NCLEX REVIEW
RULE: MED SURGE ASSIGN MED SURGE FLOAT NURSE
1. Diabetes mellitus 2. DVT( deep vein thrombosis) 3. Hypertension 4.Surgeries 5.Chronic condition 6. seizures
the client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as high risk for immobility complications. Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Performed active range of motion exercises every 4 hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.
1. The head of the clients bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility.
the clients diagnosed with a gunshot wound to the head assumes decorticate pOsturing when the nurse applies painful stimuli. Which assessment data obtained 3 hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 millimeters in size and nonreactive to painful stimuli.
1. purposeless movement indicates that the clients cerebral edema is decreasing. The best motor responses purposeful movement, but purpose less movement indicates an improvement over the Decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity.
A client with chronic renal failure has started receiving epoetin alfa (Epogen). The nurse reminds the client about the importance of taking which prescribed medication to enhance the effects of this therapy? a) ferrous gluconate b) aluminum carbonate c) aluminum hydroxide gel d) calcium carbonate (Tums)
A - In order to form healthy red blood cells, which is the purpose of epoetin alfa, the body needs adequate stores of iron, folic acid, and vitamin B12. The client should take these supplements regularly to enhance the hematocrit-raising benefit of this medication. The other options are incorrect.
the nurse is caring for a client with bacterial pneumonia. The effectiveness of the clients oxygen therapy is best determined by? 1.absence of cyanosis 2.clients RR 3.ABG value 4.clients LOC
3
A nurse is preparing to provide instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which of the following diets would likely be prescribed for this client? 1. Low-protein diet 2. Low-sodium diet 3. High-sodium diet 4. Low-carbohydrate diet
3. HIGH SODIUM TO HELP PREVENT EXCESS NA AND H2O LOSS
The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.
B. Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths.
What should be included in change of shift report?
Changes in condition, new medications, complications, diagnostic procedures, treatments (lasix for crackles, etc.)
How to nutritionally manage end stage CKD.
If you have kidney failure/ESRD, you must monitor the amounts of fluid and certain nutrients you take in each day. This can help keep waste and fluid from building up in your blood and causing problems. Exactly how strict your diet should be depends on your treatment plan and other health concerns. Most people on dialysis need to limit: Potassium Phosphorus Fluids Sodium
What is given to anyone with acute exposure to any infection or enlarged lymph nodes?
Immunoglobulins
What is Cyclosporine used for?
Immunosuppressive agent. Patients that receive organ transplants will need to take them for the rest of their lives
RNs should delegate to what level of a person's confidence? Based on?
Highest level of confidence and based on experience, training, and licensure.
What is the #1 finding with Guillian-Barre?
Progressive ascending paralysis
Reabsorption of H2O occurs with _________.
Reabsorption of H2O occurs with ADH.
What is the Tubular Function?
Reabsorption of essential materials, and excretion of nonessential materials.
A member of the clinic housekeeping staff experiences a needlestick by a contaminated needle. Which of the following should be administered by the healthcare provider to provide the patient with passive immunity against the hepatitis B virus? A. Antiviral medication B Hepatitis B immune globulin (HBIG) C Hepatitis B vaccine d. Antibiotics
b
What is a D-Dimer test used for/indicative of?
blood test that can be used to help rule out the presence of a serious blood clot. DVT
A client has developed HELLP syndrome and the last liver function tests suggest acute liver failure is beginning. The nurse should prepare for which intervention?I a. Insertion of a intrahepatic shunt B Administration of penicillin G c Delivery by cesarean section d Administration of acyclovir
c
A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which nursing action should be included in the plan of care? A. Institute seizure precautions .B. Reorient to time and place PRN. C. Monitor intake and output. D. Place on cardiac monitor.
c
Prothrombin Time (PT)
test to measure activity of prothrombin in the blood Use to see if warfarin(Coumadin) is effective
In the acute phase it is very important to assess ______________ every 2 hours
motor function of all muscles (especially the diaphragm)
Hematocrit
percentage of blood volume occupied by red blood cell 35-50%
What are the clinical manifestation of CKD r/t the Metabolic System?
🔺Waste product accumulation 🔺Defective carbohydrate metabolism (moderate hyperglycemic & hyperinsulemia effect). 🔺Elevated triglycerides (hyperlipidemia). 🔺Metabolic acidosis 🔺Electrolyte imbalances (Hypernatremia, hypocalcemia, Hyperkalemia).
Wafarin (Coumadin)
Oral anticoagulant
What is the memonic to remember how to use the fire extinguisher?
PASS= Pull Pin, Aim, Squeeze, and Sweep
Fluid replacement 71+ kg
2500/24 hours. (Adult fluid requirement)
Alpha-glucosidase inhibitors
Block breakdown of carbohydrates and sugars in the intestines so less is absorbed
How can Stage 1 CKD be DX?
The only way to DX is 24 hours urine collection creatine clearance test.
Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?
The patient cleans the catheter while taking a bath every day.
What does it mean if the vent is beeping with a high pressure alarm?
The patient is causing problems (fighting the vent- holding breath,etc.).
The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which information should be reported immediately to the health care provider?
The patient's peritoneal effluent appears cloudy.
Define Chronic Kidney Disease
The progressive, irreversible destruction of both kidneys. Nephrons destroyed, replaced with scar tissue. Kidneys get bigger then they get smaller as the disease goes and the tissue is replaced with scar tissue.
Polypharmacy
The use of many different drugs concurrently in treating a patient, who often has several health problems.
CCPD
*Continuous cycling peritoneal dialysis* 🔺Machine at night which is good for retired people and takes around 10 hours.
Creatinine
0.6-1.3mg/dl nitrogenous waste excreted in the urine
Serum Creatinine Range
0.6-1.5 mg/dl
What information do you need to know prior to starting your shift?
Blood sugars, pre-ops, post-ops, change of condition on last shift, and new admits.
4. Which symptom should the nurse expect to assess in the client diagnosed with hemophilia A? 1. Epistaxis. 2. Petechiae. 3. Subcutaneous emphysema. 4. Intermittent claudication.
1
What two things should you use to help determine appropriate delegation tasks for a UAP?
Their ability and demonstration of the task.
What does it mean if the vent is beeping with a low pressure alarm?
There is a problem with the machine so get a new one and send the broken one to biomed engineering to have it fixed.
What does it mean if there is continuous bubbling in the H20 seal chamber of a chest tube?
There is an air leak so a new Plurovac should be used.
A client is brought to the Emergency Department with a C5-6 fracture involving the posterior wall of the vertebral body and bilateral lamina. During assessment, the nurse notes the client can feel touch on the toes. Which ASIA impairment scale designation best reflects this injury?
There is not enough information to determine this parameter
What does it mean if the glucometer isn't giving a reading?
There isn't enough blood to get a reading.
What should be done if someone presents with dilated pupils and decreased LOC?
They probably have increased ICP so sit them up to help decrease the pressure.
Who is at risk for falling blind/deaf patients or those with canes/walkers/or small animals?
Those with canes/walkers/small animals (geriatrics) are at risk for falling.
What is contraindicated with an allergy to bananas, kiwi, chesnuts, an avocado?
Latex/rubber
Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? a. Peaches b. Cottage cheese c. Popsicle d. Lima beans
c. HYDRATION FOR SICKLE CELL
Before feeding in a patient with Guillian-Barre you must __________________.
check the gag reflex
fluid replacement 21-70 kg
20ml / kg
infant respiratory rate
25-55 breaths per min
Metformin (Glucophage)
"Use: Type 2 diabetes mellitus Class: Antidiabetic, biguanide AEs: Lactic acidosis" Controls glucose Helps endogenous insulin work better
What does Antidiuretic Hormone do?
*ADH conserves H2O and decrease urine volume.*
CAPD
*Continuous ambulatory peritoneal dialysis* 🔺QID, this takes time but its good for active people.
WHAT IS THE MEANING OF PHYSIOLOGICAL SIGN IN PSYCH PATIENT
.Anxiety (also called angst or worry) is a psychological and physiological sign and also including vital signs of the patient...
A nurse is reviewing a plan of care for a client with Addison's disease. The nurse notes that the client is at risk for dehydration and suggests nursing interventions that will prevent this occurrence. Which nursing intervention is an appropriate component of the plan of care? Select all that apply. 1. Encouraging fluid intake of at least 3000 mL/day 2. Encouraging an intake of low-protein foods 3. Monitoring for changes in mental status 4. Monitoring intake and output 5. Maintaining a low-sodium diet
1,3,4 INCREASE sodium intake, carbs, protein
Pediatric output
1-2 ml/ kg / hour
Which of the following assessments in a child with hemophilia would lead the nurse to suspect early hemarthrosis? 1. Child's reluctance to move a body part 2. Cool, pale, clammy extremity 3. Eccymosis formation around a joint 4. Instability of a long bone in passive movement
1.
RULE: ASSIGN OB FLOAT NURSE (telemetery)
1. Closed abdominal surgeries 2. Hypertension 3. Diabetes Mellitus 4. Epidurals 5. IV drips
The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit? 1. Complaints of extreme fatigue and hair loss. 2. Exophthalmos and complaints of nervousness. 3. Complaints of profuse sweating and flushed skin. 4. Tetany and complaints of stiffness of the hands.
1. low and slow
Pediatric specific gravity
1.005-1.015
Specific Gravity Range
1.016 - 1.022
Magnesium
1.5-2.5 mEq/L
Serum BUN Range
10-30mg/dl
Fluid replacement 0-10 kg
100ml/kg
What is the Serum BUN to Creatinine Ratio?
10:1 to 20:1
adolescent respiratory rate
12-18 breaths per min
Hemoglobin
12-18 g/dL
Sodium
135-145 meq/L
The medication order reads: heparin (HIGH ALERT) IV at 1400 units/hr. The pharmacy sends a bag of heparin containing 25,000 units in 250 ml D5W. What infusion rate should the RN set the IV pump? Answer with a number only. _____ ml/hr
14 ml/hr
School age respiratory rate
14-22 breaths / min
What should be done 1st and 2nd if the event of a med error, pt injury, or attempted suicide?
1st provide care, and 2nd notify MD.
How are patients on the psych ward prioritized?
1st: Physiological, 2nd: Change in psych behavior, 3rd: Safety
5. The client with hemophilia A is experiencing hemarthrosis. Which intervention should the nurse recommend to the client? 1. Alternate aspirin and acetaminophen to help with the pain. 2. Apply cold packs for 24 to 48 hours to the affected area. 3. Perform active range-of-motion exercise on the extremity. 4. Put the affected extremity in the dependent position.
2
A client with bacterial pneumonia is to start IV antibiotics. The nurse should verify which diagnostic test before administration? 1.urinalysis 2.sputum cultures 3.chest radiograph 4.RBC count
2
the 29-year-old client that was employed as a forklift operator sustains a traumatic brain injury secondary to a motor vehicle accident. The client is being discharged from the rehabilitation unit after 3 months and has cognitive deficits. Which goal would be more realistic for this client? 1. The client will return to work within 6 months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance. 4. The client will regain power and bladder control.
2 . Cognitive pertains to mental processes of comprehension, judgment, memory, and reasoning.
Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply. 1. Instruct the client to use a razor blade to shave. 2. Avoid administering enemas to the client .3. Encourage participation in noncontact sports. 4. Teach the client how to apply direct pressure if bleeding occurs. 5. Explain the importance of not flossing the gums
2,3,4
Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm? 1. Obstipation and hypoactive bowel sounds. 2. Hyperpyrexia and extreme tachycardia. 3. Hypotension and bradycardia. 4. Decreased respirations and hypoxia.
2. HOT STORM, FAtal
preschool respiratory rate
20-25 breaths/min
toddler respiratory rate
20-30 breaths/min
the nurse is caring for the following clients. Which client what the nurse assess first after receiving the shift report? 1. The 22 year old male client diagnosed with a concussion who is complaining someone is waking him up every 2 hours. 2. The 36 year old female client admitted with complaints of left sided weakness who is scheduled for an MRI scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. 4. The 62-year-old client diagnosed with CVA who has expressive aphasia.
3. The Glasgow Coma Scale is used to determine a client's response to stimuli such asEye opening response, best verbal response, and best motor response secondary to a neurological problem scores range from 3 which is a deep coma to 15 which is intact neurological function. A client with a score of 6 should be assessed first.
47. A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activa- tor (t-PA)? 1. Ask what medications the client is taking. 2. Complete a history and health assessment. 3. Identify the time of onset of the stroke. 4. Determine if the client is scheduled for any surgical procedures.
3. Tpa 4.5 hours
A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identity as the primary safety precaution to use? - 1. Wear a patch over one eye. - 2. Place personal items on the sighted side. -3. Lie in bed with the unaffected side toward the door. - 4. Turn the head from side to side when walking.
4
WBC
5,000-10,000/mm3
A nurse is working on a renal unit in a local hospital. The nurse interprets that which client with renal failure is best suited for peritoneal dialysis as a treatment option? a) a client with severe congestive heart failure b) a client with a history of ruptured diverticuli c) a client with a history of herniated lumbar disk d) a client with a history of three previous abdominal surgeries
A - Peritoneal dialysis may be the treatment option of choice for clients with severe cardiovascular disease, which would be worsened by the rapid shifts in fluid, electrolytes, urea, and glucose that occur with hemodialysis. Contraindications to peritoneal dialysis include diseases of the abdomen, such as ruptured diverticuli or malignancies, extensive abdominal surgeries, history of peritonitis, obesity, and history of back problems, which could be aggravated by the fluid weight of the dialysate. Severe disease of the vascular system also may be a contraindication.
A nurse is caring for a client who has begun using peritoneal dialysis. The nurse determines that which manifestation indicates the onset of peritonitis? a) oral temperature of 100F b) history of gastrointestinal (GI) upset 1 week ago c) clear dialysate output d) presence of crystals in dialysate output
A - Typical symptoms of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output. The complaint of GI upset is too vague to be correct. Peritonitis would cause cloudy dialysate but would not cause crystals to appear in the dialysate.
diabetes type 2
A chronic condition where the body does not use insulin properly and becomes insulin resistant.
Define Acute Kidney Injury
A rapid decline in kidney function leading to azotemia. Symptomatic azotemia = uremia. *Decrease in UO <400cc/24hrs*. (oliguria). Can occur in healthy people and is brought on by a stressor. Some cases have people who have urine still and its due to the kidneys not concentrating the urine.
metabolic syndrome
A syndrome marked by the presence of usually three or more of a group of factors (as high blood pressure, abdominal obesity, high triglyceride levels, low HDL levels, and high fasting levels of blood sugar) that are linked to increased risk of cardiovascular disease and Type 2 diabetes. I
Because clients with cystic fibrosis (CF) are at increased risk for infection, what does the nurse advise the client with CF to do? A. Avoid Cystic Fibrosis Foundation-sponsored events. B. Avoid the hospital. C. Stay at home most of the time. D. Use an antiseptic hand gel.
A) A serious bacterial infection for clients with CF is Burkholderia cepacia, which is spread by casual contact from one CF client to another. For this reason, the Cystic Fibrosis Foundation bans infected clients (those who have had a positive sputum culture) from participating in any foundation-sponsored events.
A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which of these preoperative interventions can be accomplished by an LPN/LVN working on the unit? A. Administering preoperative antibiotics and anxiolytics B. Assessing the client's nutritional status and need for nutrition supplements C. Having the client sign the operative consent form D. Teaching the client about the need for tracheal suctioning after surgery
A) Administering medication is a skill within the LPN/LVN scope of practice. As a reminder, anxiolytics must be administered AFTER the operative consent has been signed, or the consent will be invalid.
Which of the components of a client's family history are of particular importance to the home health nurse who is assessing a new client with asthma? A. Brother is allergic to peanuts. B. Father is obese. C. Mother is diabetic. D. Sister is pregnant.
A) Clients with asthma often have a family history of allergies. It will be important to assess whether this client has any allergies that may serve as triggers for an asthma attack.
The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds? A. Crackles B. Rhonchi C. Pleural friction rub D. Wheeze
A) Crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways. The airways have been deflated due to the presence of fluids in the lungs, and crackles should be considered to be a sign of fluid overload.
The nurse is caring for a client who is taking a first-generation antihistamine. What is the most important fact for the nurse to teach the client? A. "Do not drive after taking this medication." B. "Make sure you drink a lot of liquids while on this medication." C. "Take this medication on an empty stomach." D. "Do not take this medication for more than 2 days."
A) First-generation antihistamines cause drowsiness.
A client who has had a recent laryngectomy continues to report pain. Which of the following medications would be best used as an adjunct to a narcotic once he can take oral nutrition? A. Liquid NSAIDs B. Liquid steroids C. Opioid antagonists D. Oral diazepam
A) NSAIDs are an excellent adjunct when used with narcotics or opioid analgesia.
A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of these actions by the new graduate is indicated? A. Encourage the client to use the incentive spirometer and to cough. B. Administer oxygen by nasal cannula. C. Request a prescription for sodium bicarbonate from the health care provider. D. Inform the charge nurse that no changes in therapy are needed.
A) Respiratory acidosis is caused by CO2 retention and impaired chest expansion secondary to anesthesia. The nurse takes steps to promote CO2 elimination, including maintaining a patent airway and expanding the lungs through breathing techniques.
Which two factors in combination are the greatest risk factors for head and neck cancer? A. Alcohol and tobacco use B. Chronic laryngitis and voice abuse C. Marijuana use and exposure to industrial chemicals D. Poor oral hygiene and use of chewing tobacco
A) The combination of alcohol and tobacco use is one of the greatest risk factors for head and neck cancer.
A newly hired RN with no previous emergency department (ED) experience has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse? A. Client with epistaxis with profuse bleeding on warfarin (Coumadin) B. Client with facial burns caused by a mattress fire while sleeping C. Client with possible facial fractures after a motor vehicle collision (MVC) D. Client with suspected bilateral vocal cord paralysis and stridor
A) The initial treatment for epistaxis is upright positioning with direct lateral pressure to the nose. A nurse with minimal ED experience could be expected to safely provide care for this client. In addition, laboratory work should be obtained to assess the client's ability to clot, given that he is on warfarin (Coumadin)
The nurse assists the client with acute kidney injury (AKI) to modify the diet in which way? Select all that apply: A. Restricted protein B. Liberal sodium C. Fluid restriction D. Low potassium E. Low fat
A, C, and D: Restricted protein (Breakdown of protein leads to azotemia and increased blood urea nitrogen (BUN). Fluid is restricted during the oliguric phase of acute renal failure. Potassium intoxication may occur; dietary potassium is restricted.
In what order should patients be removed in the event of a disaster?
ABC= Ambulatory, bed ridden, and critical care patients.
What is Antidiuretic Hormone inhibited by?
ADH inhibited by: inc ECF, dec in osmolarity
The RN has just received change-of-shift report. Which of the assigned clients should be assessed first? A. A client with chronic kidney failure who was just admitted with shortness of breath B. A client with kidney insufficiency who is scheduled to have an arteriovenous (AV) fistula inserted C. A client with azotemia whose blood urea nitrogen and creatinine are increasing D. A client receiving peritoneal dialysis who needs help changing the dialysate bag
A. A client with chronic kidney failure who was just admitted with shortness of breath: This client's dyspnea may indicate pulmonary edema and should be assessed immediately.
Which finding in the first 24 hours after kidney transplantation requires immediate intervention? A. Abrupt decrease in urine output B. Blood-tinged urine C. Incisional pain D. Increase in urine output
A. Abrupt decrease in urine output: An abrupt decrease in urine output may indicate complications such as rejection, acute tubular necrosis (ATN), thrombosis, or obstruction. Blood-tinged urine, incisional pain, and an increase in urine output is an expected finding after kidney transplantation.
The client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? A. Auscultate for pericardial friction rub B. Assess for crackles C. Monitor for decreased peripheral pulses D. Determine whether the client is able to ambulate
A. Auscultate for pericardial friction rub The client with uremia is prone to pericarditis; symptoms include inspiratory chest pain, low-grade fever, and ST segment elevation. Crackles and tachycardia are symptomatic of fluid overload; fever is not present
The client with a recently created vascular access for hemodialysis is being discharged. In planning discharge instructions, which information does the nurse include? A. Avoiding venipuncture and blood pressure measurements in the affected arm B. Discussion on modifications to allow for complete arm rest C. Information on how to assess for bruit D. Information on proper nutrition
A. Avoiding venipuncture and blood pressure measurements in the affected arm: Compression of vascular access causes decreased blood flow and may cause occlusion; dialysis will not be possible. The arm is exercised to encourage venous dilation, not rested.
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from an artery in the neck." b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."
A. In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is replaced" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure.
Which clinical manifestation indicates the need for increased fluids in the client with kidney failure? A. Increased blood urea nitrogen B. Increased creatinine C. Pale urine D. Decreased sodium
A. Increased blood urea nitrogen: An increase in blood urea nitrogen can be an indication of dehydration, and an increase in fluids is needed. Increased creatinine indicates kidney impairment.
Which of these interventions is essential for the client in the oliguric phase of acute kidney injury (AKI)? A. Restrict fluids B. Replace potassium C. Administer blood transfusions D. Monitor arterial blood gases (ABGs)
A. Restrict fluids: During the oliguric phase of AKI, the client will be at risk for fluid overload; fluid restriction is necessary to limit this problem. Hyperkalemia results from kidney injury; do not replace potassium unless clearly decreased. Blood transfusions replace the oxygen-carrying capacity of the blood and are used for shortness of breath or chest pain; use is not specific to the oliguric phase.
When gathering data to assist with assessments of clients, you will find which of the following clients most at risk for sensory overload? [Hint] A. a client in pain B. a homebound client C. a client on bed rest D. a client in isolation
A. a client in pain
What are some nursing diagnosis for Dialysis?
Altered Nutrition rt loss of appetite. Fluid volume excess rt compromised regulatory mechanisms Activity intolerance rt fatigue Anticipatory guidance rt effects of loss of kidney function Self-esteem disturbance rt body image changes, lifestyle changes
What does Serum Bun tell us?
Amount of urea nitrogen in blood. Urea is a protein metabolism byproduct. Limit is that it can be elevated in things other than kidney failure.
What does it mean if the bladder scanner doesn't produce a reading?
Bladder is empty
The client has a fever of 104° F (40° C). In which direction, if any, will this shift the oxyhemoglobin dissociation curve? A. Down B. To the left C. To the right D. Will not shift
C) A client with fever has a higher demand for oxygen, so the curve will shift to the right for easier dissociation.
What type of patient should be discharged during an emergency?
Select patient with stable chronic condition. DO NOT discharge acute surgical patients. Pressure ulcers are considered chronic.
What adults should be transferred to the Peds ward if necessary?
Adult with condition/tx similar to that which is seen in the pediatric population. (COPD is like cystic fibrosis, pneumonia is pneumonia).
Patients on/with what should never be sent to surgery?
ANTICOAGULATED PATIENTS: With low platelets, high PT or PTT, or on coumadin/heparin.
Is AKI permanent?
AcRF reversible.
Uremia
Accumulation of waste products in blood normally excreted in the kidney.
What three things should the Dr. be called for?
Acute epiglottitis, back pain (Abdominal Aortic Aneurysm (triple A)), and Eye Pain (glaucoma or cataract surgery). Only call MD for abnormal situations not what is expected.
What are the rules for prioritizing patients?
Acute problems more serious than chronic. <24 hrs post op= more serious than medical conditions/older surgeries. Unstable patient more serious (ACUTE) than stable, when in doubt Select the more vital organ (heart or lungs over toes, fingers and legs).
What is Kernig's sign?
After flexing the hip and knee at 90 degree angles, pain and resistance are noted.
If there is a problem that requires immediate attention when should you call the doctor?
After you have initiated an ACTIVE INTERVENTION. If it is serious enough to call the Dr. then need something to keep them alive until Dr. gets there.
What should you be concerned about first with someone who experienced burns?
Airway and breathing bc if they were close enough to get burned they were close enough to inhale smoke.
Reabsorption of Na+ and H2O is due to _________.
Aldosterone
Aldosterone
Aldosterone promotes Na and H20 reabsorption, K excretion.
Which of these is within the RN scope of practice? Starting IVs, Isolation placement, Problem w/NGs, and Room assignments.
All are within the RN scope of practice.
What is important to know about evaluating a treatment?
All drugs/tx are used to bring a pt back to normal. A successful tx will always reverse the presenting signs and symptoms (ask why treatment initiated).
Who should ambulate an acutely ill, chronic condition patient?
An LPN
Who should do an assessment on a stable acute patient?
An LPN
Who should do an assessment on a stable chronic patient?
An LPN
A patient has impairments from a SCI at C4 classified as incomplete C on the American Spinal Injury Association, (ASIA) Impairment Sclae. Which patient assessment is the nurse likely to observe in this patient? A. poor propricopetor in the legs B. poor peristalsis in the intestines C. Absent gag and blinking reflexes D. Absent bladder fulness sensation
Answer is B A patient who has a SCI has neurologic impairment to all extremities and the diaphragm. However, because the injury is C on the ASIA impairment Scale, sensory function can be intact but motor function will be impaired significantly or absent.the patient can lose moderate to complete peristatlic action in the intestines but should reatine the ability to sense bladder fulnessand the position of the legs.
RULES TO WATCH THE PATIENT WHEN THE PATIENT HAVE SERIOUS PROBLEMS
Anytime a forgien object inserted into the body the complication may be rupture of the organ. Cold/ Dehydrated baby is the DEAD BABY. Drunks and druggies commit SUICIDE Never discharge a WHEEZER watch for MUSCLE and WEAKNESS.
What should be given to a patient on coumadin before they have surgery? When should it be given?
Aqua Mephyton (Vitamin K) is needed b4 surgery for someone on coumadin so they don't bleed out (it helps coagulation). If it is D/C 24 hours before they may still bleed because it's not long enough prior to surgery so Vit K will help.
Renal Osteodystrophy
Bone lesions due to secondary hyperparathyroidism due to chronic renal disease.
FLOATERS (NRSES WHO FLOAT FROM THE OTHER UNITS)
Assign the float nurse a condition they would see their own ward. Give them the most stable patients. Float nurses NEVER get Cardiac pts, Borderline/ Antisocial
Last week a client sustained a gunshot wound that caused a T2 SCI. This morning the client has a B/P of 210/108 and a flushed face, and complains of nasal stuffiness and a headache. The nurse responds to this assessment rapidly because of the potential for it to indicate which disorder?
Autonomic dysreflexia Neurogenic shock would result in hypotension instead of hypertension. Nasal stuffiness and facial flushing would not be present.
What should be done for pain and discomfort?
Avoid drugs, use nursing interventions (positioning, heat, etc.), when in doubt flush the patient out.
10. A patient with Addison's Disease is being discharged home on Prednisone. Which of the following statements by the patient warrants you to re-educate the patient? A. "I will notify the doctor if I become sick or experience extra stress." B. "I will take this medication as needed when symptoms present." C. "I will take this medication at the same time every day." D. "My daughter has bought me a Medic-Alert bracelet."
B
A client demonstrates understanding of flunisolide (AeroBid) by saying that he will do what? a. Take two puffs to treat an acute asthma attack. b. Rinse his mouth with water after each use. c. Immediately stop taking his oral prednisone when he starts using AeroBid. d. Not use his albuterol inhaler while he is taking AeroBid.
B) Flunisolide (AeroBid) is an inhaled corticosteroid. Rinsing the mouth will help prevent oral candidal infections. It is not used to treat an acute asthma attack and should be taken with the client's bronchodilator medications. If the client is taking oral prednisone, it needs to be tapered off to prevent acute adrenal crisis because flunisolide is minimally absorbed systemically.
The nurse coming on shift prepares to perform an initial assessment of the sedated ventilated client. Which are priorities for the nurse to carry out? Select all that apply. A. Ask visitors to leave. B. Assess the client's color and respirations. C. Confirm alarms and ventilator settings. D. Ensure that the tube cuff is inflated and is in the proper position. E. Listen for bilateral chest sounds. F. Provide routine tracheotomy and endotracheotomy and mouth care.
B) The first priority when caring for the critically ill client is to assess airway and breathing. C) Alarm settings should be confirmed each shift, more frequently if necessary. D) Ensuring that the client cannot speak ensures that air is going through the endotracheal tube and not around it. E) Auscultating for equal bilateral breath sounds assists in confirming that the tube is above the carina.
Why are the turbinates important? A. They decrease the weight of the skull on the neck. B. They increase the surface area of the nose for heating and filtering. C. They move inspired particles from nose to throat for removal. D. They separate two nasal passages down the middle.
B) The turbinates increase the surface area of the nose, so that more heating, filtering, and humidifying of inspired air can occur before air passes into the nasopharynx.
the client is diagnosed with an anaphylactic reaction is admitted to the ED. which assessment data indicate the client is not responding to treatment? a the client has a urinary output of 120ml in 2 hours b. the client has an hr of 110 and a BP of 90/60 c. the client has clear breath sounds and an RR of 26 d. the client has hyperactive bowel sounds
B.
When caring for the client with a left forearm arteriovenous (AV) fistula created for hemodialysis, the nurse must do which of these? Select all that apply. A. Check brachial pulses daily B. Auscultate for a bruit each shift C. Teach the client to palpate for a thrill over the site D. Elevate the arm above heart level E. Ensure that no blood pressures are taken in that arm
B. Auscultate for a bruit each shift, C. Teach the client to palpate for a thrill over the site, and E. Ensure that no blood pressures are taken in that arm
The nurse in the transplantation unit assesses for which of these signs and symptoms of rejection of the transplanted kidney. Select all that apply. A. Blood urea nitrogen (BUN) 21, creatinine 0.9 B. Crackles in lung fields C. Temperature 98.8 D. Blood pressure 164/98 E. +3 edema of lower extremities
B. Crackles in lung fields, D. Blood pressure 164/98, E. +3 edema of lower extremities
The client has some equipment that is noisy, and the roommate also has equipment that makes noise, and the room is close to a noisy nursing station, where they can be watched a little closer. Which of the following interventions by the nurse would be best for the client as well as reduce the risk of sensory overload? [Hint] A. Move the client away from the nurses' station area. B. Explain the sounds in the environment. C. Tell the client to ignore the sounds. D. Play the client's favorite music louder than the sounds.
B. Explain the sounds in the environment.
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).
B. Following a transient ischemic attack (TIA), patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
When administering medications to the client with chronic kidney disease, the nurse recognizes that which of these medications is most effective in slowing the progression of kidney failure? A. Diltiazem (Cardizem) B. Lisinopril (Zestril) C. Clonidine (Catapres) D. Doxazosin (Cardura)
B. Lisinopril (Zestril): Angiotensin-converting enzyme (ACE) inhibitors appear to be the most effective drugs to slow the progression of kidney failure. Calcium channel blockers (diltiazem/Cardizem) may indirectly prevent kidney disease by controlling hypertension but are not specific to slowing progression of kidney disease.
A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse? A. Abscess B. Pneumonia C. Pneumothorax D. Pulmonary embolism
C) A pneumothorax would be the complication of thoracentesis that causes the greatest concern, along with these symptoms.
When caring for the client with acute kidney injury and a temporary subclavian hemodialysis catheter, which of these should the nurse report to the provider? A. Crackles at lung bases B. Temperature of 100.8 F C. +1 ankle edema D. Anorexia
B. Temperature of 100.8 F: Infection is a major complication of temporary catheters. Report all symptoms of infection, including fever, to the provider. The catheter may have to be removed. Some degree of fluid retention is expected. Rising blood urea nitrogen (BUN) may result in anorexia, nausea, and vomiting.
The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient? a. Impaired transfer ability b. Risk for caregiver role strain c. Ineffective health maintenance d. Risk for unstable blood glucose level
B. The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should further assess the situation and take appropriate actions. The data about the control of the patient's diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not priority concerns at this time. Because the patient is able to ambulate with a cane, the nursing diagnosis of impaired transfer ability is not supported.
The culturally sensitive nurse will realize which of the following about a client from a large active Latino family who is put into isolation for a communicable disease? [Hint] A. The number of visitors greatly needs to be restricted. B. may be accustomed to, and need, high stimulation level C. is a likely candidate for sensory overload D. will need more personal space than other clients
B. may be accustomed to, and need, high stimulation level
People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilations? Select all that apply. A. Bakers B. Coal miners C. Electricians D. Furniture refinishers E. Plumbers F. Potters
Bakers Coal miners Furniture refinishers Potters A) Being exposed to flour as a baker for prolonged periods of time may cause a condition called occupational asthma. B) Coal miners are at risk to develop pneumoconiosis as the result of inhalation of coal dust. D) Owing to the chemicals used to refinish furniture (paint strippers, solvents), masks and adequate ventilation are essential for furniture refinishers. One of the main solvents involved will metabolize in the body to carbon monoxide and will impair the ability of the tissue to extract oxygen. F) Silicosis or inhalation of silica dust is a hazard for professional and recreational potters.
Diabetes Type 2 Treatment
Begin with weight control for obese, dietary treatment, exercise, early use of oral antidiabetics (metformin)
What should be taught regarding home safety?
Bikes & skateboards should not be ridden in the street, guns should not be in homes with children even if they are locked up, <1 year old=sit in back seat facing backward >1 yr & <12 yrs= sit in back seat facing forward, home oxygen should be kept away from flames (stove, fireplace, no wool blankets, and no smoking- the smoke itself won't cause an explosion).
A nurse is applying for a position at a facility where care is provided to clients who have incomplete spinal cord injuries. The nurse can expect to care for clients with which condition?
Brown-Sequard syndrome
2. The nurse is caring for an adolescent patient with systemic lupus erythematosus (SLE) who is receiving antihypertensive therapy and has been eating a low-salt diet. Which assessment finding should prompt the nurse to alert the health care provider immediately? A. Blood pressure of 98/60 B. Bilateral edema of both wrists C. Mild confusion during conversation D. Bright red rash on the shoulders following sun exposure
C
6. A client sustained a head injury when falling off of a ladder. While in the hospital, the client begins voiding large amounts of clear urine and states he is very thirsty. The client states that he feels weak and has had an 8-lb weight loss since admission. What should the client be tested for? a) Hypothyroidism b) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) c) Diabetes insipidus (DI) d) Pituitary tumor
C
A patient is diagnosed with an infection caused by the hepatitis A virus. Which statement, if made by the patient, would indicate the patient needs further teaching about the infection? A "I will wash raw fruits and vegetables thoroughly before I eat them." B"Before I take any over-the-counter medicines I should call the clinic." C"I might get liver cancer someday because I have this infection." D"It's important for me to remember to wash my hands after I use the bathroom."
C
To gain access to the vein and artery, an AV shunt was used for Mr. Roberto. The most serious problem with regards to the AV shunt is: A. Septicemia B. Clot formation C. Exsanguination D. Vessel sclerosis
C
When caring for Mr. Roberto's AV shunt on his right arm, you should: A. Cover the entire cannula with an elastic bandage B. Notify the physician if a bruit and thrill are present C. User surgical aseptic technique when giving shunt care D. Take the blood pressure on the right arm instead
C
You are a charge nurse on a surgical floor. The LPN/LVN informs you that a new client who had an earlier bronchoscopy has the following vital signs: heart rate 132, respiratory rate 26, and blood pressure 98/50. The client is anxious and his skin is cyanotic. What will be your first action? A. Call the Rapid Response Team. B. Give methylene blue 1% 1 to 2 mg/kg by IV injection C. Administer oxygen. D. Notify the physician immediately.
C) Administering oxygen and reassessing vital signs to observe for improvement is the first action. Administration of oxygen by itself may help relieve the client's anxiety.
Which instruction will the nurse include when teaching a client about the proper use of metered-dose inhalers? a. "After you inhale the medication once, repeat until you obtain relief." b. "Make sure that you puff out air repeatedly after you inhale the medication." c. "Hold your breath for 10 seconds if you can after you inhale the medication." d. "Hold the inhaler in your mouth, take a deep breath, and then compress the inhaler."
C) Holding the breath for 10 seconds allows the medication to be absorbed in the bronchial tree rather than be immediately exhaled.
Which acid-base disturbance does the nurse anticipate the client with morbid obesity may develop? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
C) Respiratory acidosis is related to CO2 retention secondary to respiratory depression, inadequate chest expansion, airway obstruction, and reduced alveolar-capillary diffusion, common in the morbidly obese, who experience inadequate chest expansion owing to their size and work of breathing.
The nurse is developing the plan of care for the client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? A. Inadequate nutrition related to food-drug interactions and anticoagulant therapy B. Potential for infection related to leukocytosis C. Hypoxemia related to ventilation-perfusion mismatch D. Insufficient knowledge related to the cause of pulmonary
C) Restoring adequate oxygenation and tissue perfusion takes priority when a client presents with a PE.
A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? a. Obtain computed tomography (CT) scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use GCS to assess
C, D, A, B The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.
Discharge teaching has been provided for the client recovering from kidney transplantation. Which information indicates that the client understands the instructions? A. "I can stop my medications when my kidney function return to normal." B. "If my urine output is decreased, I should increase my fluids." C. "The anti-rejection medications will be taken for life." D. "I will drink 8 ounces of water with my medications."
C. "The anti-rejection medications will be taken for life." Adherence to immune suppressive drugs is crucial to survival for clients with transplanted kidneys. Lack of adherence can lead to complications such as rejection, graft loss, return to dialysis, and death. Oliguria is a symptom of transplant rejection; the transplant team should be contacted immediately.
A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.
C. A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.
The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).
C. Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN).
The nurse carefully observes for toxicity of drugs excreted through the kidney. Which of these represents a sign or symptom of digoxin toxicity? A. Serum digoxin level of 1.2 ng/mL B. Polyphagia C. Anorexia D. Serum potassium of 5.0 mEq/L
C. Anorexia: Anorexia, nausea, and vomiting are symptoms of digoxin toxicity.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.
C. Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the left-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place objects needed on the patient's left side. d. Teach the patient that the left visual deficit will resolve.
C. During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.
The nurse recognizes that the client with end-stage kidney disease has difficulty adhering to the fluid restriction when which of these is found? A. Blood pressure 118/78 B. Weight loss of 3 lbs during hospitalization C. Dyspnea and anxiety at rest D. Central venous pressure (CVP) of 6 mm Hg
C. Dyspnea and anxiety at rest: Dyspnea is a sign of fluid overload and possible pulmonary edema; the nurse assists the client in correlating symptoms of fluid overload with nonadherence to fluid restriction. Excess fluid intake and fluid retention are manifested by elevated CVP (>8 mm Hg). Excess fluid intake and fluid retention are manifested by weight gain, not loss. Nonadherence to fluid restriction results in fluid volume excess and higher blood pressures; 118/78 is a normal blood pressure.
You are about to bathe an unconscious client. Which of the following interventions are most important on your part? [Hint] A. Vary the schedule of bathing and care from day to day. B. Tune the radio to client's favorite music during bath time. C. Explain procedures to client, and talk as if client can hear. D. Speak louder to the client than to other clients.
C. Explain procedures to client, and talk as if client can hear.
Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.
C. Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.
A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia
C. The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.
A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.
C. The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
What are the various types of Peritoneal Dialysis?
CAPD CCPD IPD
A patient who has acute glomerulonephritis is hospitalized with acute kidney injury (AKI) and hyperkalemia. Which information will the nurse obtain to evaluate the effectiveness of the prescribed calcium gluconate IV?
Cardiac rhythm
Biguanides and Thiazolidinediones
Cause the liver to produce less glucose and reduce insulin resistance
What does it mean if the pulse ox is not alarming when O2 is at 92%?
Check the alarm level settings. May be too low and need readjusted.
During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first?
Check the patient's blood pressure.
What should be done if a pressure ulcer vacuum device has no suction?
Check to see if the tape is loose.
What types of conditions doesn't the interdisciplinary team not meet for?
Chronic stable conditions that are compliant and/or resolved by surgery or medical management (Ex: Pyloric stenosis, cleft lip, nephritis, glomerulonephritis, multiple fx after MVA, and acute leukemia on chemo).
What are the rules to remember when delegating to UAPs?
Chronic stable patient only. Assigned tasks defiened in procedures Can take VS on stable patients and 1/2 hour after blood is started. NO delegation of tasks where medical knowledge is necessary or required WATCH KEY WORDS AND STAY AWAY FROM: (show,explain, monitor, teach, check, assess, and demonstrate=NO), Can walk stable patients, reorient/co-conduct . NO TO uap : Sterile procedures Assessments including VS on new admits Feeding choking risk patients Drugs (even OTC topicals), teaching, chest tubes, art lines, trachs, endo tubes, contagious diseases, or vents.
What conditions require seizure precautions?
Cirrhosis encephalopathy, PIH (HTN), DTs, ICP, CVA, Meningitis, Brain surgery, and Head trauma.
What kinds of patients could be assigned to an OB float nurse?
Closed abdominal surgeries, HTN, DM, Epidurals, and IV drips. If cardiac maybe telemetry bc similar.
What is the first symptoms of GBS?
Clumsiness in ambulation (function in legs and feet is lost first)
Creatinine Clearance Test
Collect urine for 24 hrs and calculate GFR 85-135 ml/min. This allows a more precise calculation of a GFR.
How is treatment generally approached with CKD?
Conservative management before dialysis.
Nurse is assessing a patient who has a spinal cord injury?Which should the nurse include in the nervous system assessment to determine the extent of the patient's injury? select all that apply. a. vital sign b. romberg test c. plantar reflexes d. bilatereal hand grasps e. description of trauma
Correct Answer (s): a, c, d, e the assessment to determine the level of spinal cord injury includes analyzing the -vital sign, plantar reflexes, bilatereal hand grasp, description of trauma. Romberg test must be performed while standing therefore not suitable for unstable patient
7.A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? a) Imbalanced nutrition: Less than body requirements b) Risk for infection c) Impaired physical mobility d) Decreased cardiac output
D
9. Addison's Disease is: A. Increased secretion of cortisol B. Increased secretion of aldosterone and cortisol C. Decreased secretion of cortisol D. Decreased secretion of aldosterone and cortisol
D
A male patient has a pinal cord injury at L 1-2 . Which clinical manifestation of the patient's injury is the nurse likely to observe before spinal shock resolves? A. opoiod analgesic Iv for foot pain B. able to blance in sitting position C. unresponsive quadriceps muscle D. requites asssist control ventilation
Correct Answer(s) : C during spinal shock neuromuscular function is lost below the level of the injury along with hyporeflexia and loss of sensation. So the pt will not be able to sit until the pinal shock resolves.
The main indicator of the need for hemodialysis is: A. Ascites B. Acidosis C. Hypertension D. Hyperkalemia
D
The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is a. transfers independently to a wheelchair. b. drives a car with powered hand controls. c. turns and repositions self independently when in bed. d. pushes a manual wheelchair on flat, smooth surfaces.
Correct Answer(s): D Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.
While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Whichaction should the nurse take next? a. Document this finding in the patients record. b. Obtain vital signs, including oxygen saturation. c. Have the patient perform the Valsalva maneuver. d. Observe for JVD with the patient upright at 45 degrees
D
A client with chronic renal failure has learned about managing diet and fluid restriction between dialysis treatments. The nurse determines that the client is compliant with the therapeutic regimen of the client gains no more than how much weight between hemodialysis treatments? a) 2 to 4kg b) 5 to 6kg c) 0.5 to 1kg d) 1 to 1.5kg
D - A limit of 1 to 1.5 kg of weight gain between dialysis treatments helps prevent hypotension that tends to occur during dialysis with the removal of larger fluid loads. The nurse determines that the client is compliant with fluid restriction if this weight gain is not exceeded.
which is the highest priority nursing intervention for the client who is having an anaphylactic reaction? a. administer parenteral epinephrine, an adrenergic agonist b. prepare for immediate endotracheal intubation c provide a calm assurance when caring for the client d establish and maintain a patent airway
D. AIRWAY TOP PRIORITY (give EPI to protect the airway)
A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Administer tissue plasminogen activator (tPA) per protocol. d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
D. Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. that Plavix will dissolve clots in the cerebral arteries. c. that Plavix will reduce cerebral artery plaque formation. d. to call the health care provider if stools are bloody or tarry.
D. Clopidogrel (Plavix) inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions
D. Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).
D. The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
A PATIENT WITH GLAUCOMA IS TREATED WITH MANNITOL?
DIAMOX is used for glaucoma patient to decrease aqueous humor. But here mannitol used for PAIN (eye).
What kinds of patients could be assigned to a medical surgical float nurse?
DM, DVT, HTN, SURGERIES, CHRONIC CONDITIONS, AND SEIZURES.
A client has developed HELLP syndrome and the last liver function tests suggest acute liver failure is beginning. The nurse should prepare for which intervention? Insertion of a intrahepatic shunt Administration of penicillin G Delivery by cesarean section Administration of acyclovir
Delivery by cesarean section
What causes the paralysis of GBS?
Demyelination of peripheral nerves (unknown cause)
What is contraindicated with an allergy to iodine/shellfish?
Diagnostic test with dye/ cleaning solution for foleys/surgery.
What do the labs look like in Stage 1 of CKD?
Diminished renal reserve 🔺BUN, GFR normal to higher. 🔺Creatine is normal.
A 22 month old child is admitted with second degree burns to his arms and legs due to a kitchen accident involving boiling water. While the RN tries to assess his vital signs he cries, clings to his blanket and continuously points to the door. When the child's grandmother, his primary caregiver at home, finally arrives the child begins crying even louder and tries to physically escape the RN's arms into the arms of the grandma. The nurse assesses this behavior as A. indicative of pain and the need for pharmacologic intervention. B. likely from the abusive situation that led to the burns; contact CPS. C. possibly the result of regression back to the stage of trust vs. mistrust. D. evidence of the need for an early intervention program with the social worker. E. none of the above.
E. normal behavior bonded with grandma
What does the electrolyte imbalance look like during Oliguric Phase?
Electrolyte imbalances (hyponatremic 2/2 NA loss, hypocalcemia, increased phosphates).
What should be done if the pyxis doesn't deliver a stat medication?
Filled Q24 hours so call the pharmacy for the med.
What is Stage 5 of CKD?
End stage renal failure/disease (ESRD) or uremia.
How might Anemia be treated in CKD
Epogen
How is Anemia 2/2 CKD treated?
Erythropoietin TID Injection and IRON, FOLIC ACID.
Azotemia
Excessive urea and nitrogenous substances in the blood.
B
F
What is the memonic for remembering who to see first (prioritizing patients)?
FIRST= Find hypoxia (oxygenation first-anxiousness and cardiac patient). Immunocompromised (prevent infection). Rectal bleeding (hemorrhaging from major artery otherwise don't care- VS changes) Safety, and Try Infection (Ex: septic and high temperature, need to take blood culture before start the antibiotics).
Toddler to school age pain scale
FLACC
School age to early adolescent pain scale
Faces scale
The patient completely recovers from Guillian-Barre. (T/F)
False, there are usually residual effects but they do recover most of what was lost
What are some Nurisng diagnoses for AKI?
Fluid Volume Excess rt compromised regulatory mechanisms. Risk for Infection rt altered immune response secondary to renal failure. Activity Intolerance rt fatigue, Anxiety rt uncertainty of prognosis
How is fluid limited in ESRD?
Fluid intake is based on output (1200cc QD).
What procedures are done non-sterile in the home?
Foley catheter, trach suctioning, insulin, injections, intermittent, and suprapublic catheters.
For whom does the interdisciplinary team meet?
For those with chronic non compliance issues (Ex: sickle cell admitted 3x for crisis, DM admitted for hyperglycemia, celiac not gaining weight, asthma admitted for bronchospasms several times a year).
What is happening during the Recovery phase of AKI?
GFR increase to near normal and this may take up to a year.
Serum BUN to Creatinine Ratio
Helpful because this ratio determines whether it is just a renal issue or a renal issue with some other issue. 10:1 to 20:1
What is worn for droplet precautions?
Glove, gown, and mask
How can HTN be managed in CKD and what is the goal for BP?
Goal BP<150/100 - NA and fluid restriction.
What is happening during the Diuretic phase of AKI?
Gradual increase in output to 1-3 L/day. Indicates recovery of nephrons. Issues with electrolyte balances. May take a few weeks before the body is back to normal.
What patients are immunocompromised?
HIV, cancer, chemo, steroids, organ transplants, cushings, addisons, and radiation.
What interventions are needed to prevent aspiration?
HOB elevated to eat, bed in low position, place on right side after eating, call bell in reach, suction available, and side rails elevated.
What are the rules to remember when delegating to an LPN?
HOSPITAL: An LPN works under direct supervision of an RN. IN a nursing home they might be charge nurses and handle all aspects of care. EX: plan, assess, evaluate, intervene and notify Dr. GET IN HOSPITAL Assign: stable chronic conditions with predictable outcomes .(Pts 24 hours after surgery). NO: discharge planning, admission assessments (including VS). NO IVs, and NO teaching. CAN: give narcotics. HAVE patient 72 hours after MI, CVA, SCI (spinal cord injury), Vents, or low coma scale (after 1 week), and may reinforce teaching.
What causes a non priority patient to become priority if it exits ?
Head trauma with INCREASED ICP, Bleeding FROM MAJOR ARTERY, Increased (blood sugar)BS IN COMA, decreased BS C S&S OF SHOCK, Paperwork FOR PREOP CHECKLIST, Poop FROM AN SCI ABOVE T6 OR APPENDICITIS (STRAIN AND RUPTURE), lab studies- ABGs, chronic conditions C ACUTE LIFE THREATENING PROBLEM. Angina c decreased LOC, decreased cardiac output = decreased urine output, arrhythmia, dizziness/faint PAIN- BACK PAIN : abdominal aortic aneurysm, RLQ: appendicitis, (RLQ with rebound tendernessand rigidity over the right rectus muscle or McBurney's point) ectopic pregnancy, or back pain with blood transfusions, .
A client is brought to the Emergency Department after being injured in a head-on car accident. The nurse would be most concerned about which kind of spinal cord injury?
Hyperflexion
What do electrolyte imbalances look like in CKD?
Hypernatremia Hypocalcemia Hyperkalemia
Lets talks about Sodium R/T Hypernatremia and Hyponatremia?
Hypernatremia=Chronic Hyponatremia=AKI
What is a patient at risk for after parathyroidectomy?
Hypocalcemia
What does it mean if a PCA pump isn't delivering medication to the patient?
The may be asking to often or not enough medication to control the pain.
What kills the immunocompromised patients?
Infection, live viruses (oral polio or varicella), Pneumocystis Carnii Pneumonia (PCP) (danger to immcprd pts only).
IPD
Intermittent peritoneal dialysis.
What should be your response when a patient will be harmed d/t lack of intervention?
Intervene immediately and do procedure correctly. (Ex: Staff contaminating foley).
What does it mean if a patients pacemaker is set at 75 and the patients rate is 80?
It OK and working fine. The patients heart can do better than the pacemaker just no worse!
A nurse manager is explaining autonomic dysreflexia to a nurse who has recently transferred to the ICU. Which statement would the manager evaluate as indicating this nurse has a good understanding of this disorder?
It is a vasoconstrictive problem produced by excessive sympathetic nervous system stimulation.
What does it mean if the patients pacemaker is set at 75 and the patient's rate is 60?
It is defective and the MD should see the patient.
What is important to remember about prioritizing in the ER?
It won't be the obvious answer and don't be swayed by adjectives.
What does it mean if there is no pulse ox reading?
It's on too fat of a finger or no light is seen through the finger. Put it on another location.
Loop of Henle
Key in the reabsorption of Na+ and Cl-.
Which teaching by the nurse will help the client prevent renal osteodystrophy? A. Low-calcium diet B. Avoiding peas, nuts, and legumes C. Drinking cola beverages only once daily D. Avoiding dairy enriched with vitamin D
Kidney failure causes hyperphosphatemia. Client must restrict phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes. Kidney failure decreases serum calcium, resulting in demineralization of the bone; do not restrict calcium in the diet. Cola beverages are high in phosphorus and are to be avoided. Dairy products are high in phosphorus, contributing to hypocalcemia and bone breakdown.
What happens to the kidneys physically as they die?
Kidneys get bigger then they get smaller as the disease goes and the tissue is replaced with scar tissue.
Who does an interdisciplinary team consist of?
MD, RN, PT, Social worker, etc.
What is contraindicated with an allergy to egg?
MMR and flu shot
What should be done if staff applies restraints to a patient to keep them from falling or wandering?
MORE EDUCATION
What should be done if staff doesn't recognize false imprisonment such as gerichair c tray, not allowing patient to leave w/o MD orders, or anything preventing freedom to move about?
MORE EDUCATION
What should be done if staff turns of alarms on equipment?
MORE EDUCATION
What should be done if staff uses extension cords for equipment?
MORE EDUCATION
What should be done if staff breaches confidentiality (taking in public areas, giving D/C instructions with others in room, teaching with family in room, calling support groups w/o pt permission?
MORE EDUCATION. NURSE MANAGER OFFICE IS NOT OPEN TO THE GENERAL PUBLIC (=safe place to discuss).
A client has a suspected ligament injury to the spinal vertebrae. The nurse would prepare this client for which diagnostic test?
MRI
Lets discuss Postrenal causes of AKI.
Mechanical obstruction of urinary outflow (hydronephrosis - enlarged kidneys). Urinary output around 200ml a day. 🔺Calculi formation. 🔺Prostatic hypertrophy.
What types of patients should never be transferred from the OB floor to the med surg floor?
Moms c babies, in labor, or c complications
When a patient who has had progressive chronic kidney disease (CKD) for several years is started on hemodialysis, which information about diet will the nurse include in patient teaching?
More protein will be allowed because of the removal of urea and creatinine by dialysis.
What are examples of progressive neurological diseases? What kind of death do they suffer from?
Multiple Sclerosis, Amynotrophic lateral Sclerosis (ALS), Parkinsons, Huntingtons Chorea, Gullian Barre Syndrome, Myasthenia Gravis, and Scleroderma (hardening). THEY DIET A RESPIRATORY DEATH.
STRESS RELATED CONDITION PATIENT
Multiple sclerosis (MS), Lupus, psoriasis Addison, Rheumatoid arthritis, Rayanuds Crohn's and asthma These patient need relaxation technoques: Meditation, quite environment, imagery, music, breathing exercise and regular exercise.
Fluid replacement: remaining weight kg
Multiply XXX by 20 ml/kg
Fluid replacement: First 10 kg
Multiply first 10kg X 100ml/kg
Fluid replacement: SECOND 10 kg
Multiply second 10kg X 50ml/kg
What does it mean if the patient with an NG tube complains of N&V?
NG may be occluded so irrigate.
Infant pain scale
NIPS - facial expression, cry, breathing pattern, muscle tone, state of arousal
can an LPN... admit a patient from PACU?
NO
can an LPN... document a stoma's appearance?
NO
can an LPN... initiate a primary IV medication?
NO
can an LPN... teach a patient anything?
NO
can a UAP... instruct a pt admitted with renal calculi to strain all urine?
NO (RN bc it is pt education)
can a UAP... logroll a stable pt with a cervical collar?
NO (a nurse needs to be present for spinal cord stabilization)
What meds/herbs should you make sure to ask patients if they are taking (so can implement bleeding precautions)?
NSAIDS, ASA, Heparin, Coumadin, Garlic, Ginkgo, Ginseng, and Vitamin E.
With which conditions are droplet precautions important?
Neisseria meningitis, mycoplasma pneumonia, strep group A, or pertussis.
What are the 2 general rules for vaccines?
No vaccine given if pt temp > 101 or on an antibiotic.
can 2 UAPs pull up a pt that is 300lbs?
No... 3 people are preferred for a pt over 200 lbs
HbA1c
Normal <5.6 glycosylated hemoglobin
What is normal GFR?
Normal GFR = 125cc/min.
What is are normal GFR lab results?
Normal GFR is >90, labs max out at 60
What should be done if someone is brought in with fixed and dilated pupils, not breathing and no heart rate present?
Nothing they are dead so go to the next person.
How should Peds patients be transferred to the Med Surg floor?
Oldest child 1st, No communicable diseases, Not immunocompromised, and No teaching needed.
What patients are on bleeding precautions?
On coumadin/heparin, hemophilia, problems with bone marrow, chemo, liver disease, HIV, DIC, ASA/NSAIDS, and Cancer.
Bronchodilators Side Effects
Palpitations, tachycardia Hyperglycemia Decreased clotting time
Heparin
Parenteral anticoagulant found in blood and tissue cells Used for DVT with PE
What does it mean if the pulse ox read 100% but patient is restless?
Patient may have been exposed to carbon monoxide.
Which patient information will the nurse plan to obtain in order to determine the effectiveness of the prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?
Phosphate level
What is the most aggressive medical therapy for GBS?
Plasmapheresis - to remove antibodies from the blood
What are the clinical manifestation of CKD r/t the Urinary System?
Polyuria ⬇️ Nocturia ⬇️ Oliguria ⬇️ Anuria
What are the 3 ways that we discuss how people can get AKI?
Prerenal Intrarenal Postrenal
What should be done if someone is pulling out their IVs?
Put a mitten on them (least restrictive).
What is the memonic to help you prioritize steps in the event of a fire?
RACE= Remove, Activate, Contain, and Extinguish. Remove the client, Activate the fire alarm, confine the fire and extinguish the fire).
What would you think is wrong with a person who has protein and RBCs in their urine?
RBC and protein are not filtered through here, if RBC of protein is noted in urine there is issues with the Glomerulus.
What should be done if a cooling blanket is on a patient with a temp of 38 C (100.4 F), then after three hours their temp is 102F?
Send to biomed engineering and obtain a new cooling blanket.
Which interventions are contraindicated in the care of a client in a halo vest? Select all that apply.
Removing the vest for daily hygiene and bathing, Using the vest's struts to help pull the client up in bed
What are S/S of Stage 2-4 CKD?
Renal insufficiency: mild, moderate or severe decrease in GFR. 🔺Fatigue 🔺Nocturia 🔺Polyuria 🔺HA
Why would Renin released?
Renin is released in response to: 🔺⬇️ In BP 🔺⬇️ In renal blood flow 🔺⬇️ In ECF 🔺⬆️ Urinary Na concentration. 🔺Hyponatremia 🔺Hyperkalemia
After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take?
Report the patient's symptoms to the health care provider.
What should be done if a peritoneal dialysis machine (CAPD) shows 2000 ml in and 1500 ml cloudy output?
Reposition patient and call MD.
What should be done if there is no drainage from an NG tube?
Reposition patient or tube
What should be done if an IV pump (IVAC) set to run 1 liter of fluid at 150 ml/hr after 6 hours there is 200 ml left in the bag?
Send to biomed engineering and obtain another pump.
What is the biggest danger of GBS?
Respiratory arrest secondary to diaphragmatic paralysis
MISC: FACTS ON PSYCH WARD
SUICIDE: highest in patient with drinkand /or take drugs. ALWAYS bring the patient back to reality --- avoid selecting answers that advise----giving meds or using restrains When choosing nursing intervention for patient problems------STAY AWAY FROM CRY BABIES.
Phases of CKD
Stage 1: Diminished renal reserve. Stage 2 to 4: Renal insufficiency Stage 5: End stage renal failure/disease (ESRD) or uremia
What types of activities should a nurse delegate to UAPs?
Standard unchanging procedures and Stable patients only. Always ask, which patient will die 1st.
Sulfonylueras and meglitinides
Stimulate pancreatic beta cells to release more insulin
T
T
With which conditions are airborne precautions important?
TB, varicella, or measles.
What things should an RN never delegate?
TIA= Teaching, Interventions, and Assessments
WHAT IS THE MEMONIC TO REMEMBER THE PROPER TRIAGE PRIORITIES? (NEED TO KNOW WHO TO HELP!)
TRIAGE= Trauma-no internal injuries (breathing, bleeding, broken bones, burns), Respiratory (1st)/ Cardiac (2nd), ICP (Head trauma, LOC/seizure-airway or numerous head and facial abrasions and lacerations), AN Infection (septic shock). NOT MPORTANT: meaning not priority GI (bleed, pain, and distention-not impt), Elimination- (pyelonephritis or trouble voiding) these client should be triaged.
What should be your response to Non-patient/non-medical issues that arise?
Tell direct supervisor (Ex: staff eating off of patient's trays).
Who should do the steps of the nursing process (assess, plan, interventions, outcomes)?
The RN
Who should manage IVs for regular infusions, TPN, ABX, and drips?
The RN (LPN or NA should never manage IVs)
12. While conversing with a patient who had a stroke six months ago, you note their speech is hard to understand and slurred. This is known as: A. Dysarthria B. Apraxia C. Alexia D. Dysphagia
The answer is A.
14. You need to obtain informed consent from a patient for a procedure. The patient experienced a stroke three months ago. The patient is unable to sign the consent form because he can't write. This is known as what: A. Agraphia B. Alexia C. Hemianopia D. Apraxia
The answer is A.
15. You're assessing your patient's pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as: A. Hemianopia B. Opticopsia C. Alexia D. Dysoptic
The answer is A.
A patient with CKD has a low erythropoietin (EPO) level. The patient is at risk for? A. Hypercalcemia B. Anemia C. Blood clots D. Hyperkalemia
The answer is B. EPO (erythropoietin) helps create red blood cells in the bone marrow. The kidneys produce EPO and when the kidneys are damaged in CKD they can decrease in the production of EPO. Therefore, the patient is at risk for anemia.
18. In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered? A. 6 hours after the onset of stroke symptoms B. 3 hours before the onset of stroke symptoms C. 3 hours after the onset of stroke symptoms D. 12 hours before the onset of stroke symptoms
The answer is C. tPa dissolves the clot causing the blockage in stroke by activating the protein that causes fibrinolysis. It should be given within 3 hours after the onset of stroke symptoms. It can be given 3 to 4.5 hours after onset IF the patient meets strict criteria. It is used for acute ischemia stroke, NOT hemorrhagic!!
10. You're patient who had a stroke has issues with understanding speech. What type of aphasia is this patient experiencing and what area of the brain is affected? A. Expressive; Wernicke's area B. Receptive, Broca's area C. Expressive; hippocampus D. Receptive; Wernicke's area
The answer is D.
6. A patient is demonstrating signs and symptoms of stroke. The patient reports loss of vision. What area of the brain do you suspect is affected based on this finding? A. Brain stem B. Hippocampus C. Parietal lobe D. Occipital lobe
The answer is D. The occipital lobe is responsible for vision and color perception.
What does it mean if an O2 mask with a rebreather bag deflates during inspiration?
The bag should NEVER deflate so get new equipment.
A client is brought to the Emergency Department after sustaining a spinal injury in a boating accident. The diagnosis of unstable spinal injury is made. How should the nurse interpret this information?
The client's injury includes disruption of two or more of the spinal columns and close attention must be paid to decrease the chance of secondary injury
A client with an SCI is receiving methylprednisolone. Which finding would the nurse interpret as indicating a possible complication of this therapy?
The client's stools are positive for blood.
What are the clinical manifestation of CKD related to?
The clinical manifestations are related to uremic toxins.
Lets discuss Intrarenal causes of AKI.
The damage to renal tissue, nephrons malfunction. 🔺Prolonged prerenal problem. 🔺Infection. 🔺Nephrotoxins (lead, mercury, medicaitons). 🔺Intravascular hemolysis (blood transfusions, DIC [blockages]). 🔺Myoglobinuria (crushing, falls = damaged muscles).
Collecting Ducts
The location of the final concentration of urine. Water is reabsorbed by ADH.
Secretion
The moving of substances from blood into tubule (filtrate) = excreted
A nurse documents that a client with an SCI has full strength in the left arm on initial assessment. Which actions has this nurse taken? Select all that apply.
The nurse has asked the client to move the arm against the nurse's resistance. The nurse has asked the client to dangle the arm off the bed and move it.
Who should floaters be assigned to?
To patients with a condition similar to what they would see on their own floor, and most stable person possible, NEVER cardiac patients or borderline/antisocial patients (will eat them up bc so manipulative).
Who should an NA never position?
Total Hip replacement, total knee replacement, Increased ICP, acute CVA, or Above knee/below knee amputations.
Latanoprost (Xalatan)
Treatment of glaucoma Reduces intraocular pressure in the by increasing fluid drainage
What happens with UREA build up?
UREA build up=decreased ability to fight infections! 💀
Uremic Encephalopathy
Uremic encephalopathy is an organic brain disorder. It develops in patients with acute or chronic renal failure, usually when the estimated glomerular filtration rate (eGFR) falls and remains below 15 mL/min.
Timolol maleate (Timoptic)
Use for treatment of glaucoma Reduces intraocular pressure by decreasing fluid production
What are interventions for a patient with a progressive neurological disease who may have respiratory problems as a result?
Use peak flow meter, get advanced directive, mechanical soft diet, and thickened liquids.
Pioglitazone (Actos)
Use: Type 2 Diabetes mellitus Helps control glucose Helps endogenous insulin work better
Epogen
Used in treating anemia because it increases RBC production.
Albueterol (Proventil, Ventolin)
Used to reverse airway constriction Facilitates removal of secretions bronchodilator
Ipratropium Bromide (Atrovent)
Used to reverse airway constriction Facilitates removal of secretions bronchodilator
What should you NEVER Massage?
Veins, Z-track, Pressure ulcers, SQ heparin, Wilm's tumor, and intradural (PPD TB test).
What kind of infection precedes Guillian-Barre?
Viral
Metabolic syndrome tests
Waist circumference Blood pressure FBG/FBS HDL cholesterol Triglycerides BMI
What should be your response if a staff members action is incorrect but will not harm the patient?
Wait until they are finished then teach the correct procedure to them.
How are calcium and phosphate imbalances dealt with?
With Phosphate Binders that are taken with meals.
can a UAP... measure vitals just prior to beginning RBC transfusion?
YES
can a UAP... perform ROM exercises?
YES
can a UAP... reapply wrist restraints after toileting?
YES
can a UAP... take the 4th set of vital signs to a pt getting RBCs?
YES
can an LPN... administer IM medication?
YES
can an LPN... administer PO medication?
YES
can an LPN... administer SQ medication?
YES
A patient has a history of heart failure. Which of the following statements by the patient indicates the patient may be experiencing heart failure exacerbation?SATA A. "I've noticed that I've gain 6 lbs in one week." B. "While I sleep I have to prop myself up with a pillow so I can breathe." C. "I haven't noticed any swelling in my feet or hands lately."
a,b
The healthcare provider is teaching a patient diagnosed with hepatitis C about the disease. Which of these statements made by the patient indicate that the patient has an understanding of the teaching?Choose all answers that apply: A"I should get vaccinated for hepatitis A and hepatitis B." B"It's important for me to use barrier protection when I have sex." C"I should not drink any wine, beer or other alcoholic beverages." D"I'll plan to do all my activities in the morning when I'm most rested." E"I should avoid sharing drinking cups and eating utensils with my family." F"Acetaminophen is the best medication for me if I have a headache."
a,b,c
the client is experiencing an anaphylactic reaction to bee venom. which interventions should the nurse implement? list in order of priority a. establish a patent airway b. administer epinephrine IM c. teach the client to carry an EpiPen when outside d. administer diphenhydramine (Benadryl), an antihistamine, IVP
a,b,d,c
The RN is caring for a patient whose cultural background is different from the RN's own. Which actions are appropriate for the RN to take? Select all that apply. A. Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures. B. Explain the RN's beliefs so that the patient will understand the differences. C. Respect the patient's cultural beliefs. D. Ask the patient about cultural or religious requirements that should be considered for nursing care. E. Understand that most cultures experience and respond to pain the same way.
a,c,d
Which of the following patients are MOST at risk for developing heart failure? Select-all-that-apply: A.A 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction. B. A 55 year old female with a health history of asthma and hypoparathyroidism. C. A 30 year old male with a history of endocarditis and has severe mitral stenosis. D. A 45 year old female with lung cancer stage 2. E. A 58 year old female with uncontrolled hypertension and is being treated for influenza.
a,c,e
Which nursing actions are considered tertiary health promotion? Select all that apply. a. A nurse runs an immunization clinic in the inner city. b. A nurse teaches a patient with an amputation how to care for the residual limb. c. A nurse provides range-of-motion exercises for a paralyzed patient. d. A nurse teaches parents of toddlers how to childproof their homes. e. A school nurse provides screening for scoliosis for the students .f. A nurse teaches new parents how to choose and use an infant car seat.
b,c
A patient diagnosed with chronic hepatitis has developed hepatic encephalopathy. When assessing the patient, the healthcare provider looks for which of the following clinical manifestations characteristic of this condition Choose all answers that apply: ARetroperitoneal bleeding BInvoluntary hand tremoe CBloody emesis DShortened attention span EHypersomnia FSlurred speech
b,d,e,f
A 9 month old infant is hospitalized after a three day history of nausea and vomiting. Which urine specific gravity indicates achievement of an expected outcome related to rehydration? 1.001 1.007 1.018 1.025
b. 1.007
The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear? a. Stridor b. Crackles c. Wheezes d. Friction rubs
b. Crackles LHF
the nurse is caring for a client diagnosed with epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93 percent. 4. Perform deep Nasal suction every 2 hours. 5. Administer mild sedative.
correct answers 2, 3,5. Stool softeners are initiated to prevent the Bell sell the maneuver which increaseS ICP. oxygen saturation higher the 93 percent ensures oxygenation of the brain tissues. decreasing oxygen levels increase cerebral edema.mild sedative will reduce the clans agitation. Strong narcotics would not be administered because they decrease the clients loc.
A patient with early evidence of obstructive airway disease states, "My smoking has already damaged my lung. Why stop now?" On what information should the RN base the response? a Encouraging patients to stop smoking is rarely effective. b Smoking cessation rates are low, even with drug therapy. c Avoiding environmental irritants can minimize the effect of smoking. d If smoking cessation occurs in time, the changes may be reversible.
d
Considering the developmental tasks of toddlers, which approach would best enhance communication between the RN and the child? A. respect the child's need for privacy; close the door when providing care. B. Prepare the child several days in advance for painful or invasive procedures. C. Use appropriate medical terminology; allow the child to ask questions. D. Integrate dolls, storytelling and picture books into conversations.
d
Erythropoietin sometimes is administered subcutaneously to treat which of the following? (Select all that apply.) a. Clients with marrow suppression b. Clients with chronic liver disease c. Clients with Hodgkin's disease and non-Hodgkin's lymphoma d. Clients with anemia and fatigue related to non-myeloid cancers
d
The pediatric surgery team arrives to perform an unscheduled, potentially painful procedure on a 3 year old child. What is the RN's best action? A. Encourage the mom to hold the child in the bed while the RN sets up supplies. B. Assign the child life specialist to distract the child with a toy. C. Demonstrate the procedure using a teddy bear first. D. Facilitate the set up for the procedure in the treatment room.
d
You're providing diet discharge teaching to a patient with a history of heart failure. Which of the following statements made by the patient represents they understood the diet teaching? A. "I will limit my sodium intake to 5-6 grams a day." B. "I will be sure to incorporate canned vegetables and fish into my diet." C. "I'm glad I can still eat sandwiches because I love bologna and cheese sandwiches." D. "I will limit my consumption of frozen meals."
d
7. A patient has right side brain damage from a stroke. Select all the signs and symptoms that occurs with this type of stroke: A. Right side hemiplegia B. Confusion on date, time, and place C. Aphasia D. Unilateral neglect E. Aware of limitations F. Impulsive G. Short attention span H. Agraphia
he answers are B, D, F, and G. Patients who have right side brain damage will have LEFT side hemiplegia (opposite side), confused on date, time, and place, unilateral neglect (left side neglect), DENIAL about limitations, be impulsive, and have a short attention span. Agraphia, right side hemiplegia, aware of limitations, and aphasia occur in a LEFT SIDE brain injury.
can a UAP... recharge a JP or Hemovac drain?
no (according to u world- they can record output though) JUST KIDDING IDKKKKKK
What are some contraindications to Peritoneal Dialysis?
🔺Abdominal Surgery 🔺Obesity 🔺Back Problems 🔺Lung Disease
Lets discuss Peritoneal Dialysis
🔺Catheter inserted into abdominal wall (looks like a G tube but lower and more central). 🔺Dialysis solution instilled (2L) and remains in peritoneal cavity it stays there for 6 hours and when it comes out it looks like urine and is normally a larger amount. 🔺Dialysis solution later drained.
What are the clinical manifestation of CKD r/t the Reproductive System?
🔺Decreased Hormone Levels 🔺Infertility
What are the clinical manifestation of CKD r/t the Psychosocial System?
🔺Depression 🔺Fatigue 🔺Self-esteem 🔺Role changes
What are some adverse effects of Hemodialysis>
🔺Disequibrium syndrome. 🔺Cramping. 🔺Fatigue can be common or they can be energized.
What are some disadvantages to Peritoneal Dialysis?
🔺Exit-site Infections 🔺Peritonitis
What are indications for Dialysis?
🔺Fluid Overload 🔺Hyperkalemia 🔺Severe acidosis 🔺Altered CNS 🔺Pericarditis 🔺Uremia
What are some S/S of recurrent kidney issues?
🔺Fluid retention 🔺Twitching 🔺Cramping 🔺electrolyte Imbalances
Who should manage a patient's on a vent for the first week (acute)?
An RN
Who should transcribe orders?
An RN
Who should complete sterile procedures?
An RN or LPN
Who should evaluate a patients pain after a narcotic?
An RN or LPN
Who should up date a patient's plan of care?
An RN or LPN
Who should administer medications?
An RN or LPN (no IVs)
48. A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign? 1. pulse 2. respirations 3. blood pressure 4. temperature
3
the client has sustained a severe closed head injury and the neurosurgeon is determining if the client is brain dead. Which data support That the client is brain dead?1. The clients head is turned to the right, the eyes turn to the righT. 2. the EEG has identifiable waveforms. 3. There is no Eye activity when the cold caloric test is performed. 4 the client assumes decorticate posturing when painful stimuli are applied.
3. The cold caloric test, also called the ocular vestibular test, is used to determine if the brain is intact or dead. No Eye activity indicates brain death. If the client eyes moved, that would indicate that the brainstem is intact.
What should pregnant nurses avoid?
5th disease (slapface/Parovirus), measles, varicella, internal radiation, isotopes, and chemo drug handing.
BUN
6-20 mg/dL blood urea nitrogen
REGULAR Rate on EKG
60-100
Neonate Blood Pressure
60-90/20-60
school age heart rate
60-95 bpm
fasting blood sugar
60-99 ml/dl
Preschool heart rate
65-110
Toddler heart rate
70-110bpm
Infant heart rate
80-160 bpm
Infant Blood Pressure
87-105/53-66
Calcium
9-11 mg/dL
The client with hemophilia A is experiencing hemarthrosis. Which intervention should the nurse recommend to the client? 1. Alternate aspirin and acetaminophen to help with the pain. 2. Apply cold packs for 24 to 48 hours to the affected area. 3. Perform active range-of-motion exercise on the extremity. 4. Put the affected extremity in the dependent position.
2. Ice is good NO HEAT PACKS
The client is admitted to the intensive care department diagnosed with myxedemacoma. Which assessment data warrant immediate intervention by the nurse? 1. Serum blood glucose level of 74 mg/dL. 2. Pulse oximeter reading of 90%. 3. Telemetry reading showing sinus bradycardia. 4. The client is lethargic and sleeps all the time.
2. O2, circulation rest are expected
Toddler Blood Pressure
95-105/53-66
School Age Blood Pressure
97-112/57-71
Normal ORS interval
<0.12 seconds
the resident in a long term care facility Fell during the previous shift and has a laceration in the occiptal area that has been closed with steri strips. Which signs or symptoms would warrant transferring the resident to the emergency department?1. A 4 centimeters area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that's resolved with medication.
2. These signs and symptoms indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.
Adolescent to adult pain scale
0-10 numeric scale
Normal PR interval
0.12-0.20 seconds
A nurse is developing an informational session about hepatitis B infection. Which information should the nurse include? Select all that apply. 1. A vaccination against hepatitis B is available. 2. Hepatitis B is rarely seen in middle-aged adults. 3. Hepatitis B can be considered a sexually transmitted infection. 4. Hepatitis B is spread by contaminated food or water. 5. Hepatitis B is endemic in the United States.
1 3
he nurse identifies the client problem "risk for imbalanced body temperature" fort he client diagnosed with hypothyroidism. Which intervention should be included in the plan of care? 1. Discourage the use of an electric blanket. 2. Assess the client's temperature every two (2) hours. 3. Keep the room temperature cool. 4. Space activities to promote rest.
1. Not good, hypothyroidism already has a low bp, electric blanket will vasodilate lowering bp even more
For the client who is experiencing expressive aphasia, which nursing iNtervention in promoting communication is most effective: 1, speaking loudly and slew 2. using a "picture board" fs the client to point to pictures 2. writing directions so the client can read them 4. speaking in short sentences
2
43. Following a stroke, a client has dysphagia mad left-sided facial paralysis. Which feeding tech- ique will be most helpful at this time? 1. Encourage sipping diluted liquid meal supplements from a straw. 2. Position the client with the bed at a 30-degree angle. 3. Offer solid foods from the unaffected side of the mouth. 4. Feed the client a soft diet from a spoon intothe left side of the mouth.
3
End-stage renal disease is defined as GFR less than ________________ ml/min per 1.73m2. A. 10 B. 5 C. 30 D. 45 E. 15
E
What procedures are done sterile in the home?
IVs, dressings, and peritoneal dialysis.
A client is about to have a blood transfusion and asks the nurse which type of hepatitis is most frequently transmitted through food. Which type of hepatitis should the nurse teach the client about being most associated with food? Hepatitis.... A B C D
Hepatitis A
What is contraindicated with an allergy to yeast?
Hepatitis B vaccine
13. You're reading the physician's history and physical assessment report. You note the physician wrote that the patient has apraxia. What assessment finding in your morning assessment correlates with this condition? A. The patient is unable to read. B. The patient has limited vision in half of the visual field. C. The patient is unable to wink or move his arm to scratch his skin. D. The patient doesn't recognize a pencil or television.
The answer is C.
What does it mean if the doppler isn't reading?
Patient may not have pulses
Who should be isolated?
Pt with night sweats/temp/ and cough (TB), Pt with HA and stiff neck (meningitis), adult patient with rash or blisters (shingles), and any patient showing S&S of infection (increased temp, rash, increased WBCs) until verified. Follow CDC guidelines.
What patients are prioritizing-----life threatening
RLQ (appendix) pain, LLQ (diverticulosis) pain, mid epigastric pain (preg-seizure), spinal cord injury above T6, child drooling (epiglotitis), central line with SOB, compartment syndrome (pain not relieved by drugs/cast or crushing injury c swelling), muffled heart sounds (cardiac tamponade), taking nitro within 1 week of MI (may be another MI), Femur/Pelvis fx c S&S of fat emboli, enlarged veins on Abd (portal HTN), DVT/PE, Immunocompromised pt with nonproductive cough (PCP) or temp, restlessness, abnormal electrolytes, progressive neurological diseases, burns c smoke inhalation, withdrawal symptoms of drugs/alcohol, angina c indigestion=MI, neuroleptic malignant syndrome, toxic levels of medication, and Spinal cord injury (SCI) c autonomic dysreflexia (crazy high BP).
What needs to be done prior to transferring patient to another unit?
Receiving unit must be familiar with the disease/treatment, be alert for gender specific wards (OB), don't transfer (unstable pts, unknown diagnosis pts, or pt whose condition is made worse with stress (addisons, lupus, RA, raynauds, asthma, etc.).
Renin
Released in response to decreased blood flow or decreased pressure in nephrons.
Distal Tubule
The final regulation of water and acid-base balance. Reabsorption of H2O occurs with ADH. Reabsorption of Na+ and H2O due to aldosterone. Acid/base balance - reabsorption of bicarbonate and secretion of H+.
Reabsorption
The moving of substances from tubules into blood = retained.
Specific Gravity
The renal concentrating ability: 1.016 - 1.022 - not the best since many things can affect it. A low specific gravity means that it is diluted or diabetes insipidus, chronic renal insufficiency, or other things. High specific gravity 2/2 dehydration, protein, HF.
Which is the nurse's PRIORITY action when managing a client experiencing a type I hypersensitivity? A. Management of arthralgia B. Airway management C. Stopping the blood transfusion D. Decreasing a fever
b AIRWAY
What are the clinical manifestation of CKD r/t the Neuromuscular System?
🔺General Depression of CNS 🔺Peripheral Neuropathy 🔺Muscle Weakness 🔺Twitching 🔺Uremic Encephalopathy. 🔺Renal osteodystrophy - bone and mineral disorder.
RBC
3.5-5 mill/mm3
Potassium
3.5-5.0 mEq/L
For relief of hypoxemia in the newly admitted client with chronic obstructive pulmonary disease (COPD), what does the client most likely need? A. Oxygen flow rate of 1 to 2 L/min via nasal cannula B. Oxygen flow rate of 2 to 4 L/min via nasal cannula C. Oxygen flow rate of up to 60% via Venturi mask D. 100% non-rebreather mask
A) The client who is hypoxemic and also has chronic hypercarbia requires lower levels of oxygen delivery, usually 1 to 2 L/min via nasal cannula. A low arterial oxygen level is this client's primary drive for breathing.
A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first? A. Ask the client whether CPAP has been used consistently at night. B. Discuss the use of autotitrating positive airway pressure (APAP). C. Plan to teach the client about treatment with modafinil (Provigil). D. Suggest that a nasal mask be used instead of a full facemask.
A) The nurse should assess whether the client has actually consistently been using CPAP at night because clients may have difficulty with the initial adjustment to this therapy.
Which intervention will be most effective in reducing anxiety in the client with a pulmonary embolism (PE)? A. Remain with the client, and provide oxygen in a calm manner. B. Have the client breathe into a brown paper bag using pursed lips. C. Offer the client a mild sedative. D. Allow a family member to remain in the room
A) The underlying cause for anxiety with a PE is hypoxemia, which will be alleviated by oxygen. Remaining with a client in distress is appropriate.
The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients should be rescheduled for a visit on the following day. Which of these clients would be best to reschedule? A. Client with emphysema who has been on home oxygen for a month and has SPO2 levels of 91% to 93% B. Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test C. Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment D. Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea
A) This client has an appropriate Spo2 for home oxygen use.
The medical-surgical unit nurse should call the Rapid Response Team to assess which of these clients? A. The client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright red hemoptysis B. The client with deep vein thrombosis who is receiving low-molecular weight heparin and has ongoing calf pain C. The client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry of 94% D. The client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs
A) This client is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin. This indicates a significant decline in status and warrants activation of the Rapid Response Team.
The healthcare provider is teaching a patient diagnosed with hepatitis C about the disease. Which of these statements made by the patient indicate that the patient has an understanding of the teaching? Choose all answers that apply: A "I should get vaccinated for hepatitis A and hepatitis B." B "It's important for me to use barrier protection when I have sex." C "I should not drink any wine, beer or other alcoholic beverages." D "I'll plan to do all my activities in the morning when I'm most rested." E "I should avoid sharing drinking cups and eating utensils with my family." F "Acetaminophen is the best medication for me if I have a headache."
A, B, C Hepatitis C is a parenterally transmitted virus. Inflammation caused by the hepatitis C virus can result in cirrhosis and liver cancer, so the patient will want to take steps to avoid further damage to the liver Patients infected with the hepatitis C virus should avoid alcohol, avoid acetaminophen, and get vaccinated for hepatitis A and B. Barrier protection should be used during sex, but casual household contact is not a risk factor for transmission. Fatigue is best managed by spacing activities throughout the day and taking rest periods as needed.
What is the most important nursing diagnosis for a patient in end-stage renal disease? A. Risk for injury B. Fluid volume excess C. Altered nutrition: less than body requirements D. Activity intolerance
B Kidneys are unable to rid the body of excess fluids which results in fluid volume excess during ESRD.
When caring for a client with a pulse oximetry level of 89%, which action should the nurse take first? A. Get the client out of bed. B. Apply oxygen as prescribed. C. Notify the client's physician. D. Auscultate breath sounds.
B) Applying oxygen is the first priority for a client with hypoxemia.
Which statement indicates that the client understands the teaching about beclomethasone diproprionate (Beconase)? A. "I will need to taper off the medication to prevent acute adrenal crisis." B. "This medication will help prevent the inflammatory response of my allergies." C. "I will need to monitor my blood sugar more closely because it may increase." D. "I need to take this medication only when my symptoms get bad."
B) Beclomethasone diproprionate (Beconase) is a steroid spray administered nasally. It is used to prevent allergy symptoms. Its effect is localized, and therefore the client does not have systemic side effects with normal use and does not have to worry about weaning off the medication as with oral corticosteroids.
The nurse is caring for a client who has taken a large quantity of furosemide (Lasix) to promote weight loss. The nurse anticipates the finding of which acid-base imbalance? A. PO2 of 78 mm Hg B. HCO of 34 mEq/L C. PCO2 of 56 mm Hg D. pH of 7.31
B) Diuretics (non-potassium sparing) cause metabolic alkalosis.
The nurse is caring for a group of clients. The client with which condition is in greatest need of immediate intubation? A. Difficulty swallowing oral secretions B. Hypoventilation and decreased breath sounds C. O2 saturation of 90% D. Thick, purulent secretions and crackles
B) Intubation may be indicated for the client who is hypoventilating and has decreased breath sounds.
What is the most important thing for the nurse to teach a client who is switching allergy medications from diphenhydramine (Benadryl) to loratadine (Claritin)? A. This medication can potentially cause dysrhythmias. B. This medication has fewer sedative effects. C. This medication has increased bronchodilating effects. D. This medication causes less gastrointestinal upset.
B) Loratadine (Claritin) does not affect the central nervous system and therefore is nonsedating.
What does the nurse do first when setting up a safe environment for the new client on oxygen? A. Ensures that staff wear protective clothing B. Ensures that no combustion hazards are present in the room C. Sets the oxygen delivery to maintain no fewer than 16 breaths per minute D. Uses a pulse oximetry unit
B) Oxygen is highly flammable. The nurse needs to ensure that no open flames or combustion hazards are present in a room where oxygen is in use.
The change-of-shift report has just been completed on the medical-surgical unit. Which of the following clients will the oncoming nurse plan to assess first? A. Client with COPD who is ready for discharge but is not able to pay for prescribed home medications. B. Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38. C. Hospice client with terminal pulmonary fibrosis and an oxygen saturation level of 89%. D. Client with lung cancer who needs an IV antibiotic administered before going to surgery.
B) The client with cystic fibrosis, an elevated temperature, and an elevated respiratory rate is exhibiting signs of an exacerbation and needs to be assessed first.
The registered nurse is overseeing a nursing student who is administering medications to a group of clients with pulmonary disorders. Under which circumstance does the nurse NOT correct the student? A. "You will receive enoxaparin (Lovenox) through the intravenous line for 3 days." B. "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." C. "Once the physician orders warfarin (Coumadin), we will discontinue the intravenous heparin." D. "If bleeding develops, we will give you aminocaproic acid to reverse the anticoagulant."
B) The international normalized ratio (INR), a measurement of anticoagulation with Coumadin, is in the therapeutic range between 2 and 3. ------- A) Enoxaparin (Lovenox) is a low-molecular weight heparin that must be given by the subcutaneous route. C) Heparin and Coumadin are overlapped until the INR is in the therapeutic range, then the heparin can be discontinued. D) Aminocaproic acid (Amicar) is used as an antidote for thrombolytic therapy and in the treatment of subarachnoid hemorrhage.
The nurse is performing a client assessment for the client's potential employer. The client reports dyspnea when climbing stairs but is not dyspneic at rest. Which dyspnea classification does the nurse assign to this client in the report to the employer? A. Class I, can perform perform manual labor B. Class II, can perform desk job C. Class III, minimally employable D. Class IV, must remain at home
B) This client is dyspneic when climbing stairs or walking on an incline but not on level walking. Therefore, this client is employable only for a sedentary job or under special circumstances.
A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention? A. Blood in the sputum B. Mucoid sputum C. Pink frothy sputum D. Yellow sputum
C) Pink frothy sputum is common with pulmonary edema and requires immediate attention and intervention to prevent the client's condition from getting worse.
The nurse is caring for a client with an oxygen saturation of 88% and accessory muscle use. The nurse provides oxygen and anticipates which of these physician orders? A. Administration of IV sodium bicarbonate B. Computed tomography (CT) of the chest, stat C. Intubation and mechanical ventilation D. Administration of concentrated potassium chloride solution
C) Support with mechanical ventilation may be needed for clients who cannot keep their oxygen saturation at 90% or who have respiratory muscle fatigue.
The nurse is caring for a group of clients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)? A. A client with diabetes and cellulitis of the leg B. A client receiving IV fluids through a peripheral line C. A client returning from an open reduction and internal fixation of the tibia D. A client with hypokalemia receiving potassium supplements
C) Surgery and immobility are risks for deep vein thrombosis (DVT) and PE.
A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.
C. Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.
Discharge teaching to a client receiving a beta-agonist bronchodilator should emphasize reporting which side effect? a. Hypoglycemia b. Nonproductive cough c. Sedation d. Tachycardia
D) A beta-agonist bronchodilator stimulates the beta receptors of the sympathetic nervous system, resulting in tachycardia, bronchodilation, hyperglycemia (if severe), and alertness.
Your client has been diagnosed with chronic bronchitis and started on a mucolytic. What is the rationale for ordering a mucolytic for this client? A. Mucolytics decrease secretion production. B. Mucolytics increase gas exchange in the lower airways. C. Mucolytics provide bronchodilation in clients with chronic obstructive pulmonary disease (COPD). D. Mucolytics thin secretions, making them easier to expectorate.
D) The term mucolytic means "breaking down mucus." Mucolytics cause secretions to thin and make them easier to be expectorated. This is important for a client with chronic bronchitis.
The nurse is caring for a client who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal bleeding and an international normalized ratio (INR) of 6.9. For which of the following should the nurse assess this client? A. Consumption of green leafy vegetables B. Prolonged exhalation C. Client has massaged his calves. D. Use of aspirin or salicylates
D) Use of aspirin and salicylates will prolong the INR and cause gastric irritation.
When caring for the client hoping to receive a kidney transplant, the nurse recognizes that which of these problems will exclude the client from transplantation? A. History of hiatal hernia B. Client with diabetes and HbA1c of 6.8 C. Basal cell carcinoma removed from nose 5 years ago D. Client with tuberculosis
D. Client with tuberculosis: Long-standing pulmonary disease and chronic infection typically exclude clients from transplantation; these conditions worsen with immune suppressants required to prevent rejection.
The nurse is teaching a patient with Addison's disease about corticosteroid therapy. The nurse should prioritize which of these teaching points? Multiple choice question a. "Plan a high-carbohydrate diet." b. "Increase your daily intake of sodium." c. "Decrease your daily intake of calcium." d. "Do not stop taking the medication abruptly."
D. TAPER STEROIDS
A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest? A. Adventitious breath sounds B. Fremitus C. Oxygenation status D. Respiratory excursion
A) Adventitious sounds are additional breath sounds superimposed on normal sounds. They indicate pathologic changes in the lung.
Who should feed a stable trach patient on a vent?
An LPN
The client says, "I hate this stupid COPD." What is the best response by the nurse? A. "Then you need to stop smoking." B. "What is bothering you?" C. "Why do you feel this way?" D. "You will get used to it."
B) Encourage the client and the family to express their feelings about limitations on their lifestyle and about disease progression.
In responding to visceral stimuli, the client would be most likely to experience which of the following? [Hint] A. being aware train is coming because of hearing whistle B. being aware of which foot is forward when walking C. awareness of a full stomach D. being aware of an unpleasant smell
C. awareness of a full stomach
What medication might be employed during Hyperkalemia 2/2 CKD to protect the heart?
Calcium Glutinate IV
Lets discuss Prerenal causes of AKI.
Conditions outside kidneys that impair renal blood flow and cause decreased GFR. 🔺⬇️ Vascular Volume 🔺⬇️ Cardiac Output 🔺 Intravascular pooling of blood/peripheral vasodilation. 🔺⬆️ Renal vascular resistance or an obstruction.
A patient with newly diagnosed SLE asks the nurse how the disease will affect her life. The best response by the nurse is: A. You can plan to have a near-normal life since SLE rarely causes death B. It is difficult to tell because to disease is so variable in its severity and progression C. Life span is shortened somewhat in people with SLE, but the disease can be controlled with long-term use of corticosteroids D. Most people with SLE have alternating periods of remissions and exacerbations with rapid progression to permanent organ damage
2.
the client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order with the nurse question? 1. A subcutaneous anti coagulant. 2. An intravenous osmotic diuretics. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.
2. An Osmotic diuretic is ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit.
the client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place 2x2 Gauze under the nose to collect drainage.
3. The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid and the HCP should be notified immediately.
The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse? 1. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. 2. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGsof pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45,P 124, and R 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomytwo (2) days ago and has a negative Trousseau's sign.
3. low bp, increased hr could be addison crisis
A client with chronic renal failure has been prescribed calcium carbonate. What is the rationale for this particular medication? 1) Diminishes incidence of gastric ulcer formation 2) Alleviates constipation 3) Binds with phosphorus to lower concentration 4) Increase tubular reabsorption of sodium
3: Clients with ARF have hyperphosphatemia. Clients are prescribed calcium-based phosphate binders to improve excretion of phosphorus.
A client with acute renal failure develops sever hyperkalemia. What would the nurse anticipate to be used to treat this imbalance? 1) Furosemide (Lasix) 2) Amphojel (aluminum hydroxide) 3) 50% glucose and regular insulin 4) Epoetin (Procrit)
3: Hyperkalemia can develop into an emergency situation (Cardia Arrest). It is important to quickly move the potassium back into the cells by administering 50% glucose and regular insulin, usually in conjunction with some type of base to correct the acidosis, such as sodium bicarbonate or calcium gluconate given IV. Insulin assists in the movement of potassium into the cells and helps to reduce the serum potassium level. Amphojel is used for the treatment of hyperphosphatemia that occurs with ARF. Procrit is used for the treatment of anemia caused by a decrease in erythropoietin production by the kidneys. A diuretic, such as Lasix, may lead to a loss of potassium, but the rate is too slow.
A client with chronic renal failure has an internal venous access site for hemodialysis on her left forearm. What action will the nurse take to protect this access site? 1) Irrigate with heparin and NS q8 hrs 2) Apply warm moist packs to the area after hemodialysis 3) Do not use the left arm to take blood pressure readings. 4) Keep the arm elevated above the level of the heart.
3: Protect the arm with the functioning shunt. No blood pressure readings should be taken from that arm, and there should be no needle sticks. The access is not irrigated with Heparin.
Which clinical manifestation should the nurse expect to note when assessing a client with Addison's disease? 1. Edema 2. Obesity 3. Hirsutism 4. Hypotension
4
the client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess nurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.
4. The most important nursing goal in the management of a client with a head injury is to establish and maintain adequate airway.
the nurse is enjoying a day out at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health care provider to respond to the accident. Which intervention should be implemented first? 1. Assess the clients loc. 2. Organize onlookers to remove the client from the lake. 3. Perform a head to toe assessment to determine injuries. 4. Stabilize the clients cervical spine.
4. The nurse should always assume that the client with traumatic head injury may have sustained spinal cord injury. Moving the client could further injure the spinal cord and cause paralysis.Therefore the nurse should stabilize the cervical spinal cordas best as possible prior to removing the client from the water.
Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism? 1. Increase the amount of fiber in the diet. 2. Encourage a low-calorie, low-protein diet. 3. Decrease the client's fluid intake to 1,000 mL/day. 4. Provide six (6) small, well-balanced meals a day.
4. small frequent meals to help with the increased appetite
Recovery usually occurs within ____ to ____ months for patients with Guillian-Barre?
4; 6
Fluid replacement 11-20 kg
50ml/kg
Adolescent heart rate
55-90
Adolscent blood pressure
<120 / < 80
Hypoglycemia
<60 mg/dl
Diabetes HbA1C
>/= 6.5%
hyperglycemia
>126
fasting blood sugar diabetes
>126 mg/dL
Immunosuppression following Kidney transplantation is continued: A. For life B. 24 hours after transplantation C. A week after transplantation D. Until the kidney is not anymore rejected
A
A patient diagnosed with viral hepatitis is prescribed ribavirin and interferon alfa-2a. The patient calls the clinic to report shortness of breath and increasing fatigue over the past week. Which of the following responses would be most appropriate for the healthcare provider to make? A"Do you have any other symptoms such as a headache or rash?" B "Please come to the clinic so we can send some of your blood to the lab' C "How many hours of sleep do you usually get each night?" D "These symptoms are very common in patients diagnosed with hepatitis.'
A Although it's true these symptoms are associated with hepatitis, the healthcare provider will want to assess for serious problems associated with the prescribed medications. Think about other physiological problems besides hepatitis that can cause these symptoms. Ribavirin toxicity can cause hemolytic anemia, and interferon alpha-2a can cause bone marrow depression. This can lead to decreased oxygen-carrying capacity of the blood resulting in fatigue and shortness of breath.
What will the nurse expect to find that would indicate a therapeutic effect of acetylcysteine (Mucomyst)? a. Decreased cough reflex b. Decreased nasal secretions c. Liquefying and loosening of bronchial secretions d. Relief of bronchospasms
C) Acetylcysteine is a mucolytic drug used to liquefy and loosen bronchial secretions in order to enhance their expectoration.
A female client is admitted for treatment of chronic renal failure (CRF). Nurse Julian knows that this disorder increases the client's risk of: A. water and sodium retention secondary to a severe decrease in the glomerular filtration rate. B. a decreased serum phosphate level secondary to kidney failure. C. an increased serum calcium level secondary to kidney failure. D. metabolic alkalosis secondary to retention of hydrogen ions
A A client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.
A client receiving hemodialysis treatment arrives at the hospital with a blood pressure of 200/100, a heart rate of 110, and a respiratory rate of 36. Oxygen saturation on room air is 89%. He complains of shortness of breath, and +2 pedal edema is noted. His last hemodialysis treatment was yesterday. Which of the following interventions should be done first? A. Administer oxygen B. Elevate the foot of the bed C. Restrict the client's fluids D. Prepare the client for hemodialysis
A Airway and oxygenation are always the first priority. Because the client is complaining of shortness of breath and his oxygen saturation is only 89%, the nurse needs to try to increase his levels by administering oxygen. The client is in pulmonary edema from fluid overload and will need to be dialyzed and have his fluids restricted, but the first interventions should be aimed at the immediate treatment of hypoxia. The foot of the bed may be elevated to reduce edema, but this isn't the priority.
A patient with ESRD has an arteriovenous fistula in the left arm for hemodialysis. Which intervention do you include in his plan of care? A. Apply pressure to the needle site upon discontinuing hemodialysis B. Keep the head of the bed elevated 45 degrees C. Place the left arm on an arm board for at least 30 minutes D. Keep the left arm dry
A Apply pressure when discontinuing hemodialysis and after removing the venipuncture needle until all the bleeding has stopped. Bleeding may continue for 10 minutes in some patients.
A male client develops acute renal failure (ARF) after receiving I.V. therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 ml, Nurse Billy suspects that the client is at risk for: A. cardiac arrhythmia B. paresthesia C. dehydration D. pruritus
A As urine output decreases, the serum potassium level rises; if it rises sufficiently, hyperkalemia may occur, possibly triggering a cardiac arrhythmia. Hyperkalemia doesn't cause paresthesia (sensations of numbness and tingling). Dehydration doesn't occur during this oliguric phase of ARF, although typically it does arise during the diuretic phase. In a client with ARF, pruritus results from increased phosphates and isn't associated with hyperkalemia.
You have a paraplegic patient with renal calculi. Which factor contributes to the development of calculi? A. Increased calcium loss from the bones B. Decreased kidney function C. Decreased calcium intake D. High fluid intake
A Bones lose calcium when a patient can no longer bear weight. The calcium lost from bones form calculi, a concentration of mineral salts also known as a stone, in the renal system.
Which of the following is the most significant sign of peritoneal infection? A. Cloudy dialysate fluid B. Swelling in the legs C. Poor drainage of the dialysate fluid D. Redness at the catheter insertion site
A Cloudy drainage indicates bacterial activity in the peritoneum. Other signs and symptoms of infection are fever, hyperactive bowel sounds, and abdominal pain. Swollen legs may be indicative of congestive heart failure. Poor drainage of dialysate fluid is probably the result of a kinked catheter. Redness at the insertion site indicates local infection, not peritonitis. However, a local infection that is left untreated can progress to the peritoneum.
The nurse assesses the client who has chronic renal failure and notes the following: crackles in the lung bases, elevated blood pressure, and weight gain of 2 pounds in one day. Based on these data, which of the following nursing diagnoses is appropriate? A. Excess fluid volume related to the kidney's inability to maintain fluid balance B. Increased cardiac output related to fluid overload C. Ineffective tissue perfusion related to interrupted arterial blood flow D. Ineffective therapeutic Regimen Management related to lack of knowledge about therapy
A Crackles in the lungs, weight gain, and elevated blood pressure are indicators of excess fluid volume, a common complication in chronic renal failure. The client's fluid status should be monitored carefully for imbalances on an ongoing basis.
A patient who received a kidney transplant returns for a follow-up visit to the outpatient clinic and reports a lump in her breast. Transplant recipients are: A. At increased risk for cancer due to immunosuppression caused by cyclosporine (Neoral) B. Consumed with fear after the life-threatening experience of having a transplant C. At increased risk for tumors because of the kidney transplant D. At decreased risk for cancer, so the lump is most likely benign
A Cyclosporine suppresses the immune response to prevent rejection of the transplanted kidney. The use of cyclosporine places the patient at risk for tumors.
Which sign indicated the second phase of acute renal failure? A. Daily doubling of urine output (4 to 5 L/day) B. Urine output less than 400 ml/day C. Urine output less than 100 ml/day D. Stabilization of renal function
A Daily doubling of the urine output indicates that the nephrons are healing. This means the patient is passing into the second phase (dieresis) of acute renal failure.
What is the appropriate infusion time for the dialysate in your 38 y.o. patient with chronic renal failure? A. 15 minutes B. 30 minutes C. 1 hour D. 2 to 3 hours
A Dialysate should be infused quickly. The dialysate should be infused over 15 minutes or less when performing peritoneal dialysis. The fluid exchange takes place over a period ranging from 30 minutes to several hours.
You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining? A. Check for kinks in the outflow tubing B. Raise the drainage bag above the level of the abdomen C. Place the patient in a reverse Trendelenburg position D. Ask the patient to cough
A Tubing problems are a common cause of outflow difficulties, check the tubing for kinks and ensure that all clamps are open. Other measures include having the patient change positions (moving side to side or sitting up), applying gentle pressure over the abdomen, or having a bowel movement.
A female client with acute renal failure is undergoing dialysis for the first time. The nurse in charge monitors the client closely for dialysis equilibrium syndrome, a complication that is most common during the first few dialysis sessions. Typically, dialysis equilibrium syndrome causes: A. confusion, headache, and seizures B. acute bone pain and confusion C. weakness, tingling, and cardiac arrhythmias D. hypotension, tachycardia, and tachypnea
A Dialysis equilibrium syndrome causes confusion, a decreasing level of consciousness, headache, and seizures. These findings, which may last several days, probably result from a relative excess of interstitial or intracellular solutes caused by rapid solute removal from the blood. The resultant organ swelling interferes with normal physiologic functions. To prevent this syndrome, many dialysis centers keep first-time sessions short and use a reduced blood flow rate. Acute bone pain and confusion are associated with aluminum intoxication, another potential complication of dialysis. Weakness, tingling, and cardiac arrhythmias suggest hyperkalemia, which is associated with renal failure. Hypotension, tachycardia, and tachypnea signal hemorrhage, another dialysis complication.
After the first hemodialysis treatment, your patient develops a headache, hypertension, restlessness, mental confusion, nausea, and vomiting. Which condition is indicated? A. Disequilibrium syndrome B. Respiratory distress C. Hypervolemia D. Peritonitis
A Disequilibrium occurs when excess solutes are cleared from the blood more rapidly than they can diffuse from the body's cells into the vascular system.
The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of a headache and nausea and is extremely restless. Which of the following is the most appropriate nursing action? A. Notify the physician B. Monitor the client C. Elevate the head of the bed D. Medicate the client for nausea
A Disequilibrium syndrome may be due to the rapid decrease in BUN levels during dialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs of disequilibrium syndrome and appropriate treatments with anticonvulsant medications and barbituates may be necessary to prevent a life-threatening situation. The physician must be notified.
Which criterion is required before a patient can be considered for continuous peritoneal dialysis? A. The patient must be hemodynamically stable B. The vascular access must have healed C. The patient must be in a home setting D. Hemodialysis must have failed
A Hemodynamic stability must be established before continuous peritoneal dialysis can be started.
The client with chronic renal failure tells the nurse he takes magnesium hydroxide (milk of magnesia) at home for constipation. The nurse suggests that the client switch to psyllium hydrophilic mucilloid (Metamucil) because: A. MOM can cause magnesium toxicity B. MOM is too harsh on the bowel C. Metamucil is more palatable D. MOM is high in sodium
A Magnesium is normally excreted by the kidneys. When the kidneys fail, magnesium can accumulate and cause severe neurologic problems. MOM is harsher than Metamucil, but magnesium toxicity is a more serious problem. A client may find both MOM and Metamucil unpalatable. MOM is not high in sodium.
Which drug is indicated for pain related to acute renal calculi? A. Narcotic analgesics B. Nonsteroidal anti-inflammatory drugs (NSAIDS) C. Muscle relaxants D. Salicylates
A Narcotic analgesics are usually needed to relieve the severe pain of renal calculi. Muscle relaxants are typically used to treat skeletal muscle spasms. NSAIDS and salicylates are used for their anti-inflammatory and antipyretic properties and to treat less severe pain.
Dialysis allows for the exchange of particles across a semipermeable membrane by which of the following actions? A. Osmosis and diffusion B. Passage of fluid toward a solution with a lower solute concentration C. Allowing the passage of blood cells and protein molecules through it D. Passage of solute particles toward a solution with a higher concentration
A Osmosis allows for the removal of fluid from the blood by allowing it to pass through the semipermeable membrane to an area of high concentrate (dialysate), and diffusion allows for passage of particles (electrolytes, urea, and creatinine) from an area of higher concentration to an area of lower concentration. Fluid passes to an area with a higher solute concentration. The pores of a semipermeable membrane are small, thus preventing the flow of blood cells and protein molecules through it.
A client is admitted to the hospital and has a diagnosis of early stage chronic renal failure. Which of the following would the nurse expect to note on assessment of the client? A. Polyuria B. Polydipsia C. Oliguria D. Anuria
A Polyuria occurs early in chronic renal failure and if untreated can cause severe dehydration. Polyuria progresses to anuria, and the client loses all normal functions of the kidney. Oliguria and anuria are not early signs, and polydipsia is unrelated to chronic renal failure.
You're developing a care plan with the nursing diagnosis risk for infection for your patient that received a kidney transplant. A goal for this patient is to: A. Remain afebrile and have negative cultures B. Resume normal fluid intake within 2 to 3 days C. Resume the patient's normal job within 2 to 3 weeks D. Try to discontinue cyclosporine (Neoral) as quickly as possible
A The immunosuppressive activity of cyclosporine places the patient at risk for infection, and steroids can mask the signs of infection. The patient may not be able to resume normal fluid intake or return to work for an extended period of time and the patient may need cyclosporine therapy for life.
The dialysis solution is warmed before use in peritoneal dialysis primarily to: A. Encourage the removal of serum urea B. Force potassium back into the cells C. Add extra warmth into the body D. Promote abdominal muscle relaxation
A The main reason for warming the peritoneal dialysis solution is that the warm solution helps dilate peritoneal vessels, which increases urea clearance. Warmed dialyzing solution also contributes to client comfort by preventing chilly sensations, but this is a secondary reason for warming the solution. The warmed solution does not force potassium into the cells or promote abdominal muscle relaxation.
A male client is scheduled for a renal clearance test. Nurse Sheldon should explain that this test is done to assess the kidneys' ability to remove a substance from the plasma in: A. 1 minute B. 30 minutes C. 1 hour D. 24 hours
A The renal clearance test determines the kidneys' ability to remove a substance from the plasma in 1 minute. It doesn't measure the kidneys' ability to remove a substance over a longer period.
What change indicates recovery in a patient with nephrotic syndrome? A. Disappearance of protein from the urine B. Decrease in blood pressure to normal C. Increase in serum lipid levels D. Gain in body weight
A With nephrotic syndrome, the glomerular basement membrane of the kidney becomes more porous, leading to loss of protein in the urine. As the patient recovers, less protein is found in the urine.
A client with chronic renal failure has a protein restriction in the diet. The nurse should include in a teaching plan to avoid which of the following sources of incomplete protein in the diet? a) nuts b) eggs c) milk d) fish
A - The client whose diet has a protein restriction should be careful to ensure that the proteins eaten are complete proteins with the highest biological value. Foods such as meat, fish, milk, and eggs are complete proteins, which are optimal for the client with chronic renal failure.
A client has just been diagnosed with acute renal failure. The laboratory calls the nurse to report a serum potassium level of 6.1 mEq/L on the client. The nurse takes which immediate action? a) calls the physician b) checks the sodium level c) encourages an extra 500ml of fluid intake d) teaches the client about foods low in potassium
A - The client with hyperkalemia is at risk of developing cardiac dysrhythmias and resultant cardiac arrest. Because of this, the physician must be notified at once so that the client may receive definitive treatment. Fluid intake would not be increased because it would contribute to fluid overload and wouldn't effectively lower the serum potassium level. Dietary teaching may be necessary at some point, but this action is not the priority. The nurse might also check the result of a serum sodium level, but this is not a priority action of the nurse.
A 32-year-old flight attendant is undergoing diagnostics due to a significant drop in renal output. The physician has scheduled an angiography and you are in the midst of completing client education about the procedure. The client asks what the angiography will reveal. What is your response, as her nurse? a. Renal circulation b. Urine production c. Kidney function d. Kidney structure
A A renal angiogram (renal arteriogram) provides details of the arterial supply to the kidneys, specifically the location and number of renal arteries (multiple vessels to the kidney are not unusual) and the patency of each renal artery.
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment?
A Determine the level at which the patient has intact sensation. B Assess the level at which the patient has retained mobility. C Check blood pressure and pulse for signs of spinal shock. D Monitor respiratory effort and oxygen saturation level.
A patient with an obstruction of the renal artery causing renal ischemia exhibits HTN. One factor that may contribute to HTN: a. increase renin release b. increased ADH secretion c. decreased aldosterone secretion d. increased synthesis and release of prostaglandins
A Renin is released in resonse to decreased B/P, renal ischemia, eosinophil chemotactic factor (ECF) depletion, and other factors affecting blood suppy to the kidney. It is they catalyst of the renin-angiotensin-aldosterone system, which raises B/P when stimulated. ADH is secreted by the posterior pituitary in response to serum hyperosmolality and low blood volume. Aldosterone is secreted within the renin-angiotensin II, and kidney prostaglandins lower B/P by causing vasodilation.
A client has just been admitted to the intensive care unit (ICU) after having a left lower lobectomy with a video-assisted thoracoscopic surgery (VATS). Which of these requests will the nurse implement first? A. Adjust oxygen flow rate to keep O2 saturation at 93% to 100%. B. Administer 2 g of cephalothin (Keflin) IV now. C. Give morphine sulfate 4 to 6 mg IV for pain. D. Infuse 1 unit of packed red blood cells (PRBCs) over the next 2 hours.
A) Airway and oxygenation are main priorities in the immediate postoperative period. The client will likely be intubated, so coordination of care with Respiratory Therapy will be important.
A client with asthma has pneumonia, is reporting increased shortness of breath, and has inspiratory and expiratory wheezes. All of these medications are prescribed. Which medication should the nurse administer first? A. Albuterol (Proventil) 2 inhalations B. Fluticasone (Flovent) 2 inhalations C. Ipratropium (Atrovent) 2 inhalations D. Salmeterol (Serevent) 2 inhalations
A) Albuterol is a beta2 agonist that acts rapidly as a bronchodilator.
Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention? A. Client with acute allergic reaction B. Client with dyspnea on exertion C. Client with lung cancer with cough D. Client with sinus infection with fever
A) An acute allergic reaction can lead to immediate respiratory distress. This is an emergent situation that requires the immediate attention of the nurse.
The RN has received report about all of these clients. Which client needs the most immediate assessment? A. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry B. Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes C. Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago D. Client with pleural effusion who has decreased breath sounds at the right base
A) An oxygen saturation level less than 91% indicates hypoxemia and requires immediate assessment and intervention to improve blood and tissue oxygenation.
A client is prescribed an antitussive medication. What is the most important thing for the nurse to teach the client? A. "This medication may cause drowsiness and dizziness." B. "Watch out for diarrhea and abdominal cramping." C. "This may cause tremors and anxiety." D. "Headache and hypertension are common side effects."
A) Antitussive medications also affect the CNS, thus causing drowsiness and dizziness.
A client is admitted to the medical floor with a new diagnosis of lung cancer. How can the nurse assist the client initially with the anxiety associated with the new diagnosis? A. Encourage client to ask questions and verbalize concerns. B. Leave client alone to deal with his own feelings. C. Medicate client with diazepam (Valium) for anxiety every 8 hours. D. Provide journals about cancer treatment.
A) Anxiety causes increased oxygen consumption. Oxygen availability is limited in lung cancer. The availability of the nurse to answer questions and listen to the client's concerns will decrease anxiety.
After surgery for placement of a chest tube, the client reports burning in the chest. What does the nurse do first? A. Assesses airway, breathing, and circulation B. Calls for the Rapid Response Team C. Checks the patency of the chest tubes D. Listens for breath sounds
A) Assessing the ABCs is the priority to determine possible causes of burning in the client's chest.
All of these clients are being cared for on the intensive care step-down unit. Which client should the charge nurse assign to an RN who has floated from the pediatric unit? A. Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask. B. Client with chronic pleural effusions who is scheduled for a paracentesis in the next hour. C. Client with emphysema who requires instruction about correct use of oxygen at home. D. Client with lung cancer who has just been transferred from the ICU after having a left lower lobectomy the previous day.
A) Because asthma is a common pediatric diagnosis, the pediatric nurse would be familiar with the assessment and care needed for a client with this diagnosis.
Which action should the nurse take first for the client who is admitted to the emergency department (ED) with a panic attack and whose blood gases indicate respiratory alkalosis? A. Encourage the client to take slow breaths. B. Obtain a prescription for a fluid and electrolyte infusion. C. Administer oxygen using ED standard orders. D. Place an emergency cart close to the client's room.
A) Because respiratory alkalosis is caused by hyperventilation, the nurse's first action should be to assist the client in slowing the respiratory rate.
The nursing assistant has taken vital signs of the ventilated postoperative client who has had radical neck surgery. What does the nurse tell the assistant to be especially vigilant for? A. Bright red blood rapidly seeping through the dressing B. Decreased level of consciousness C. Effective pain management D. Heart rate and blood pressure trending up over several hours
A) Bright red blood indicates a rupture in the carotid artery and requires immediate attention.
The client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response? A. "Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." B. "Because your body isn't getting enough oxygen. Not getting enough oxygen is what stimulates you to wake up and breathe." C. "Because your tongue may be blocking your throat, and you wake up because you are choking." D. "It isn't really that often. It just feels that way."
A) During sleep, the muscles relax and the tongue and neck structures are displaced with the tongue falling back, causing an upper airway obstruction. This obstruction leads to apnea and increased levels of carbon dioxide. Respiratory acidosis stimulates neural centers in the brain, and the client awakens, takes a deep breath, and goes back to sleep. After the client returns to sleep, the cycle may be repeated as often as every 5 minutes as the airway is re-obstructed.
While the nurse is talking with the postoperative thoracic surgery client, the client coughs and the chest tube collection water seal chamber bubbles. What does the nurse do? A. Calmly continues talking B. Checks the tube for blocks or kinks C. Immediately calls the physician D. Strips the chest tube
A) Gentle bubbling in the water seal chamber is normal during the client's exhalation, forceful cough, or position changes.
Which intervention for the client in the intensive care unit will decrease the incidence of "ICU psychosis"? A. Decreasing nighttime disruptions B. Keeping the lights on to promote orientation C. Administering sedation D. Providing television or radio for stimulation
A) ICU psychosis can be minimized not only by encouraging sleep, but also by keeping to a regular routine.
The client has received packing for a posterior nosebleed. In reviewing the client's orders, which order does the nurse question? A. "Give ibuprofen 800 mg every 8 hours as needed for pain." B. "Encourage bed rest, with the head of the bed elevated 45 to 60 degrees." C. "Provide humidified air." D. "Suction at the bedside."
A) Ibuprofen is contraindicated in a client with a nosebleed because NSAIDs inhibit clotting.
In the older adult client, which respiratory change does not require further assessment by the nurse? A. Increased anteroposterior (AP) diameter B. Increased respiratory rate C. Shortness of breath D. Sputum production
A) Increased AP diameter is normal with aging.
The nurse is caring for a critically ill client with septic shock. The serum lactate level is 6.2. For which of the following acid-base disturbances should the nurse assess? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
A) Increased lactate levels are associated with hypoxia and metabolic acidosis secondary to anaerobic metabolism.
Your client is the football coach at a local high school. His chief problem is hoarseness. Which of the following is the best recommendation the nurse can make regarding his care? A. Complete voice rest B. Drinking hot tea with lemon C. Prescription for antibiotics D. Whispering instead of using full voice
A) Nodules on the vocal cords from overuse may cause hoarseness. Complete voice rest is the best recommendation.
Which client has a higher risk for developing a pulmonary embolism (PE)? A. 25-year-old woman who frequently flies to different countries B. 67-year-old man who works on a farm C. 45-year-old man admitted for a heart attack D. 23-year-old woman with a bleeding disorder
A) People who engage in prolonged and frequent air travel are at higher risk for PE.
All of these nursing actions are included in the plan of care for a client who has just been extubated. Which action should the RN delegate to unlicensed assistive personnel (UAP)? A. Keep the head of the bed elevated. B. Teach about incentive spirometer use. C. Monitor vital signs every 5 minutes. D. Adjust the nasal oxygen flow rate.
A) Positioning of clients is included in UAP education and the job description and can be delegated to UAP.
The nurse is caring for a group of clients. Which clients should be monitored closely for respiratory failure? Select all that apply. A. Client with a brainstem tumor B. Client with acute pancreatitis C. Client with a T3 spinal cord injury D. Client using patient-controlled analgesia E. Client experiencing cocaine intoxication
A) Pressure on the brainstem may depress respiratory function. B) Acute pancreatitis is a risk factor for acute respiratory distress syndrome (ARDS); abdominal distention also ensues, which can limit respiratory excursion. D) Opiates, which can depress the brainstem, present risk factors for respiratory failure.
When suctioning a client with an endotracheal tube for the first time, what does the nurse do first? A. Briefly explains the procedure B. Preoxygenates the client C. Sets up a sterile field D. Suctions for 10 to 15 seconds
A) Suctioning can be anxiety producing for the client. Explaining the procedure can decrease the client's anxiety level and, in doing so, can decrease oxygen consumption. Each time the client is suctioned, reinforcement of how the procedure is completed can decrease anxiety.
The nurse is assessing a client with possible pulmonary embolism. For which symptoms should the nurse assess? Select all that apply. A. Dizziness and fainting B. Shortness of breath (SOB) worsening over the last 2 weeks C. Inspiratory chest pain D. Productive cough E. Pink, frothy sputum
A) Syncope, hypotension, and fainting are symptoms associated with pulmonary embolism. C) Sharp, pleuritic, inspiratory chest pain is characteristic of PE.
The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply. A. Excess Fluid Volume B. Imbalanced Nutrition; Less than Body Requirements C. Activity Intolerance D. Impaired Gas Exchange E. Pain
A,B,C Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure
The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client's outflow is less than the inflow. Select actions that the nurse should take. A. Place the client in good body alignment B. Check the level of the drainage bag C. Contact the physician D. Check the peritoneal dialysis system for kinks E. Reposition the client to his or her side
A,B,D,E If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.
3. A patient is undergoing diagnostic testing for suspected systemic lupus erythematosus (SLE). Which assessment findings may help confirm the diagnosis? Select all that apply. A. Malar butterfly rash B. Photosensitivity C. Painful sores in the oral cavity D. Decreased white blood cell count E. Multiple swollen and painful joints
A,B,E
1. patient presents with malaise, a fever, and joint pain. If a systemic lupus erythematosus (SLE) diagnosis is being considered, which additional assessments should the nurse perform? Select all that apply.] A. Take patient blood pressure B. Assess for enlarged thyroid gland C. Ensure that urine is collected for a urinalysis D. Palpate the abdomen and listen to bowel sounds E. Ask the patient simple questions and note patient response
A,C,E
A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.
A. Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
The nurse is admitting a person who has had a sudden loss of eyesight. On assessing this client, the nurse finds that the client is disoriented. The nurse will most suspect which of the following about the disorientation? [Hint] A. Disorientation is a normal reaction to sudden blindness. B. Compensatory behavior to eyesight loss includes disorientation. C. Client will compensate for the eyesight loss within 48 hours. D. Disorientation is a symptom of the cause of sudden eyesight loss.
A. Disorientation is a normal reaction to sudden blindness. Sudden loss of eyesight can result in disorientation. With gradual loss of sensory function, individuals often develop behaviors to compensate for loss, whereas with sudden loss, the compensatory behavior often takes days or weeks to develop.
the client is diagnosed with a bee sting allergy is being discharged from the ED. which priority discharge instruction should be taught to the client? a. demonstrate how to use the EpiPen, an adrenergic agonist b. teach the client to never go outdoors in the spring and summer c. have the client buy diphenhydramine over the counter to use when stung d. discuss wearing a medic alert bracelet when going outside
A. Epi education
The nurse teaches the client recovering from acute kidney disease to avoid which of these? A. Nonsteroidal anti-inflammatory drugs B. Angiotensin-converting enzyme (ACE) inhibitors C. Opiates D. Acetaminophen
A. Non-steroidal anti-inflammatory drugs (NSAIDs): Nonsteroidal anti-inflammatory drugs may be nephrotoxic. ACE inhibitors are used for treatment of hypertension and to protect the kidneys, especially in the diabetic client, from progression of kidney disease. Opiates may be used by clients with kidney disease if severe pain is present; however, excretion may be delayed. Acetaminophen is hepatotoxic, not generally nephrotoxic.
A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm? A Normal sinus rhythm B Sinus tachycardia C Sinus bradycardia D Sinus arrhythmia
A. Normal sinus rhythm Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.04 to 0.10 seconds. P and QRS waves are consistent in shape.
A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.
A. The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.
A. The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
A client, who lives alone in the country, was admitted to the hospital two days ago. The client begins to show signs of confusion and disorientation. You would most suspect which of the following problems as most contributing to the confusion and disorientation? [Hint] A.changes in quantity and quality of sensory stimuli B. changes in the amount or type of medication C. excessive worry about a variety of things D. a mental condition that has previously gone undetected
A. changes in quantity and quality of sensory stimuli
After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled
A. tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.
What stimulated the release of Antidiuretic Hormone?
ADH stimulated by: 🔺⬇️ ECF volume 🔺⬆️ Osmolarity of blood 🔺⬇️ In central venous pressure. 🔺Stress 🔺Pain 🔺Surgery 🔺Anesthesia.
Who should manage a patient on a vent after a week (chronic/stable)?
An LPN
Who should take care of an SCI after a week (chronic/stable)?
An LPN
Who should take care of patients with airborne, droplet, or contact precautions?
An LPN
Who should ambulate a one day P/O patient?
An LPN or an NA
Who should change sheets, get water for, enemas, stool spec/I&O for stable patients?
An NA
Who should feed a patient with a chronic CVA?
An NA
Who should feed a person with chronic parkinson's?
An NA
Who should transport a patient to an area within the hospital?
An NA
Who should ambulate a newly admitted post-op/acutely ill patient?
An RN
Who should ambulate a stable medical & surgical patient?
An RN
Who should do an assessment on a new admit and new P/O patient?
An RN
Who should establish a patient's initial plan of care?
An RN
Who should evaluate an initial post op patient's pain?
An RN
Who should feed a new trach patient?
An RN
Who should feed a patient with an acute CVA?
An RN
Who should take care of an SCI patient during their first week (acute)?
An RN
Who should teach self injections, dressing changes, or diets (except DM and CRF)?
An RN
The nurse is caring for a group of critically ill clients. Which client has the greatest risk for developing acute respiratory distress syndrome (ARDS)? A. A client with diabetic ketoacidosis (DKA) B. A client with atrial fibrillation C. A client with aspiration pneumonia D. A client with acute renal failure
C) Aspiration of acidic gastric contents is a risk for ARDS.
Your patient becomes restless and tells you she has a headache and feels nauseous during hemodialysis. Which complication do you suspect? A. Infection B. Disequilibrium syndrome C. Air embolus D. Acute hemolysis
B Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and other solutes from the blood. This can lead to cerebral edema and increased intracranial pressure (ICP). Signs and symptoms include headache, nausea, restlessness, vomiting, confusion, twitching, and seizures.
Which client is most likely to exhibit the following ABG results: pH, 7.30; PaCO2, 49; HCO , 26; PO2, 76? A. Client with kidney failure B. Client taking hydromorphone (Dilaudid) C. Client with anxiety disorder D. Client with hyperkalemia
B) Hydromorphone (Dilaudid), a narcotic analgesic, can cause respiratory depression, hypoventilation, and respiratory acidosis, as this blood gas reading demonstrates.
8. Which of the following patients are at risk for developing Cushing's Syndrome? A. A patient with a tumor on the pituitary gland, which is causing too much ACTH to be secreted. B. A patient taking glucocorticoids for several weeks. C. A patient with a tuberculosis infection. D. A patient who is post-opt from an adrenalectomy.
B
A 19-year-old student comes to the student health center at the end of the semester complaining that, My heart is skipping beats. An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next? a. Start supplemental O2 at 2 to 3 L/min via nasal cannula. b. Ask the patient about current stress level and caffeine use. c. Ask the patient about any history of coronary artery disease. d. Have the patient taken to the hospital emergency department (ED).
B
A client with glomerulonephritis is at risk of developing acute renal failure. The nurse monitors the client for which sign of this complication? a) bradycardia b) hypertension c) decreased cardiac output d) decreased central venous pressure
B
A member of the clinic housekeeping staff experiences a needlestick by a contaminated needle. Which of the following should be administered by the healthcare provider to provide the patient with passive immunity against the hepatitis B virus? A. Antiviral medication B Hepatitis B immune globulin (HBIG) C Hepatitis B vaccine D Interferon
B Eliminate the options that interfere with viral replication, since this is not a characteristic of passive immunity. Vaccines stimulate the immune system to make antibodies. HBIG contains IgG antibodies specific to hepatitis B, providing passive immunity (which means that a person is given antibodies to a disease instead of producing them through his or her own immune system). HBIG is used for prophylaxis after exposure to the hepatitis B virus.
A patient returns from surgery with an indwelling urinary catheter in place and empty. Six hours later, the volume is 120ml. The drainage system has no obstructions. Which intervention has priority? A. Give a 500 ml bolus of isotonic saline B. Evaluate the patient's circulation and vital signs C. Flush the urinary catheter with sterile water or saline D. Place the patient in the shock position, and notify the surgeon
B A total UO of 120ml is too low. Assess the patient's circulation and hemodynamic stability for signs of hypovolemia. A fluid bolus may be required, but only after further nursing assessment and a doctor's order.
Which cause of hypertension is the most common in acute renal failure? A. Pulmonary edema B. Hypervolemia C. Hypovolemia D. Anemia
B Acute renal failure causes hypervolemia as a result of overexpansion of extracellular fluid and plasma volume with the hypersecretion of renin. Therefore, hypervolemia causes hypertension.
The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the dwell time for the dialysis at the prescribed time because of the risk of: A. Infection B. Hyperglycemia C. Fluid overload D. Disequilibrium syndrome
B An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis.
Which of the following nursing interventions should be included in the client's care plan during dialysis therapy? A. Limit the client's visitors B. Monitor the client's blood pressure C. Pad the side rails of the bed D. Keep the client NPO
B Because hypotension is a complication of peritoneal dialysis, the nurse records intake and output, monitors VS, and observes the client's behavior. The nurse also encourages visiting and other diversional activities. A client on PD does not need to be placed in bed with padded side rails or kept NPO.
During the client's dialysis, the nurse observes that the solution draining from the abdomen is consistently blood tinged. The client has a permanent peritoneal catheter in place. Which interpretation of this observation would be correct? A. Bleeding is expected with a permanent peritoneal catheter B. Bleeding indicates abdominal blood vessel damage C. Bleeding can indicate kidney damage D. Bleeding is caused by too-rapid infusion of the dialysate
B Because the client has a permanent catheter in place, blood tinged drainage should not occur. Persistent blood tinged drainage could indicate damage to the abdominal vessels, and the physician should be notified. The bleeding is originating in the peritoneal cavity, not the kidneys. Too rapid infusion of the dialysate can cause pain.
The client with chronic renal failure has an indwelling catheter for peritoneal dialysis in the abdomen. The client spills water on the catheter dressing while bathing. The nurse should immediately: A. Reinforce the dressing B. Change the dressing C. Flush the peritoneal dialysis catheter D. Scrub the catheter with povidone-iodine
B Clients with peritoneal dialysis catheters are at high risk for infection. A dressing that is wet is a conduit for bacteria for bacteria to reach the catheter insertion site. The nurse assures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnecting of peritoneal dialysis.
A 30 y.o. female patient is undergoing hemodialysis with an internal arteriovenous fistula in place. What do you do to prevent complications associated with this device? A. Insert I.V. lines above the fistula. B. Avoid taking blood pressures in the arm with the fistula C. Palpate pulses above the fistula D. Report a bruit or thrill over the fistula to the doctor
B Don't take blood pressure readings in the arm with the fistula because the compression could damage the fistula. IV lines shouldn't be inserted in the arm used for hemodialysis. Palpate pulses below the fistula. Lack of bruit or thrill should be reported to the doctor.
What is the priority nursing diagnosis with your patient diagnosed with end-stage renal disease? A. Activity intolerance B. Fluid volume excess C. Knowledge deficit D. Pain
B Fluid volume excess because the kidneys aren't removing fluid and wastes. The other diagnoses may apply, but they don't take priority.
The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious. The nurse suspects air embolism. The nurse should: A. Continue the dialysis at a slower rate after checking the lines for air B. Discontinue dialysis and notify the physician C. Monitor vital signs every 15 minutes for the next hour D. Bolus the client with 500 ml of normal saline to break up the air embolism
B If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the physician, and administer oxygen as needed.
The most common early sign of kidney disease is: A. Sodium retention B. Elevated BUN level C. Development of metabolic acidosis D. Inability to dilute or concentrate urine
B Increased BUN is usually an early indicator of decreased renal function.
You expect a patient in the oliguric phase of renal failure to have a 24 hour urine output less than: A. 200ml B. 400ml C. 800ml D. 1000ml
B Oliguria is defined as urine output of less than 400ml/24hours.
The client with chronic renal failure is at risk of developing dementia related to excessive absorption of aluminum. The nurse teaches that this is the reason that the client is being prescribed which of the following phosphate binding agents? A. Alu-cap (aluminum hydroxide) B. Tums (calcium carbonate) C. Amphojel (aluminum hydroxide) D. Basaljel (aluminum hydroxide)
B Phosphate binding agents that contain aluminum include Alu-caps, Basaljel, and Amphojel. These products are made from aluminum hydroxide. Tums are made from calcium carbonate and also bind phosphorus. Tums are prescribed to avoid the occurrence of dementia related to high intake of aluminum. Phosphate binding agents are needed by the client in renal failure because the kidneys cannot eliminate phosphorus.
The hemodialysis client with a left arm fistula is at risk for steal syndrome. The nurse assesses this client for which of the following clinical manifestations? A. Warmth, redness, and pain in the left hand B. Pallor, diminished pulse, and pain in the left hand. C. Edema and reddish discoloration of the left arm D. Aching pain, pallor, and edema in the left arm
B Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and a diminished pulse distal to the fistula. The client also complains of pain distal to the fistula, which is due to tissue ischemia. Warmth, redness, and pain more likely would characterize a problem with infection.
The nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse determines that the client best understands the information given if the client states to record the daily: A. Pulse and respiratory rate B. Intake, output, and weight C. BUN and creatinine levels D. Activity log
B The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording intake and output and measuring weight daily. Ideally, the hemodialysis client should not gain more than 0.5 kg of weight per day.
A client with chronic renal failure has asked to be evaluated for a home continuous ambulatory peritoneal dialysis (CAPD) program. The nurse should explain that the major advantage of this approach is that it: A. Is relatively low in cost B. Allows the client to be more independent C. Is faster and more efficient than standard peritoneal dialysis D. Has fewer potential complications than standard peritoneal dialysis
B The major benefit of CAPD is that it frees the client from daily dependence on dialysis centers, home health care personnel, and machines for life-sustaining treatment. The independence is a valuable outcome for some people. CAPD is costly and must be done daily. Side effects and complications are similar to those of standard peritoneal dialysis.
The nurse is preparing to care for a client receiving peritoneal dialysis. Which of the following would be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis? A. Monitor the clients level of consciousness B. Maintain strict aseptic technique C. Add heparin to the dialysate solution D. Change the catheter site dressing daily
B The major complication of peritoneal dialysis is peritonitis. Strict aseptic technique is required in caring for the client receiving this treatment. Although option 4 may assist in preventing infection, this option relates to an external site.
A nurse is assessing the patency of an arteriovenous fistula in the left arm of a client who is receiving hemodialysis for the treatment of chronic renal failure. Which finding indicates that the fistula is patent? A. Absence of bruit on auscultation of the fistula B. Palpation of a thrill over the fistula C. Presence of a radial pulse in the left wrist D. Capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand
B The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula. Although the presence of a radial pulse in the left wrist and capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess fistula patency.
A patient with diabetes mellitus and renal failure begins hemodialysis. Which diet is best on days between dialysis treatments? A. Low-protein diet with unlimited amounts of water B. Low-protein diet with a prescribed amount of water C. No protein in the diet and use of a salt substitute D. No restrictions
B The patient should follow a low-protein diet with a prescribed amount of water. The patient requires some protein to meet metabolic needs. Salt substitutes shouldn't be used without a doctor's order because it may contain potassium, which could make the patient hyperkalemic. Fluid and protein restrictions are needed.
A client is diagnosed with chronic renal failure and told she must start hemodialysis. Client teaching would include which of the following instructions? A. Follow a high potassium diet B. Strictly follow the hemodialysis schedule C. There will be a few changes in your lifestyle D. Use alcohol on the skin and clean it due to integumentary changes
B To prevent life-threatening complications, the client must follow the dialysis schedule. Alcohol would further dry the client's skin more than it already is. The client should follow a low-potassium diet because potassium levels increase in chronic renal failure. The client should know hemodialysis is time-consuming and will definitely cause a change in current lifestyle.
Your patient is complaining of muscle cramps while undergoing hemodialysis. Which intervention is effective in relieving muscle cramps? A. Increase the rate of dialysis B. Infuse normal saline solution C. Administer a 5% dextrose solution D. Encourage active ROM exercises
B Treatment includes administering normal saline or hypertonic normal saline solution because muscle cramps can occur when the sodium and water are removed to quickly during dialysis. Reducing the rate of dialysis, not increasing it, may alleviate muscle cramps.
In planning teaching strategies for the client with chronic renal failure, the nurse must keep in mind the neurologic impact of uremia. Which teaching strategy would be most appropriate? A. Providing all needed teaching in one extended session B. Validating frequently the client's understanding of the material C. Conducting a one-on-one session with the client D. Using videotapes to reinforce the material as needed
B Uremia can cause decreased alertness, so the nurse needs to validate the client's comprehension frequently. Because the client's ability to concentrate is limited, short lesions are most effective. If family members are present at the sessions, they can reinforce the material. Written materials that the client can review are superior to videotapes, because the clients may not be able to maintain alertness during the viewing of the videotape.
A nurse is caring for a client who is receiving immunosuppressant therapy including corticosteroids following a renal transplant. The nurse would plan to carefully monitor which laboratory result for this client? a) serum albumin b) blood glucose c) magnesium d) potassium
B - Corticosteroid therapy can result in glucose intolerance, leading to elevated blood glucose levels. The nurse monitors these levels to detect this side effect of therapy. With successful transplant, the client's serum electrolyte levels should be better regulated, although corticosteroids could also cause sodium retention.
A client with chronic renal failure has completed a hemodialysis treatment. The nurse measures which parameters at the completion of the hemodialysis procedure to monitor for hemodynamic stability and to determine effectiveness of fluid extraction? a) vital signs and blood urea nitrogen (BUN) b) vital signs and weight c) sodium and potassium levels d) BUN and creatinine levels
B - Following dialysis, the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared with the client's "dry weight" to determine effectiveness of fluid extraction. Laboratory studies are done as per protocol, but are not necessarily done after the hemodialysis treatment has been ended.
The nurse is administering epoetin alfa (Epogen) to a client with chronic renal failure. The nurse monitors the client for which adverse effect of this therapy? a) anemia b) hypertension c) iron intoxication d) bleeding tendencies
B - The client taking epoetin alfa is at risk of hypertension and seizure activity as the most serious adverse effects of therapy. This medication is used to treat anemia. The medication does not cause iron intoxication. Bleeding tendencies is not an adverse effect of this medication.
A client who has been diagnosed with chronic renal failure has been told that hemodialysis will be required. The client becomes angry and withdrawn, and states, "I'll never be the same now." The nurse formulates which of the following nursing diagnoses for this client? a) disturbed thought processes b) disturbed body image c) anxiety d) noncompliance
B - The client with any renal disorder, such as renal failure, may become angry and depressed because of the permanence of the alteration. Because of the physical change and the change in lifestyle that may be required to manage a severe renal condition, the client may experience Disturbed body image. Options A, C, and D are unrelated to the client's statement.
A client with chronic renal failure has received dietary counseling about potassium restriction in the diet. The nurse determines that the client has learned the information correctly if the client states to do which of the following for preparation of vegetables? a) eat only fresh vegetables b) boil them and discard the water c) use salt substitute on them liberally d) buy frozen vegetables whenever possible
B - The potassium content of vegetables can be reduced by boiling them and discarding the cooking water. Options 1 and 4 are incorrect. Clients with renal failure should avoid the use of salt substitutes altogether, because they tend to be high in potassium content.
A client undergoing hemodialysis becomes hypotensive. The nurse immediately prepares to take which action? a) administer 1000 ml 5% dextrose in water b) administer a 250 ml normal saline bolus c) increase the blood flow into the dialyzer d) lower the client's legs and feet
B - To treat hypotension during hemodialysis, a normal saline bolus of up to 500 mL may be given. The client's feet and legs are raised to enhance cardiac return. Albumin may be given as per protocol to increase colloid oncotic pressure. The blood flow rate into the dialyzer may be decreased. All of these measures should improve the circulating volume and blood pressure. Five percent dextrose in water is not prescribed because it is less likely to improve the circulating volume and blood pressure.
An adult with renal insufficiency has been placed on a fluid restriction of 1200 mL per day. The nurse discusses the fluid restriction with the dietitian and then plans to allow the client to have how many milliliters of fluid from 7:00 AM to 3:00 PM? a) 400 b) 600 c) 800 d) 1000
B - When a client is on a fluid restriction, the nurse informs the dietary department and discusses the allotment of fluid per shift with the dietitian. When calculating how to distribute a fluid restriction, the nurse usually allows half of the daily allotment (600 mL) during the day shift, when the client eats two meals and takes most medications. Another two-fifths (480 mL) is allotted to the evening shift, with the balance (120 mL) allowed during the nighttime.
A nurse is caring for a client undergoing peritoneal dialysis. The nurse checks the client and notes that the drainage from the outflow catheter is cloudy. The nurse should take which action? a) stop the peritoneal dialysis b) obtain a culture and sensitivity of the drainage c) institute hemodialysis temporarily d) add antibiotics to the next several dialysis bags
B - When the drainage becomes cloudy, peritonitis is suspected. A culture and sensitivity is obtained, and broad-spectrum antibiotics are added to the dialysis solution, pending culture and sensitivity results. The dialysis solution may also be heparinized to prevent catheter occlusion. Some clients must switch to hemodialysis if peritonitis is severe or recurring, but the nurse does not make this decision. The peritoneal dialysis is not stopped.
A female client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, nurse Sarah knows that the client is most likely to experience: A. hematuria B. weight loss C. increased urine output D. increased blood pressure
B Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss. Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine. Hemodialysis doesn't increase urine output because it doesn't correct the loss of kidney function, which severely decreases urine production in this disorder. By removing fluids, hemodialysis decreases rather than increases the blood pressure.
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first? A Administer the ordered acetaminophen (Tylenol). B Check the Foley tubing for kinks or obstruction. C Adjust the temperature in the patient's room. D Notify the physician about the change in status.
B Check the Foley tubing for kinks or obstruction.
A nurse, when caring for a client, notes that the specific gravity of the client's urine is low. What could have lead to the low specific gravity of urine? a. Repeated diarrhea b. Excess fluid intake c. Frequent vomiting d. Urine retention
B Excess fluid intake results in low specific gravity of urine. Excessive fluid intake will result in formation of dilute urine. When the urine is diluted, it results in low specific gravity of urine. Frequent vomiting, repeated diarrhea, and urine retention will result in high specific gravity of urine.
The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia? a. BP 146/88 b. Respirations 28 shallow c. Weight gain of 10 pounds in 6 months d. Pink complexion
B increased O2 demand
The client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure? A. "I hope I can learn esophageal speech." B. "I really will miss the taste of my favorite food." C. "I won't be able to breathe through my nose anymore." D. "It is hard to believe that I will never hear my own voice again."
B) A laryngectomy does not involve the taste buds, so the client will still be able to taste foods. However, laryngectomies do affect the sense of smell, and this has an effect on taste.
The nurse is planning care for the non-English-speaking client who is on complete voice rest. What alternative method of communication does the nurse implement? A. Alphabet board B. Picture board C. Translator at the bedside D. Word board
B) A picture board overcomes language barriers and can be used to communicate with clients who do not speak English as well as their family members if a translator or a translation phone is not readily available.
The health care provider orders ipratropium bromide (Atrovent), albuterol (Proventil), and beclomethasone (Vanceril) inhalers for a client. What is the nurse's best action? a. Question the order; three inhalers should not be given at one time. b. Administer the albuterol first, wait 5 minutes, and administer ipratropium bromide, followed by beclomethasone several minutes later. c. Administer each inhaler at 30-minute intervals. d. Administer beclomethasone first, wait 2 minutes, and administer ipratropium bromide, followed by the albuterol several minutes later.
B) Administering the bronchodilator albuterol (Proventil) first allows the other drugs to reach deeper into the lungs as the bronchioles dilate. Anticholinergics such as ipratropium bromide (Atrovent) also help bronchodilate, but to a lesser extent. Corticosteroids such as beclomethasone (Vanceril) do not dilate and are therefore given last.
Which statement by the client with chronic obstructive pulmonary disease (COPD) indicates the need for additional follow-up instruction? A. "I don't need to use my oxygen all the time." B. "I don't need to get the flu shot." C. "I need to eat more protein." D. "It is normal to feel more tired than I use to."
B) An annual influenza vaccine (flu shot) is important for all clients with COPD. At the same time, a pneumonia vaccine could be offered since pneumonia is one of the most common complications of COPD.
The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation? A. Oropharyngeal airway B. Bi-level positive airway pressure (BiPAP) C. Non-rebreathing mask with 100% oxygen D. Positive end-expiratory pressure (PEEP)
B) Bi-level positive-pressure ventilation is a noninvasive method that may provide short-term ventilation without intubation.
Which of these assessment findings will be of greatest concern when the nurse is assessing a client with emphysema? A. Barrel-shaped chest B. Bronchial breath sounds heard at the bases C. Hyperresonance to percussion of the chest D. Ribs lying horizontal
B) Bronchial breath sounds are not normally heard in the periphery and may indicate increased lung density, as in a tumor or an infective process such as pneumonia.
The client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? A. Teach the client to avoid using dental floss. B. Monitor the platelet count daily. C. Ensure adequate staffing for the unit. D. Notify radiology of an impending scan.
B) Daily platelet counts are a safety priority in assessing for thrombocytopenia. Heparin-induced thrombocytopenia is a possible side effect.
When caring for a client with pulmonary embolism, which blood gas result does the nurse anticipate early in the course of the disease? A. pH 7.24, PCO2 55, HCO 26, PO2 56 B. pH 7.46, PCO2 30, HCO 26, PO2 68 C. pH 7.35, PCO2 45, HCO 24, PO2 80 D. pH 7.47, PCO2 35, HCO 30, PO2 75
B) Hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (Paco2) and high pH. No compensation is present as the HCO3 is normal, and hypoxemia is present, consistent with PE.
A client who has fallen off a roof arrives in the emergency department with possible head, neck, and chest trauma. All of these physician requests are received. Which action will the nurse take first? A. Give oxygen to keep O2 saturation greater than 93%. B. Immobilize the neck with a cervical collar. C. Infuse normal saline by large-bore IV catheter. D. Obtain CT scan of head, neck, and chest.
B) If the cervical spine has not already been stabilized by EMS (emergency medical services), this is the nurse's top priority. The neck should be held in place manually until a properly fitted cervical collar can be applied. Innervation of the diaphragm is between cervical spine levels 3 and 5.
The standard laryngectomy plan of care for a client admitted with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery? A. Educate the client about ways to avoid aspiration when swallowing after the surgery. B. Establish a means for communication during the immediate postoperative period, such as a Magic Slate or an alphabet board. C. Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease social isolation after surgery. D. Teach the client and significant others about how to suction and do wound care of the stoma.
B) In the immediate postoperative period, relieving pain and anxiety is going to be a major priority. Because the client will be unable to communicate verbally, establishing a way to communicate before the surgery will help by having a plan in place.
A client complains of worsening nasal congestion despite the use of oxymetazoline (Afrin) nasal spray every 2 hours. What is the nurse's best response? A. "Oxymetazoline is not an effective nasal decongestant." B. "Overuse of nasal decongestants results in rebound congestion." C. "Oxymetazoline should be administered every hour for severe congestion." D. "You are probably displaying an idiosyncratic reaction to oxymetazoline."
B) Oxymetazoline (Afrin) is an effective nasal decongestant, but overuse results in worsening or "rebound" congestion. It should not be used more than every 4 hours. To avoid future rebound congestion with nasal sprays, it is recommended that they be used for no more than 3 to 5 days.
The ventilated client in the intensive care unit begins to pick at the bedcovers. Which action should the nurse take next? A. Increase the sedation, B. Assess for adequate oxygenation, C. Explain to the client that he has a tube in his throat to help him breathe, D. Request that the family leave to decrease the client's agitation,
B) Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia.
The nurse is teaching the client who has been newly diagnosed with cancer. For which side effect specific to radiation does the nurse teach prevention techniques? A. Hair loss B. Increased risk for sunburn C. Loss of appetite D. Pain at site of treatment
B) Skin in the path of radiation is more sensitive to sun damage; therefore clients must avoid direct skin exposure to the sun during treatment and for at least 1 year after radiation is completed.
A client has been diagnosed with asthma. Which statement below indicates that he correctly understands how to use an inhaler with a spacer correctly? A. "I don't have to wait between the two puffs if I use a spacer." B. "If the spacer makes a whistling sound, I am breathing in too rapidly." C. "I should rinse my mouth and then swallow the water to get all of the medicine." D. "Shake the inhaler only if you want to see whether it is empty."
B) Slow and deep breaths ensure that the medication is reaching deeply into the lungs. The whistling noise serves as a reminder to the client of which technique needs to be used.
The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure (PEEP). Which findings would cause the nurse to suspect a left-sided tension pneumothorax? A. Chest caves in on inspiration and "puffs out" on expiration. B. Trachea is deviated to the right side and cyanosis is present. C. The left lung field is dull to percussion with crackles present on auscultation. D. Client has bloody sputum and wheezes.
B) Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, JVD (jugular venous distention), cyanosis, and hyperresonance to percussion over the affected area.
Where does gas exchange occur? A. Acinus B. Alveolus C. Bronchus D. Carina
B) The alveolus is the structural unit of the lung where gas exchange occurs.
In assessing the client's respiratory status, blood gas test results reveal pH of 7.50, PaO2 of 99, PaCO2 of 29, and HCO of 22. What action does the nurse need to take first? A. Call the physician. B. Encourage the client to slow his breathing rate. C. Nothing. These results are within the normal range. D. Provide oxygen support.
B) The arterial blood gases (ABGs) indicate respiratory alkalosis, which is commonly caused by hyperventilation. Encouraging the client to slow down his breathing rate may help him return to normal breathing and may correct this abnormality.
The client tells the nurse that she has a bad cold, is coughing, and feels like she has "stuff" in her lungs. What should the nurse do? A. Administer dextromethorphan. B. Administer guaifenesin. C. Encourage the client to drink fluids hourly. D. Administer fluticasone (Flonase).
B) The client needs an expectorant. This medication will help the client cough the "stuff" out of her lungs. Dextromethorphan and fluticasone will not help the client expectorate. There is no information about the client's fluid intake, so hourly fluids may be too much.
Which client needs immediate attention by the RN? A. 40-year-old who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing B. 54-year-old who is mechanically ventilated and has tracheal deviation C. 57-year-old who was recently extubated and is reporting a sore throat D. 60-year-old who is receiving O2 by facemask and whose respiratory rate is 24
B) This client is showing signs of a tension pneumothorax that could lead to decreased cardiac output and shock if not addressed promptly.
Which of these clients would be appropriate to assign to the new nurse working on the unit? A. A client with diabetic ketoacidosis and change in mental status who has a pH of 7.18 B. A client with emphysema and cellulitis with a PaCO2 level of 58 mm Hg C. A client with reactive airway disease, wheezing, and a PaO2 level of 62 mm Hg D. A client with a small bowel obstruction and vomiting with a bicarbonate level of 40 mEq/L
B) This finding, although abnormal, is anticipated for a client with chronic obstructive pulmonary disease (COPD) and is stable for a new graduate.
The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first? A. Assess the puncture site for drainage. B. Implement NPO (nothing by mouth) status. C. Monitor for signs of anaphylaxis. D. Perform aggressive chest physiotherapy
B) Until the client has a gag reflex and is fully alert, he should be maintained on NPO status to prevent aspiration.
A client is prescribed ipratropium and cromolyn sodium. What will the nurse teach the client? a. "Do not take these medications within 4 hours of each other." b. "Take the ipratropium at least 5 minutes before the cromolyn." c. "Administer both medications together in a metered-dose inhaler." d. "Take the ipratropium only in the mornings."
B) When using an anticholinergic in conjunction with an inhaled glucocorticoid or cromolyn, the ipratropium should be used 5 minutes before the steroid. This causes the bronchioles to dilate so the steroid or cromolyn can get deeper into the lungs.
Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.
B. Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke, but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
Which of the following interventions would most help reduce olfactory stimuli for a client who is hospitalized with a draining wound and is sensory overloaded? [Hint] A. Use strong disinfectants to clean the wound. B. Place liquid deodorant on a gauze near the clean, covered wound. C. Spray strong floral room deodorizer in room to mask wound odor. D. Use strong disinfectant on everything possible in room.
B. Place liquid deodorant on a gauze near the clean, covered wound.
Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
B. To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.
Your assigned first day post-operative client, who has a new colostomy, seems to worry a lot and has symptoms of sensory overload. Which of the following client goals, if met, would most contribute to reducing sensory overload for this client? [Hint] A. Will not sleep or nap during the day. B. Will report pain at 4 or less on a 10-point scale. C. Will attend classes on colostomy care. D. Will look at colostomy during colostomy care.
B. Will report pain at 4 or less on a 10-point scale. People who have sensory overload may appear fatigued. They cannot internalize new information and experience cognitive overload as a result of everything that is happening to them. Such factors as pain, lack of sleep, and worry can also contribute to sensory overload.
A clinic nurse is reviewing the laboratory results of an adult client seen in the health care clinic. The nurse determines that the blood urea nitrogen (BUN) level is normal if which of the following is noted on the laboratory results? a) 35 mg/dL b) 29 mg/dL c) 15 mg/dL d) 3 mg/dL
C The normal BUN ranges from 5 to 25 mg/dL. Options A and B reflect elevated values, which may indicate renal abnormalities or dehydration. Option D reflects a lower than normal value, which may not be clinically significant.
A patient is diagnosed with an infection caused by the hepatitis A virus. Which statement, if made by the patient, would indicate the patient needs further teaching about the infection? A "I will wash raw fruits and vegetables thoroughly before I eat them." B"Before I take any over-the-counter medicines I should call the clinic." C"I might get liver cancer someday because I have this infection." D"It's important for me to remember to wash my hands after I use the bathroom."
C Hepatitis A virus is more common in areas that lack adequate sanitation or have poor hygiene practices. Infection with hepatitis A may be caused by eating contaminated foods such as fruits, vegetables, or shellfish. Many over-the-counter medications contain acetaminophen. Hepatitis A does not lead to chronic liver problems.
When caring for a patient diagnosed with viral hepatitis, the healthcare provider experiences a needlestick with a contaminated needle. Which of the following actions should the healthcare provider do first? A. Make an appointment with the infection control department B. Put the needle in a biohazard bag for testing C Wash the area thoroughly with soap and water D Report to the emergency department
C The healthcare provider will follow the facility-specific protocol for when a needlestick occurs. The initial action is aimed at reducing the possibility of infection. The puncture site and skin should be washed thoroughly with soap and water. Then the healthcare provider will follow the next steps in the facility protocol.
Aluminum hydroxide gel (Amphojel) is prescribed for the client with chronic renal failure to take at home. What is the purpose of giving this drug to a client with chronic renal failure? A. To relieve the pain of gastric hyperacidity B. To prevent Curling's stress ulcers C. To bind phosphorus in the intestine D. To reverse metabolic acidosis
C A client in renal failure develops hyperphosphatemia that causes a corresponding excretion of the body's calcium stores, leading to renal osteodystrophy. To decrease this loss, aluminum hydroxide gel is prescribed to bind phosphates in the intestine and facilitate their excretion. Gastric hyperacidity is not necessarily a problem associated with chronic renal failure. Antacids will not prevent Curling's stress ulcers and do not affect metabolic acidosis.
A male client in the short-procedure unit is recovering from renal angiography in which a femoral puncture site was useD. When providing postprocedure care, the nurse should: A. keep the client's knee on the affected side bent for 6 hours. B. apply pressure to the puncture site for 30 minutes. C. check the client's pedal pulses frequently. D. remove the dressing on the puncture site after vital signs stabilize
C After renal angiography involving a femoral puncture site, the nurse should check the client's pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client's knee bent is unnecessary. By the time the client returns to the short-procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse shouldn't remove this dressing for several hours — and only if instructed to do so.
The nurse teaches the client with chronic renal failure when to take the aluminum hydroxide gel. Which of the following statements would indicate that the client understands the teaching? A. "I'll take it every 4 hours around the clock." B. "I'll take it between meals and at bedtime." C. "I'll take it when I have a sour stomach." D. "I'll take it with meals and bedtime snacks
C Aluminum hydroxide gel is administered to bind the phosphates in ingested foods and must be given with or immediately after meals and snacks. There is no need for the client to take it on a 24-hour schedule. It is not administered to treat hyperacidity in clients with CRF and therefore is not prescribed between meals.
The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: A. Just before dialysis B. During dialysis C. On return from dialysis D. The day after dialysis
C Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. No rationale exists for waiting a full day to resume the medication. This would lead to ineffective control of the blood pressure.
A patient with diabetes has had many renal calculi over the past 20 years and now has chronic renal failure. Which substance must be reduced in this patient's diet? A. Carbohydrates B. Fats C. Protein D. Vitamin C
C Because of damage to the nephrons, the kidney can't excrete all the metabolic wastes of protein, so this patient's protein intake must be restricted. A higher intake of carbs, fats, and vitamin supplements is needed to ensure the growth and maintenance of the patient's tissues.
The nurse is assisting a client on a low-potassium diet to select food items from the menu. Which of the following food items, if selected by the client, would indicate an understanding of this dietary restriction? A. Cantaloupe B. Spinach C. Lima beans D. Strawberries
C Cantaloupe (1/4 small), spinach (1/2 cooked) and strawberries (1 ¼ cups) are high potassium foods and average 7 mEq per serving. Lima beans (1/3 c) averages 3 mEq per serving.
What is the primary disadvantage of using peritoneal dialysis for long term management of chronic renal failure? A. The danger of hemorrhage is high B. It cannot correct severe imbalances C. It is a time consuming method of treatment D. The risk of contracting hepatitis is high
C The disadvantages of peritoneal dialysis in long-term management of chronic renal failure is that is requires large blocks of time. The risk of hemorrhage or hepatitis is not high with PD. PD is effective in maintaining a client's fluid and electrolyte balance.
The nurse helps the client with chronic renal failure develop a home diet plan with the goal of helping the client maintain adequate nutritional intake. Which of the following diets would be most appropriate for a client with chronic renal failure? A. High carbohydrate, high protein B. High calcium, high potassium, high protein C. Low protein, low sodium, low potassium D. Low protein, high potassium
C Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.
The client asks whether her diet would change on CAPD. Which of the following would be the nurse's best response? A. "Diet restrictions are more rigid with CAPD because standard peritoneal dialysis is a more effective technique." B. "Diet restrictions are the same for both CAPD and standard peritoneal dialysis." C. "Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because dialysis is constant." D. "Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because CAPD works more quickly."
C Dietary restrictions with CAPD are fewer than those with standard peritoneal dialysis because dialysis is constant, not intermittent. The constant slow diffusion of CAPD helps prevent accumulation of toxins and allows for a more liberal diet. CAPD does not work more quickly, but more consistently. Both types of peritoneal dialysis are effective.
For a male client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important? A. Encouraging coughing and deep breathing B. Promoting carbohydrate intake C. Limiting fluid intake D. Providing pain-relief measures
C During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.
A male client who has been treated for chronic renal failure (CRF) is ready for discharge. Nurse Billy should reinforce which dietary instruction? A. "Be sure to eat meat at every meal." B. "Monitor your fruit intake, and eat plenty of bananas." C. "Increase your carbohydrate intake." D. "Drink plenty of fluids, and use a salt substitute.
C In a client with CRF, unrestricted intake of sodium, protein, potassium, and fluid may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit intake of sodium; meat, which is high in protein; bananas, which are high in potassium; and fluid, because the failing kidneys can't secrete adequate urine. Salt substitutes are high in potassium and should be avoided. Extra carbohydrates are needed to prevent protein catabolism.
Polystyrene sulfonate (Kayexalate) is used in renal failure to: A. Correct acidosis B. Reduce serum phosphate levels C. Exchange potassium for sodium D. Prevent constipation from sorbitol use
C In renal failure, patients become hyperkalemic because they can't excrete potassium in the urine. Polystyrene sulfonate acts to excrete potassium by pulling potassium into the bowels and exchanging it for sodium.
A client newly diagnosed with renal failure is receiving peritoneal dialysis. During the infusion of the dialysate the client complains of abdominal pain. Which action by the nurse is most appropriate? A. Slow the infusion B. Decrease the amount to be infused C. Explain that the pain will subside after the first few exchanges D. Stop the dialysis
C Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment. The infusion amount should not be decreased, and the infusion should not be slowed or stopped.
Which statement correctly distinguishes renal failure from prere.nal failure? A. With prerenal failure, vasoactive substances such as dopamine (Intropin) increase blood pressure B. With prerenal failure, there is less response to such diuretics as furosemide (Lasix) C. With prerenal failure, an IV isotonic saline infusion increases urine output D. With prerenal failure, hemodialysis reduces the BUN level
C Prerenal failure is caused by such conditions as hypovolemia that impairs kidney perfusion; giving isotonic fluids improves urine output. Vasoactive substances can increase blood pressure in both conditions.
A patient is experiencing which type of incontinence if she experiences leaking urine when she coughs, sneezes, or lifts heavy objects? A. Overflow B. Reflex C. Stress D. Urge
C Stress incontinence is an involuntary loss of a small amount of urine due to sudden increased intra-abdominal pressure, such as with coughing or sneezing.
You suspect kidney transplant rejection when the patient shows which symptoms? A. Pain in the incision, general malaise, and hypotension B. Pain in the incision, general malaise, and depression C. Fever, weight gain, and diminished urine output D. Diminished urine output and hypotension
C Symptoms of rejection include fever, rapid weight gain, hypertension, pain over the graft site, peripheral edema, and diminished urine output.
The client with acute renal failure has a serum potassium level of 5.8 mEq/L. The nurse would plan which of the following as a priority action? A. Allow an extra 500 ml of fluid intake to dilute the electrolyte concentration B. Encourage increased vegetables in the diet C. Place the client on a cardiac monitor D. Check the sodium level
C The client with hyperkalemia is at risk for developing cardiac dysrhythmias and cardiac arrest. Because of this the client should be placed on a cardiac monitor. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Vegetables are a natural source of potassium in the diet, and their use would not be increased. The nurse may also assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action at this time.
The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action should the nurse take first? A. Check the ventilator alarm settings. B. Assess the set tidal volume. C. Listen to the client's breath sounds. D. Call the respiratory therapist
C) A typical reason for the high pressure alarm to sound is the need for suctioning with tension pneumothorax.
A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the dwell clamp is opened to allow the dialysate to drain. The nurse notes that the drainage has stopped and only 500 ml has drained; the amount the dialysate instilled was 1,500 ml. Which of the following interventions would be done first? A. Change the client's position B. Call the physician C. Check the catheter for kinks or obstruction D. Clamp the catheter and instill more dialysate at the next exchange time
C The first intervention should be to check for kinks and obstructions because that could be preventing drainage. After checking for kinks, have the client change position to promote drainage. Don't give the next scheduled exchange until the dialysate is drained because abdominal distention will occur, unless the output is within parameters set by the physician. If unable to get more output despite checking for kinks and changing the client's position, the nurse should then call the physician to determine the proper intervention.
Your patient returns from the operating room after abdominal aortic aneurysm repair. Which symptom is a sign of acute renal failure? A. Anuria B. Diarrhea C. Oliguria D. Vomiting
C Urine output less than 50ml in 24 hours signifies oliguria, an early sign of renal failure. Anuria is uncommon except in obstructive renal disorders.
A client is undergoing hemodialysis and receives heparin during the dialysis procedure. The nurse monitors the results of which of the following laboratory tests during the dialysis procedure? a) thrombin time b) bleeding time c) partial thromboplastin time (PTT) d) prothrombin time (PT)
C - Heparin is used as an anticoagulant during hemodialysis. The hemodialysis nurse monitors the extent of anticoagulation by measuring the PTT, which measures heparin effect. The PT is measured to monitor the effect of warfarin (Coumadin) therapy. Thrombin and bleeding times are not used to measure the effect of heparin therapy, although they are useful in the diagnosis of other clotting abnormalities.
A client is being discharged to home while recovering from acute renal failure (ARF). The client indicates an understanding of the therapeutic dietary regimen if the client states the need to eat foods that are lower in: a) fats b) vitamins c) potassium d) carbohydrates
C - Most of the excretion of potassium and the control of potassium balance are normal functions of the kidneys. In the client with renal failure, potassium intake must be restricted as much as possible (30 to 50 mEq/day). The primary mechanism of potassium removal during ARF is dialysis. Options A, B, and D are not normally restricted in the client with ARF unless a secondary health problem warrants the need to do so.
A client undergoing long-term peritoneal dialysis is experiencing a problem with reduced outflow from the dialysis catheter. The nurse assessing the client would inquire whether the client has had a recent problem with: a) vomiting b) diarrhea c) constipation d) flatulence
C - Reduced outflow may be caused by catheter position and adherence to the omentum, infection, or constipation. Constipation may contribute to reduced outflow in part because peristalsis seems to aid in drainage. For this reason, bisacodyl suppositories are sometimes used prophylactically, even without a history of constipation. The other options are unrelated to impaired catheter drainage.
A nurse is caring for a client who has been diagnosed as having a kidney mass. The client asks the nurse the reason for renal biopsy when other tests such as computed tomography (CT) scan and ultrasound are available. In formulating a response, the nurse incorporates the knowledge that renal biopsy : a) helps differentiate between a solid mass and a fluid-filled cyst b) provides an outline of the renal vascular system c) gives specific cytological information about the lesion d) determines if the mass is growing rapidly or slowly
C - Renal biopsy is a definitive test that gives specific information about whether the lesion is benign or malignant. An ultrasound discriminates between a fluid-filled cyst and a solid mass. Renal arteriography outlines the renal vascular system. Although some types of cancer grow more quickly than others, it is not possible to determine this by biopsy.
While reading the product literature regarding ofloxacin (Floxin), the nurse notes that the medication could cause crystalluria. The nurse decides to tell the client taking the medication to do which of the following to decrease the likelihood of this adverse effect? a) avoid beverages that contain salts, such as mineral water b) avoid carbonated soft-drink beverages c) drink at least 1500 to 2000 ml of fluid per day d) drink at least three glasses of milk per day
C - To prevent crystalluria, the client should drink at least 1500 to 2000 mL of fluid per day. Milk interferes with the absorption of the medication and should be avoided. Consumption of carbonated beverages or mineral water is not harmful.
The nurse is reviewing a urinalysis report for a client with acute renal failure and notes that the results are highly positive for proteinuria. The nurse interprets that this client has which type of renal failure? a) prerenal failure b) postrenal failure c) intrinsic renal failure d) atypical renal failure
C - With intrinsic renal failure, there is a fixed specific gravity and the urine tests positive for proteinuria. In prerenal failure, the specific gravity is high, and there is very little or no proteinuria. In postrenal failure, there is a fixed specific gravity and little or no proteinuria. There is no such classification as atypical renal failure.
A client with acute renal failure has an elevated blood urea nitrogen (BUN). The client is experiencing difficulty remembering information due to uremia. The nurse avoids which of the following when communicating with this client? a) giving simple, clear directions b) including the family in discussions related to care c) giving thorough, lengthy explanations of procedures d) explaining treatments using understandable language
C - the client with acute renal failure nay have difficulty remembering information and instructions because of anxiety and the increased level of the BUN. The nurse should avoid giving lengthy explanations about procedures because this information may not be remembered by the client and could increase client anxiety.
Julia Lee, a 57-year-old financial officer, has been exhibiting signs and symptoms which lead her urologist to suspect the adequacy of her urinary function. Beginning with the least invasive tests, which of the following would you expect the physician to prescribe to assess kidney function? Choose all correct options. a. Blood urea nitrogen (BUN) level b. Creatinine clearance c. Angiography d. All options are correct
C Angiography provides the details of the arterial supply to the kidneys, specifically the number and location of renal arteries. Radiography shows the size and position of the kidneys, ureters, and bladder. A CT scan is useful in identifying calculi, congenital abnormalities, obstruction, infections, and polycystic diseases. Cystoscopy is used for providing a visual examination of the internal bladder.
After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates understanding of the nurse's instructions? A. "Asthma drugs help everybody breathe better." B. "I must carry my emergency inhaler only when activity is anticipated." C. "I must have my emergency inhaler with me at all times." D. "Preventive drugs can stop an attack."
C) Because asthma attacks cannot always be predicted, clients with asthma must always carry a rescue inhaler such as a short-acting beta agonist (SABA) like albuterol (Proventil).
What is the most important thing for the nurse to teach the client with a history of diabetes and asthma who has started on albuterol PRN? a. Take Tylenol for headaches when taking albuterol. b. Monitor for orthostatic hypotension every 2 hours when taking albuterol. c. Monitor blood glucose levels every 4 hours when taking albuterol. d. An antianxiety agent may be prescribed to help with nervousness.
C) Beta2 agonists may increase blood glucose levels. Clients with diabetes should monitor serum glucose levels frequently while taking this medication.
A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test will the nurse teach the client about to help confirm the diagnosis? A. Bronchoscopy B. Chest x-ray C. Computed tomography (CT) scan D. Thoracoscopy
C) CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli.
Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse? A. Client with pain on deep inspiration B. Client with pain on palpation C. Client with pain radiating to the shoulder D. Client with pain that is rubbing in nature
C) Chest pain radiating to the shoulder should be assumed to be cardiac in origin until proven otherwise; this requires the immediate attention of the nurse.
In a presentation to middle school students, what does the nurse teach as the major risk factor for lung cancer? A. Alcohol consumption B. Asbestos exposure C. Cigarette smoking D. Smoking marijuana
C) Cigarette smoking is the number one risk factor for lung cancer and COPD.
Which finding in the postoperative client after nasoseptoplasty requires immediate intervention by the nurse? A. Ecchymosis B. Edema C. Excessive swallowing D. Sore throat
C) Excessive swallowing in a client who has undergone a nasoseptoplasty may indicate posterior nasal bleeding and requires immediate attention.
Which is the best instruction for the nurse to include when teaching a client about the use of expectorants? A. Restrict fluids in order to decrease mucus production. B. Take the medication once a day only, at bedtime. C. Increase fluid intake in order to decrease viscosity of secretions. D. Increase fiber and fluid intake to prevent constipation.
C) Expectorant drugs are used to decrease viscosity of secretions and allow them to be more easily expectorated. Increasing fluid intake helps this action.
The nurse is caring for a group of clients with acidosis. The nurse recognizes that Kussmaul respirations are consistent with which situation? A. Client receiving mechanical ventilation B. Use of hydrochlorothiazide C. Aspirin overdose D. Administration of sodium bicarbonate
C) If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises; this is known as Kussmaul respirations. Metabolic acidosis is caused by alcoholic beverages, methyl alcohol, and acetylsalicylic acid (aspirin).
Which nursing intervention is the priority in preparing the client for pulmonary function testing (PFT)? A. Administer bronchodilator medication on call. B. Encourage clear fluid intake 12 hours before the procedure. C. Ensure no smoking 6 hours before the test. D. Provide supplemental oxygen as testing begins.
C) If the client has been smoking, this may alter parts of the PFT (diffusing capacity [DlCO]), yielding inaccurate results.
A client with a history of asthma is short of breath and says, "I feel like I'm having an asthmatic attack." What is the nurse's best action? a. Call a code. b. Ask the client to describe the symptoms. c. Administer a beta2 adrenergic agonist. d. Administer a long-acting glucocorticoid.
C) In an acute asthmatic attack, the short-acting sympathomimetics are the first line of defense.
The nurse has been teaching improved airflow techniques to the client, who has continued to have restrictive breathing problems. Which is the best indicator of success? A. Peak flowmeter readings that are yellow after the third reading B. Productive cough C. SpO2 level of 92% after ambulating 50 feet D. Stable arterial blood gases (ABGs)
C) Maintaining a baseline Spo2 of 92% after ambulating 50 feet is an excellent indicator that the client has achieved better airflow, and that the nurse's teaching has been effective.
The client has asthma that only gets worse during the summer. She tells the nurse she will be taking a medicine every day so she does not get short of breath when she walks to work. About which medicine does the nurse need to educate the client? A. Albuterol (Proventil) inhaler B. Guaifenesin (Organidin) C. Montelukast (Singulair) D. Omalizumab (Xolair)
C) Montelukast is a leukotriene antagonist that works well for asthma that occurs during certain seasons. It is taken on a daily basis as a preventive medication.
The client is 1 day postoperative from a total laryngectomy for cancer. He has indicated to you that he is experiencing pain. Pain management for him is best achieved with which medication? A. IV ketorolac (Toradol) B. IV midazolam (Versed) C. IV morphine sulfate (Morphine) D. Oral acetaminophen (Tylenol)
C) Morphine or other opioids are the best choice for this client in the immediate postoperative period. They can be given both as a bolus dose and continuously by patient-controlled analgesia (PCA). The client's airway and respiratory status must be carefully observed.
The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate? A. Sedation is needed so your loved one does not rip the breathing tube out. B. Suctioning is important to remove organisms from the lower airway. C. Paralysis and sedatives help decrease the demand for oxygen. D. We are encouraging oral and intravenous fluids to keep your loved one hydrated.
C) Paralytics and sedation decrease oxygen demand.
What is the purpose of wearing fluoride gel trays during radiation therapy of the mouth? A. Keep the mouth moist during treatments B. Keep the teeth from turning yellow after treatment C. Prevent radiation scatter when the beam hits metal in the mouth D. Protect the taste buds on the tongue
C) The gel trays help prevent radiation scatter when the beam hits metal in the mouth.
A client is having surgery. He asks his nurse, "When they put that tube in my throat, where does it really go?" What is the name of the opening of the vocal cords? A. Arytenoid cartilage B. Epiglottis C. Glottis D. Palatine tonsils
C) The glottis is the opening of the vocal cords into which the endotracheal tube is passed during intubation for surgery.
The nurse is caring for a client with a theophylline level of 14 mcg/mL. What is the priority nursing intervention? a. Increase the IV drip rate. b. Monitor the client for toxicity. c. Continue to assess the client's oxygenation. d. Stop the IV for an hour then restart at lower rate.
C) The therapeutic theophylline level is 10 to 20 mcg/mL. The nurse should continue interventions and monitor oxygenation.
A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Monitor the blood pressure. b. Send the patient for a computed tomography (CT) scan. c. Check the respiratory rate and effort. d. Assess the Glasgow Coma Scale score.
C. The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).
C. The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.
C. Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
The nurse advises a woman considering pregnancy of the importance of being tested for syphilis and rubella. What is most likely the reason the nurse is offering this advice? [Hint] A. suspicion that a client has high risk of sexual and drug behaviors B. assess factors that mainly cause visual impairments in baby C. assess factors that mainly cause hearing impairments in baby D. the health history assessment findings
C. assess factors that mainly cause hearing impairments in baby. Women who are considering pregnancy should be advised of the importance of testing for syphilis and rubella, which can cause hearing impairments in newborns.
A patient with heart failure is taking Losartan and Spironolactone. The patient is having EKG changes that presents with tall peaked T-waves and flat p-waves. Which of the following lab results confirms these findings? A. Na+ 135 B. BNP 560 C. K+ 8.0 D. K+ 1.5
C. tall t waves = hyperkalemia
The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?a. Roast beef, gelatin salad, green beans, and peach pie b. Chicken salad sandwich, coleslaw, French fries, ice cream c. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie d. Pork chop, creamed potatoes, corn, and coconut cake
C. want foods that are high in iron
A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient's spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the family members that the patient can perform ADLs independently. b. remind the patient about the importance of independence in daily activities. c. recognize that it is important for the patient's family to be involved in the patient's care and support their activities. d. develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and parents.
Correct Answer((s): D Rationale: The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the family that the patient can perform ADLs independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the family members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient.
The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? A) Central cord syndrome B) Spinal shock syndrome C) Anterior cord syndrome D) Brown-Séquard
Correct Answer(s): B About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.
A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet q2-3hr c. Use of the Credé method to empty the bladder d. Catheterization for residual urine after voiding
Correct Answer(s): A Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.
A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where "they know what they are doing." The best response by the nurse to the patient's behavior is to a. ask for the patient's input into the plan for care. b. clarify that abusive behavior will not be tolerated. c. reassure the patient that the anger will pass and rehabilitation will then progress. d. ignore the patient's anger and continue to perform needed assessments and care.
Correct Answer(s): A Rationale: The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Refusal to acknowledge the patient's anger by telling the patient that the anger is just a phase is inappropriate. Continuing to perform needed assessments and care is appropriate, but the nurse should seek the patient's input into what care is needed.
Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? A) Headache and rising blood pressure B) Irregular respirations and shortness of breath C) Decreased level of consciousness or hallucinations D) Abdominal distention and absence of bowel sounds
Correct Answer(s): A Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.
Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia? A) Urinary catheterization B) Administration of benzodiazepines C) Suctioning of the patient's upper airway D) Placement of the patient in the Trendelenburg position
Correct Answer(s): A Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated and suctioning is likely unnecessary.
Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? A) Bradycardia B) Hypertension C) Neurogenic spasticity D) Bounding pedal pulses
Correct Answer(s): A Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.
A patient with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Notify the patient's health care provider. b. Check the blood pressure (BP). c. Give the ordered antiemetic. d. Assess for a fecal impaction.
Correct Answer(s): B Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is causing the symptoms, including hypertension. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.
When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to a. administer oxygen at 7 to 9 L/min with a face mask. b. place the hands on the epigastric area and push upward when the patient coughs. c. encourage the patient to use an incentive spirometer every 2 hours during the day. d. suction the patient's oral and pharyngeal airway.
Correct Answer(s): B Rationale: The nurse has identified that the cough effort is poor, so the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia, and oxygen will not help expel respiratory secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.
A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.
Correct Answer(s): B Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.
The nurse admnisters methylprenisone(Solu-Medrol) as a continous IV fusion to a male patient who has fractures of the cervical vertebrae. Which intervention would prevent or detect adverse effects of the medication? A. record pt baseline weight B. adminster PPI( proton pump inhibitor) C. Check the hear rate for bradycardia D. suction the patient's oropharynx
Correct Answer(s): B the nurse should adminster PPI because they are at high risk for Gi erosion and bleeding. from the steroid.
When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Continuous cardiac monitoring for bradycardia b. Administration of methylprednisolone (Solu-Medrol) infusion c. Assessment of respiratory rate and depth d. Application of pneumatic compression devices to both legs
Correct Answer(s): C Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions are also appropriate but are not as important as assessment of respiratory effort.
The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess a. blood pressure and heart rate. b. respiratory effort and O2 saturation. c. motor and sensory function of the legs. d. bowel sounds and abdominal distension.
Correct Answer(s): C Rationale: The purpose of methylprednisolone administration is to help preserve neurologic function; therefore, the nurse will assess this patient for lower-extremity function. Sympathetic nervous system dysfunction occurs with injuries at or above T6, so monitoring of BP and heart rate will not be useful in determining the effectiveness of the medication. Respiratory and GI function will not be impaired by a T10 injury, so assessments of these systems will not provide information about whether the medication is effective.
In which order will the nurse perform the following actions when caring for a patient with possible cervical spinal cord trauma who is admitted to the emergency department? a. Administer O2 using a non-rebreathing mask. b. Monitor cardiac rhythm and blood pressure. c. Immobilize the patient's head, neck, and spine. d. Transfer the patient to radiology for spinal CT.
Correct Answer(s): C, A, B, D Rationale: The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, continuous monitoring of heart rhythm and BP is indicated. CT scan to determine the extent and level of injury is needed once initial assessment and stabilization is accomplished.
A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. the presence of hyperactive reflex activity below the level of the injury. d. flaccid paralysis and lack of sensation below the level of the injury.
Correct Answer(s): D Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury.
A 26-year-old patient with a C8 spinal cord injury tells the nurse, "My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually." The most appropriate response by the nurse to the patient's comment is to a. advise the patient to talk to his wife to determine how she feels about his sexual function. b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury. c. inform the patient that most patients with upper motor neuron injuries have reflex erections. d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling.
Correct Answer(s): D Rationale: Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be handled by someone with expertise in sexual counseling. Although the patient should discuss these issues with his wife, open communication about this issue may be difficult without the assistance of a counselor. Sildenafil does assist with erectile dysfunction after spinal cord injury, but the patient's sexuality is not determined solely by the ability to have an erection. Reflex erections are common after upper motor neuron injury, but these erections are uncontrolled and cannot be maintained during coitus.
The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? A) Tachycardia B) Hypotension C) Hot, dry skin D) Throbbing headache
Correct Answer(s): D Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A) Risk for impairment of tissue integrity caused by paralysis B) Altered patterns of urinary elimination caused by quadriplegia C) Altered family and individual coping caused by the extent of trauma D) Ineffective airway clearance caused by high cervical spinal cord injury
Correct Answer(s): D Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.
A 70 yr old patient who has a spinal cord injury at C8 resulting in central cord syndrome. Which effect of the patient's most likely to be life threatening after completeing rehabiliation? A. increased bone density loss B. higher tisk for tissue hpoxia C. vasomotor compensation lost D. Weakness of thoracic muscles
Correct Answer(s): D Weakness of thoracic muscle is most likely to cause life-threatening complications because affects patients oxygentation and ventilation.
The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following? a. "Over time, the nerve fibers will regrow new tracts, and you can have bowel movements again." b. "Wearing an undergarment will become more comfortable over time." c "Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." d "It is not going to happen. Your nerve cells are too damaged."
Correct Answer(s: ) C Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact The act of defecation is a spinal reflex involving the parasympathetic nerve fibers. Normally, the external anal sphincter is maintained in a state of tonic contraction. With a spinal cord injury, the client no longer has this nervous system control and is often incontinent.
A female nurse is injured in an automobile accident and suffers acute compresssion of the anterior apinal cord at T8-10 Which nursing rols is a potential source of employment for the patients after completing rehabilitation ? A. Certified nurse practioner B. Community health nursing C. Hospital case mangement D. Inpatient behavioral health
Correct C. Hospital case management(s) the nurse in most likely to have an anterior cord syndrome resulting in the loss of neuromuscular and pain and temp sensation below t8. Pt will have full use of upper extremities , upper back, and resp muscles.thus she will be in a wheel chair.
A 25-yr old male pt who is a professional motorcross racer has anterior spinal cord syndrome at T10. His history includes tobacco use, alcohol abuse, marijuana abuse. What is the nurse's priority during rehabilation? A. Monitor the patient 4 times an hour B. Encourage him to verbalize feeling. C. Prevent urniary tract infection D. Teach about using gastrocolic reflex
Correct answer(s) B The pt is at high risk for depression and self-injury because he is likely to lose function below the umblicus . resulting in loss motor function. In addition he will need to be in a wheelchair, impaired sexual function, and can not use tobacco, alcohol, marijuana abuse for coping.
The nurse is caring for a young child who has been prescribed an inhaler for control of her asthma. The child is having difficulty using the inhaler. What is the nurse's best action? a. Tell the parent to hold the inhaler for the child. b. Ask the health care provider to switch to oral medications. c. Tell the parent that young children should not use inhalers. d. Teach the child to use a spacer.
D) If a child is unable to use the inhaler, the medication will be trapped in the mouth. Using a spacer helps the medication to be deposited to the lungs.
The nurse answers the client's call light and realizes that the client has an upper airway obstruction. What is the nurse's first action? A. Attempts to remove the obstruction B. Calls the Rapid Response Team to intubate immediately C. Calls the Rapid Response Team to perform an emergency cricothyroidotomy D. Determines the cause of obstruction
D) The first step the nurse will take is to determine the cause of the obstruction. After the cause has been determined (e.g., tongue, food, inflammation), the nurse can decide the next course of action.
Which nursing intervention takes priority for a client admitted with severe metabolic acidosis? A. Perform medication reconciliation. B. Assess the client's strength in the extremities. C. Obtain a diet history for the past 3 days. D. Initiate cardiac monitoring.
D) The nurse follows the ABCs and initiates cardiac monitoring to observe for signs of hyperkalemia or cardiac arrest.
The nurse is caring for clients on the pulmonary unit. Which client should not receive epinephrine if ordered? a. The client with a history of emphysema b. The client with a history of type 2 diabetes c. The client who is 16 years old d. The client with atrial fibrillation with a rate of 100
D) The side effects of epinephrine include tachycardia, dysrhythmias, and palpitations. This client should not receive epinephrine.
A client has a history of chronic renal failure and received hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which of the following interventions is included in this client's plan of care? A. Keep the AV fistula site dry B. Keep the AV fistula wrapped in gauze C. Take the blood pressure in the left arm D. Assess the AV fistula for a bruit and thrill
D Assessment of the AV fistula for bruit and thrill is important because, if not present, it indicates a non-functioning fistula. No blood pressures or venipunctures should be taken in the arm with the AV fistula. When not being dialyzed, the AV fistula site may get wet. Immediately after a dialysis treatment, the access site is covered with adhesive bandages.
Your patient with chronic renal failure reports pruritus. Which instruction should you include in this patient's teaching plan? A. Rub the skin vigorously with a towel B. Take frequent baths C. Apply alcohol-based emollients to the skin D. Keep fingernails short and clean
D Calcium-phosphate deposits in the skin may cause pruritus. Scratching leads to excoriation and breaks in the skin that increase the patient's risk of infection. Keeping fingernails short and clean helps reduce the risk of infection.
A female client requires hemodialysis. Which of the following drugs should be withheld before this procedure? A. Phosphate binders B. Insulin C. Antibiotics D. Cardiac glycosides
D Cardiac glycosides such as digoxin should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digitalis toxicity. Phosphate binders and insulin can be administered because they aren't removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis.
What is the best way to check for patency of the arteriovenous fistula for hemodialysis? A. Pinch the fistula and note the speed of filling on release B. Use a needle and syringe to aspirate blood from the fistula C. Check for capillary refill of the nail beds on that extremity D. Palpate the fistula throughout its length to assess for a thrill
D The vibration or thrill felt during palpation ensures that the fistula has the desired turbulent blood flow. Pinching the fistula could cause damage. Aspirating blood is a needless invasive procedure.
Which of the following represents a positive response to administration of erythropoietin (Epogen, Procrit)? A. Hematocrit of 26.7% B. Potassium within normal range C. Free from spontaneous fractures D. Less fatigue
D. Less fatigue: Treatment of anemia with erythropoietin will result in increased (H&H) and decreased shortness of breath (SOB) and fatigue.
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a female client's uremia. Which finding signals a significant problem during this procedure? A. Potassium level of 3.5 mEq/L B. Hematocrit (HCT) of 35% C. Blood glucose level of 200 mg/dl D. White blood cell (WBC) count of 20,000/mm3
D An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.
During your morning assessment of a patient with heart failure, the patient complains of sudden vision changes that include seeing yellowish-green halos around the lights. Which of the following medications do you suspect is causing this issue? A. Lisinopril B. Losartan C. Lasix D. Digoxin
D
A female adult client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? A. Blood urea nitrogen (BUN) level of 22 mg/dl B. Serum creatinine level of 1.2 mg/dl C. Serum creatinine level of 1.2 mg/dl D. Urine output of 400 ml/24 hours
D ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is demonstrated by a urine output of 400 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.
Which intervention do you plan to include with a patient who has renal calculi? A. Maintain bed rest B. Increase dietary purines C. Restrict fluids D. Strain all urine
D All urine should be strained through gauze or a urine strainer to catch stones that are passed. The stones are then analyzed for composition. Ambulation may help the movement of the stone down the urinary tract. Encourage fluid to help flush the stones out.
Which of the following factors causes the nausea associated with renal failure? A. Oliguria B. Gastric ulcers C. Electrolyte imbalances D. Accumulation of waste products
D Although clients with renal failure can develop stress ulcers, the nausea is usually related to the poisons of metabolic wastes that accumulate when the kidneys are unable to eliminate them. The client has electrolyte imbalances and oliguria, but these don't directly cause nausea.
The client with an arteriovenous shunt in place for hemodialysis is at risk for bleeding. The nurse would do which of the following as a priority action to prevent this complication from occurring? A. Check the results of the PT time as they are ordered B. Observe the site once per shift C. Check the shunt for the presence of a bruit and thrill D. Ensure that small clamps are attached to the AV shunt dressing
D An AV shunt is a less common form of access site but carries a risk for bleeding when it is used because two ends of an external cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. If accidental connection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site to use if needed. The shunt site should be assessed at least every four hours.
A male client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should nurse Olivia assess first? A. Blood pressure B. Respirations C. Temperature D. Pulse
D An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also can delay assessing respirations and temperature because these aren't affected by the serum potassium level.
Which of the following clients is at greatest risk for developing acute renal failure? A. A dialysis client who gets influenza B. A teenager who has an appendectomy C. A pregnant woman who has a fractured femur D. A client with diabetes who has a heart catheterization
D Clients with diabetes are prone to renal insufficiency and renal failure. The contrast used for heart catherization must be eliminated by the kidneys, which further stresses them and may produce acute renal failure. A teenager who has an appendectomy and a pregnant woman with a fractured femur isn't at increased risk for renal failure. A dialysis client already has end-stage renal disease and wouldn't develop acute renal failure.
The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for: A. Hypertension, tachycardia, and fever B. Hypotension, bradycardia, and hypothermia C. Restlessness, irritability, and generalized weakness D. Headache, deteriorating level of consciousness, and twitching
D Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, and vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.
A client with chronic renal failure has completed a hemodialysis treatment. The nurse would use which of the following standard indicators to evaluate the client's status after dialysis? A. Potassium level and weight B. BUN and creatinine levels C. VS and BUN D. VS and weight
D Following dialysis, the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared with the client's predialysis weight to determine effectiveness of fluid extraction. Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended.
In a client in renal failure, which assessment finding may indicate hypocalcemia? A. Headache B. Serum calcium level of 5 mEq/L C. Increased blood coagulation D. Diarrhea
D In renal failure, calcium absorption from the intestine declines, leading to increased smooth muscle contractions, causing diarrhea. CNS changes in renal failure rarely include headache. A serum calcium level of 5 mEq/L indicates hypercalcemia. As renal failure progresses, bleeding tendencies increase.
The nurse is reviewing a list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse bases the response knowing that the glucose: A. Prevents excess glucose from being removed from the client B. Decreases risk of peritonitis C. Prevents disequilibrium syndrome D. Increases osmotic pressure to produce ultrafiltration
D Increasing the glucose concentration makes the solution increasingly more hypertonic. The more hypertonic the solution, the greater the osmotic pressure for ultrafiltration and thus the greater amount of fluid removed from the client during an exchange.
Your patient has complaints of severe right-sided flank pain, nausea, vomiting and restlessness. He appears slightly pale and is diaphoretic. Vital signs are BP 140/90 mmHg, Pulse 118 beats/min., respirations 33 breaths/minute, and temperature, 98.0F. Which subjective data supports a diagnosis of renal calculi? A. Pain radiating to the right upper quadrant B. History of mild flu symptoms last week C. Dark-colored coffee-ground emesis D. Dark, scanty urine output
D Patients with renal calculi commonly have blood in the urine caused by the stone's passage through the urinary tract. The urine appears dark, tests positive for blood, and is typically scant.
Your patient had surgery to form an arteriovenous fistula for hemodialysis. Which information is important for providing care for the patient? A. The patient shouldn't feel pain during initiation of dialysis B. The patient feels best immediately after the dialysis treatment C. Using a stethoscope for auscultating the fistula is contraindicated D. Taking a blood pressure reading on the affected arm can cause clotting of the fistula
D Pressure on the fistula or the extremity can decrease blood flow and precipitate clotting, so avoid taking blood pressure on the affected arm.
Which instructions do you include in the teaching care plan for a patient with cystitis receiving phenazopyridine (Pyridium). A. If the urine turns orange-red, call the doctor. B. Take phenazopyridine just before urination to relieve pain. C. Once painful urination is relieved, discontinue prescribed antibiotics. D. After painful urination is relieved, stop taking phenazopyridine
D Pyridium is taken to relieve dysuria because is provides an analgesic and anesthetic effect on the urinary tract mucosa. The patient can stop taking it after the dysuria is relieved. The urine may temporarily turn red or orange due to the dye in the drug. The drug isn't taken before voiding, and is usually taken 3 times a day for 2 days.
The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment the nurse notes that the client's temperature is 100.2. Which of the following is the most appropriate nursing action? A. Encourage fluids B. Notify the physician C. Monitor the site of the shunt for infection D. Continue to monitor vital signs
D The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity purposes.
Frequent PVCs are noted on the cardiac monitor of a patient with end-stage renal disease. The priority intervention is: A. Call the doctor immediately B. Give the patient IV lidocaine (Xylocaine) C. Prepare to defibrillate the patient D. Check the patient's latest potassium level
D The patient with ESRD may develop arrhythmias caused by hypokalemia. Call the doctor after checking the patient's potassium values. Lidocaine may be ordered if the PVCs are frequent and the patient is symptomatic.
A client with chronic renal failure has been on dialysis for 4 years and has been taking aluminum hydroxide (Amphojel tablets) as prescribed as part of the medication regimen. The client develops confusion and dementia, and complains of bone pain. The nurse interprets that this client is at risk for developing: a) advancing uremia b) folic acid defieciency c) phosphate overdose d) aluminum intoxication
D - Aluminum intoxication can occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. Symptoms include mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. This complication is treated with aluminum chelating agents, which make aluminum available to be dialyzed from the body. It is prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum.
A nurse is caring for a client receiving peritoneal dialysis and notes a brownish tinge to the dialysate output. The nurse interprets that this finding could be a result of: a) early infection b) insufficient fluid instillation c) bladder perforation d) bowel perforation
D - Brown-tinged or bloody drainage could indicate perforation of the bowel by the peritoneal dialysis catheter. If noted, this must be reported to the physician immediately. Early signs of infection include cloudy dialysate output or fever and, most likely, abdominal discomfort. Bladder perforation could yield yellow or bloody drainage. Insufficient fluid instillation is an incorrect option. The client would have no signs as a result of insufficient fluid instillation except outflow of smaller amounts of dialysate.
A hemodialysis client has a newly created left arm fistula. The nurse monitors the affected extremity for which signs and symptoms that indicate a complication related to steal syndrome? a) edema and purplish discoloration b) aching pain, pallor, and edema c) warmth, redness, and pain d) pallor, diminished pulse. and pain
D - Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and diminished pulse distal to the fistula and complains of pain distal to the fistula from tissue ischemia. Warmth, redness, and pain would more likely characterize a problem with infection. The patterns described in options A and B are not usually observed because they do not relate to a complication following fistula creation.
A nurse is assessing the renal function of a client. The nurse checks which item as the best indirect indicator of renal status? a) bladder distention b) level of conciousness c) pulse rate d) blood pressure
D - The kidneys normally receive 20% to 25% of the cardiac output, even under conditions of rest. In order for kidney function to be optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequacy of cardiac output. The pulse rate affects the cardiac output, but can be altered by factors unrelated to kidney function. Bladder distention reflects a problem or obstruction that is most often distal to the kidneys. Level of consciousness is an unrelated item.
A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis? a. Perform deep-breathing exercises vigorously. b. Avoid carrying heavy items. c. Auscultate the lungs frequently. d. Wear a mask when performing exchanges
D The nurse should advise the client to wear a mask while performing exchanges. This prevents contamination of the dialysis catheter and tubing, and is usually advised to clients with upper respiratory infection. Auscultation of the lungs will not prevent contamination of the catheter or tubing. The client may also be advised to perform deep-breathing exercises to promote optimal lung expansion, but this will not prevent contamination. Clients with a fistula or graft in the arm should be advised against carrying heavy items.
The nurse is working in an urgent clinic. Which of these four clients needs to be evaluated first by the nurse? A. Client who is short of breath after walking up two flights of stairs B. Client with soreness of the arm after receiving purified protein derivative (PPD) (Mantoux) skin test C. Client with sore throat and fever of 39° C oral D. Client who is speaking in three-word sentences and has SaO2 of 90% by pulse oximetry
D) A client should be able to speak in sentences of more than three words, and Sao2 of 90% indicates hypoxemia that requires intervention on the part of the nurse.
A new client arrives in the medical-surgical unit with a flap. The flap appears dusky in color. What is the nurse's first action? A. Apply a hot pack over the flap site. B. Massage the flap site vigorously. C. Place a tight dressing over the flap. D. Use a Doppler to assess flow to the area.
D) A complete assessment of the area including Doppler activity of major feeding vessels needs to be completed and the surgeon needs to be notified because the client may have to be returned to the operating room immediately.
When caring for a group of clients at risk for respiratory acidosis, the nurse identifies which person as at highest risk? A. An athlete in training B. Pregnant woman with hyperemesis gravidarum C. Person with uncontrolled diabetes D. Client who smokes cigarettes
D) Cigarette smoking worsens gas exchange, leading to disorders that contribute to hypoventilation and respiratory acidosis.
The RN and the nursing assistant are working together to provide care for a group of clients. Which of these nursing activities could the RN delegate to the nursing assistant? A. Auscultate for improvement in breath sounds in a client who has had a right lower lobectomy. B. Document discharge instructions for a client being discharged with new asthma medications. C. Monitor the effectiveness of oxygen therapy for a client admitted with chronic bronchitis. D. Reinforce the use of slow expiration through pursed lips to maximize gas exchange for a client with sarcoidosis.
D) Client education is an RN level skill, but reinforcement of previously taught material can be delegated to unlicensed personnel who are caring for the client.
An RN and an LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which of these actions is best accomplished by the RN? A. Administer the purified protein derivative (PPD) for tuberculosis testing. B. Assess vital signs and the puncture site after thoracentesis. C. Monitor oxygen saturation using pulse oximetry every 4 hours. D. Plan client and family teaching regarding upcoming pulmonary function testing.
D) Developing the teaching plan is the most complex of the skills listed and requires RN education and licensure.
A client's mother asks what is the most important thing she will need to know to care for her son who is having an inner maxillary fixation (IMF) completed as an outpatient. What does the RN tell her? A. "Give him Phenergan (promethazine) by rectum around the clock so he does not vomit." B. "He can only drink milk and eat ice cream until the wires come off." C. "He must brush his teeth every 2 hours." D. "Make sure he always has wire cutters with him."
D) It is extremely important that the client always have wire cutters in the event of emesis, so the wires can be cut to prevent aspiration. Remind the client to contact the surgeon as soon as possible if the wires have been cut, so that fixation can be re-established.
Which statement by the client with a laryngectomy indicates the need for further discharge teaching? A. "I must avoid swimming." B. "I can clean the stoma with soap and water." C. "I can project mucus when I laugh or cough." D. "I can't put anything over my stoma to cover it."
D) Loose clothing or a covering such as a scarf can be used to cover the stoma if the client desires.
Your client has been diagnosed with oral and laryngeal cancer. He completed a course of radiation, and it is 2 days since he underwent a total laryngectomy. The client had been very anxious about his surgery. Which of the following medications would you expect to find on his home medication list? A. Amitriptyline (Elavil) B. Diazepam (Valium) C. Ketorolac (Toradol) D. Lorazepam (Ativan)
D) Lorazepam is a short-acting antianxiety medication that would be the most appropriate choice for this client.
To decrease the risk of acid-base imbalance, what goal must the client with diabetes mellitus strive for? A. Checking blood glucose levels once daily B. Drinking 3 L of fluid per day C. Eating regularly, every 4 to 8 hours D. Maintaining blood glucose level within normal limits
D) Maintaining blood glucose levels within normal limits is the best way to decrease the risk of acid-base imbalance.
The nurse manager at a long-term care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks will be best to delegate to a nursing assistant? A. Administering throat-numbing lozenges B. Assessing the mouth for inflammation and infection C. Teaching about skin care while receiving radiation D. Washing the skin with soap and water
D) Personal hygiene is within the scope of practice of the nursing assistant.
The nurse is caring for a client with hypoxemia and metabolic acidosis. Which of these tasks can be delegated to the nursing assistant who is helping with the client's care? A. Assess the client's respiratory pattern. B. Increase the IV normal saline to 120 mL/hr. C. Titrate O2 to maintain an O2 saturation of 95% to 100%. D. Apply the pulse oximeter for continuous readings.
D) Placing a peripheral pulse oximeter is a standardized nursing skill that is within the scope of practice for unlicensed personnel.
The nurse is instructing a client about the advantages of salmeterol (Serevent) over other beta2 agonists such as albuterol (Proventil). How will the nurse explain to the client the difference in these two medications? a. Salmeterol has a shorter onset of action. b. Salmeterol does not have any side effects. c. Albuterol has a longer onset of action. d. Salmeterol has a longer duration of action.
D) Salmeterol (Serevent) has a longer duration of action, requiring the client to use it only twice a day instead of four times a day with albuterol (Proventil).
The nurse is caring for a client in the clinic who states that he is afraid of taking antihistamines because he is a truck driver. What is the best information for the nurse to give this client? A. "Take the medication only when you are not driving." B. "Take a lower dose than normal when you have to drive." C. "You are correct, you should not take antihistamines." D. "You may be able to safely take a second-generation antihistamine."
D) Second-generation antihistamines are often called nonsedating antihistamines. These may be safer for the client to take, but the client should still monitor for signs of excessive sedation.
The client is a marathon runner who has asthma. Which category of medication is used as a rescue inhaler? A. Corticosteroids B. Long-acting beta agonists C. NSAIDs D. Short-acting beta agonists
D) Short-acting beta agonist medications have a rapid onset and cause bronchodilation. These medications would be excellent for marathon running because some types of asthma may be exercise induced.
Which clinical manifestation in the client with facial trauma is the nurse's first priority? A. Bleeding B. Decreased visual acuity C. Pain D. Stridor
D) Stridor is an indication of a partial airway obstruction and requires immediate attention.
Which clinical manifestation requires immediate action by the nurse for the client with laryngeal trauma? A. Aphonia B. Hemoptysis C. Hoarseness D. Tachypnea
D) Tachypnea is a sign of respiratory distress that may accompany laryngeal trauma. This requires immediate action on the part of the nurse.
An environmental assessment of a factory is conducted, and inhalation exposure with a high level of particulate matter is found. What does the factory nurse do to generate the quickest compliance? A. Encourages proper building ventilation B. Refers workers to a tobacco cessation program C. Suggests that workers find another job D. Teaches workers how to use a mask
D) Teaching everyone to use a mask when working in areas with high levels of particulate matter can reduce individual exposure.
A newly diagnosed client with asthma says that his peak flow meter is reading 82% of his personal best. What does the nurse do? A. Nothing. This is in the green zone. B. Provides the rescue drug and reassesses C. Provides the rescue drug and seeks emergency help D. Repeats the peak flow test
D) The client is newly diagnosed with asthma. This would be an excellent opportunity for the nurse to observe the client using the peak flow meter to ensure that the client is using it properly, so readings are accurate and in the green zone, at least 80% of the client's personal best.
A client is admitted with asthma. How is this disease differentiated from other chronic lung disorders? A. It affects only young people. B. The client has dyspnea. C. The client is coughing. D. The client is symptom free between exacerbations.
D) The client may be completely symptom free between exacerbations.
A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.
D. Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.
Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway
D. Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (Chest x-ray) c. 12-Lead electrocardiogram (ECG) d. Noncontrast computed tomography (CT) scan
D. Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
When caring for a client who receives peritoneal dialysis (PD), which of these findings must the nurse report to the provider immediately? A. Pulse oximetry reading of 95% B. Sinus bradycardia, rate of 58 C. Blood pressure of 148/90 D. Temperature of 101.2 F
D. Temperature of 101.2 F: Peritonitis is the major complication of PD caused by intra-abdominal catheter site contamination; use meticulous aseptic technique when caring for PD equipment.
A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.
D. The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
What should be done for effective infection control?
ID type of precautions required (airborne, droplet, contact, or standard), put infected patients in private rooms or with patient c same organism, airborne in private room with negative pressure (TB), Droplet (mask within 3 feet), contact (gown & gloves), and infected patients can leave room as long as wear same PPE out of room as ppl wear going into the room.
can a UAP... collect a urine specimen for culture and sensitivity from a pt with a foley catheter?
NO (bc its a strike procedure) however a clean catch yes
can a UAP... change bed linens while log rolling a pt from side to side of a pt in skeletal traction?
NO (bc logrolling a pt in traction will require multiple staff members)
can an LPN... assess the skin around an ostomy?
NO (they can monitor the skin for areas of breakdown though)
Glomerulus
Semi-permeable membrane. Amount of blood filtered by glomeruli in a given time = Glomerular filtration rate (GFR). Normal GFR = 125cc/min.
What is important to remember with room assignments?
RISK= Radiation (isolation), Infection/Immunocompromised/Isolation, Safety/Sex, and Know growth and development. If older than 6= must have a same sex roommate and must be both children have the same disease( example: one child has a fractured femur and another child with a fracture or a post-procedure with no infection = best room placement. HOWEVER, there is another 6 years old child but the child has an infection, this would not be an appropriate roomate for the child due to the risk of transmitting the infection.
What patients are NOT a priority?
RUQ (gallbladder) pain, Pain in the(CVA) costovertebral angle= (kidney stones), head trauma, bleeding, pain butt to ankle (sciatica), straining to urinate with bloody urine, menieres disease (these people always dizzy), chronic conditions, COPD, cystic fibrosis, laprascopy c chest or shoulder pain, Paperwork (document wait end of shift), calling doctor, teaching, bleeding, high or low BS, Poop, FXs, obtaining lab studies, and Pain.
Serum Creatinine
Serum creatinine is a better indicator: 0.6-1.5 mg/dl. Inc Creatine is indicative of nephron damage. Elevated CR equals damage to kidney. Significant damage to kidneys must occur, changes are seen at 50% damage.
5. A patient's MRI imaging shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding? A. Vision problems B. Balance impairment C. Language difficulty D. Impaired short-term memory
The answer is B. The cerebellum is important for coordination and balance.
21. A patient has experienced right side brain damage. You note the patient is experiencing neglect syndrome. What nursing intervention will you include in the patient's plan of care? A. Remind the patient to use and touch both sides of the body daily. B. Offer the patient a soft mechanical diet with honey thick liquids. C. Ask direct questions that require one word responses. D. Offer the bedpan and bedside commode every 2 hours
The answer is A. It is important to watch for neglect syndrome. This tends to happen in right side brain damage. The patient ignores the left side of the body in this condition. The nurse needs to remind the patient to use and touch both sides of the body daily and that the patient must make a conscious effort to do so.
20. You're assisting a patient who has right side hemiparesis and dysphagia with eating. It is very important to: A. Keep the head of bed less than 30′. B. Check for pouching of food in the right cheek. C. Prevent aspiration by thinning the liquids. D. Have the patient extend the neck upward away from the chest while eating.
The answer is B. Because the patient has weakness on the right side and dysphagia the nurse should regularly check for pouching of food in the right cheek. Pouching of food in the cheek can lead to aspiration or choking. The HOB should be >30′, liquids thickened per MD order, and the patient should tuck in the chin to the chest while swallowing.
1. A patient is admitted with uncontrolled atrial fibrillation. The patient's medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for? A. Ischemic thrombosis B. Ischemic embolism C. Hemorrhagic D. Ischemic stenosis
The answer is B. If a patient is in uncontrolled a-fib they are at risk for clot formation within the heart chambers. This clot can leave the heart and travel to the brain. Hence, an ischemic embolism type stroke can occur. An ischemic thrombosis type stroke is where a clot forms within the artery wall of the neck or brain.
17. You receive a patient who is suspected of experiencing a stroke from EMS. You conduct a stroke assessment with the NIH Stroke Scale. The patient scores a 40. According to the scale, the result is: A. No stroke symptoms B. Severe stroke symptoms C. Mild stroke symptoms D. Moderate stroke symptoms
The answer is B. Scores on the NIH stroke scale range from 0 to 42, with 0 (no stroke symptoms) and 21-42 (severe stroke symptoms).
2. Which patient below is at most risk for a hemorrhagic stroke? A. A 65 year old male patient with carotid stenosis. B. A 89 year old female with atherosclerosis. C. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago. D. A 55 year old female with atrial flutter.
The answer is C. A hemorrhagic stroke occurs when bleeding in the brain happens due to a break in a blood vessel. Risk factors for a hemorrhagic stroke is uncontrolled hypertension, history of brain aneurysm, old age (due to aging blood vessels.) All the other options are at risk for an ischemic type of stroke.
16. A patient who has hemianopia is at risk for injury. What can you educate the patient to perform regularly to prevent injury? A. Wearing anti-embolism stockings daily B. Consume soft foods and tuck in chin while swallowing C. Scanning the room from side to side frequently D. Muscle training
The answer is C. Hemianopia is limited vision in half of the visual field. The patient needs to scan the room from side to side to prevent injury.
4. A patient who suffered a stroke one month ago is experiencing hearing problems along with issues learning and showing emotion. On the MRI what lobe in the brain do you expect to be affected? A. Frontal lobe B. Occipital lobe C. Parietal lobe D. Temporal
The answer is D. The temporal lobe is responsible for hearing, learning, and feelings/emotions.
8. You're educating a group of nursing students about left side brain damage. Select all the signs and symptoms noted with this type of stroke: A. Aphasia B. Denial about limitations C. Impaired math skills D. Issues with seeing on the right side E. Disoriented F. Depression and anger G. Impulsive H. Agraphia
The answers are A, C, D, F, and H. Patients who have left side brain damage will have aphasia, be AWARE of their limitations, impaired math skills, issues with seeing on the right side, no deficit in memory, depression/anger, cautious, and agraphia. All the other options are found in right side brain injury.
9. During discharge teaching for a patient who experienced a mild stroke, you are providing details on how to eliminate risk factors for experiencing another stroke. Which risk factors below for stroke are modifiable? A. Smoking B. Family history C. Advanced age D. Obesity E. Sedentary lifestyle
The answers are A, D, and E. These risk factors are modifiable in that the patient can attempt to change them to prevent another stroke in the future. The other risk factors are NOT modifiable.
3. You're educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect about this condition: A. TIAs are caused by a temporary decrease in blood flow to the brain. B. TIAs produce signs and symptoms that can last for several weeks to months. C. A TIAs is a warning sign that an impending stroke may occur. D. TIAs don't require medical treatment.
The answers are B and D. Options A and C are CORRECT statements about TIAs. However, option B is wrong because TIAs produce signs and symptoms that can last a few minutes to hours and resolve (NOT several weeks to months). Option D is wrong be TIAs do require medical treatment.
19. Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke? A. A patient with a CT scan that is negative. B. A patient whose blood pressure is 200/110. C. A patient who is showing signs and symptoms of ischemic stroke. D. A patient who received Heparin 24 hours ago.
The answers are B and D. Patients who are experiencing signs and symptoms of a hemorrhagic stroke, who have a BP for >185/110, and has received heparin or any other anticoagulants etc. are NOT a candidate for tPA. tPA is only for an ischemic stroke.
11. You're patient has expressive aphasia. Select all the ways to effectively communicate with this patient? A. Fill in the words for the patient they can't say. B. Don't repeat questions. C. Ask questions that require a simple response. D. Use a communication board. E. Discourage the patient from using words.
The answers are C and D. Patients with expressive aphasia can understand spoken words but can't respond back effectively or at all. Therefore be patient, let them speak, be direct and ask simple questions that require a simple response, and communicate with a dry erase board etc.
For what things should you use massage?
To decrease PAD pain, claudication (pain with walking) and increase circulation= increased O2 and decreased pain, prevent hemorrhage after delivery, decrease neuropathy, after bleeding stop hemophiliac.
What is happening during the Oliguric phase of AKI?
UO <400ml/24 hrs, decrease in specific gravity, issues in concentrating urine. (increased sodium release). 1-7d post event, the longer they are in this phase the worse the prognosis is.
GFR
Uses serum Creatine level used to calculate GFR, > 60ml/min/1.73m2 (age, gender, and race are calculated). (Normal GFR is >90, labs max out at 60)
can an LPN... administer drugs by an NG?
YES
can an LPN... monitor IV flow rate and administer IV piggyback meds?
YES
can an LPN... monitor pain level and administer pain medication?
YES
can an LPN... participate in narcotics/controlled substances count?
YES
can an LPN... perform wound care and/ or dressing changes?
YES
can an LPN... place a urinary catheter?
YES
can an LPN... program the feeding pump to administer a prescribed bolus feeding?
YES
can an LPN... remove wound sutures or staples?
YES
can an LPN... titrate o2 per unit protocol?
YES
can a UAP... perform oral suctioning? perform oral care, using a tonsil tip suction devise to suction the oropharynx to a pt with a trach?
YES (according to uworld) & YES
can a UAP... reapply a nasal cannula if it accidentally comes off?
YES (but can not ADMINISTER oxygen)
A client has acute liver failure. The nurse would assess for which skin changes? Select all that apply. Poor wound healing Dark-brownish discolorations on the chest Pale mucous membranes Presence of pruritus Presence of petechiae
Your Answers: Pale mucous membranes Presence of petechiae Presence of pruritus Bleeding may result in pale mucous membranes. Problems with coagulation can result in presence of petechiae. Pruritus is a common finding associated with acute or chronic liver failure.
A 6 month old infant is sleeping. The RN notes a heart rate of 140 beats per minute on the hard wired monitor. What is the RN's best action? A. Chart the normal pulse. B. Recheck after arousing the infant. C. Report the abnormal pulse immediately. D. Retake the pulse apically in 15 minutes.
a
You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining? A. Check for kinks in the outflow tubing B. Raise the drainage bag above the level of the abdomen C. Place the patient in a reverse Trendelenburg position D. Ask the patient to cough
a
the client diagnosed with a mild concussion is being discharged from the emergency department. which discharge instruction should the nurse teach the clients significant other? 1. awake in the client every 2 hours. 2. monitor for increased intracranial pressure. 3. observe frequently for hypervigilance. 4. offer the client food every 3 to 4 hours.
answer 1. Awakening the client every 2 hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety, all signs a post concussion syndrome ,which would warrant a return to the emergency department.
An 8-month-old infant is sitting quietly on the mother's lap, chewing on a toy. When preparing to perform a routine assessment of this infant the RN should plan to do which action first? A. Measure head circumference. B. Auscultate heart and lung sounds. C. Perform a neuro check. D. Obtain a body weight.
b
The RN is planning care for a four year old child admitted with viral gastroenteritis. The child who is NPO, has been vomiting and has a urine specific gravity of 1.020 over the last 24 hours. Which client problem is the highest priority? A. Imbalanced nutrition B. Fluid volume deficit C. Risk for infection D. Altered urinary elimination
b
When auscultating the heart, the RN identifies the S1 component as the closing of which valves? A. Mitral and aortic valves B. Mitral and tricuspid valves C. Tricuspid and pulmonic valves D. Tricuspid and aortic valves
b
Which items are part of the neuro check, but are not an assessment of LOC? A. Vision and hearing ability. B. Pupillary size and reaction to light. C. Alertness and verbal response. D. Best motor response.
b
During the patient's hospital stay, the patient states, "I told my wife that I was going to start exercising and I think I will join a fitness club." What stage of Prochaska's Transtheoretical model of Health Behavior change is the patient exhibiting? a Action b Preparation c Precontemplation d Maintenance
b preparation
A patient diagnosed with chronic hepatitis has developed hepatic encephalopathy. When assessing the patient, the healthcare provider looks for which of the following clinical manifestations characteristic of this condition Choose all answers that apply: Choose all answers that apply: A Retroperitoneal bleeding B Involuntary hand tremor C Bloody emesis D Shortened attention span E Hypersomnia F Slurred speech
b,d,e,f Hepatic encephalopathy is a result of hepatic dysfunction and portal hypertension. Hepatic encephalopathy is characterized by neuropsychiatric abnormalities secondary to increased serum ammonia levels. Hepatic encephalopathy characterized by progressive cognitive deficits and impaired neuromuscular function, so the healthcare provider would anticipate assessing symptoms such as sleep disturbances, confusion, impaired attention span, slurred speech, and asterixis (flapping tremor). Esophageal varices often result in bloody emesis, and retroperitoneal bleeding is a symptom of pancreatitis.
A patient diagnosed with hepatitis is undergoing a liver biopsy. When caring for the patient, which of these actions would be essential for the healthcare provider to take? Choose all answers that apply: A Review the patient's baseline liver function tests B Ensure the patient's clotting profile is within normal limits C Provide a mechanical soft diet for before the procedure D Ensure the patient has an empty bladder before the procedure E Help the patient assume a left lateral position after the procedure F Monitor the patient's vital signs after the procedure
b,d,f
Which of the following are NOT typical signs and symptoms of right-sided heart failure? Select-all-that-apply: A. Jugular venous distention B. Persistent cough C. Weight gain D. Crackles E. Nocturia F. Orthopnea
b,d,f
A patient diagnosed with hepatitis is undergoing a liver biopsy. When caring for the patient, which of these actions would be essential for the healthcare provider to take? Choose all answers that apply: (Choice A) A Review the patient's baseline liver function tests B Ensure the patient's clotting profile is within normal limits C Provide a mechanical soft diet for before the procedure D Ensure the patient has an empty bladder before the procedure E Help the patient assume a left lateral position after the procedure F Monitor the patient's vital signs after the procedure
b,d,f The liver is located in the right upper quadrant of the abdomen Liver function labs will be assessed, but these are not directly related to the procedure. Hemorrhage is a potential complication of the procedure. To manage bleeding, the patient's clotting profile should be within normal limits and the patient should be positioned on the right side after the procedure to provide pressure to the site. Vital signs are checked afterwards to detect changes that could signal hemorrhage. An empty bladder before the procedure will ensure it isn't damaged. The patient is usually advised to have nothing to eat or drink for six hours before the procedure.
A 3.12 kg baby is ordered to have a medication via IV piggyback every six hours. Which type of delivery device should the RN use to administer this medication? a Standard IV tubing since there is nothing in the stem to indicate otherwise. b There is no way to answer this question without more information. c Syringe tubing for such a small child. d Call the primary health care provider or pharmacist for advice. e IV push method would work best.
c
During an acute exacerbation, a patient with SLE is treated with corticosteroids. The nurse would expect the steroids to begin to be tapered when serum laboratory results indicate: A. Increased RBCs B. Decreased ESR C. Decreased anti-DNA D. Increased complement
c
The 2.96 kg baby is ordered to have Ampicillin 155 mg. IVPB. every six hours. Which type of delivery device should the RN choose to administer this medication? A.Standard IV tubing; there is nothing in the stem to indicate otherwise. B.The syringe will be enough; for such a small baby and small dose, IV Push would work best. C.Syringe tubing is small bore; given this child's age and weight a 4 ml flush is the best choice .D.Without knowing the underlying morbidity, i.e. cardiac and renal status, there is no way to answer this question. E.Call the doctor or pharmacist for advice.
c
When completing discharge teaching for the mother of a toddler, which activity should the RN recommend to help the child meet the major developmental task for this age group? a Feed the child favorite foods at mealtime. b Read the child bedtime stories. c Allow the child to pull a small wagon. d Have the child watch "Sesame Street".
c
When caring for a patient diagnosed with viral hepatitis, the healthcare provider experiences a needlestick with a contaminated needle. Which of the following actions should the healthcare provider do first? A. Make an appointment with the infection control department B. Put the needle in a biohazard bag for testing C Wash the area thoroughly with soap and water D Report to the emergency department
c wash then notify
A client has acute liver failure. The nurse would assess for which skin changes? Select all that apply. a Poor wound healing b Dark-brownish discolorations on the chest c Pale mucous membranes d Presence of pruritus e Presence of petechiae
c,d,e
How do you therapeutically manage AKI?
🔺Treat precipitating cause 🔺Control symptoms (dialysis) and prevent complications. 🔺Fluids and diuretics. 🔺Medications to control electrolyte imbalances.
What are the clinical manifestation of CKD r/t the Gastrointestinal System?
🔺Ulceration and bleeding of GI mucosa. 🔺Anorexia (metallic taste). 🔺Nausea. 🔺Bowel problems (constipation and diarrhea).
What are some S/S of the Oliguric phase?
🔺Urinary changes 🔺Fluid volume excess 🔺Metabolic acidosis (respiratory compensation). 🔺Electrolyte imbalances (hyponatremic 2/2 NA loss, hypocalcemia, increased phosphates). 🔺Neurologic - concentration issues, seizures, comma, etc. 2/2 urea build up.
What are the clinical manifestation of CKD r/t the Cardiovascular System?
🔺HTN 🔺Edema 🔺CHF 🔺Cardiac Arrhythmias 🔺Uremic Pericarditis 🔺Anemia 🔺Clotting Defects
What are the two type of Dialysis?
🔺Hemodialysis 🔺Peritoneal
What are some advantage to Peritoneal Dialysis?
🔺Home and/or mobile. 🔺Fewer dietary restrictions. 🔺Preferred for diabetics and those with poor access.
How is Hyperkalemia treated in CKD?
🔺IV Glucose & Insulin. 🔺Calcium Glutinate IV 🔺Kayexalate (PO)
What can Peritoneal dialysis cause?
🔺Infection 🔺Cramping 🔺Respiratory Issues
What are the clinical manifestation of CKD r/t the Respiratory System?
🔺Kussmaul's respirations 🔺Dyspnea 🔺Pneumonia
Lets discuss Hemodialysis
🔺Machine, blood is removed through vascular access device (VAD). 🔺Blood filtered through synthetic membrane in machine. 🔺Filtered blood returned through same VAD. 🔺200cc blood leaving the body at one time and a small amount of Heparin. 🔺Process lasts for 2-5 hours and is for 3 times a week.
What are some inuring interventions for AKI?
🔺Managing fluid (I&O)/ daily weight. 🔺Monitoring electrolytes. 🔺Prevent respiratory complications - C&DB. 🔺Infection protection 🔺Skin care 🔺Psychosocial support 🔺Education regarding: S&S of recurrent kidney problems (fluid retention, twitching, cramping) and e-lyte imbalances.
What are some nursing management points for CKD?
🔺Monitor I&O 🔺Monitor Electrolytes 🔺Prevent respiratory complications. 🔺Infection protection. 🔺Skin care 🔺Psychosocial Interventions 🔺Education
What are the 3 clinical courses of AKI?
🔺Oliguric Phase 🔺Diuretic Phase 🔺Recovery Phase
What are the clinical manifestation of CKD r/t the Integumentary System?
🔺Pallor 🔺Pruritus
What are the 4 functions of the kidneys
🔺Regulate volume and composition of ECF, pH and osmolarity. 🔺Excrete metabolic end products. 🔺Activation of Vitamin D. 🔺Secrete renin and erythropoietin.
What are the goals of Dialysis?
🔺Remove waste products and fluid. 🔺Correct electrolytes and acidosis.