Med Surge 2 practice midterm questions

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions?

"Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." The correct procedure to maximize use of an incentive spirometer is to exhale completely, then take a slow, deep breath through the spirometer and hold it as long as possible. This procedure will maximize inspiratory function by expanding the lungs. The client should practice using the incentive spirometer before surgery. When teaching clients, it is important to provide exact step-by-step instructions, thus not leaving out any critical points.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing?

Hyponatremia

After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature?

a fever increased the cardiac workload

Cyanocobalamin (vitamin B12) 0.2 mg intramuscularly (IM) is prescribed for a client with pernicious anemia. A vial of the drug labeled "1 mL = 100 mcg" is available. How many milliliters should the nurse administer? Record your answer using a whole number. ___mL

2 ml

Which ECG report shows atrial fibrillation?

Image 4 shows a wavy baseline with atrial electrical activity and an irregular ventricular rhythm which indicates atrial fibrillation. Image 1 shows normal sinus rhythm in which both atrial and ventricular rhythms are essentially regular. There is one P wave before each QRS complex, and all the P waves are of a consistent morphology or shape. Image 2 shows sinus tachycardia. Image 3 shows sinus bradycardia.

A client develops ventricular fibrillation in a coronary care unit. Which action is priority?

Initiate defibrillation Ventricular fibrillation is a lethal dysrhythmia and, once identified, must be terminated immediately by defibrillation so the sinus node can act again as the heart's pacemaker. Oxygen is administered to correct hypoxia, but if the heart is not pumping, oxygen will not be delivered to the tissues; it does not take priority over defibrillation. Cardioversion is not effective in ventricular fibrillation. Bicarbonate is administered to correct acidosis; it does not take priority over defibrillation.

A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the best response by the nurse?

"you should share your feelings with him while you can" It is difficult to work through a loss; however, encouraging the sharing of feelings helps both parties feel better about having to let go. The response, "You must keep up a strong appearance for him," impedes the work of acceptance of one's finality and the use of the remaining time to the best advantage. There is no evidence to suggest that the client cannot cope with these emotions; the response, "I think he'd have difficulty dealing with that now," denies that this is a time for closeness and honesty. The response, "Don't you think he knows that without you telling him?" is demeaning, closes off communication, and does not foster the expression of feelings.

The nurse is caring for a client with complete partial seizures. Put in priority order the care activities performed by the nurse

1. maintaining airway 2. record time and duration of seizure 3. assess vital signs 4. performing neuro checks Maintaining the airway is the priority for a client with any type of seizure. Then the nurse should record the time and duration of the seizure to determine the severity of the condition. Then the nurse should assess the client's vital signs after completion of the seizure. Then the nurse should assess the client's neurologic status.

Kübler-Ross has identified the five stages of dying/grief. Place the following nursing statements reflecting the five stages in the correct order.

1."You do understand that your child experienced fatal head trauma in the automobile accident?" 2."Being angry at your partner for dying and leaving you alone is a natural grief reaction." 3."Have you discussed with your oncologist how long radiation therapy might prolong your life?" 4."Can we talk about the benefits of agreeing to take an antidepressant medication?" 5."I've collected the information you requested concerning end-of- life planning." Denial is the first stage; this statement addresses possible denial of the severity of the child's injury. Anger is the second stage; this statement acknowledges the presence of anger. Bargaining is the third stage; negotiating for more time is common. Depression is the fourth stage; discussing the management of depression is now appropriate. Acceptance is the fifth and final stage; planning for one's death is characteristic of acceptance.

The nurse is assessing a client with an open fracture who is in a trauma condition. What are the nursing interventions in order of priority?

1.Assessing for airway patency, breathing, and circulation 2.Cutting away the clothing from the fracture site 3.Applying direct pressure on the injured area 4.Administering morphine sulfate intravenously The priority nursing intervention for a client in a trauma condition is to assess for airway patency, breathing, and circulation. Next priority is to cut away clothing from the fractured site. After clothing is removed, direct pressure is applied on the injured area to prevent bleeding. After stabilizing the client, pain is managed by administering morphine sulfate through the intravenous route.

Which intravenous fluid should the nurse classify as hypertonic?

5% dextrose in normal saline

Oral phenobarbital 30 mg every 6 hours is prescribed for a toddler who has had a seizure. A bottle of phenobarbital liquid labeled 20 mg/4 mL is available. How much solution (mL) will the nurse administer? Record your answer using a whole number. ___ mL

6 mL

A nurse is assessing four clients with musculoskeletal disorders. Which client does the nurse suspect of having Parkinson disease? A. festinating gait (trunk and knees flex when body is rigid) B. Short leg gait (limping) C. spastic gait (uncoordinated, cross-knee (scissor) movement D. steppage gait (increased hip and knee flexion to make a step)

A Festinating gait, when the neck, trunk, and knees flex when the body is rigid, in client A indicates Parkinson disease. A leg-length discrepancy of more than one inch due to arthritis or fracture may lead to the short-leg gait in client B. Neurogenic disorders such as cerebral palsy and hemiplegia may lead to the spastic gait in client C, which is manifested by jerky, uncoordinated, and cross-knee movement. Neurogenic disorders such as peroneal nerve injury and paralyzed dorsiflexor muscles may lead to the steppage gait in client D; this is manifested by increased hip and knee flexion to clear the foot from the floor and foot-dropping while walking.

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?

A score of 8 or below indicates coma. The Glasgow Coma Scale is used to assess the extent of neurologic damage; it consists of three assessments: eye opening, response to auditory stimuli, and motor response. Consciousness exists on a continuum from full consciousness to coma. A score can be from 3 to 15; the lower the score the more indicative of coma. To achieve the ratings of 9, 12, or 15 the client must be exhibiting some meaningful responses.

Identify abnormal assessment findings in the client's musculoskeletal system. Select all that apply. A. Joint crepitation B. Muscular atrophy C. Muscle strength of 5 D. Tenderness of the spine EFull range of motion in joints

A,B,D Crepitation, a cracking and popping sound of the joint, is not a normal assessment finding. Muscular atrophy, wasting of the muscle, is also an abnormal finding. Spine tenderness on palpation of spine, joints, or muscles is not a normal finding on physical assessment of the musculoskeletal system. Muscle strength of 5 indicates active movement of the muscle against full resistance without evident fatigue, or normal muscle strength. Full range of motion in the joints is a normal finding.

While receiving a blood transfusion, a client develops acute dyspnea, generalized urticaria, a heart rate of 128, and a blood pressure of 70/38. What type of reaction does the nurse conclude that the client probably is experiencing?

Anaphylactic Anaphylactic reactions result from hypersensitivity to a product in the blood. Signs and symptoms are due to bronchospasm, systemic vasodilation, and compensatory tachycardia. The client may go into life-threatening shock without prompt treatment. Panic reactions (also known as panic attacks) involve high levels of anxiety and may be coupled with autonomic symptoms such as tachycardia. Bacterial pyrogens are present in contaminated blood and can cause a febrile transfusion reaction; signs include fever and chills. Hemolytic reaction results from the incompatibility of a recipient's antibodies with transfused red blood cells (RBCs); the reactions result from RBC hemolysis, agglutination, and capillary plugging.

When a client exhibits severe bradycardia, which type of drug should the nurse be prepared to administer?

Anticholinergic An anticholinergic drug will block parasympathetic effects, causing an increased heart rate. Cardiac nitrate will dilate coronary arteries, not increase the heart rate. Antihypertensive drugs will lower the blood pressure and may decrease the heart rate. Cardiac glycoside will improve cardiac contractility but will decrease the heart rate.

The nurse observes the following pattern on a client's electrocardiogram (ECG) strip. What dysrhythmia does the nurse identify?

Premature ventricular complex

What is the most definitive test to confirm a diagnosis of multiple myeloma?

Bone marrow biopsy

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of?

Cardiac irritability Cardiac irritability is the cardinal reason for PVCs. Atrial fibrillation is a type of dysrhythmia, not the cause of PVCs; the source of atrial fibrillation is the atrium, not the ventricles. Impending heart block type of dysrhythmia is associated with interference with the conduction system. Ventricular tachycardia is a type of dysrhythmia, not the cause of PVCs.

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what?

Causing local vasoconstriction, preventing edema and muscle spasms Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasms. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain.

While playing on a jungle gym in the school playground, a school-aged child falls and sustains head trauma. The nurse suspects dysfunction of the brainstem at a low level when the child assumes the posturing depicted in the illustration. How should the nurse document this posturing in the child's hospital record?

Decerebrate decerebate posturing includes rigid extension and pronation of the arms and legs; it is associated with dysfunction at the level of the midbrain. Orthotonos is a tetanic spasm marked by rigidity of the body with the arms and legs in extension in a straight line; it is associated with tetanus or strychnine poisoning. Decorticate posturing consists of adduction of the arms at the shoulders, flexion of the arms on the chest with the wrists flexed and the hands fisted, and extension and adduction of the lower extremities; it is associated with dysfunction at or above the upper brainstem. Opisthotonos is a tetanic spasm in which the head and heels are bent backward and the body is bowed forward; it is associated with tetanus, strychnine poisoning, rabies, and severe meningitis.

A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority?

Decrease the workload on the heart and promote maximum coronary artery filling With a myocardial infarction, circulation of blood to cardiac muscle is reduced, depriving it of oxygen; therefore, the oxygen demands of the body need to be decreased to reduce stress on the heart and reduce cardiac output. Increased coronary artery filling allows more blood and, therefore, oxygen to reach cardiac muscle; this increases myocardial efficiency. Increasing left ventricular filling increases the workload of the heart. Oxygenation of vital organs must be maintained. Decreasing oxygen to vital organs of the body may interfere with their ability to function. Increasing venous return to the right atrium increases the workload of the heart.

A nurse is caring for a client who just had coronary artery bypass graft surgery. For which complication should the nurse monitor the client in the immediate postoperative period?

Dysrhythmias, especially atrial fibrillation Dysrhythmias such as atrial fibrillation, bradydysrhythmias, or heart block must be closely monitored for in the client immediately after surgery. Postpericardiotomy syndrome with fever and friction rub may occur later, not in the immediate postoperative period. Mediastinitis can occur, but it is not in the immediate postoperative period. Hemoglobin and hematocrit levels usually decrease, not increase; anemia can be a problem after this surgery.

A client has a synchronous pacemaker inserted. The nurse observes spikes on the monitor at a regular rate that are not followed by myocardial activity. What conclusion should the nurse make about the pacemaker based on this data?

Failure to stimulate the heart If pacemaker spikes are present, the pacemaker is firing appropriately, but the lack of resulting QRS complexes indicates that it is not stimulating or "capturing" the heart. Loss of battery power is indicated by a slowing or irregular heart rate. Each pacemaker spike should be followed by a QRS complex. A fixed or asynchronous pacemaker is designed to work independently of the client's intrinsic rhythm.

A client with a diagnosis of uncontrolled diabetes began receiving furosemide 2 days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L (Canada: 2.8 mmol/L). What is the most appropriate action for the nurse to take?

Notify the primary healthcare provider of the critically low result. The healthcare provider should be notified because a potassium level of 2.8 mEq/L (2.8 mmol/L) is low. Normal range for serum potassium is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Clients who are on diuretics require monitoring of serum electrolytes, especially potassium and sodium, because they also are excreted with water. The nurse should not hold the diuretic or repeat the lab test unless advised by the healthcare provider. The client's serum potassium level is critically below the normal limit and the healthcare provider should be notified. An increase in furosemide would cause an increased loss of potassium.

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present?

Paresthesias Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is what?

Potassium

When providing preoperative teaching, what should the nurse focus primarily on?

Providing general information to reduce client and family anxiety

The nurse is interpreting an electrocardiogram rhythm. What part of the electrical pattern represents ventricular contraction?

QRS interval Atrial and ventricular depolarization and repolarization are represented on the electrocardiogram (ECG) as a series of waves: the P wave followed by the QRS complex and the T wave. The first deflection is the P wave associated with right and left atrial depolarization followed by the QRS complex that reflects ventricular depolarization.

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results?

Sodium and chloride levels Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.

A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. The nurse prepares for cardioversion. What nursing action is essential to prevent the potential danger of inducing ventricular fibrillation during cardioversion?

Synchronizer switch is in the "on" position. The precordial shock during cardioversion must not be delivered on the T wave, or ventricular fibrillation may ensue. By placing the synchronizer in the "on" position, the machine is preset so that it will not deliver the shock on the T wave. The energy level may be set from 50 to 100 Watts/second. Skin electrodes applied after the T wave and an alarm system of the cardiac monitor functioning simultaneously will not ensure that the shock is not delivered on the T wave.

Which assessment finding of the nail indicates the risk of anemia in the client?

The second figure depicts the concave curving of a nail, which is known as koilonychia. This condition may indicate anemia. Beau's lines (option 1) are deep grooved transverse lines on the nail (as depicted in the first figure); this condition may be caused by a severe infection or a nail injury. Paronychia is the inflammation of the skin at the edge of the fingernail, as shown in the third figure. The fourth figure depicts clubbing, which is the softening of the nail bed and a change in the angle between nail and nail base. This condition may be due to a chronic lack of oxygen, heart disease, or lung disease.

A nurse in a long-term care facility is caring for a bedridden client with multiple chronic illnesses. Although usually continent, the client expresses anger through urinary incontinence. What should the nurse do to best address this situation?

assist the client in setting realistic short-term goals People with chronic illnesses often feel helpless and powerless. This can turn into anger and acting-out behaviors against those providing care. Helping the client set and achieve realistic short-term goals fosters client independence and hope. Because the client is able to control elimination, frequent toileting is not the problem. Although distraction is important, it should be varied and the client's preferences taken into consideration. Radio and television do not promote interaction. As a means of preventing urinary stasis and dehydration, fluid intake should be encouraged. Also, restricting fluid intake will not prevent intentional incontinence.

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?

autonomy The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit others.

What is the priority nursing action when caring for a client with disseminated intravascular coagulation?

avoid giving intramuscular injections Massive amounts of clots formed in the microcirculation deplete platelets and clotting factors, leading to bleeding; the trauma of an injection may cause excessive bleeding. Monitoring for Homans sign is associated with thrombophlebitis. Taking temperatures via the rectal route could be traumatic and precipitate bleeding. Sequential compression stockings are used to prevent thrombophlebitis.

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? Select all that apply.

boiled spinach dried apricot

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply.

chemotherapy, blood transfusion, radiation therapy Palliative care is a combination of care provided when cure is not possible for a chronic disease. It may include symptom management and comfort measures. Chemotherapy, radiation therapy, and blood transfusions are a part of palliative care meant to alleviate symptoms and promote well-being. These therapies may not be required in a client who is about to die and is receiving end-of-life care. End-of-life care comprises measures to make the client as comfortable as possible. It may include measures such as regular oral care and repositioning.

After reviewing a client's reports, the primary healthcare provider suggests palliative care for the client. Which conditions would qualify the client for this type of care? Select all that apply.

chronic renal failure congestive heart failure chronic obstructive lung disease Palliative care aims to minimize client suffering and reduce the undesirable effects resulting from an incurable disease or condition. Disease conditions such as severe chronic renal failure, congestive heart failure, and chronic obstructive lung disease cannot be cured completely with medications, but palliative care may reduce client suffering from the beginning of the therapy to the end stages. Conditions such as peptic ulcer and cognitive impairment can be completely reversed by medications; therefore, these clients do not require palliative care.

The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation?

client with wheezing Wheezing indicates anaphylactic and allergic reactions in the client who is on blood transfusion therapy. Therefore the client with wheezing should be treated first. Itching, flushing, and pruritus indicate a mild allergic reaction. Clients with itching, flushing, and pruritus can be treated after treating the client with wheezing symptoms.

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply.

confusion weakness dysrhythmias Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause confusion, weakness, and cardiac dysrhythmias.

Within 4 to 6 hours after a client has a myocardial infarction, the nurse expects which blood level to increase?

creatine kinase-MB band (CK-MB) CK-MB is an isoenzyme of creatine phosphokinase (CPK) found in cardiac muscle; it increases in 4 to 6 hours after chest pain and begins to decline in 12 to 24 hours. LDH-1 increases within 6 to 12 hours after the onset of pain. ESR is nonspecific; it indicates the presence of inflammation or infection. AST increases within the first 12 hours; it is not specific enough to provide a definitive indicator within 4 to 6 hours.

The nurse is preparing a blood transfusion for a client with renal failure. Why does anemia often complicate renal failure?

decrease in erythropoietin The hormone erythropoietin, produced by the kidneys, stimulates the bone marrow to produce red blood cells. In renal failure there is a deficiency of erythropoietin that often results in the client developing anemia. Therefore the nurse is instructed to administer blood. In renal failure, increased blood pressure is due to impairment of renal vasodilator factors and is not treated by administration of blood. Phosphate is retained in the body during renal failure, causing binding of calcium leading to done demineralization, not anemia. Increase in urinary sodium concentration and decrease in serum sodium concentration trigger the release of renin from the juxtaglomerular cells.

A client who has had a myocardial infarction experiences a noticeably decreased pulse pressure. What does this indicate to the nurse?

decreased force of contraction A direct relationship exists between systolic blood pressure and the force of left ventricular contraction. A decreased pulse pressure is associated with heart failure or hypovolemia. A decreased blood volume is indicated by a decreased pulse pressure. Hyperactivity of the heart is indicated by dysrhythmias and tachycardia. A decreased pulse pressure indicates decreased cardiac sufficiency.

The registered nurse is caring for a client with tonic-clonic seizures. Which action should the nurse perform immediately according to priority?

ensuring patent airway

A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings would alert the nurse to the possible development of thrombocytopenia? Select all that apply.

headache, hematuria, ecchymosis Thrombocytopenia is a condition characterized by abnormally low levels of thrombocytes, also known as platelets, in the blood. This reduction in platelet activity impairs blood clotting, so any assessment finding associated with potentially abnormal bleeding would alert the nurse to the possibility of thrombocytopenia. This includes headache (bleeding into brain tissue), hematuria (bleeding within the renal system) and ecchymosis (bleeding into skeletal soft tissue). Fever and diarrhea are common side effects of chemotherapy, but are not findings specifically attributed to thrombocytopenia.

A client with a history of multiple chronic illnesses comes to the emergency department (ED) reporting a slight progressive weight loss over the last month as well as frequent urination and feeling lethargic, hungry, and thirsty all the time. The client's vital signs are blood pressure (BP) 118/78 mm Hg, oral temperature 99.6 °F (37.6 °C), and regular pulse of 72 beats per minute with irregular respirations of 22 breaths per minute. What condition does the nurse suspect that this client is experiencing?

hyperglycemia The client is reporting a slight progressive weight loss over the last month and feeling lethargic, hungry, and thirsty all the time. These adaptations are related to hyperglycemia. The client's blood pressure is within the expected range for an adult. The average blood pressure of a healthy adult is 120/80 mm Hg. The blood pressure will be decreased and heart rate increased if a client is experiencing hypervolemia. The client's temperature is within the expected range for an adult (96.8 to 100.4 °F) (36 to 38 °C). The temperature will be increased when a client is experiencing an infectious process. Although the respiratory rate of 22 breaths per minute is slightly more than the expected respiratory rate for a healthy adult (15 to 20 breaths per minute), the client is not exhibiting signs of respiratory distress (e.g., labored breathing, use of accessory muscles of respiration).

A client is admitted to the cardiac care unit with an anterior lateral myocardial infarction. The healthcare provider prescribes 500 mL of D5W with 50 mg of nitroglycerin to be administered intravenously to relieve pain. The nurse should assess for which most common side effect of this medication?

hypotension The major action of intravenous nitroglycerin is venous and then arterial dilation, leading to a decrease in blood pressure. Nausea is not a common side effect of intravenous nitroglycerin. Syncope is an infrequent effect when nitroglycerin is given intravenously. Reflex tachycardia may occur with the decrease in blood pressure.

The nurse is caring for a client who is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect?

improved hemoglobin and hematocrit levels Vitamin B12 is essential for appropriate maturation of red blood cells; therefore relieving the deficiency is expected to improve hemoglobin and hematocrit (H & H) levels and decrease hypoxia-related problems. This disorder is known as pernicious anemia. Normal serum electrolytes, healthy skin integrity, and resolution of peripheral edema, if present, would be secondary to improved hemoglobin and hematocrit levels.

A nurse is teaching a group of clients about risk factors for heart disease. Which factors will the nurse include that increase a client's risk for a myocardial infarction (MI)? Select all that apply.

obesity hypertension Obesity increases cardiac workload associated with vascular changes that lead to ischemia, which causes an MI. Hypertension damages blood vessels and increases peripheral resistance and cardiac workload, which may lead to an MI. Diabetes mellitus, not insipidus, is a risk factor for an MI. The risk is higher for African-Americans, not Asian-Americans. Increased levels of low-density lipoprotein (LDL), not HDL, increase the risk for heart disease.

Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest?

older adults The incidence of chronic illness increases in older adults because of the multiple stresses of aging. Younger individuals have greater physiologic reserves, and chronic illnesses are not common.

A client is hospitalized with head trauma. Which imaging test should the nurse anticipate being prescribed by the primary healthcare provider to rule out a cervical spine fracture?

plain x-ray A plain x-ray is used to identify the fracture. Cerebral angiography is used to visualize blockages in arteries or veins present in the brain. Computed tomography (CT) is used to generate three-dimensional detailed anatomical pictures of the brain and spinal cord. Positron emission tomography (PET) shows the type and location of brain dysfunction by measuring metabolic activity.

A nurse is caring for a client after cardiac surgery. Which signs will cause the nurse to suspect cardiac tamponade? Select all that apply.

pulsus paradoxus muffled heart sounds jugular vein distention Pulsus paradoxus is present in cardiac tamponade. Blood in the pericardial sac compresses the heart so the ventricles cannot fill; this leads to a rapid, thready pulse and muffled heart sounds. The increased venous pressure associated with cardiac tamponade causes jugular vein distention. Tamponade causes hypotension, not hypertension, and a narrowed pulse pressure. As the heart becomes more inefficient, there is a decrease in kidney perfusion and therefore a decrease in urine output.

Which interventions should the nurse perform when caring for an actively dying client? Select all that apply.

reassure the client and family manage the clients symptoms The nurse should provide comfort care for a client who is actively dying by managing the client's symptoms and reassuring the client and family during the dying process. Reassuring the client and family by providing simple bits of information and using therapeutic communication during the dying process can help to reduce their emotional anxiety. Symptom management maximizes the client's quality of life and improves the client family experience with the dying process of a loved one. The client should not be admitted to hospice care while actively dying; there will likely not be enough time and this action could be traumatic for the client and family. A client is admitted to hospice care if they are not actively dying and death is expected within 6 months. The client does not require laboratory tests while actively dying. The client should be repositioned as needed for comfort; for example, placing the head of the bed in the highest position can facilitate breathing comfort.

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what?

relieve the clients discomfort Palliative measures are aimed at relieving discomfort without curing the problem. A cure or recovery is not part of palliative care; with a terminal disease the other goals are unrealistic. Although support of significant others is indicated, palliative care is related directly to relieving the client's discomfort.

When monitoring a client for hyponatremia, which assessment findings should the nurse consider significant? Select all that apply.

seizures confusion Confusion and seizures are associated with hyponatremia. Cellular swelling and cerebral edema are associated with hyponatremia; as extracellular sodium level decreases, the cellular fluid becomes relatively more concentrated and pulls water into cerebral cells, leading to confusion and seizures. Thirst is a symptom of hypernatremia; it may indicate dehydration. Erythema is not associated with hyponatremia. Diarrhea, not constipation, is associated with hyponatremia.

While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation?

stop the blood transfusion immediately An incompatible blood transfusion can result in an acute hemolytic reaction in the client. During acute hemolytic reactions, the nurse should stop a blood transfusion as a priority nursing intervention. After stopping the blood transfusion, the nurse should report it to the primary healthcare provider. The nurse can then recheck the client's identifying tags and numbers and maintain a patent IV line with saline solution.

Ten minutes after the initiation of a blood transfusion, a client reports lumbar pain. What is the next nursing action?

stop transfusion This is a sign of an acute hemolytic transfusion reaction, indicating that the recipient's blood is incompatible with the transfused blood; pain is caused by hemolysis, agglutination, and capillary plugging in the kidneys. Obtaining the vital signs and assessing the pain further are unsafe actions; more incompatible blood will be infused, increasing the severity of the transfusion reaction. Increasing the flow of normal saline is unsafe; the transfusion must be stopped first, and then normal saline should be infused to keep the line patent and to maintain blood volume.

A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply.

tachycardia, restlessness, decreased urinary output The heart rate increases and the respiratory rate increases in an attempt to meet the oxygen demands of the body. Restlessness occurs because of cerebral hypoxia. The urine output drops to less than 30 mL/hr because of decreased arterial perfusion to the kidneys and the compensatory mechanism of reabsorbing fluid to increase the circulating blood volume. The skin becomes cool and pale as blood shunts from the peripheral blood vessels to the vital organs.

A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests are prescribed. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction?

troponin T Troponin T has an extraordinarily high specificity for myocardial cell injury. Cardiac troponins elevate sooner and remain elevated longer than many of the other enzymes that reflect myocardial injury. ALT is found predominantly in the liver; it is found in lesser quantities in the kidneys, heart, and skeletal muscles and is primarily used to diagnose and monitor liver, not heart, disease. AST, also known as serum glutamic-oxaloacetic transaminase (SGOT), is elevated 8 hours after a myocardial infarction. Total LDH levels elevate 24 to 48 hours after a myocardial infarction.