV maintains a preset amount of pressure during spontaneous ventilation to decrease the work of breathing

A patient recovering from surgery rates pain as being 7 on a scale of 0 to 10 but the nurse notes the patient is relaxed, smiling, and visiting with friends. Which action should the nurse take? A. Reassess the patient's pain after his friends have left B. Administer the prescribed analgesic dose C. Document your assessment but take no further action D. Note that the patient is developing tolerance to the prescribed opioid analgesic

B. Pain is a subjective response and the patient provides the most accurate information about its intensity. The nurse should provide the medication as prescribed. Behavioral responses to pain may or may not coincide with the patient's report of pain and are not always reliable cues to the pain experience. Pain assessment is considered the fifth vital sign and not taking action after learning of pain is a violation of regulatory agency expectations for accreditation. Additional information is needed before determining if the patient is developing a tolerance to the pain medication.

The nurse is instructing a patient with asthma on the use of a metered-dose inhaler (MDI) for medication administration. What should the nurse teach the patient about the medications being provided through this device? A. Rinse the mouth after using the inhaler to reduce systemic absorption of the drug B. Use the anti-inflammatory drug as needed to treat acute episodes of wheezing C. Take quick shallow breaths in rapid succession while holding the canister down D. Use the inhaler containing the anti-inflammatory drug first, then the bronchodilator

B. The anti-inflammatory effect of corticosteroids helps both prevent and treat acute episodes. Corticosteroids are used to reduce the frequency and severity of asthma attacks and allow reduced dosages of other drugs. These medications decrease the synthesis and release of inflammatory mediators, reduce inflammatory cell activation and infiltration, decrease airway edema, decrease mucous production in the airways, and increase the number and receptivity of beta2 receptors. Press and hold the canister down while inhaling deeply and slowly for 3 to 5 seconds. Then hold the breath for 10 seconds, release pressure on the container, remove from the mouth, and exhale. Wait 20 to 30 seconds before repeating the procedure for a second puff. Administer anti-inflammatory inhaler doses after bronchodilators to facilitate transit of the medication to distal airways. Rinse the mouth after using the inhaler to reduce the risk of fungal infections.

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. I am allergic to morphine B. I take antacids several times a day C. I had a blood clot in my leg several years ago D. It hurts to take a deep breath

B. The greatest risk to this client is the possibility of bleeding from a peptic ulcer. Further assessment should be completed and the nurse should notify the provider of the finding

Which statement should the nurse use to determine the quality of a patient's pain? A. Rate the pain on a scale of 0-10 B. Describe what the pain feels like C. Tell me where it hurts D. Tell me how this pain affects sleeping

B. The quality of the pain is assessed through descriptive statements such as sharp, stabbing, aching, burning, stinging, deep, crushing, viselike, or gnawing. Asking where it hurts identifies the location or region of the pain. Rating the pain on a scale determines pain intensity. Asking if the pain affects sleep helps to determine how the pain impacts the patient's quality of life.

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium (Norcuron) to a client who has acute respiratory distress syndrome. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. This medication is given to treat infection B. This medication is given to facilitate ventilation C. This medication is given to decrease inflammation D. This medication is given to reduce anxiety

B. Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption

A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor Judgement C. Inability to recognize familiar objects D. Loss of depth perception

C

A nurse is caring for a client admitted to the hospital with respiratory difficulty after being diagnosed with ALS approximately 1 year ago. Which of the following client findings should the nurse anticipate? (Select all that apply) A. Loss of sensation B. Fluctuations in blood pressure C. Incontinence D. Ineffective cough E. Loss of cognitive function

C, D Incontinence and ineffective cough from muscle weakness is a finding in a patient with ALS

A burned client newly arrived from an accident scene is prescribed 4 mg of morphine sulfate intravenously. What is the most important reason the nurse administers the analgesic to this client by the IV route? A. The drug will be effective more quickly than if given IM or SubQ B. It is less likely to interfere with the client's breathing and oxygenation C. The danger of an overdose during fluid remobilization in reduced D. The client has delayed gastric emptying

C.

A patient has a peripherally inserted central catheter (PICC) line placed by an advanced practice nurse at the bedside. Before using the catheter, how is its placement verified? A. The physician who ordered the PICC insertion procedure verifies placement B. The line is slowly flushed with 10 ml of saline while the nurse notes the east of flow. C. A chest x ray is taken which shows the catheter tip in the lower superior vena cava D. The line is aspirated gently and the nurse watches for blood return

C.

A patient is to receive an entire 500 mL bag of saline over the next 6 hours and the drop rate in the IV tubing chamber is 15 drops/mL. At what drop rate will the RN set this IV? A. 16 drops/min B. 18 drops/min C. 21 drops/min D. 32 drops/min

C.

An ABO acute hemolytic reaction includes the following: A. Occurs in the first 6 hours of transfusion of blood B. Occurs weeks after transfusion of blood C. Occurs in the first 15 minutes of transfusion of blood D. Occurs when platelets are below 50,000

C.

If stroke volume decreases, cardiac output can be maintained is the: A. BP increases B. Blood viscosity increases C. HR increases D. HR decreases

C.

The nurse prepares to administer a blood transfusion to a patient. Which means of identification does the RN use to ensure that the blood is administered to the correct patient? A. Ask the patient whether his or her name is the one on the blood product tag. B. Ask the patient's spouse if the client is supposed to have a transfusion C. Compare the name and ID number on the blood product tag with the name and ID number on the patient's ID band D. Compare the unit and room number of the patient with the unit and room number listed on the blood product tag.

C.

You are the RN in charge and the student nurse asks what the universal blood donor type is. You explain to the student nurse that the universal donor blood type is: A. Type A B. Type B C. Type O D. Type AB

C.

The nurse evaluating a tuberculin test result 72 hours after it was administered notes an area of induration 9 m in diameter. What additional information indicates to the nurse that this is a positive result? A. The patient is an injection drug user B. The patient was born in Southeast Asia C. The patient has HIV D. The patient resides in a long-term care facility

C. A 9-mm area of induration is a positive tuberculosis test result in a patient with HIV disease. Being an intravenous drug user, born in Southeast Asia, and residing in a long-term care facility are not criteria for a positive tuberculosis test with a 9-mm area of induration.

The nurse is providing discharge teaching to a patient with a fractured rib. What should the nurse instruct the patient to do? A. Remain on bed rest for a week to allow the fracture to stabilize B. Use elastic roller bandages like ACE wraps to stabilize the chest wall and promote comfort C. Use a small pillow to splint the area when coughing D. Avoid using pain medications to prevent respiratory depression

C. A patient with a fractured rib should be urged to use a small pillow to splint the area when coughing to reduce the movement of rib cage and pain. Providing adequate analgesia to promote breathing, coughing, and movement is the primary intervention. Bed rest is not required with a rib fracture. Rib belts, binders, and taping to stabilize the rib cage are not recommended, because they may interfere with ventilation and lead to atelectasis.

A victim of a house fire was transported to the emergency department for treatment of smoke inhalation. Which assessment finding should cause the nurse the greatest concern? A. Fine crackles in bilateral bases B. Ash-like material in the sputum C. Respiratory rate of 36 D. Skin and mucus membranes pink

C. A respiratory rate of 36 indicates respiratory distress and is of greatest concern. Adventitious lung sounds like crackles can occur after an inhalation injury. Ash-like material in the sputum is expected after an inhalation injury. Pink mucous membranes and skin indicate adequate oxygenation

A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath in the left lower lobe with dyspnea, blood pressure 118/68, HR 124/min, RR 38/min, temp 38.6 (101.4), and SaO2 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest x ray B. Prepare for chest tube insertion C. Administer oxygen via a high flow mask D. Initiate IV access

C. According to ABCs, administering oxygen via high flow mask is priority.

The nurse is planning care for a patient with chronic obstructive pulmonary disease. Which information should the nurse consider when determining if the patient should have supplemental oxygen? A. Because oxygen is flammable, the patient should not smoke B. Oxygen is used only at night for patients with COPD C. The patient needs to be closely monitored for signs of respiratory depression D. Oxygen is never used for patients with COPD because they may become dependent on it

C. Administering oxygen to patients with chronic elevated carbon dioxide levels in the blood can actually increase the PaCO2, leading to increased somnolence and even respiratory failure. Close monitoring of level of consciousness and arterial blood gases during oxygen therapy is vital. Long-term oxygen therapy is used for severe and progressive hypoxemia. It also reduces the rate of hospitalization and increases length of survival. Oxygen may be used intermittently, at night, or continuously. For severely hypoxemic patients, the greatest benefit is seen with continuous oxygen. The patient with chronic obstructive pulmonary disease should be working on a smoking cessation plan.

A nurse is caring for a client who has a prescription for bethanechol (Urecholine) 50 mg PO three times a day. The nurse should recognize that which of the following findings is a clinical manifestation of extreme muscarinic stimulation? A. Tachycardia B. Hypertension C. Excessive perspiration D. Fecal impaction

C. Bethanechol is a muscarinic agonist. Extreme muscarinic stimulation can result in sweating

A nurse is caring for a client who received a bolus dose of succinylcholine (Anectine) IV before an endoscopy procedure. During the procedure, the client suddenly develops rigidity, and his body temperature begins to rise. The nurse should anticipate a prescription for which of the following medications? A. A second dose of succinylcholine (Anectine) B. Naloxone as an antagonist at receptor sites C. Dantrolene (Dantrium) to slow metabolic activity of muscles D. Vecuronium (Norcuron) as an adjunct to muscle relaxation

C. Dantrolene acts on skeletal muscles to reduce metabolic activity

The nurse is determining goals of care for a patient with chronic obstructive pulmonary disease. Which would be an appropriate goal for this patient? A. Will verbalize self-care measures to regain lost lung function B. Arterial blood gases will be within normal limits by discharge C. Will maintain SaO2 of 90% or higher D. Will identify strategies to help reduce number of cigarettes smoked per day

C. During an acute exacerbation of COPD, keeping the SaO2 above 90% is an appropriate goal. Lung function that has been lost from chronic obstructive pulmonary disease cannot be regained. Arterial blood gases will not be normal because the patient's oxygen and carbon dioxide levels are altered due to lung changes. The nurse should help the patient develop a smoking cessation plan to preserve remaining lung functioning.

*A nurse instructs a client who has MG about home care and the risk factors that can exacerbate the disease. Which of the following client statements indicates a need for further teaching? A. I should take my medication 45 minutes before meals B. I have suction equipment at home in case I start to choke C. I will soak in a warm bath every day D. I ordered a medical identification bracelet to wear

C. Hot temperatures and hot water can cause a client who has MG to have an exacerbation

The nurse identifies nursing diagnoses that are appropriate for a patient with an acute asthma attack. Which diagnosis is of the highest priority? A. Ineffective Health Maintenance related to lack of knowledge about attack triggers and appropriate f medications B. Ineffective breathing pattern related to anxiety C. Ineffective airway clearance related to bronchoconstriction and increased mucous production D. Anxiety related to difficulty breathing

C. Ineffective airway clearance is the highest priority. Bronchospasm and bronchoconstriction, increased mucous secretion, and airway edema narrow the airways and impair airflow during an acute attack of asthma. Both inspiratory and expiratory volumes are affected, decreasing the oxygen available at the alveolus for the process of respiration. Narrowed air passages increase the work of breathing, increasing the metabolic rate and tissue demand for oxygen. The diagnoses that address anxiety, ineffective breathing pattern, and ineffective health maintenance are important and can be focused on after the patient's ineffective airway clearance is addressed.

A patient who smashed a finger in the car door relates that the pain initially was sharp, but now it is dull and throbbing. What should the nurse recall as the reason for the current type of pain that the patient is experiencing? A. It is an example of the gate theory of pain transmission B. Indicates that the injury is less severe than initially perceived C. Transmission of pain stimuli via unmyelinated C fibers D. It is the result of interpretation of the pain stimulus by the thalamus

C. Initial or "fast" pain is sharp and well defined because the stimulus is transmitted along myelinated A delta fibers to the thalamus and cerebral cortex. The smaller unmyelinated C fibers transmit the stimulus more slowly, producing a second or "slow" pain that is less well localized, dull, and throbbing. The gate-control theory of pain is a base for further research about pain-modulating systems. The change from acute sharp pain to dull throbbing pain does not indicate that the injury is less severe than initially perceived.

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vital signs are: HR 117/min, RR 38/min, temp 38.4 (101.2), BP 100/54. Which of the following actions is the priority action at this time? A. Notify the provider B. Administer heparin via IV infusion C. Administer oxygen therapy D. Obtain a spiral CT scan

C. Meeting the oxygenation needs first is the priority action according to ABCs

What approach should the nurse use to assess pain in a patient who is moderately cognitively impaired? A. Use only behavioral cues such as grimacing, pacing, or agitation B. Have the family evaluate the intensity of the patient's pain C. Ask the patient to rate the pain using the faces pain scale D. Administer the prescribed analgesic on an around-the-clock basis

C. Research has shown that patients with moderate cognitive impairment can use a pain scale to indicate the intensity of pain. The faces pain scale may be more accurate and effective for use with adults who have cognitive impairments. The family will not be able to accurately evaluate the patient's pain. Providing around-the-clock pain medication might result in overmedicating the patient. Physical responses and behavioral cues to pain are not always consistent. The nurse needs to use a pain rating scale that is appropriate to the patient's cognitive status.

The nurse caring for a patient with asthma notices that the patient's respirations have slowed and coughing has stopped. Breath sounds are diminished throughout his lung fields and absent in the bases. Which action should the nurse take? A. Obtain a chest x ray B. Ask family members to leave C. Notify the healthcare provider D. Allow the patient to rest undisturbed

C. Respiratory status can change rapidly during an acute asthma attack and its treatment. Slowed, shallow respirations with significantly diminished breath sounds and decreased wheezing may indicate exhaustion and impending respiratory failure. Immediate intervention is necessary so the healthcare provider needs to be notified. The healthcare provider might prescribe a chest x-ray. Asking the family members to leave is not a priority. Allowing the patient to rest undisturbed could eventually lead to respiratory arrest.

*A nurse is teaching a client who has ALS about a new prescription for riluzole (Rilutek). Which of the following instructions should the nurse give the client? A. Take this medication immediately prior to eating B. Drink a glass of milk with the medication C. Avoid consuming alcoholic beverages D. Monitor your blood pressure daily

C. Riluzole is hepatotoxic, o alcoholic beverages should be avoided to decrease the risk of liver damage

A nurse is completing discharge teaching with a client who has a new prescription for prednisone (Deltasone) for asthma. Which of the following client's statements indicates a need for further teaching? A. I will drink plenty of fluids while taking this medication B. I will tell the doctor if I have black, tarry stools C. I will take my medication on an empty stomach D. I will monitor my mouth for canker sores

C. The client should take this medication with food. Taking prednisone on an empty stomach can cause GI distress

What should the nurse include when teaching a patient about a transdermal pain medication? A. Replace this patch every 24 hours, applying it to clean, dry skin B. When reapplying the patch, place it on the anterior thigh C. Contact the physician if this medication causes excessive sleepiness D. This medication should be effective within 2 to 4 hours; contact the physician if the pain is not at an acceptable level after that

C. Transdermal patches are slowly absorbed, reaching a therapeutic level 12 to 72 hours after application. The drug can accumulate in the body tissues, leading to a toxic level accompanied by manifestations such as sleepiness or respiratory difficulty. A transdermal patch is applied to a clean, dry area on the upper torso. The patch is effective for about 72 hours. When transdermal therapy is initiated, the therapeutic level is not reached until approximately 12 to 24 hours have passed.

The nurse is teaching a patient who is prescribed prophylactic daily isoniazid (INH) for conversion of a tuberculin test. What should the nurse include in this patient's teaching? A. This drug turns the urine red-orange, which is harmless B. Periodic eye examinations are required during treatment C. Report numbness and tingling of extremities to the physician D. Do not use aspirin while taking this drug, because abnormal bleeding may occur

C. When teaching a patient who is taking INH, the nurse needs to include information on adverse effects such as numbness and tingling of extremities and how these effects need to be reported to the physician. Rifampin may cause an orange-red coloration of saliva and urine. Ethambutol may affect red-green color discrimination and visual acuity. Periodic eye examinations are recommended. Aspirin may interfere with rifampin absorption and should not be taken concurrently.

Contracts heart muscle

Calcium

A 45 year old patient arrives in the ED following a motor vehicle accident presenting with fluid volume deficit. The medical history reveals the patient has a history of hepatitis. You need to start an IV for fluid volume replacement and choose from the IV solution below as the best choice: A. 5% Dextrose in LR B. D5W C. 0.45 NS D. 0.9 NS

D

The burn client asks the nurse not to remove the loosened bits of skin and tissue during the dressing change, saying "The more skin you take off, the longer it will take me to heal." What is the nurse's best response? A. Do you want some pain medication before I begin? B. The only things I am removing are blocks of bacteria growth, not skin C. Don't worry, I have worked on the burn unit for years and know what I am doing D. The tissue is no longer living and as long as it is present, real healing cannot start

D

A nurse is assessing a peripheral IV site, upon examination the nurse observes a red streak the length of the vein, and the vein feels hard and cordlike. What actions by the nurse takes priority A. Apply continuous heat B. Continue monitoring the site C. Elevate the extremity D. Remove the catheter

D.

The nurse assesses the wound of a client burned as a result of stepping into a bathtub filled with very hot water. Which assessment finding of the burned areas on the tops of both feet does the nurse use as a basis to document a probable full-thickness injury? A. Most of the wounded area is red B. The client reports that the area hurts when touched C. The area does not blanch when firm pressure is applied D. Thrombosed blood vessels are visible beneath the skin surface

D.

The nurse is assessing a patient with a history of heart failure who is receiving a unit of packed red blood cells. The patient's respiratory rate is 32 breaths/min and blood pressure is 140/90 mmHg. Which action does the RN take first? A. Continue to monitor the patient's vital signs B. Stop the infusion of PRBCs C. Administer pain medication D. Slow the infusion rate of the transfusion

D.

When assessing the patient's peripheral IV site, the RN notices edema and tenderness above the site. What action should the nurse take first? A. Apply cold compresses to the IV site B. Elevate the extremity on a pillow C. Flush the catheter D. Stop the infusion of IV liquids

D.

A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on his left side B. Use the incentive spirometer C. Cough at regular intervals D. Perform the Valsalva maneuver

D. The client should be instructed to take a deep breath, exhale, and bear down as the chest tube is being removed. This increases intrathoracic pressure and reduces the risk of an air embolism

A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via a endotracheal tube. Which of the following should the nurse include in the teaching? A. Apply a vest restraint if self-extubation is attempted B. Monitor ventilator settings every 8 hours C. Document tube placement in centimeters at the angle of jaw D. Assess breath sounds every 1 to 2 hours

D. The nurse should assess the breath sounds of a client on mechanical ventilation every 1-2 hours

A nurse working on a medical-surgical unit admits a client. Two hours after admission, the client's SaO2 is 91% and he is exhibiting audible wheezes and use of his accessory muscles. Which of the following medications should the nurse expect to administer? A. Antibiotic B. Beta-blocker C. Antiviral D. Beta 2 agonist

D. A beta 2 agonist should be given to relive the client's symptoms

A nurse is orienting a newly licensed nurse on the care of a client who is receiving hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates the teaching was effective? A. "Air should be instilled into the monitoring system." B. "The client should be in the prone position." C. "The transducer should be level with the 2nd intercostal space" D. "A chest X-ray is needed to verify placement."

D. A chest x-ray is obtained to confirm proper placement of the lines

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms

D. Bronchospasms can indicate the client is having difficulty maintaining a patent airway. The nurse should notify the provider immediately

What information should the nurse include when teaching a patient with chronic malignant pain about opioid analgesics? A. There is a risk of addiction with this drug; stop the drug if you find that it no longer provides the degree of pain relief necessary B. This drug may interfere with urination; contact your physician if that if that becomes a problem C. This drug may cause itching and rash; take diphenhydramine (Benedryl) as needed D. Increase fluid and fiber intake; you may need a stool softener or laxative to prevent constipation

D. Constipation is a common side effect of opioid narcotics, especially when used on a regular basis. The nurse should instruct the patient to increase intake of fluids and fiber in the diet to prevent constipation. If this does not relieve constipation, the nurse should suggest the patient contact the provider if additional measures such as laxatives are needed to manage constipation. It is outside of the nurse's scope of practice to prescribe medications so suggesting the use of diphenhydramine (Benadryl) should not be done. The nurse also cannot instruct a patient to stop taking a medication without discussing it with the physician. Opioid analgesics are not known to interfere with urination.

The RN is preparing to flush a PICC line.The protocol specifies using 50 units of heparin. Available is a multipdose vial containing heparin 10units/mL. Which syringe does the nurse use to draw up and administer heparin? A. 2 mL syringe B. 3 mL syringe C. 5 mL syringe D. 10 mL syringe

D. Even though the RN only needs to draw up 5mL of heparin, using a 10 mL syringe lowers the pressure on the catheter and decreases the chances of blowing the line.

A nurse is teaching a client the importance of remaining still following angiography. Which of the following is an appropriate statement by the nurse? A. "Moving in bed raises your blood pressure." B. "Too much activity increases your risk for infection." C. "Moving in bed increases your risk of a complication due to anesthesia." D. "Too much activity places you at risk for bleeding."

D. Following angiography, it is important that the client lie still due to the increased risk for bleeding at the insertion site.

The nurse is assessing a patient with chronic obstructive airway disease. Which finding would be expected when conducting the physical examination of this patient? A. Mental confusion and lethargy B. Three+ pitting edema of ankles and lower legs C. Oxygen saturation readings of 85% or less D. AP chest diameter equal to or greater than lateral chest diameter

D. In the patient with chronic obstructive airway disease, air trapping and hyperinflation increase the anterior-posterior chest diameter, causing barrel chest. Mental confusion, oxygen saturation levels below 85%, and 3+ pitting edema of the ankles and lower legs are not expected assessment findings and should be reported to the healthcare provider.

A nurse in a provider's office is reviewing the health care record of a client who reported urinary incontinence and asked about a prescription for oxybutynin (Ditropan). The nurse should recognize that oxybutynin is contraindicated in the presence of which of the following conditions? A. Bursitis B. Sinusitis C. Depression D. Glaucoma

D. Oxybutynin is an anticholinergic and can increase intraocular pressure. Therefore, it is contraindicated for clients who have glaucoma

A nurse in a clinic is caring for a client who has sinusitis. Which of the following techniques should the nurse use to identify clinical manifestations of this disorder? A. Percussion of posterior lobes of lungs B. Auscultation of the trachea C. Inspection of the conjunctiva D. Palpation of the orbital areas

D. Palpation of the orbital, frontal, and facial areas will elicit a report of tenderness, which is a clinical manifestation in a client who has sinusitis

A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following should be included in the teaching? A. notify your provider if you experience weakness B. You should be able to return to work in 1 week C. You need to wear a mask when in crowded areas D. Notify your provider if you experience a cough

D. The client should notify the provider of a cough which may indicate that the client has a respiratory infection and should be treated

A patient is scheduled for a thoracentesis. What should the nurse do to assist the patient for this procedure? A. Remind to remain on quiet bed rest for 4 hours following the procedure B. Encourage to cough as the fluid is withdrawn C. Coach to breathe deeply as the needle is inserted D. Help to sit upright and leaning forward during the procedure

D. The patient having a thoracentesis needs to sit upright, leaning forward during the procedure to spread the rib cage for easier placement of the needle. The patient should not cough as fluid is withdrawn. The patient does not need to breathe deeply when the needle is inserted. The patient only needs to remain positioned on the unaffected side for 1 hour after the procedure to allow the pleural puncture to heal.

Aids in neuromuscular transmission and heart muscle contraction

Magnesium

A nurse is providing discharge teaching for a client who has a prescription for furosemide (Lasix) 40 mg PO daily. What time of day should the nurse encourage the client to take this medication?

Morning

Promotes transmission of nerve impulses and causes contractility of muscle tissue

Potassium

Maintains extracellular osmolality

Sodium

The nurse notes that a patient with bacterial pneumonia has an overall gray skin tone with a bluish tinge around the lips. In which order should the nurse provide the listed interventions? Notify the healthcare provider. Start oxygen. Raise the head of the bed. Assess breath sounds. Obtain oxygen saturation level.

Start oxygen. Raise the head of the bed. Obtain oxygen saturation level. Assess breath sounds. Notify the healthcare provider. Overall gray skin color and bluish tinge to lips indicate hypoxemia; supplemental oxygen is highest priority. Second, raise the head of the bed to promote chest expansion and alveolar ventilation. Assessment of oxygen saturation and breath sounds can be completed next. The physician should be contacted after the patient is receiving oxygen and assessments are completed.

A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in two weeks that the client experienced hypoglycemia. Which of the following data should the nurse report to the provider?

Takes metoprolol (Lopressor) daily