Module 9: Monitoring for Health Problems
A nurse is reviewing lab results for a client who is at risk for nephrotoxicity b/c of meds being taken. Which serum creatinine result does the nurse document as normal
1.0 mg/dL (normal BUN 0.6-1.3)
A nurse is reviewing the results of renal fxn testing in a client with renal calculi. Which finding indicates to the nurse that the client's BUN level is within the normal range
18mg/dL (normal BUN 6-20)
A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin. Which result indicates that the prescribed dose is therapeutic
16mcg/mL
oxygen by way of NC has been prescribed for a client with emphysema. The nurse checks the HCP's rx to ensure that the prescribed flow is not greater than which liter per min
3L/min
Blood is drawn from a male client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level
4.4mg/dL
A nurse is assessing the status of a client with DM. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated HbA1c is less than which value
7%
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first
check the degree of suction being applied
A nurse is monitoring a client who has undergone pleural bx. Which finding causes the nurse to suspect that the client is experiencing a complication
complaints of SOB
A nurse is preparing to examine a client's skin using a Wood light. What should the nurse do to facilitate his procedure
darken the exam room
A nurse is admitting a client with a dx of hypothermia to the hospital. Which signs does the nurse anticipate that this client will exhibit
decreased HR and decreased BP
A client with type 1 DM has a BGL of 620. After the nurse calls the HCP to report the finding and monitors the client closely for which condition
metabolic acidosis
a nurse reviews a client's UA report. Which finding does the nurse recognize as abdnormal
the presence of ketones
A HCP is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client
upright
A client reports for a scheduled EEG. Which statement by the client indicates a need for additional prep for the test
"I didn't shampoo my hair"
A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than which value
200mg/dL
A client's baseline VS are temp 98 F, HR 74bpm, resp rate 18/min, and BP 124/76 mmHg. The client suddenly spikes a fever of 103 F. Which resp rate would the nurse anticipate as part of the body's response to the change in client status
22 breaths/min
A client with CVD is scheduled to receive a daily dose of furosemide. Which potassium level would cause the nurse, reviewing the client's electrolyte values, to contact the HCP before administering the dose
3.0 mEq/L
A client admitted to the hospital with a dx of acute pancreatitis has blood drawn for several serum lab tests. Which serum amylase value, noted by the nurse reviewing the results, would be expected in this client at this time
395 units/L (normal range is 30-122)
An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse who receives the report of the client's lab work that the client's hct is normal
43% (normal female range 35-47%)
A client w/o a hx of resp disease has a pulse-ox in place after surgery. The nurse monitors the pulse-ox readings to ensure that oxygen saturation remains above which value
95%
A client is receiving intermittent bolus feedings bu way of a NG tube. In which position should the nurse place the client once the feeding is complete
HOB elevated 30-45 degrees
A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client for the procedure
Left Sim's position
A client in the PACU has an as-needed rx for ondansetron. Which occurence would prompt the nurse to administer this med to the client
N&V
A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum lab studies. Which abnormal lab results should the nurse report to the surgeon's office SATA a) hgb 8.9 b) Na 141 c) Platelets 210 d) hct 30% e) serum creatinine 0.8
a) hgb 8.9 d) hct 30%
A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the HCP SATA a) unequal chest expansion b) resp rate of 22/min c) complaints of discomfort at the needle insertion site d) diminished breath sounds in the right lung e) HR of 82bpm
a) unequal chest expansion d) diminished breath sounds in the right lung
A nurse has a rx to apply a Holter monitor to a client for continuous cardiac monitoring for a 24 hour period. What steps should the nurse take to initiate this rx SATA a) giving the client a device holder to wear around the waist b) giving the client in a diary in which to record activity and symptoms c) telling the client to rest as much as possible during the next 24 hours d) telling the client that occasional slight shocks from the monitor will be felt but that they are harmless e) instructing the client to enclose the monitor in plastic wrap before taking a bath
a, b
A client has just been scheduled for an ERCP. What should the nurse tell the client about the procedure SATA a) that multiple position changes may be necessary to pass the tube b) that informed consent is required c) that no premedication for sedation will be necessary d) that food and fluids will be withheld before the procedure e) that the test takes about 4 hours to complete
a, b, d
A nurse is watching as an UAP measure the BP of a hypertensive client. Which actions on the part of the UAP would interfere with accurate measurement and prompt the nurse to intervene SATA a) allowing the client to talk as the BP is being measured b) measuring the BP after the client reports that he just drank a cup of coffee c) having the client sit with the arm bared and supported at heart level d) measuring the BP after the client has sat quietly for 5 min e) used a cuff with a rubber bladder that encircles at least 60% of the limb
a, b, e
A nurse is assessing a client who has a closed chest tube drainage system. the nurse notes constant bubbling in the water seal chamber. What actions should the nurse take SATA a) assess the system for an external air leak b) reduce the degree of suction being applied c) clamp the chest tube d) document assessment findings, actions taken and client response e) change the drainage system
a, d
A nurse is performing nastotracheal suctioning on a client. Which observations should be cause for concern to the nurse SATA a) the client becomes cyanotic b) clear to opaque secretions are removed c) the client gags during the procedure d) the HR varies from 80 to 82 bpm e) secretions are becoming bloody
a, e
A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse most concerned
absence of cough and gag reflexes
a client who has just undergone surgery suddenly experiences CP, dyspnea and tachypnea. the nurse suspects that the client has a pulm embolism and immediately sets about to take which action
adminstering O2 by way of NC
A client who has just undergone a skin bx is listening to d/c instructions from the nurse. The nurse determines that the client needs further teaching if the client indicates that he plans to do what as part of aftercare
apply cool compresses to the site BID for 20 min
A nurse has a rx to insert a NG tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily
asking the client to swallow as the tube is being advanced
A nurse has a rx to collect a 24 hour urine specimen from a client. Which measure should the nurse take during this procedure
asking the client to void, discarding the specimen and noting the start time
A nurse receives a call from a nurse on the PACU, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client
assess the patency of the airway
A client who experienced the sudden onset of resp distress has been intubated with an endotracheal tube. After the tube is placed in the trachea, the nurse should take which immediate action
auscultate both lungs for the presence of breath sounds
A nurse is watching as a nursing student suctions a client through a trach tube. Which action son the part of the student would prompt the nurse to intervene and demonstrate correct procedure SATA a) assessing breath sounds before suctioning b) placing the client in a supine position before the procedure c) setting the suction pressure to 60 mmHg d) applying suction throughout the procedure e) hyperoxygenating the client with 100% oxygen before suctioning
b-d
a client who has undergone renal bx complains of pain, radiating to the front of the abdomen, at the bx site. For which finding should the nurse assess the client
bleeding
A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. which action should the nurse take first
check for kinks in the drainage system
a nurse is assessing a postop client on an hourly basis. The nurse notes that the client's UOP for the past hour was 25mL. On the basis of this finding, the nurse should take which action first
check the client's overall I&O record
a client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority
checking for the return of the gag reflex
Blood for arterial blood gas determinations is drawn on a client with PNA and testing reveals a pH of 7.45, PaCO2 of 30mmHg, and HCO3 of 19 mEq/L. The nurse interprets these resutls as indivative of which disorder
compensated resp alkalosis
A nurse administers scopolamine as prescribed to a client. For which s/e of this med does the nurse monitor the client
complaints of dry mouth
A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action
cover the abdominal wound with a sterile dressing moistened with sterile saline sltn
a nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action
cover the insertion site with a sterile occlusive dressing
A client with COPD who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2L/min. The nurse responds that this would be harmful b/c it could cause which effect
decrease the client's oxygen based resp drive
A client is recieving a continuous IV infusion of heparin for the tx of DVT. The client's aPTT level is 88sec. The client's baseline before the initiation of therapy was 30sec. Which action does the nurse anticipate is needed
decreasing the rate of heparin infusion
a nurse is suctioning a client through a trach tube. During the procedure, the client begins to cough and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. Which action should the nurse take first
disconnect the suction source from the catheter
A client with a hx of lung disease is at risk for resp acidosis. For which s/s does the nurse assess this client
disorientation and dyspnea
A client has undergone pericardiocentesis to treat cardiac tamponade. for which signs should the nurse assess the client to determine whether the tamponade is recurring
distant muffled heart sounds
Polyethylene glucol-electrolyte solution is rx'd for a hospitalized client scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate
document the diarrhea in the medical record
A pelvic u/s is prescribed o evaluate a client's ovarian mass. What should the nurse giving preprocedure instructions tell the client that it is important to do before the procedure
drink 6-8 glasses of water without voiding
A client is scheduled to undergo a CT with contrast for evaluation of an abdominal mass. The nurse should provide the client with which information about the test
dye is injected and may cause a warm flushing sensation
A client who has received sodium bicarb in large amounts is at risk for metabolic alkalosis. For which s/s does the nurse assess this client
dysrhythmias, and decreased resp rate and depth
A client has just returned to the nursing unit after CT with contrast medium. Which action should the nurse plan to take as part of routine after-care for this client
encourage fluid intake
A nurse is preparing a client for transfer to the OR. Which action should the nurse take in the care of this client at this time
ensuring that the client has voided
A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure
flat
A nurse has a rx to d/c a client's NG tube. The nurse auscultates the client's bowel sounds, positions the client properly and flushes the tube with 15mL of air to clear secretions. The nurse then instructs the client to take a deep breath and do what
hold the breath during tube removal
A client who is mouth breathing is receiving oxygen by facemask. The UAP asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to promote which goal
humidify the oxygen that is bypassing the client's nose
a client has been given a dx of multiple myeloma. Which result does the nurse reviewing the client's lab findings recognize as being specifically related to this dx
increased calcium level
A nurse is monitoring the resp status of a client who has just undergone surgery and is wearing a pulseox. Which coexisting problem is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate
low BP
A nurse is getting a client out of bed for the first time since surgery. The nurse raises the HOB and the client complains of dizziness. which action should the nurse take first
lower the HOB slowly until the dizziness is relieved
A client is brought to the ED by a neighbor. The client is lethargic and has a fruity odor on the breath. The ABG results are pH 7.25, PaCO2 34mmHg, PaO2 86mmHg, HCO3 14 mEq/L. Which acid-base disturbance does the nurse recognize in these results
met acid
A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client
met acidosis
A client tells the nurse that he has been experiencing frequent heartburn and has been "living on antacids". For which acid-base disturbance does the nurse recognize a risk
met alkalosis
A nurse is caring for a client who is vomiting. For which acid-base imbalance does the nurse assess the client
metabolic alkalosis
A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage system who has undergone a CXR. The report states that the client's affected lung is fully reexpanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding
no fluctuation in the water seal chamber
A client who just returned from the recovery room after a T&A is restless and the HR is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. the nurse should take which immediate action
notify the surgeon
A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing
oranges
A client has been scheduled for an MRI. Which condition, is a contraindication to MRI, does the nurse check the client's medical hx
pacemaker insertion
a client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding
pallor and coolness of the right leg
A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client's neck primarily for which reason
palpating both carotid pulses simultaneously could cause the HR and BP to drop
A client has just undergone a renal bx. Which intervention should the nurse include in the post-procedure plan of care
periodically testing the urine for occult blood
A nurse is preparing for intershift report when a UAP pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who reutrned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's BP is 88/60 mmHg. Which action should the nurse take first
place the client in a modified Trendelenburg position
A nurse checks the residual volume from a client's NG tube feeding before administering an intermittent tube feeding and finds 35mL of gastric contents. What should the nurse do before administering the prescribed 100mL of formula to the client
pour the residual volume into the NG tube through a syringe with the plunger removed
A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume
pulse rate
A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important
questioning the client about allergies to iodine or shellfish
A client is scheduled for a barium swallow in 2 days. The nurse, providing preprocedure instructions, should tell the client to implement which measure
remove all metal and jewelry before the test
A client with histoplasmosis has the following ABG results: pH 7.30, PaCO2 58mmHg, PaO2 75mmHg, HCO3 26 mEq/L. Which acid-base disturbance does the nurse recognize in these results
resp acid
A nurse reviews the blood gas results of a client in resp distress. The pH is 7.32 and the PaCO2 is 50mmHg. Which acid-base imbalance does the nurse recognize in these findings
resp acidosis
A client has the following ABG results: pH 7.51, PaCO2 31 mmHg, PaO2 94mmHg, HCO3 24 mEq/L. Which acid-base disturbance does the nurse recognize in these results
resp alkalosis
A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contract medium by monitoring for the presence of which
resp distress
A nurse is reviewing the results of serum lab studies of a client with suspected hepatitis. Which increased parameter is interpreted by the nurse as the most specific indicator of this disease
serum bilirubin
A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The HCP has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client's room before allowing the client to drink
suction equipment
A client who is anxious about an impending surgery is at risk for resp alkalosis. For which s/s of resp alkalosis does the nurse assess this client
tachypnea, dizziness, and paresthesias
A client who has undergone an EGD returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take
take the client's vital signs
A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client
taping the connections b/w the chest tube and the drainage system
A client who has sustained a MI is scheduled to have an echocardiogram. Which measure should the nurse take before the procedure
telling the client that the procedure is painless and takes 30-60 min to complete
A woman has been scheduled for a routine mammogram. The nurse should provide the client with which information about the test
that deodorants, powders, or creams in the axillary or breast area must be washed off before the test
A nurse is reading the CXR report of a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm about the carina. The nurse interprets that the tube is positioned above which anatomical area
the bifurcation of the right and left main stem bronchi
A nurse is assessing the chest tube drainage system of a postop client who has undergone the right upper lobectomy. The closed drainage system contains 300mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. On the basis of these findings, what should the nurse assess first
the chest tube connections
A nurse provides info to a client who is scheduled for cardiac catheterization to r/o coronary occlusion. The nurse should provide which information to the client
the client may have feelings of warmth or flushing during the procedure
A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ cound of 450 cells per cubic milimeter of blood. the nurse interprets this test result as indicating which
the need for antiretroviral therapy
A client has made an appt for her annual Pap smear. The nurse who schedules the appt should provide which information to the client
the test cannot be performed while the client is menstruating
A client is tested for HIV with the use of ELISA and the test result is positive. The nurse should provide which information to the client about the test
the test will need to be confirmed with the use of a Western blot
a client has a chest drainage system in place. the fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication of which
the tube is patent
A nurse is providing post-procedure instructions to a client returning home after athroscopy of the shoulder. The nurse should provide the client with which information
to report to the HCP the development of fever or redness and heat at the site
A client with DM is scheduled to have blood drawn in the morning for a fasting blood glucose determination. What does the nurse tell the client that it is acceptable to consume on the morning of the test
water
A nurse in a HCP's office has just made an appt for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should provide which information to the client
wear comfortable rubber-soled shoes such as sneakers