NURS-200 Exam 2 - Version A

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When planning care for a client with chronic hepatitis, which collaborative discipline will be most helpful in treating continued alcohol use? A) Social worker B) Primary provider C) Pharmacist D) Dietitian

Answer: A The social worker is an expert at identifying additional resources for treatment of substance abuse. The primary provider, pharmacist, and dietitian will all contribute to the plan of care.

A nurse is caring for a client diagnosed with an HBV infection. Which of the following clinical manifestations would indicate that this client had entered the icteric phase? A) Fatigue B) Jaundice C) Loss of appetite D) Nausea

Answer: B The icteric phase begins with the onset of jaundice, approximately 5—10 days after initial symptoms manifest, although some clients will never develop jaundice. The prodromal phase of acute hepatitis occurs between exposure to the virus and the appearance of clinical manifestations such as jaundice resulting from increased levels of bilirubin in the blood. Fatigue, loss of appetite, and nausea are among the symptoms that may be seen during this phase.

The destruction of which types of cells in the islets of Langerhans cause type 1 diabetes mellitus? A. Delta cells B. Alpha cells C. Beta cells D. Gamma cells

Which finding supports the nurse's evaluation that an older adult client with sepsis has maintained a normal mental status? A) The client is agitated. B) The client has a Glasgow coma score of 4. C) The client responds to questions appropriately. D) The client's pupils are fixed and dilated.

A nurse is caring for a client with septicemia. What assessment by the nurse best addresses the potential for ineffective peripheral perfusion? A) Monitor heart rate every hour. B) Assess temperature every 4 hours. C) Monitor pupil reactions every 8 hours. D) Monitor for cyanosis.

The nurse is planning care for a client with type 2 diabetes mellitus. Which nursing diagnosis would be most appropriate for this client? A. Risk for Decreased Cardiac Tissue Perfusion B. Self Neglect C. Impaired Tissue Integrity D. Risk for Infection

Which test is commonly used to screen for type 2 diabetes in the general population? A. Oral glucose tolerance test B. Serum cholesterol levels C. Urine ketone levels D. Fasting plasma glucose

Septic shock

Endotonxins (gram-negative bacteria) and mediators causing massive vasodilation

Cardiogenic shock

Pump failure due to MI, heart failure, cardiomyopathy, dysrhythmia, and valvular rupture or stenosis

9) A client with liver disease presents to the hospital with severe ascites. What pathophysiologic changes does the nurse recognize as contributing to the development of ascites? Select all that apply. A) Presence of portal hypertension B) Presence of hyperalbuminemia C) Increased colloidal osmotic pressure D) Sodium and water retention E) Presence of hypoaldosteronism

11) When individuals engage in excessive alcohol consumption, which liver function is impacted, leading to subsequent liver damage? A) Metabolism B) Synthesis C) Detoxification D) Glycogen storage

The nurse is assessing a client with irreversible shock. The nurse should document which finding? diuresis hypertension circulatory collapse increased alertness

circulatory collapse Explanation: Severe hypoperfusion to all vital organs results in failure of the vital functions and then circulatory collapse. Hypotension, anuria, respiratory distress, and acidosis are other symptoms associated with irreversible shock. The client in irreversible shock will not be alert.

Which is characteristic of cardiogenic shock? decreased myocardial contractility increased cardiac output hypovolemia infarction

decreased myocardial contractility Explanation: Cardiogenic shock occurs when myocardial contractility decreases and cardiac output greatly decreases. The circulating blood volume is within normal limits or increased. Infarction is not always the cause of cardiogenic shock.

The nurse should assess the client who is being admitted to the hospital with upper GI bleeding for which finding? Select all that apply. thirst widening pulse pressure dry, flushed skin tachycardia rapid respirations decreased urine output

decreased urine output tachycardia rapid respirations thirst Explanation: The client who is experiencing upper GI bleeding is at risk for developing hypovolemic shock from blood loss. Therefore, the signs and symptoms the nurse should expect to find are those related to hypovolemia, including decreased urine output, tachycardia, rapid respirations, and thirst. The client's skin would be cool and clammy, not dry and flushed. The client would also be likely to develop hypotension, which would lead to a narrowing pulse pressure, not a widening pulse pressure. Remediation

Which condition can place a client at risk for acute respiratory distress syndrome (ARDS)? chronic obstructive pulmonary disease heart failure septic shock asthma

septic shock Explanation: The two risk factors most commonly associated with the development of ARDS are gram-negative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inflammatory response syndrome (which can be caused by any physiologic insult that leads to widespread inflammation). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS.

A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? "A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" "A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces" "Generally caused by decreased blood volume" "It is due to severe hypersensitivity reaction resulting in massive systemic vasodilation."

"A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" Explanation: Shock may have different causes (e.g., hypovolemia, cardiogenic, septic), but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Movement of plasma into the interstitial spaces could reflect dependent edema and sepsis. Decreased blood volume is an example of hypovolemia. A hypersensitivity reaction is an example of anaphylactic shock or distributive shock.

A patient is brought to the emergency department with hypotension, tachycardia, reduced capillary refill, and oliguria. During the assessment, the nurse determines the patient is experiencing cardiogenic shock because of which additional finding? 1. Jugular vein distention 2. Dry mucous membranes 3. Poor skin turgor 4. Thirst

The nurse is caring for a teenage client on a burn unit who has sustained third-degree burns over 40% of the body. A family member asks why the client isn't reporting of more pain. Which of the following is the best response by the nurse? "The severe burns have damaged nerves that sense pain." "The burns are not deep enough to cause much pain." "The client is confused and can't verbalize a pain rating." "The pain medication is working adequately." SUBMIT ANSWER Exit quiz

"The severe burns have damaged nerves that sense pain." Explanation: Full-thickness burns damage nerve endings and initially may feel somewhat painless. Regeneration of the nerve endings in recovery may cause significant pain. Confusion, adequate pain medication, and burns that are not deep enough would not be the most likely explanation of the client's lack of reports of pain.

Which of the following statements indicate that a family member of a client in cardiogenic shock understands the need for an intra-aortic balloon pump? "This device increases how hard the heart has to work." "This device decreases the heart's need for oxygen." "This device decreases the blood flow in the heart." "This device helps stop life-threatening heart rhythms." SUBMIT ANSWER

"This device decreases the heart's need for oxygen." Explanation: An intra-aortic balloon pump increases coronary perfusion and cardiac output, and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock. A defibrillator is commonly used for termination of life-threatening ventricular rhythms.

A patient is being treated for pericarditis. The nurse will plan interventions to prevent the onset of which type of shock? 1. Obstructive 2. Hypovolemic 3. Distributive 4. Cardiogenic

A patient is experiencing an anaphylactic reaction to a medication. The nurse is concerned that the patient will develop distributive shock because: 1. The release of histamine causes vasodilation with plasma leakage. 2. Sympathetic innervation is interrupted. 3. Microorganisms overwhelm the vascular system. 4. Parasympathetic innervation functions are unopposed.

A patient is prescribed vasopressin 0.03 units/minute as treatment for septic shock. What action will the nurse take when providing this medication? 1. Provide the vasopressin infusion in addition to a norepinephrine infusion. 2. Infuse through a peripheral line. 3. Utilize a rapid infuser. 4. Administer with 0.9% normal saline.

A patient is receiving phenylephrine 50 mcg/min as treatment for shock. Which assessment finding indicates this medication is effective? 1. Blood pressure 110/68 mm Hg 2. Heart rate 110 3. Respiratory rate 12 and regular 4. Decreased peripheral pulses

A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is due to: 1. Reduced cardiac output 2. Increased stroke volume 3. Reduced blood volume 4. Blood flow blocked in the pulmonary circulation

The nurse, caring for a patient recovering from an acute myocardial infarction, is planning interventions to reduce the risk of which type of shock? 1. Cardiogenic 2. Hypovolemic 3. Distributive 4. Obstructive

Which assessment finding indicates that an infusion of intravenous epinephrine 4 mcg/min is effective in the treatment of a patient with anaphylactic shock? 1. Reduced wheezing 2. Heart rate 55 and regular 3. Blood pressure 98/50 mm Hg 4. Respiratory rate 28

Which finding indicates that rehydration is complete and hypovolemic shock has been successfully treated in a patient? 1. CVP = 8 mm Hg 2. MAP = 45 mm Hg 3. Urinary output of 0.1 mL/kg/hr 4. Hct = 54%

A patient is receiving norepinephrine 30 mcg/min for treatment of refractory shock. Which assessment findings suggest the patient is experiencing peripheral vasoconstriction from the medication? Select all that apply. 1. Decreased peripheral pulses 2. Drop in body temperature 3. Onset of paresthesias 4. Drop in blood pressure 5. Increased cardiac output

1, 2, 3

A patient, experiencing vasodilation, is diagnosed with distributive shock. The nurse will assess the patient for which etiologies? Select all that apply. 1. Sepsis 2. Spinal cord injury 3. Anaphylaxis 4. Hemorrhage 5. Pulmonary embolism

1, 2, 3

During an assessment the nurse is concerned that a patient is developing cardiogenic shock. What did the nurse assess in this patient? Select all that apply. 1. Systolic blood pressure 82 mm Hg 2. Capillary refill 10 seconds 3. Crackles bilateral lung bases 4. Heart rate 55 and regular 5. Warm dry skin

1, 2, 3

A patient is brought to the emergency department with manifestations of anaphylactic shock. What will the nurse assess as possible causes for this disorder? Select all that apply. 1. Recent bee sting 2. Ingestion of drugs 3. History of latex allergy 4. Recent diagnostic imaging tests 5. Recent myocardial infarction

1, 2, 3, 4

The nurse is explaining the mechanism of a pulmonary embolism to the family of a patient diagnosed with the disorder. Place in order the steps the nurse will use to instruct the family about this disease process. Choice 1. Blood clot causes backup of blood in the right ventricle. Choice 2. Blood clot blocks blood to the left ventricle. Choice 3. Left ventricle does not get enough blood to pump through the body. Choice 4. Amount of blood the heart has to pump to the body drops. Choice 5. Blood pressure drops. Choice 6. Amount of blood going to the body drops.

1, 2, 3, 4, 5, 6

A patient being treated for cardiogenic shock is being hemodynamically monitored. Which findings are consistent with the patient's diagnosis? Select all that apply. 1. Elevated pulmonary arterial wedge pressure 2. Elevated central venous pressure 3. Elevated systemic vascular resistance index 4. Elevated mean arterial pressure 5. Elevated stroke volume

1,2,3

A patient is experiencing acute respiratory distress after eating an item of a known food allergy. What interventions will the nurse implement when providing emergency care to this patient? Select all that apply. 1. Administer epinephrine 1:1000 intramuscularly. 2. Apply oxygen via face mask as prescribed. 3. Provide diphenhydramine 25 mg intravenous. 4. Administer vasopressin. 5. Prepare to administer antithrombolytic agents as prescribed.

1,2,3

The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock? Select all that apply. 1. Hypotension 2. Bradycardia 3. Warm dry skin 4. Abdominal cramps 5. Palpitations

1,2,3

The nurse is preparing medications for a patient being treated for cardiogenic shock. Which medications will the nurse most likely provide to this patient? Select all that apply. 1. Dopamine 2. Norepinephrine 3. Dobutamine 4. Epinephrine 5. Phenylephrine

1,2,3,5

A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill. The nurse suspects the patient is experiencing which type of shock? 1. Hypovolemic 2. Cardiogenic 3. Anaphylactic 4. Obstructive

The nurse should warm intravenous fluids when a rapid infuser is being utilized to prevent which complication? 1. Hemorrhagic shock 2. Hypothermia 3. Sepsis 4. Cardiogenic shock

Which finding indicates that a patient is experiencing increased peripheral resistance and vasoconstriction? 1. Strong bounding pulse with deep red coloring 2. Pale, cool extremities with decreased pulses 3. Increased venous engorgement with strong pulses 4. Faster than normal capillary refill time

Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock? 1. Serum sodium of 130 mEq/L (130 mmol/L) 2. Metabolic acidosis validated by arterial blood gases 3. Serum lactate of 3 mmol/L 4. SvO2 greater than 80%

Which solution would be the most appropriate initial volume replacement for a patient with severe GI bleeding? 1. 200 mL of normal saline (NS) per hour for 5 hours 2. A liter of Ringer's lactate (RL) over 15 minutes 3. Two liters of D5W over half an hour 4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour

Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? Select all that apply. 1. Fluid volume overload 2. Renal insufficiency 3. Cerebral ischemia 4. Gastric stress ulcer 5. Pulmonary edema

2, 3

What will the nurse identify as symptoms of hypovolemic shock in a patient? Select all that apply. 1. Temperature of 97.6°F (36.4°C) 2. Restlessness 3. Decrease in blood pressure of 20 mm Hg when the patient sits up 4. Capillary refill time greater than 3 seconds 5. Sinus bradycardia of 55 beats per minute

2,3,4

A school-age child who has received burns over 60% of his body is to receive 2,000 mL of IV fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump? Record your answer as a whole number. ? mL/hour

250 Explanation: 2,000 mL/8 hours = 250 mL/hour

The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient with: 1. Decreased cardiac output 2. Severe constipation, causing watery diarrhea 3. Ascites 4. Syndrome of inappropriate ADH (SIADH)

The nurse, caring for a patient in hypovolemic shock, will not utilize a hypotonic solution for fluid resuscitation because hypotonic solutions: 1. Move quickly into the interstitial spaces and can cause third spacing 2. Stay longer to expand the intravascular space but deplete intracellular fluid levels 3. Do not stay in the intravascular space long enough to expand the circulating blood volume 4. Need a smaller bore needle to run at a slower rate to keep the intravascular space low

A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number. ? percent

36 Explanation: The anterior and posterior portion of one leg is 18%. If both legs are burned, the total is 36%.

A patient with neurogenic shock is demonstrating bradycardia. What action will the nurse take at this time? 1. Limit patient movement. 2. Prepare to administer crystalloids. 3. Administer phenylephrine as prescribed. 4. Administer atropine as prescribed.

A patient weighing 220 lbs is prescribed 10 mcg/kg/min of dopamine to improve cardiac output from cardiogenic shock. How many milligrams of dopamine will the patient receive in an hour?

A client with sepsis and hypotension is being treated with dopamine. The nurse asks a colleague to double-check the dosage that the client is receiving. There are 400 mg of dopamine in 250 ml, the infusion pump is running at 23 ml/hour, and the client weighs 79.5 kg. How many micrograms per kilogram per minute is the client receiving? Record your answer using two decimal places. ? mcg/ml/minute

7.71 Explanation: First, calculate how many micrograms per milliliter of dopamine are in the bag: 400 mg/250 ml = 1.6 mg/ml Next, convert milligrams to micrograms: 1.6 mg/ml × 1,000 mcg/mg = 1,600 mcg/ml Lastly, calculate the dose: 1,600 mcg/ml × 23 ml/hour/79.5 kg 79.5 kg/60 minutes/hour = 7.71 mcg/kg/minute

An older client is diagnosed with disorders of fat metabolism, reduced absorption of fat-soluble vitamins, and a slightly elevated blood glucose level. When developing interventions for this client, the nurse considers that normal age-related changes in which endocrine organ are likely to contribute to reduced absorption of fat-soluble vitamins? A. Pancreas B. Adrenal medulla C. Pituitary D. Thyroid

One method of preventing sepsis in hospitalized clients is A) using aseptic techniques when inserting a catheter. B) placing clients with infections in negative airflow rooms. C) using airborne precautions when assessing clients. D) teaching proper techniques for using tampons.

The healthcare provider prescribes sitagliptin (Januvia) for a client with type 2 diabetes mellitus. For which potential side effect should the nurse monitor in this client? A. Pancreatitis B. Elevated blood lipid levels C. Renal insufficiency D. Hyperglycemia

The nurse is preparing to teach a client who is newly diagnosed with type 1 diabetes mellitus on the preferred area to self-inject insulin. On which area should the nurse focus, based on insulin absorption rates? A. Abdomen B. Deltoid C. Thigh D. Hip

The nurse, teaching a class to a group of community members about the importance of weight loss in decreasing the risk of type 2 diabetes mellitus, is asked why weight loss reduces the risk associated with the development of this health problem. Which response by the nurse is most appropriate? A. "Excess body weight impairs the body's release of insulin." B. "Thin people are less likely to become diabetic." C. "The physical inactivity associated with obesity causes a reduced ability by the body to produce insulin." D. "The amount of food taken in by those who are overweight requires more insulin to adequately metabolize, resulting in diabetes."

The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse? A Sa02 reading is 92% A urinary output of 50 mL in the past 3 hours Vital signs T 38° C (100.4° F), P 104, R 26 and B/P 100/60 A white blood cell count of 19,000mm3 SUBMIT ANSWER

A urinary output of 50 mL in the past 3 hours Explanation: Sepsis can cause the release of myoglobin from the cells which will directly block the renal tubules causing decreased urinary output. If it is not treated with hydration and antibiotics, the client could develop renal failure. A high white blood cell count is expected with sepsis. Temperature can be elevated or below normal, in clients with sepsis. The elevated pulse and respirations are normal in the presence of infection and should be monitored. The saturated oxygen level is within normal limits as is the blood pressure.

The nurse is assessing a client. Which findings indicate a potential problem related to adrenal medulla function? Select all that apply. A. Respiratory rate of 22 B. Blood pressure of 132/84 C. Heart rate of 104 D. Weight decreased 10 lb since previous appointment E. Dry and cracked heels

A, B, C, D

After reviewing the population demographics for an urban community, the community health nurse determines that community members would benefit from teaching on type 2 diabetes mellitus in children. What findings support this nurse's conclusion? Select all that apply. A. 25% of children between the ages of 10 and 19 are Hispanic. B. 60% of community families have both parents diagnosed with type 2 diabetes mellitus. C. 35% of school-age children do not routinely receive the annual flu vaccination. D. 50% of children between the ages of 10 and 19 are African American. E. 75% of school-age children are raised in families where both parents are unemployed.

A, B, D

The nurse is planning care for a client admitted with diabetic ketoacidosis (DKA). On what should the nurse focus for this client's care? Select all that apply. A. Intravenous fluid infusions B. Insulin infusion C. Administration of oral glucose D. Frequent blood glucose monitoring E. Monitoring for fluid volume overload

A, B, D

A nurse is caring for an adult client recently diagnosed with hypothyroidism. After reviewing the nursing admission assessment, on which documented findings should the nurse plan care for this client? Select all that apply. A. Hypothermia B. Nausea C. Constipation D. Tachycardia E. Hot flashes

A, C

While performing an endocrine assessment on a client suspected of having an endocrine disorder, the nurse asks if the client has experienced recent weight changes. The nurse asks this question because he understands that alterations in which endocrine glands are most directly related to weight changes? Select all that apply. A. Pituitary gland B. Parathyroid gland C. Adrenal gland D. Thyroid gland E. Gonads

A, C, D

he nurse is finalizing a plan of care for a school-age client newly diagnosed with type 1 diabetes mellitus. Which areas should the plan prioritize to achieve the maximum outcomes for this client? Select all that apply. A. Self-management of glucose monitoring and medications B. Ways to minimize the number of school days missed C. Signs and symptoms of hypoglycemia and actions to take D. Identification and referral to community resources E. Physical activities that limit exposure to injuries

A, C, D

A nurse is caring for a client and reviewing a new prescription for an afterload-reducing medication. The nurse should recognize that this medication is administered for which of the following types of shock? A. Cardiogenic B. Obstructive C. Hypovolemic D. Distributive

A. Reducing afterload will allow the heart to pump more effectively, which is needed for the client who has cardiogenic shock

The nurse is admitting a client to the intensive care unit. Earlier, the client presented to the emergency department in early septic shock. Given this information, which assessment findings should the nurse anticipate? Select all that apply. A) Normal blood pressure B) Rapid and deep respirations C) Shallow respirations D) Warm and flushed skin E) Lethargic mental status F) Decreased urine output

ABD

A client is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this client? Select all that apply. A) Tachycardia B) Pain C) Edema D) Hypotension E) Fever

ADE

What is the primary goal for the care of a client who is in shock? Maintain adequate vascular tone. Achieve adequate tissue perfusion. Prevent hypostatic pneumonia. Preserve renal function.

Achieve adequate tissue perfusion. Explanation: A primary outcome for the care of the client in shock is to achieve adequate tissue perfusion, thus avoiding multiple organ dysfunction. The lungs are susceptible to injury, especially acute respiratory distress syndrome. Vasoconstriction occurs as a compensatory mechanism until the client enters the irreversible stage of shock.

After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first? Administer the antidote for penicillin, as ordered, and continue to monitor the client's vital signs. Prepare to administer a corticosteroid IV. Administer epinephrine, as ordered, and prepare to intubate the client, if necessary. Insert an indwelling urinary catheter and begin to infuse I.V. fluids, as ordered.

Administer epinephrine, as ordered, and prepare to intubate the client, if necessary. Explanation: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator, as ordered. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications do not relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists. However, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring. However, administering epinephrine is the first priority.

The nurse anticipates the transfer of which of the following burn clients to a burn center? Select all that apply. A child with burns of hands and feet A child with 15% TBSA second-degree burns on torso An adult with an electrical burn An adult with 1.5% total body surface area (TBSA) third-degree burns of face An adult with 20% TBSA second-degree burns on lower extremities

An adult with 1.5% total body surface area (TBSA) third-degree burns of face An adult with an electrical burn A child with burns of hands and feet Explanation: Major burn injuries include second-degree burns > 25% in adults or > 20% in children, any electrical injuries, and any burns involving eyes, ears, face, hands, feet, perineum, and joints.

A client is diagnosed with viral hepatitis transmitted by the fecal-oral route. Which conditions may be acquired by this mode of transmission? A) Hepatitis A (HAV) and hepatitis E (HEV) B) Hepatitis B (HBV) and hepatitis C (HCV) C) Hepatitis D (HDV) D) Hepatitis A (HAV), hepatitis B (HBV), hepatitis C (HCV), hepatitis D (HDV), and hepatitis E (HEV)

Answer: A Hepatitis A (HAV) and hepatitis E (HEV) are transmitted by the fecal-oral route. Hepatitis C (HCV) is transmitted through blood and body fluids. Hepatitis B (HBV) and hepatitis D (HDV) are transmitted by blood, body fluids, and perinatal routes.

During an interview with a 67-year-old client diagnosed with acute hepatitis B, the nurse obtains the following data: 10 kg weight loss is noted from the client's last visit 4 months ago; review of systems reveals (1) limiting fatigue, (2) not well enough for sexual intercourse, (3) drinks 3-5 mixed drinks weekly socially, (4) right upper quadrant (RUQ) pain rated at 6/10, and "constant" pruritus. Which findings indicate that the client's hepatitis may have progressed to a chronic stage? Select all that apply. A) Fatigue B) Drinks 3-5 mixed drinks weekly socially C) RUQ pain rated at 6/10 D) Pruritus

Answer: A, C, D Acute hepatitis B tends to be asymptomatic in older adults, so although fatigue, RUQ pain, and pruritus are common clinical manifestations of acute hepatitis B, this client exhibiting these symptoms is a sign that the client's condition has progressed to chronic hepatitis B, a progression that tends to happen more quickly with older adults. The client being a social drinker does not indicate anything about the progress of the client's hepatitis.

A young adult waiter has been treated for viral hepatitis at a healthcare clinic. Which client outcome indicates the need for additional intervention? Select all that apply. A) Body mass index (BMI) changes from 24 to 21. B) Return demonstration of hand washing is correctly performed. C) Social Services notified the Health Department of the occurrence. D) Red scratch marks are noted on the arms and trunk. E) Client denies abdominal or epigastric pain.

Answer: A, D The client will need additional intervention if weight loss occurs and if the client has continued itching as evidenced by the red scratch marks. No additional intervention is needed if hand washing is performed correctly or pain is controlled. The health department must be notified if a food service worker is diagnosed due to possible exposure of patrons.

A nurse is planning a teaching session for expectant mothers regarding pediatric clients and hepatitis. Regarding hepatitis A, which of the following statements is correct? A) Infection of the mother is the most common reason hepatitis A spreads to children. B) A daycare is typically a high-risk environment for the spread of hepatitis A. C) Children with hepatitis A are commonly asymptomatic. D) Hepatitis A in children is typically a very serious illness with long-term health effects.

Answer: B Hepatitis A is the most common type of hepatitis in children and is often spread at daycare centers where children are in diapers or are being potty trained. Children with hepatitis B may be asymptomatic, but in the majority of cases, hepatitis A is mild, causes flulike symptoms, and rarely has long-term consequences. Hepatitis A is not perinatal.

The multidisciplinary care team is meeting to discuss care for a client who exhibits symptoms of the prodromal phase of hepatitis. Lab results include a positive anti-HAV IgM. The nurse creates an action plan to present to the team. Which interventions are appropriate? Select all that apply. A) High-fat, low-calorie, and no-alcohol diet teaching B) Patient education on acceptable pain medication C) Early treatment with lamivudine D) Referral to the liver transplant team E) Family teaching for transmission prevention

Answer: B, E Patient education on acceptable pain medication is necessary due to the toxic effect of common over-the-counter pain medicine. Family teaching is appropriate to avoid transmission. Most clients recover from acute viral hepatitis without pharmacologic treatment and certainly without liver transplant. A low-fat, high-calorie diet is recommended.

The nurse is planning education for an adolescent client recently diagnosed with hepatitis. The client moved back to the parents' home. Which recommendation to the client's parents will best prevent them from acquiring hepatitis B (HBV)? A) Refuse to donate blood. B) Avoid contaminated water. C) Obtain postexposure prophylaxis. D) Abstain from alcohol.

Answer: C Obtaining postexposure prophylaxis treatment will best help the client's parents from acquiring HBV. The HBV vaccine is started concurrently. HBV is not spread in water. Alcohol abuse is implicated in nonviral hepatitis. Donating blood will not increase the risk of acquiring HBV.

The nurse is explaining hepatitis to a high school health occupations class. The students all volunteer examples of how hepatitis is transmitted. Which student statement indicates the need for further education? A) "Body piercing or tattoo with infected equipment." B) "Contaminated food or fluids." C) "Alcoholism or high doses of acetaminophen." D) "Bite of an infected mosquito or tick."

Answer: D The student who believes the bite of a mosquito or tick will transmit hepatitis is incorrect and needs further education. The students who said that infected needles, contaminated food or fluids, alcoholism, or high doses of acetaminophen can cause different types of hepatitis were correct and do not require further education.

Anaphylactic shock

Antigen-antibody reaction causing massive vasodilation due to allergens (inhaled, swallowed, contacted, or introduced IV)

The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? Red blood cells (RBCs) and hemoglobin count findings White blood cell differential Oxygen saturation level Arterial blood gas (ABG) findings

Arterial blood gas (ABG) findings Explanation: Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Oxygen saturation levels are usually affected by hypoxemia but cannot be used to diagnose acid-base imbalances such as metabolic acidosis.

A 1-month-old infant is admitted to the hospital with a temperature of 102°F. What is the rationale for a complete septic workup? A) Absence of sweat glands B) Immature immune system C) Inadequate red blood cells D) Poor lung elasticity

Increasing circulating levels of thyroid hormone heighten the sympathetic nervous system's physiologic response to stimulation. What effect does this have on the cardiac system? A. Decreases cardiac rate B. Increases stroke volume C. Lengthens the QRS interval D. Decreases blood pressure

The client with diabetes mellitus reports having difficulty trimming the toenails because they are thick and ingrown. What should the nurse recommend to this client? A. Cut the nails straight across with a clipper after the bath. B. Make an appointment with a podiatrist. C. Make an appointment with a nail shop for a pedicure. D. Offer to file the tops of the nails to reduce thickness after cutting.

The nurse is caring for a 34-year-old woman who is pregnant with her third child. The client was diagnosed with hypothyroidism between her second and third pregnancies. What special considerations should the nurse include when caring for this client? A. The client may need to add a folic acid supplement to her medication regimen. B. The client may need to change her dosage of levothyroxine (Synthroid). C. The client is at higher risk for gestational diabetes. D. The client is at higher risk for diabetes insipidus.

The nurse is caring for a 76-year-old client with type 2 diabetes who is recovering from surgery following a hip fracture. In addition to blood glucose level, what should the nurse recognize as a sign of hyperosmolar hyperglycemic state (HHS)? A. Edema B. Increased urine output C. Excessive sweating D. Insomnia

The nurse is preparing an education session for nurses who work in an endocrinology clinic caring for older adult clients. Which statement about the thyroid should the nurse include in her teaching? A. Thyroid hormone is often increased for older adult clients. B. Symptoms of hypothyroidism in this group of clients are often confused with symptoms of aging. C. Hypothyroidism presents with pitting edema for this group of clients. D. Hypothyroidism is a congenital disease that manifests in older adult clients.

The nurse is providing care to a client who is receiving treatment for diabetic ketoacidosis (DKA). Which possible pathophysiologic cause should the nurse identify for the altered metabolism the client is experiencing? A. Decreased gluconeogenesis B. Insulin deficiency C. Excess production of bicarbonate D. Hypo-osmolarity

Which diagnostic test result is consistent with a diagnosis of septic shock? A) A blood pH that is higher than normal B) A hematocrit that is higher than normal C) A PaCO2 that is lower than normal D) A potassium level that is lower than normal

Which goal would be most appropriate to include in the nursing care plan of a client with type 2 diabetes? A. The client will use hand hygiene when toileting. B. The client will inspect feet at least once daily. C. The client will record daily fat intake. D. The client will monitor fasting glucose levels.

Which intervention can the nurse implement independently to provide support to clients with an alteration in metabolism? A. Order blood tests. B. Refer the client to a nutritionist. C. Administer hormone therapies. D. Refer the client to an acupuncturist.

Which potential cause of type 2 diabetes influences insulin's ability to regulate glucose metabolism and uptake by the liver, skeletal muscles, and adipose tissue? A. Exposure to toxins B. Obesity C. Young age D. Viral infection

A client with Graves disease requests that the nurse explain the results of recent laboratory tests. Which results would the nurse anticipate discussing with the client? Select all that apply. A. A decrease in serum T4 B. An increase in thyroid antibodies C. An increase in serum T3 D. An increase in TSH levels E. A decrease in T3 uptake

B, C

The nurse is planning care for a 4-year-old child newly diagnosed with type 1 diabetes mellitus. The child's mother appears unconcerned with the diagnosis and is complaining about the cost of medication, as three additional children in the family have needs. On which nursing diagnoses should the nurse focus when planning this client's care? Select all that apply. A. Disturbed Body Image B. Compromised Family Coping C. Risk for Unstable Blood Glucose Level D. Chronic Pain E. Deficient Knowledge

B, C, E

A nurse in the emergency department is completing an assessment of a client who is in shock. Which of the following findings should the nurse expect? (Select all that apply) A. Heart rate 60/min B. Seizure activity C. Respiratory rate 42/min D. Increased urine output E. Weak, thready pulse

B, C, E * Tachycardia, not bradycardia, and decreased urine output expected

What collaborative interventions are likely to improve outcomes for an 11-year-old client diagnosed with type 2 diabetes mellitus? Select all that apply. A. Weaning off oral medications B. Physical activity to be at least 30 to 60 minutes per day most days of the week C. Obtaining adequate rest and sleep D. Family participation in the lifestyle change E. Food intake based on age, sex, and physical activity

B, D, E

A nurse in a cardiac unit is assisting with the admission of a client who is to undergo hemodynamic monitoring. Which of the following actions should the nurse anticipate performing? A. Administer large volumes of IV fluids B. Assist with insertion of pulmonary artery catheter C. Obtain Doppler pulses of the extremities D. Gather supplies for insertion of a peripheral IV catheter

B. A pulmonary artery catheter and pressure-monitoring system are inserted for hemodynamic monitoring of a client

A nurse is planning care for a client who has septic shock. Which of the following is the priority action for the nurse to take? A. Maintaining adequate fluid volume with IV infusions B. Administering antibiotic therapy C. Monitoring hemodynamic status D. Administering vasopressor medication

B. Using the safety and risk reduction framework, administration of antibiotics is the priority action by the nurse. Eliminating endotoxins and mediators from bacteria will reduce the vasodilation that is occuring

List the pathophysiology concepts related to the onset of sepsis in sequential order. A) Macrophage-producing cytokines are released. B) Endotoxin released by microorganisms sets off an out-of-control inflammatory process. C) Neutrophils arrive and multiply, occluding capillaries. D) Vasodilation with increased capillary permeability and fluid leak.

BADC

Obstructive shock

Blockage of great vessels, pulmonary artery stenosis, pulmonary embolism, cardiac tamponade, tension pneumothorax and aortic dissection

A client is experiencing hypovolemic shock. Which of the following assessments best assists in evaluating the client's fluid status? Select all that apply. Respiratory rate Skin turgor Daily weight Heart rate Hemoglobin level Blood pressure

Blood pressure Heart rate Respiratory rate Skin turgor Daily weight Explanation: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. As compensatory mechanisms, heart and respiratory rates generally increase with both fluid volume deficit and overload, making those assessment essential. Skin turgor and daily weights are essential assessments in the client with any fluid imbalance. The hemoglobin level reflects red blood cell concentration, not overall fluid status.

A client who is newly diagnosed with type 1 diabetes has smoked for 30 years. When teaching the client on ways to optimize health outcomes, what should the nurse explain about the effects of smoking and diabetes? A. Smoking increases insulin resistance. B. Smoking is a major factor in the development of diabetic neuropathy. C. Smoking accelerates atherosclerotic changes in blood vessels. D. Smoking promotes weight gain.

A client with hyperthyroidism is scheduled for surgery in a few days. Which collaborative intervention would address cardiovascular symptoms that may prevent the client from undergoing the procedure? A. Nothing, because there is little effect on the quality of life in older adults. B. The ingestion of radioactive iodine, I-131 C. Administration of antithyroid medications with propranolol D. A combination treatment with levothyroxine (Synthroid) and amiodarone (Cordarone)

An alteration in parathyroid hormone levels is likely to directly affect what other nursing concept related to metabolism? A. Perfusion B. Reproduction C. Mobility D. Acid-base balance

For clients with a deficiency in any hormone, what client teaching is important for the nurse to provide? A. Teaching related to increasing fluid intake B. Teaching related to regulating sugar intake C. Teaching related to taking hormone supplements as directed D. Teaching related to decreasing body weight

The nurse is caring for a client who is prescribed calcitonin-human (Cibacalcin) nasal spray. Which teaching point should the nurse include in this client's plan of care? A. Administer the nasal spray in both nostrils at each dose. B. Always administer the nasal spray in the left nostril. C. Administer the nasal spray in alternate nostrils each day. D. Always administer the nasal spray in the right nostril.

The nurse is caring for a newborn born to a mother with uncontrolled hyperthyroidism during pregnancy. What complication should the nurse monitor the newborn for? A. Late closure of fontanels B. Slow heart rate C. Breathing problems D. Rapid weight gain

The nurse is counseling a couple who is planning a pregnancy. The woman was diagnosed with type 1 diabetes when she was 14 years old. She is now 27. Which examination should the nurse prepare the woman to have before, during, and after the pregnancy? A. Gastrointestinal examination for gastric hypotony B. Neural examination for diabetic peripheral neuropathy C. Eye examination for diabetic retinopathy D. Renal examination for urinary incontinence

The nurse is providing care for a young adult client with exophthalmos. Which nursing diagnosis would be the most appropriate for this client? A. Risk for Injury B. Activity Intolerance C. Disturbed Body Image D.Ineffective Coping

The nurse is providing teaching on preventing sepsis. Which should the nurse include as a major risk factor for the development of this health problem? A) Pneumococcal bacteria B) Leukocytosis on the complete blood count C) Undiagnosed urinary tract infection D) Elevated temperature

Type 2 diabetes mellitus is characterized by which underlying pathophysiology? A. Impaired insulin uptake B. Inability of the pancreas to produce insulin C. Insulin resistance D. Excessive insulin production

Which type of infection has been implicated in destruction of pancreatic beta cells and thus causes type 1 diabetes? A. Bacterial B. Fungal C. Viral D. Parasitic

The nurse is reviewing the laboratory test results for a client with an endocrine disorder. Which diagnostic tests would the nurse anticipate reviewing for this client? Select all that apply. A. Prothrombin time B. Ammonia level C. Liver enzymes D. T3 and T4 levels E. Serum albumin

C, D, E

A nurse in the emergency department is caring for a client who has an allergic reaction to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse expect to administer first? A. Methylprednisolone (Solu-Medrol) IV bolus B. Diphenhydramine (Benadryl) sub Q C. Epinephrine (Adrenaline) IV D. Albuterol (Proventil) inhaler

C. Using the ABC priority framework, epinephrine is administered first. It is a rapid-acting medication that promotes effective oxygenation and is used to treat anaphylactic shock

A postoperative client has exhibited decreased urine output, hypotension, and tachycardia. Which of the following is the priority nursing assessment? Check the dressing Assess IV rate Palpate the radial pulse Obtain bladder scan

Check the dressing Explanation: Although all are assessments that may be indicated for this client, and the priority is the dressing. The client is exhibiting signs of shock. Shock in a postoperative client typically results from bleeding.

The nurse is aware that, in addition to the rule of nines, which is the most important assessment priority when assessing a client with facial burns? Observing for facial swelling and disfiguration Assessing tolerance of the pain Checking for airway patency Determining oxygen saturation levels SUBMIT ANSWER Exit quiz

Checking for airway patency Explanation: Because the client has received facial burns, there may have been gasping for air resulting in a steam inhalation. The consequence is that the resultant inflammation and swelling may result in airway impairment. The other assessments are not as critical as airway patency.

A client with septic shock has continued to deteriorate and has become unresponsive. The nurse has inserted an intravenous line and an oral airway. Which of the following is the highest priority for the nurse at this time? Check the surgical dressing to ensure that it is intact. Monitor temperature every 4 hours. Examine the IV site for infiltration. Confirm the placement of the oral airway. SUBMIT ANSWER Exit quiz

Confirm the placement of the oral airway. Explanation: Confirming the placement of the oral airway ensures a patent air passage. Oxygen is essential for life, so this action takes priority. Other answers do not reflect ABC priority based on client unresponsiveness.

A client newly diagnosed with type 1 diabetes mellitus tells the nurse that the diagnosis must be wrong because the client is not overweight, eats all of the time, and is thin. Which response by the nurse is most appropriate? A. "Your lab tests indicate the presence of diabetes." B. "Thin people can be diabetic, too." C. "Your condition makes it impossible for you to gain weight." D. "You are eating large quantities because your condition makes it difficult for your body to obtain energy from the foods taken in."

An older adult client with new-onset atrial fibrillation is sweating excessively. After reviewing the client's recent laboratory results, the nurse concludes that which might be causing the client's symptoms? A. A Hgb level of 13.8 g/dL B. A hemoglobin (Hgb) level of 11.0 g/dL C. A thyroid-stimulating hormone (TSH) level of 0.25 mU/mL D. A TSH level of 18 mU/mL

Health promotion and prevention related to type 1 diabetes should include A. referring clients to a nutritionist and exercise therapist. B. providing clients with vaccinations against viruses that cause type 1 diabetes. C. teaching clients at high risk how to prevent type 1 diabetes. D. teaching clients with type 1 diabetes how to prevent complications.

The nurse is assessing the vital signs of a client experiencing hypoparathyroidism. While monitoring the blood pressure, the nurse notes the client's hand begins to spasm. Which term is appropriate for the nurse to use when documenting this assessment finding? A. Chvostek sign B. Turner sign C. Cullen sign D. Trousseau sign

The nurse is caring for an older adult client who developed sepsis from a pressure ulcer while residing in a long-term care facility. The family asks how they can help prevent this from happening again in the future. Which response by the nurse is best? A) Alert the staff when the client's IV runs dry. B) Help the nurse with dressing changes. C) Assist the client to the bathroom so there is not a fall. D) Assist the client with meals to obtain optimal nourishment.

The nurse is completing an assessment interview with an older adult client being seen for a yearly physical examination. Which client statement would indicate a possible diagnosis of diabetes mellitus? A. "I sometimes have muscle aches in my upper legs at night." B. "I feel a bit tired by mid-afternoon and take a 30-minute nap most days." C. "I'm slightly winded when I walk up a flight of stairs, but it passes quickly." D. "I've been experiencing increased thirst during the past several months."

The nurse suspects that a client is experiencing hypothyroidism. Which question should the nurse ask during the health history? A. "Do you have brown, shiny patches on your legs?" B. "Are you intolerant to heat?" C. "Is your skin often clammy?" D. "Have you had unexplained weight gain?"

What causes edema in adults with hypothyroidism? A. Increased capillary permeability in the extremities B. Decreased plasma oncotic pressure in the capillaries C. Excess reabsorption of water and sodium in the kidneys D. Water retention in mucoprotein deposits in the interstitial spaces

Which client is at the greatest risk for developing hypothyroidism? A. A 21-year-old woman who has a mother with Graves disease B. A 72-year-old man whose father had cardiovascular disease C. A 32-year-old man who has an uncle with type 1 diabetes mellitus D. A 57-year-old woman whose aunt had systemic lupus erythematosus

A client presents to the ED in shock. During what phase of shock does the nurse know that metabolic acidosis is going to most likely occur? Compensation Decompensation Irreversible Early

Decompensation Explanation: The decompensation stage occurs as compensatory mechanisms fail. The client's condition spirals Into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis.

The nurse is caring for a client in the intensive care unit. Which drug is most commonly used to treat cardiogenic shock? Enalapril Dopamine Metoprolol Furosemide

Dopamine Explanation: Cardiogenic shock is when the heart has been significantly damaged and is unable to supply enough blood to the organs of the body. Dopamine, a sympathomimetic drug, improves myocardial contractility and blood flow through vital organs by increasing perfusion pressure. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and does not have a direct effect on contractility or tissue perfusion. Metoprolol is a adrenergic blocker that slows heart rate and lowers blood pressure; neither is a desired effect in the treatment of cardiogenic shock.

Hypovolemic shock

Excessive fluid loss from diuresis, vomiting/diarrhea, blood loss

A nurse assesses a client during the third stage of labor. Which assessment findings indicate that the client is experiencing postpartum hemorrhage? Heart rate 120 beats/minute, respiratory rate 8 breaths/minute, blood pressure 150/100 mm Hg Heart rate 50 beats/minute, respiratory rate 8 breaths/minute, blood pressure 150/100 mm Hg Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg Heart rate 50 beats/minute, respiratory rate 28 breaths/minute, blood pressure 150/100 mm Hg

Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg Explanation: An increased heart rate (usually greater than 100 beats/minute, depending on the client's baseline) followed by an increased respiratory rate and decreased blood pressure may be the first signs of postpartum hemorrhage and hypovolemic shock. Remediation:

A nurse is planning postoperative care for a client who has received a general anesthetic. During the immediate postoperative period, which nursing assessment should the nurse be most concerned about? Urinary output of 190 milliliters and dark amber urine in 6 hours Dressing saturated with a moderate amount of bloody drainage, and blood pressure of 130/70 mm Hg Reports of pain and an occasional premature ventricular contraction (PVC) Heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24 SUBMIT ANSWER Exit quiz

Heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24 Explanation: The nurse should check for bleeding, monitor the vital signs, and promote urine output after airway patency has been established. Option D indicates the early signs and symptoms of shock and the nurse should be most conern.

The priority nursing diagnosis for a client who has just been admitted to the hospital with burns would be which of the following? Impaired skin integrity Risk for altered nutrition Body image disturbance Impaired social interaction SUBMIT ANSWER Exit quiz

Impaired skin integrity Explanation: Impaired skin integrity is the priority in the situation of the burned client because of the fluid and electrolyte loss and a high risk for infection. While body image, social interaction, and altered nutrition are all concerns, they are not necessarily potentially life threatening, unlike the impaired skin integrity.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? Impaired physical mobility related to the disease process Ineffective airway clearance related to edema of the respiratory passages Impaired skin integrity related to disease process Risk for infection related to breaks in the skin

Ineffective airway clearance related to edema of the respiratory passages Explanation: When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process is not appropriate because burns are not a disease. Impaired skin integrity related to disease process is not the priority and Risk for infection related to breaks in the skin may be appropriate, but they do not command a higher priority than Ineffective airway clearance because they do not reflect immediately life-threatening problems.

A client with burns to 40% of the body arrives at the emergency room. Which prescriptions by the primary healthcare provider should the nurse anticipate? Select all that apply. Insertion of a nasogastric tube Education about the importance of good nutrition Administration of lactated Ringer's (LR) solution intravenously Monitoring the client's body temperature Administration of 100% humidified oxygen

Insertion of a nasogastric tube Administration of 100% humidified oxygen Monitoring the client's body temperature Administration of lactated Ringer's (LR) solution intravenously Explanation: A client arriving to the emergency room with burns is in the emergent/resuscitative phase of managing a burn injury. The nurse should expect the primary healthcare provider to prescribe insertion of a nasogastric tube to decompress the stomach and prevent vomiting. Administration of 100% humidified oxygen and monitoring the client's body temperature are also expected. Fluid resuscitation for clients with burn injuries greater than 20% is necessary to support circulatory function and tissue perfusion. Administration of LR intravenously is the preferred fluid. The nurse would not provide education about nutrition during the emergent phase.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first? Normal saline solution with 20 mEq of potassium per 1,000 ml Lactated Ringer's solution Dextrose 5% in water (D5W) Albumin

Lactated Ringer's solution Explanation: Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental.

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? 10% dextrose in water Half-normal saline solution Lactated Ringer's solution 5% dextrose and normal saline solution

Lactated Ringer's solution Explanation: Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.

Neurogenic shock

Loss of sympathetic tone causing massive vasodilation due to trauma, spinal shock, epidural anesthesia

A nurse is developing a care plan for a client recovering from a serious thermal burn. What does the nurse determine is the priority goal of therapy? Providing emotional support to the client and family Maintaining the client's fluid and electrolyte balance Maintaining a caloric intake to meet metabolic needs Providing adequate management of pain

Maintaining the client's fluid and electrolyte balance Explanation: After maintaining respirations, the most important and immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis. Although caloric intake is important for healing, it is not the priority. Pain control and emotional support are also a lower priority than physiological needs.

What is the most important goal of nursing care for a client who is in shock? Manage increased cardiac output. Manage fluid overload. Manage vasoconstriction of vascular beds. Manage inadequate tissue perfusion.

Manage inadequate tissue perfusion. Explanation: Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock.

A client is receiving dopamine hydrochloride for treatment of shock. What action should the nurse take? Monitor blood pressure continuously. Administer pain medication concurrently. Monitor for signs of infection. Evaluate arterial blood gases at least every 2 hours.

Monitor blood pressure continuously. Explanation: The client who is receiving dopamine hydrochloride requires continuous blood pressure monitoring with an invasive or noninvasive device. The nurse may titrate the IV infusion to maintain a systolic blood pressure of 90 mm Hg. Administration of a pain medication concurrently with dopamine hydrochloride, which is a potent sympathomimetic with dose-related alpha-adrenergic agonist, beta 1-selective adrenergic agonist, and dopaminergic blocking effects, is not an essential nursing action for a client who is in shock with already low hemodynamic values. Arterial blood gas concentrations should be monitored according to the client's respiratory status and acid-base balance status and are not directly related to the dopamine hydrochloride dosage. Monitoring for signs of infection is not related to the nursing action for the client receiving dopamine hydrochloride.

A nurse is assessing a client's blood pressure 8 hours after surgery. The client's blood pressure before surgery was 120/80 mm Hg, and on admission to the postsurgical nursing unit it was 110/80 mm Hg. The client's blood pressure is now 90/70 mm Hg. After determining that other vital signs are normal, what should the nurse do first? Check the intake and output record. Notify the health care provider (HCP). Elevate the head of the bed. Administer pain medication. SUBMIT ANSWER Exit

Notify the health care provider (HCP). Explanation: The client's systolic blood pressure is dropping, and the pulse pressure is narrowing, indicating impending shock. The nurse should notify the surgeon. Elevating the head of the bed will not increase the blood pressure. Administering pain medication could cause the blood pressure to drop further. The intake and output record may indicate decreased urine output related to shock, but the nurse should first contact the HCP.

The nurse should assess a client for which of the following complications associated with disseminated intravascular coagulation (DIC)? Renal calculi Septic shock Congestive heart failure Pulmonary embolism SUBMIT ANSWER Exit quiz

Pulmonary embolism Explanation: Pulmonary embolism is an indication of intravascular clotting due to the fact that platelets have been significantly decreased and there is clotting and bleeding. Low prothrombin levels will also show that there is a delay in clotting, so the person will bleed for a longer time. The other conditions are not associated with DIC.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to infection Related to fat emboli Related to circumferential eschar Related to femoral artery occlusion

Related to circumferential eschar Explanation: As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.

A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority? Preparing for an escharotomy Preventing contractures of extremities Beginning range of motion exercises Replacing fluid and electrolytes SUBMIT ANSWER

Replacing fluid and electrolytes Explanation: After establishing a patent airway, fluid resuscitation is critical for the client with a burn injury. Positioning to prevent contractures and removing dead skin (escarotomy) are important interventions, but are not the priority. It is too soon to begin range of motion exercises.

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis? Seizures Shock Stroke Hyperglycemia

Shock Explanation: Complications of respiratory acidosis include shock and cardiac arrest. Stroke and hyperglycemia aren't associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis.

A client arrives at the emergency department with deep partial-thickness and full-thickness burns over 15% of his body. At admission, his vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply. Cleaning the burns with hydrogen peroxide Placing ice directly on the burn areas Administering tetanus prophylaxis as ordered Administering 6 mg of morphine I.V. Starting an I.V. infusion of lactated Ringer's solution Covering the burns with saline-soaked towels

Starting an I.V. infusion of lactated Ringer's solution Administering 6 mg of morphine I.V. Administering tetanus prophylaxis as ordered Explanation: The goal of immediate interventions for this client should be to stop the burning and relieve the pain. To prevent hypovolemic shock and maintain cardiac output, the nurse should begin I.V. therapy with a crystalloid such as lactated Ringer's solution. To treat pain, she should administer 2 to 25 mg of morphine or 5 to 15 mg of meperidine I.V. in small increments. The nurse should also administer tetanus prophylaxis as ordered. Hydrogen peroxide and povidone-iodine solution could cause further damage to tissue, and saline-soaked towels could lead to hypothermia. Placing ice directly on burn wounds could cause further thermal damage.

The nurse is performing triage in the emergency department. Which client should be seen first? The client with burns to his chest and neck with singed nasal hair. A primipara who is 39 weeks pregnant having contractions every 15 minutes. The client who has an open fracture of his radius. The client with flank pain.

The client with burns to his chest and neck with singed nasal hair. Explanation: The client with burns to the chest and neck has the potential to develop decreased lung expansion. Singed nasal hair is indicative of inhalation injury and delayed respiratory distress syndrome. Flank pain and open fractures will not take precedence over the client with airway problems. The primipara still has time before the baby comes.

The student nurse asks why a client is receiving an IV of lactated Ringer's with potassium following an episode of diabetic ketoacidosis. What is the best response by the nurse? Hypokalemia is associated with uncontrolled diabetes, and the lactated Ringer's is isotonic fluid replacement. Lactated Ringer's will help lower the blood pH when hypokalemia is related to ketoacidosis. With acidosis, the intracellular potassium switches places with the plasma hydrogen ions to buffer the acidosis; the lactated Ringer's helps restore the bicarbonate reserves. In acidosis, the sodium moves into the cells to buffer the acid and displaces the potassium. The lactated Ringer's helps restore the alkaline pH.

With acidosis, the intracellular potassium switches places with the plasma hydrogen ions to buffer the acidosis; the lactated Ringer's helps restore the bicarbonate reserves. Explanation: In diabetic ketoacidosis, the cellular buffers will be activated. Potassium will move out of the cell and hydrogen will move inside the cells to lessen the impact on the plasma pH. Once the acidosis is corrected by bicarbonate injections and IV lactated Ringer's, potassium will move back into the cells, resulting in hypokalemia. Potassium levels will be monitored closely, and replacement will be initiated. Lactated Ringer's helps increase the blood pH and provides a source of bicarbonate replacement to replenish the base portion of the 1:20 acid-to-base relationship that helps maintain the blood at the pH of 7.35 to 7.45. Sodium does not switch with potassium in an acidotic state.

1) The nurse is concerned that a client with potential hepatic failure is at risk for developing ascites. Which assessment finding supports the development of liver failure as manifested by ascites? A) Increased abdominal girth B) Gallbladder pain C) Yellow-tinged skin D) Bleeding and bruising easily

10) Restricted blood flow through the liver results in which condition? A) Portal hypertension B) Cirrhosis C) Jaundice D) Biliary atresia

14) The nurse is assessing a school-age child who complains of severe itching, bruising easily, restlessness, and involuntary jerking of the hands. When considering these manifestations collectively, which organ or system should the nurse anticipate needing to assess further? A) The liver B) The nervous system C) The gastrointestinal tract D) The urinary system

4) A nurse is caring for a client who was recently admitted for treatment of cirrhosis. The client is currently experiencing ascites, +3 pitting edema, and oliguria. Which nursing diagnosis should the nurse select as a priority for this client? A) Excess Fluid Volume B) Ineffective Peripheral Tissue Perfusion C) Deficient Fluid Volume D) Impaired Skin Integrity

A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. The nurse should base the response on the knowledge that there was: an obstruction of urine flow from the kidneys. a decrease in the blood flow through the kidneys. structural damage to the kidney resulting in acute tubular necrosis. a blood clot formed in the kidneys.

a decrease in the blood flow through the kidneys. Explanation: There are three categories of acute renal failure: prerenal, intrarenal, and postrenal. Causes of prerenal failure occur outside the kidney and include poor perfusion and decreased circulating volume resulting from such factors as trauma, septic shock, impaired cardiac function, and dehydration. In this case of severe myocardial infarction, there was a decrease in perfusion of the kidneys caused by impaired cardiac function. An obstruction within the urinary tract, such as from kidney stones, tumors, or benign prostatic hypertrophy, is called postrenal failure. Structural damage to the kidney resulting from acute tubular necrosis is called intrarenal failure. It is caused by such conditions as hypersensitivity (allergic disorders), renal vessel obstruction, and nephrotoxic agents.

Which finding is an indication of a complication of septic shock? acute respiratory distress syndrome (ARDS) chronic obstructive pulmonary disease (COPD) mitral valve prolapse anaphylaxis

acute respiratory distress syndrome (ARDS) Explanation: ARDS is a complication associated with septic shock. ARDS causes respiratory failure and may lead to death, even after the client has recovered from shock. Anaphylaxis is a type of distributive or vasogenic shock. COPD is a functional category of pulmonary disease that consists of persistent obstruction of bronchial airflow and involves chronic bronchitis and chronic emphysema. Mitral valve prolapse is a condition in which the mitral valve is pushed back too far during ventricular contraction.

At about one-half hour before the daily whirlpool bath and dressing change the nurse should: soak the dressing. remove the dressing. administer an analgesic. slit the dressing with blunt scissors.

administer an analgesic. Explanation: Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.

The nurse is caring for a 70-year-old male client after a colectomy. The client has received chemotherapy prior to surgery and has hypertension and diabetes mellitus. Which factors put this client at risk for sepsis? Select all that apply. weight diabetes mellitus abdominal surgery age gender

age abdominal surgery diabetes mellitus Explanation: Known risk factors for sepsis include age (<1 year and >65 years old), chronic illness, and invasive procedures. Immunosuppression and malnourishment are also risk factors. There is no correlation between gender or age and risk for sepsis. Nurses must be aware of risk factors and monitor clients at risk closely for any signs of sepsis.

There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? Select all that apply. an 8-year-old with third-degree burns over 10% of the body surface area (BSA) a 20-year-old who inhaled the smoke of the fire a 30-year-old with second-degree burns on the back of the left leg (about 9% of body surface area (BSA) a 40-year-old with second-degree burns on the right arm (about 10% of BSA) a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area (BSA)

an 8-year-old with third-degree burns over 10% of the body surface area (BSA) a 20-year-old who inhaled the smoke of the fire a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area (BSA) Explanation: Clients who should be transferred to a burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their BSA, clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA, clients of any age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.

12) What nursing intervention should be used to decrease pruritus in clients with liver disease? A) Vigorously scrub the skin with soap to prevent infection. B) Apply a lubricant on the skin to prevent dry skin. C) Use hot water rather than cool water when bathing the client. D) Administer an antihistamine as needed to reduce itching.

2) The nurse is caring for a client who complains of jaundice and pruritus. The healthcare provider suspects that the client has liver disease. What modifiable risk factor for cirrhosis of the liver might the nurse see in the client's history? A) Smokes two packs of cigarettes per day B) Drinks a six-pack of beer each evening C) History of occupational exposure to hepatic toxins D) Family history of fatty liver disease

6) The nurse is caring for a client recovering from a liver transplant necessitated by cirrhosis of the liver. Which postoperative outcome would be a priority for this client? A) Moist membranes of the mouth B) Normal serum bilirubin levels C) Ability to move the legs D) Normal pupil reaction

3) The nurse is identifying risk factors for liver disease among individuals who visit the community health center. Which does the nurse recognize as factors contributing to increased risk among certain ethnic groups? Select all that apply. A) Pollution B) Variations in alcohol metabolism C) Stress due to socioeconomic factors D) Consuming alcohol with food E) Climate

8) A nurse is caring for a client with end-stage liver disease. Which alterations should the nurse anticipate with this client? Select all that apply. A) Elevated serum albumin levels due to increased protein synthesis B) Decreased clotting factor levels due to impaired clotting factor production C) Hyperglycemia due to disrupted glucose metabolism D) Increased serum vitamin K due to impaired clearance of fat-soluble vitamins E) Increased plasma oncotic pressure due to impaired protein metabolism

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: blood pressure. temperature. heart rate. hemoglobin level.

blood pressure. Explanation: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.

13) A new mother brings her 2-week-old infant in for a checkup because he looks jaundiced and his stools are white. The provider suspects the infant might have biliary atresia. What findings does the nurse anticipate upon assessment of the infant? A) Above average weight gain B) Increased urine output C) Abdominal distention D) Reduced rooting reflex

7) A client with liver cirrhosis begins to drain bright red blood through the nasogastric tube. Which should the nurse prepare to administer to this client? A) Vitamin K B) Ferrous sulfate C) Platelets D) Folic acid

A client is admitted to the Emergency Department with a full thickness burn to the right arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should: call the health care provider (HCP) to report the loss of the radial pulse. continue to assess the arm every hour for any additional changes. administer morphine sulfate IV push for the severe pain. instruct the client to exercise his fingers and wrist.

call the health care provider (HCP) to report the loss of the radial pulse. Explanation: Circulation can be impaired by circumferential burns and edema, causing compartment syndrome. Early recognition and treatment of impaired blood supply is key. The HCP should be informed since an escharotomy (incision through full-thickness eschar) is frequently performed to restore circulation. Pain management is important for burn clients, but restoration of circulation is the priority. Assessments should be performed every 15 minutes while there is absence of the radial pulse. Exercise will not restore the obstructed circulation.

The nurse is assessing a client who is in shock. Which neurologic change indicates that the client is in the progressive stage of shock? unconsciousness incoherent speech confusion restlessness SUBMIT ANSWER

confusion Explanation: In the progressive stage of shock, the client can display listlessness or agitation, confusion, and slowed speech. Restlessness occurs in the compensatory stage. Incoherent speech and unconsciousness are clinical manifestations of the irreversible stage.

5) The nurse is providing education to the caregivers of a client with cirrhosis of the liver. The caregivers indicate that they've heard of portal hypertension, but they aren't sure which symptoms could indicate that their loved one is experiencing this condition. Which symptoms of portal hypertension should the nurse discuss with the caregivers? A) Muscle wasting B) Hypothermia C) Bleeding gums D) Hemorrhoids

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: increase the amount of scarring. decrease circulation to the fingers. increase edema in the arms. dislodge the autografts.

dislodge the autografts. Explanation: Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. Exercise doesn't cause increased edema, increased scarring, or decreased circulation.

Which finding is a risk factor for hypovolemic shock? gram-negative bacteria vasodilation hemorrhage antigen-antibody reaction

hemorrhage Explanation: Causes of hypovolemic shock include external fluid loss, such as hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration. Massive vasodilation is the initial phase of vasogenic or distributive shock, which can be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial infection is the most common cause of septic shock. Loss of sympathetic tone (vasodilation) occurs in neurogenic shock.

A teenage client is admitted to the burn unit with burns over 49% of the body surface area, including the face and neck. Carbon particles are noted around the nose and mouth. The client is slightly confused, with reports of minor pain. When assessing the client, which of the following is an immediate priority for the nurse to evaluate? Mental status changes Reports of pain Patency of airway Emotional reaction to the fire

patency of airway Explanation: It is very likely that the client has had a smoke inhalation injury after suffering a severe burn greater than 20% of the total body surface area and having burns of the face and neck. The carbon particles observed around the nose and mouth would support this. Smoke inhalation can cause severe injury to the upper airway and lead to death. The other options would be secondary to evaluating the airway.

Which nursing intervention would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? teaching cigarette smoking cessation monitoring clients for signs of hypercapnia maintaining adequate serum potassium levels replacing fluids adequately during hypovolemic states

replacing fluids adequately during hypovolemic states Explanation: One of the major risk factors for development of ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potassium level and hypercapnia are not risk factors for ARDS.

Which finding alerts the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago? urine output of 180 mL during the past 3 hours increased blood pressure and decreased pulse and respiratory rates restlessness and shortness of breath sanguineous drainage from the chest tube at a rate of 50 ml/hour during the past 3 hours

restlessness and shortness of breath Explanation: Restlessness indicates cerebral hypoxia due to decreased circulating volume. Shortness of breath occurs because blood collecting in the pleural space faster than suction can remove it prevents the lung from reexpanding. Increased blood pressure and decreased pulse and respiratory rates are classic late signs of increased intracranial pressure. Decreasing blood pressure and increasing pulse and respiratory rates occur with hypovolemic shock. Sanguineous drainage that changes to serosanguineous drainage at a rate less than 100 mL/h is normal in the early postoperative period. Urine output of 180 mL over the past 3 hours indicates normal kidney perfusion.

A client is in hypovolemic shock. In which position should the nurse place the client? supine supine with the legs elevated 15 degrees Trendelenburg's semi-Fowler's.

supine with the legs elevated 15 degrees Explanation: A client in hypovolemic shock is best positioned supine in bed with the feet elevated 15 degrees to bring peripheral blood into the central circulation. Neither semi-Fowler's position nor the supine position by itself promotes venous return. Semi-Fowler's position would not facilitate venous return. Trendelenburg's position inhibits respiratory expansion and possibly causes increased intracranial pressure.

Which indicates hypovolemic shock in a client who has had a 15% blood loss? respiratory rate of 4 breaths/minute pulse rate less than 60 bpm systolic blood pressure less than 90 mm Hg pupils unequally dilated

systolic blood pressure less than 90 mm Hg Explanation: Typical signs and symptoms of hypovolemic shock include systolic blood pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is related to central nervous system injury or possibly to a previous history of eye injury.

A client with thrombocytopenia has developed a hemorrhage. The nurse should assess the client for which finding? decreased PaCO2 tachycardia bradycardia narrowed pulse pressure

tachycardia Explanation: The nurse should assess the client who is bleeding for tachycardia because the heart beats faster to compensate for decreased circulating volume and decreased numbers of oxygen-carrying red blood cells (RBCs). The degree of cardiopulmonary distress and anemia will be related to the amount of hemorrhage that occurred and the period of time over which it occurred. Bradycardia is a late symptom of hemorrhage; it occurs after the client is no longer able to compromise and is debilitating further into shock. If bradycardia is left untreated, the client will die from cardiovascular collapse. Decreased PaCO2 is a late symptom of hemorrhage, after transport of oxygen to the tissue has been affected. A narrowed pulse pressure is not an early sign of hemorrhage.

A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because: the client shows signs of aneurysm rupture. the client is experiencing heart failure. the client is going into cardiogenic shock. the client is in the early stage of right-sided heart failure.

the client is going into cardiogenic shock. Explanation: This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.

Which client is at greatest risk for inadequate nutrition? the client who is breastfeeding the client with burns to 45% of the body the client recovering from a femur fracture the client with diabetetic peripheral neuropathy

the client with burns to 45% of the body Explanation: With illness or injury, there is a need to heal or recover. To accomplish this, the client must consistently consume adequate nutrition (and protein) to maintain a positive nitrogen balance, and to experience necessary growth and/or healing. The client with burns has the greatest nutritional needs, due to the extent of the injury. Clients with diabetic neuropathy can be encouraged to follow the diabetic diet plan and manage pharmacological therapy to prevent further neuropathy. The client with a fractured femur is not at risk for inadequate nutrition unless there is also a reason the client is not eating. The client who is breastfeeding needs additional calories, but if the client is eating a well-balanced diet with additional calories, the client is not at risk for obtaining inadequate nutrition.

An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims should be transported to a burn center? Select all that apply. the victim with chemical spills on both arms the victim who inhaled smoke the victim in respiratory distress the victim with third-degree burns of both legs the victim with first-degree burns of both hands

the victim with chemical spills on both arms the victim with third-degree burns of both legs the victim in respiratory distress the victim who inhaled smoke Explanation: Victims with chemical burns, second- and third-degree burns over more than 20% of their body surface area, and those with inhalation injuries should be transported to a burn center. The victim with first-degree burns of the hands can be treated with first aid on the scene and referred to a health care facility.

Which clients with burns will most likely require an endotracheal or tracheostomy tube? A client who has: electrical burns of the hands and arms causing arrhythmias. secondhand smoke inhalation. chemical burns on the chest and abdomen. thermal burns to the head, face, and airway resulting in hypoxia

thermal burns to the head, face, and airway resulting in hypoxia. Explanation: Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke.

A client is in the compensatory stage of shock. Which finding indicates the client is entering the progressive stage of shock? heart rate of 110 bpm temperature of 99° F blood pressure of 110/70 mm Hg urinary output of 20 ml per hour

urinary output of 20 ml per hour Explanation: In the compensatory stage of shock, the client exhibits moderate tachycardia, but as the shock continues to the progressive stage the client will have a decreased urinary output, hypotension, and mental confusion as a result of failure to perfuse and ineffective compensatory mechanisms. The body temperature initially may remain normal. These findings are indications that the body's compensatory mechanisms are failing.

The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which change on the client's chart to the health care provider (HCP)? urine output respiratory rate heart rate blood pressure

urine output Explanation: Oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decreased urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock. The other changes in vital signs on the client's chart are not as significant as the decreased urinary output.

A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? pulse rate of 112 bpm serum sodium level of 136 mEq/L (136 mmol/L) urine output of 30 mL/h blood pressure of 94/64 mm Hg

urine output of 30 mL/h Explanation: Ensuring a urine output of 30 to 50 mL/h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but is not an indicator of adequate fluid balance. The blood pressure is low, likely related to the hypervolemia, but urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits.

When assessing a client for early septic shock, the nurse should assess the client for which finding? warm, flushed skin hemorrhage increased blood pressure cool, clammy skin

warm, flushed skin Explanation: Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.

NURS-200 Exam 2 - Version A

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