NURS 306 MC questions part dos

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Which of these are common complications of uncontrolled diabetes mellitus? A. Development of COPD B. Imbalance and vertigo C. Atherosclerosis and hyperlipidemia D. Improved vision

Which of the following best describes the focus of secondary injury prevention? A. Improvement of outcomes related to non-traumatic injuries B. Reduction in the severity of the injury that has occurred C. Prevention of the occurrence of the injury D. Enhancement of outcomes related to the traumatic injury

Which client would be the highest risk for development of a deep vein thrombosis (DVT)? A. An elderly client who has osteoarthritis B. An elderly client who is post-bronchoscopy C. A middle-aged client who is postop for hernia repair D. A middle-aged client in traction for a fractured hip

A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply. A. Enlarged liver size B. Excess storage of vitamin C C. Hemorrhoids D. Accelerated behaviors and mental processes E. Ascites

A, C, E

The nurse in the burn intensive care unit is caring for a client who sustained full thickness burns over 50% of the total body surface area (TBSA), mainly on the chest and neck, from a house fire. The client develops a hoarse and brassy cough and oxygen saturation is 78% and continues to decrease. What are the immediate action(s)? Select all that apply A. Call rapid response team B. Administer morphine 4 mg IV push C. Prepare for chest tube insertion D. Prepare for endotracheal intubation E. Encourage client to cough and deep breathe

A, D

A nurse is caring for a client with DKA. What finding does the nurse expect to see on the ABG? A. Increase pCO2 B. Decreased HCO3 C. Decreased pO2 D. Increase pH

Which of the clinical findings would the nurse expect to see in a patient with Addison's disease? Select all that apply. A. Weight gain of over 2 lbs over 2 days B. Blood pressure: 98/64 C. Spiked T waves on ECG monitor D. Temperature: 97.8 F (36.6 C) E. Blood glucose 51

B, C, E

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? A. Hypertension B. Flushing of the skin C. Oliguria D. Bradypnea

Which statement made by the client indicates a correct understanding of steroid therapy for Addison's therapy? A. "This medicine probably won't affect my blood pressure." B. "I'll take the same amount from now on." C. "I'll take the medicine in the morning because if I take at night, it might keep me awake." D. "I'll increase my potassium by eating more bananas."

What should the nurse teach a client with pancreatitis is the time to take the prescribed pancrelipase (Viokase)? A. Bedtime B. When nauseated C. Mealtime D. For abdominal pain

C (This drug is PERT)

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? A. Hypotension B. Numbness C. Shivering D. Reduced blood viscosity

C Shivering is a systemic response to cold therapy as the body attempts to promote heat production

A client with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? A. Bowel tones are present B. Electrolyte levels are normal C. Grey Turner sign resolves D. Abdominal pain is decreased

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? A. Maintaining NPO status B. Providing mouth care C. Administering morphine PO as ordered D. Placing the client in a semi-Fowler's position

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for postrenal acute kidney injury (AKI)? (Select all that apply.) A. Client with prostate cancer B. Client with blood clots in the urinary tract C. Client with ureterolithiasis D. Client with severe burns E. Client with lupus

A, B, C Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes postrenal AKI. Severe burns would be a prerenal cause. Lupus would be an intrarenal cause for AKI.

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority? A. Pupil reaction B. Urine output C. Bowel sounds D. Respiratory rate

D When using the airway, breathing, circulation approach to client care, the nurse should determine the priority assessment is respiratory rate. Morphine can cause respiratory distress. The nurse should withhold the medication and notify the prescriber if the client has a respiratory rate less than 12/min.

A nurse is planning care for a client with Cushing's disease. The nurse knows the client is at greater risk for which of the following? Select all that apply A. Infection B. Gastric ulcer C. Renal calculi D. Bone fractures E. Dysphagia

A, C, D

Which client conditons will the nurse recognize as absolute contraindications to receving a kidney transplant? Select all that apply. A. Breast cancer and metastasis to the lungs B. Type 2 diabetes controlled with diet and exercise C. Urinary tract infection D. Active treatment for peptic ulcer disease E. Chemical dependency F. Living related donor

A, C, E Absolute contraindications to kidney transplants include active cancer, current infection, active psychiatric illness, active substance abuse and nonadherence with dialysis or medical regimen.

A 62-year-old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? A. The serum potassium is 4.9 mEq/L B. Urine output over an 8 hour period is 200 mL C. The blood urea nitrogen (BUN) level is 67 mg/dL D. The creatinine level is 3.0 mg/dL

A nurse is caring for a client who has end-stage kidney disease (ESKD) and reports having shortness of breath and swelling in his lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and an elevated blood pressure. The nurse should suspect which of the following based on the client's manifestations? A. Hypovolemia B. Hypervolemia C. Hyperkalemia D. Hyponatremia

The nurse is educating the client about burn self-management and support. Which education will the nurse include? A. "You will need plastic surgery to remove scars and restore appearance." B. "It is important to wear pressure dressings to prevent contractures." C. "There are not many support groups, so it is best to go to counseling." D. "The likelihood of returning to your baseline functioning is low."

What does the nurse expect the nephrology provider to prescribed when post kidney transplant client develops oliguria, elevated temperature of 100 F(38.7C), increased BP, and signs of fluid retention 9 days after the surgery? A. Immediate removal of the transplanted kidney B. Increased doses of immunosuppressive drugs C. Immediate return to either hemodialysis or PD D. Antibiotic therapy until infection symptoms are resolved

A nurse is completing preoperative teaching for a client who is scheduled for a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. "The scope will be passed through your rectum." B. "You might have shoulder pain after surgery." C. "You will have a Jackson-Pratt drain in place after surgery." D. "you should limit how often you walk for 1-2 weeks."

B. "You might have shoulder pain after surgery" Shoulder pain expected post op due to free air that is introduced into the abdomen during the laparoscopic surgery. Jackson pratt drain would be for open surgery approach. The client will be instructed to ambulate frequently following a laparoscopic surgery to minimize free air.

Which client would the triage nurse categorize as urgent? A. 35 yr old w/ chest pain and diaphoresis B. 44 yr old w/ a dislocated elbow C. 65 yr old w/ redness and swelling on the forearm due to a bee sting D. 83 yr old w/ new confusion and very elevated blood pressure compared with his baseline

B. 44 yr old w/ a dislocated elbow In the 3 tiered system the urgent category includes clients with a new onset of pneumonia (as long as resp failure does not appear imminent), renal colic, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temp greater than 103F. A & D are emergent and C is nonurgent

A client diagnosed with type 2 diabetes is admitted with hyperosmolar hyperglycemic syndrome (HHS) coma. Which assessment data should the nurse expect the client to exhibit? A. Kussmaul respirations B. Diarrhea and epigastric pain C. Dry mucous membranes D. Fruity breath

A nurse is caring for a client admitted to the hospital for acute gastritis and ascites secondary to chronic alcohol use and cirrhosis. What is most important to assess for? A. Hourly urine output B. Nausea and vomiting C. Blood in stool D. Abdominal circumference

A nurse is caring for a client with an acute Addison's disease crisis. Which of the following manifestations will the nurse expect? Select all that apply. A. Bradycardia B. Constipation C. Weakness D. Hyperpigmentation E. Postural hypotension F. Diarrhea

C, D, E

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has a Minnesota tube. What action would the nurse take first? A. Sedate the client to prevent tube dislodgement B. Maintain balloon pressure at 15-20 mmHg C. Irrigate the gastric lumen with normal saline D. Assess the client airway patency

A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider? A. Report of discomfort during dialysate inflow B. Blood-tinged dialysate outflow C. Dialysate leakage during inflow D. Purulent dialysate outflow

A nurse is caring for a client with chronic cirrhosis. Which potential complication would cause the nurse the most concern? A. Ascites B. Fetor hepaticus C. Asterixis D. Varices

The nurse is caring for a client with multiple injuries sustained during a head-on motor vehicle collision. Which assessment finding is the priority? A. Ecchymosis in the flank area B. Irregular apical pulse C. Unequal pupils D. Deviated trachea to one side

Which action by the LPN requires the nurse to intervene immediately while caring for a client on protective isolation for a burn injury? A. The LPN is providing the client with clean sheets and linens B. The LPN is performing strict hand washing technique C. The LPN is wearing gloves and a gown when assisting with wound dressing changes. D. The LPN is delivering a vase of flowers to the client

Which clinical findings would be seen in a patient with DKA? A. Random blood glucose of 180 mg/dL B. Serum sodium - 135 mEq/L C. Weight loss of 2 lbs over 1 month D. Urine output > than 200 mL/hr

Which action should the nurse take to evaluate treatment effectiveness for a client who has hepatic encephalopathy? A. Request that the client stand on one foot B. Ask the client to perform the Valsalva maneuver C. Request that the client walk with eyes closed D. Ask the client to extend both arms forward

D "That's because that's going to show you the asterixis. It's gonna show if they have that hand flapping. If they have the hand flapping, it means their encephalopathy is getting worse."

A nurse is caring for a client who is unresponsive following a car crash. The client's son states that he does not want any heroic measures performed. Which of the following responses by the nurse is appropriate? A. "Let's wait to see if your father's condition improves before we talk about this." B. "Do you think everyone in the family agrees with you?" C. "If I were you, I would let the doctor know about your wishes when she makes rounds today." D. "Does your father have advanced health care directives?"

D Advanced directives are initiated by the client while competent to specify personal health care wishes. It is a legal document that minimizes a potential ethical dilemma from developing.

A nurse is teaching a client who has a new prescription for pancrelipase to aid in digestion. The nurse should inform the client to expect which of the following gastrointestinal changes? A. Decreased mucus in stools B. Decreased black tarry stools C. Decreased watery stools D. Decreased fat in stools

D Pancrelipase is a combination of pancreatic enzymes used to increase digestion of fats, carbohydrates and proteins. The client should expect a reduction of fat in stools.

A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care? A. Measure blood glucose levels every 4 hours B. Administer a diuretic C. Initiate fluid restrictions D. Check urine specific gravity

D The nurse should check the client's urine specific gravity to monitor urine concentration in a client who has diabetes insidious. A client who has diabetes insipidus has a urine specific gravity of less than 1.005

A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan? A. Administer antibiotics B. Provide a diet high in fat C. Restrict fluids D. Encourage short periods of ambulation

D The nurse should encourage a client who has hepatitis B to alternate between activity and rest

A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider? A. Glucocorticoid medications B. Dextrose 5% in 0.45% sodium chloride C. Oral hypoglycemic medications D. 0.9% sodium chloride IV bolus

D The nurse should expect a prescription for an IV bolus of 0.9% sodium chloride to be administered at 15 to 20 mL/kg/hr for the first hour to restore volume and maintain perfusion to the vital organs. A is incorrect because glucocorticoids are administered for their anti-inflammatory effect B is incorrect because D5W in 1/2 NS is prescribed when the blood glucose level reaches 250 mg/dL to prevent hypoglycemia and cerebral edema C is incorrect because oral hypogclycemics are prescribed for clients who have type 2 DM

A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment? A. Breast cancer survivor for 8 years B. Pacemaker C. 65-years of age D. Alcohol use disorder

D The nurse should identify that a substance use disorder is a contraindication for kidney transplant.

A nurse is caring for a client who has a history of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this client is giving which of the following conditions? A. Malnutrition B. Hepatitis A C. Diabetes D. Cirrhosis

D The nurse should recognize that this client is displaying manifestations of cirrhosis. A history of alcohol use disorder increases the client's risk of developing cirrhosis and coagulation defects are a common complication of cirrhosis

A nurse assesses a client with a pelvic fracture. Which assessment finding would the nurse identify as a complication of this injury? A. Hypertension B. Diarrhea C. Infection D . Hematuria

D The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse would also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia. Diarrhea and infection are not common complications of a pelvic fracture.

On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, breath sounds are absent. What is the nurse's next action? A. Document the findings B. Loosening any dressings on the chest C. Raising the head of the bed D. Prepare for intubation

D They're not breathing soooo...

The nurse in the emergency department receives an influx of patients. Triage the following patients as emergent, urgent, or nonurgent: 1. Post-op patient has shortness of breath and screams "I feel like I'm dying!" 2. Patient is unconscious, no pulse, and no respirations 3. Female patient complains of hematuria, dysuria, and frequent urination 4. Patient with ESKD missed hemodialysis, confused and has heart palpitations 5. Patient presents with right-sided weakness and facial droop, slurred speech 6. Older patient has productive cough, low grade fever, and chills

1. Emergent, it's giving PE 2. Emergent, they're in cardiac arrest. That's bad. 3. Nonurgent, they've got a UTI. Meh. 4. Emergent, it's giving symptomatic hyperkalemia. 5. Emergent, my dude has a stroke. 6. Urgent, pneumoniaaaa.

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? A. Perform a neuromuscular assessment B. Explain the discharge instructions to the client and parents C. Provide reassurances to the client and parents D. Apply an ice pack to the casted leg

A The greatest risk to the client is neuromuscular injury. Therefore, the priority action is to perform a neuovascular assessment. This consists of assessing the involved extremity (the lower leg) at the most distal point (the foot) for circulation (color), motion (movement), and sensation, and can be remembered by the acronym "C-M-S check."

A nurse is planning care for a client who has postrenal AKI due to metastatic cancer. The client has a blood creatinine of 5 mg/dL. Which of the following interventions should the nurse include in the plan? Select all that apply A. Provide high protein diet B. Assess the urine for blood C. Monitor for intermittent anuria D. Weigh the client once per week E. Provide NSAIDs for pain

A, B, C Weigh daily, DO not give NSAIDs

The nurse documents the vital signs of a patient with chronic cirrhosis: HR = 121 bpm Respirations = 27 breaths/min BP = 94/52 mmHg Oxygen saturation: 90% What priority interventions does the nurse anticipate? Select all that apply. A. Place the patient in an upright position B. Administer oxygen 2 L/min nasal cannula C. Place an 18 gauge peripheral IV D. Administer normal saline 0.9% 500 mL bolus E. Administer morphine 2mg IV push

A, B, C, D

The nurse is assigned to care for a patient with rhabdomyolysis. What are the priority nursing action(s)? Select all that apply. A. Administer fluids to restore fluid and electrolyte balance B. Administer pain medications as needed C. Insert Foley catheter to monitor urine output D. Obtain serum labs to monitor renal function E. Prepare patient for CT scan

A, B, C, D

A nurse is planning post-procedure care for a client who received hemodialysis. Which of the following interventions should the nurse include in the plan of care? Select all that apply. A. Check BUN and blood creatinine B. Administer meds the nurse withheld prior to dialysis C. Observe for findings of hypovolemia D. Assess the access site for bleeding E. Evaluate blood pressure on the arm with AV access

A, B, C, D NEVER access BP on extremity that has AV access site and cause collapse AV fistula or graft

A nurse is caring for a patient who has Cushing's disease. Which of the following are expected lab results? Select all that apply. A. Sodium 150 mEq/L B. Potassium 3.3 mEq/L C. Calcium 8.0 mg/dL D. Lymphocytes 35% E. Fasting glucose 145 mg/dL

A, B, C, E

A nurse in the emergency department is assessing a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? Select all that apply. A. Remove wet clothing B. Maintain normal room temperature C. Apply warm blankets D. Prepare for synchronized cardioversion E. Infuse warmed IV fluids

A, C, E

A client comes to the emergency department after sustaining burns from a house fire. The client has 27% total body surface area that is affected. What are the priority nursing actions? Select all that apply. A. Administer opioid analgesics as prescribed B. Immerse the client in cool water C. Flush the client's eyes with tap water D. Remove as much of the client's clothing as possible E. Initiate two intravenous lines

A, D, E

A client with type 2 diabetes controlled with biguanide (Metformin) oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? A. Provide a high-fat diet 24 hours prior to test B. Hold the metformin medication for 48 hours prior to test C. Obtain an informed consent form for the test D. Administer pancreatic enzymes prior to the test

A diabetic patient is admitted to the hospital with a blood glucose of 748 mg/mL and urinary output of 320 mL in the first hour. The client's vital signs are blood pressure 72/62, pulse 128, irregular and thready, respirations 38, and temperature 97 F. The patient is disoriented and lethargic with warm and dry skin. What is the priority nursing action? A. Hang one unit of packed red blood cells (PRBCs) B. Administer intravenous normal saline C. Decrease the amount of oxygen therapy the client is receiving D. Continue to assess vital signs

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following prescriptions should the nurse anticipate? A. Maintain an IV of 0.45% sodium chloride B. Restrict fluid intake to 1,000 mL per day C. Provide a diet containing 2 g of sodium per day D. Administer desmopressin acetate 0.2 mg orally

B Clients who have SIADH have an increased amount of ADH, which results in excess fluid volume. This excess fluid dilutes the sodium level in the blood, causing dilution hyponatremia. Oral fluids are restricted in an attempt to restore the fluid balance and the sodium level in the blood. The nurse should offer this client frequent oral care to prevent discomfort and breakdown of the oral mucosa. A is incorrect because 1/2 NS is a hypotonic fluid, it can worsen hyponatremia by further diluting the blood. If the client requires IV fluids, an isotonic fluid such as 0.9% sodium chloride is preferred. C is incorrect because...they already have hyponatremia. We want them slamming that salt. D. is incorrect because desmospressin is an analog of ADH and the hormone replacement of choice for diabetes insipidus. In SIADH, however, there is an excess of ADH, so desmopressin is not indicated.

A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse's priority? A. Elevate the client's feet B. Increase the client's IV fluid rate C. Initiate a dopamine IV infusion for the client D. Administer a unit of packed RBCs

B When using the urgent vs non urgent approach to client care, the nurse should determine that the priority action is to increase the client's IV fluid rate. Providing fluid to the client will restore circulating volume and increase blood pressure

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Anatacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see? A. Decreased WBC B. Increased serum amylase C. Decreased serum lipase D. Increased serum calcium

B With acute pancreatitis, serum amylase rises within 24 hours of the start of the client's symptoms

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see? A. Decreased WBC B. Increased serum amylase C. Decreased serum lipase D. Increased serum calcium

B With acute pancreatitis, serum amylase rises within 24 hours of the start of the client's symptoms

Which information will be included when the nurse is teaching self management to a chronic kidney disease (CKD) patient who is receiving peritoneal dialysis? Select all that apply A. Restrict fluid intake to 3000 mL daily B. Choose high-protein foods for most meals C. Avoid commercial salt substitutes D. Take phosphate binders with each meal E. Have several servings of dairy products daily

B, C, D

Which of the following instructions should a nurse include for a patient with Addison's disease taking hydrocortisone? Select all that apply. A. Take the medication on an empty stomach B. Notify the provider of any illness or stress C. Report any manifestations of weakness or dizziness D. Do not discontinue the medication suddenly E. Eat a low-sodium diet

B, C, D E is incorrect because they're losing lots of fluid. We want adequate sodium intake to retain fluid.

A nurse in the emergency department is admitting a client who was hiking on a hot July afternoon. The client is lethargic, orients to person only, hypotensive, hypoxemic, and tachycardic. Which of the following actions should the nurse take? Select all that apply. A. Administer acetaminophen 650 mg rectal route B. Administer normal saline 0.9% 1L IV bolus C. Place client on continuous cardiac monitoring D. Apply ice packs and cooling blankets E. Apply oxygen via nonrebreather

B, C, D, E

A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? Select all that apply. A. Green beans B. Tomatoes C. Bananas D. Asparagus E. Raisins

B, C, E

A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? Select all that apply A. Anorexia B. Change in orientation C. Asterixis D. Ascites E. Fetor hepaticus

B, C, E A change in orientation indicates hepatic encephalopathy in a client with advanced cirrhosis. Asterixis is also a late complication of this. Fetor hepaticus (fruity breath) is a finding with hepatic encephalopathy. Anorexia is present in a pt with liver dysfunction but not an indication of hepatic encephalopathy. Ascites can be present in a pt w/ liver dysfunction but is not and indication of hepatic encephalopathy.

A nurse assesses a client who has liver disease. Which laboratory findings would the nurse recognize as potentially causing complications of this disorder? Select all that apply. A. Elevated aspartate transaminase B. Elevated international normalized ratio (INR) C. Decreased serum alkaline phosphatase D. Elevated serum ammonia E. Elevated prothrombin time (PT)

B, D, E A. AST is an expected finding B is correct because it can cause bleeding issues C. is incorrect because an INCREASED ALT is what you see in liver disease. A decreased ALT would be a good sign D. is correct because we'd be worried about hepatic encephalopathy E. is correct because of bleeding risk

A nurse is planning care for a client who has prerenal acute kidney injury (AKI) following abdominal aortic aneurysm repair. Urinary output is 60 mL in the past 2 hr, and blood pressure is 92/58. The nurse should expect which of the following interventions? A. Prepare the client for a CT scan with contrast dye B. Prepare to administer a fluid challenge C. Plan to administer nitroprusside D. Plan to position the client Trendelenburg

B. Prepare to administer a fluid challenge Plan to administer a fluid challenge for hypovolemia, which is indicated by the clients low urinary output and BP

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention? A. Auscultate the client's lungs B. Assist the client to a side-lying position C. Provide oral hygiene D. Withhold oral fluids and food

D To rest the pancreas and reduce secretion of pancreatic enzymes, NPO status must be initiated and maintained during the acute phase of pancreatitis. This is the priority intervention to address after the client's pain has been treated.

The nurse is planning care for a client with acute severe pancreatitis. What is the highest priority client outcome? A. Developing no ongoing pancreatic disease B. Expressing satisfaction with pain control C. Having fluid and electrolyte balance D. Maintaining normal respiratory function

A nurse is preparing to start an IV infusion of Lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hours. How many mL/hr should the nurse set the pump to infuse for the first 8 hours? (Round the answer to the nearest whole number) ____ mL/hr

325 mL/hr The nurse should infuse half of the total volume prescribed for 24 hours for a client who has sustained a burn injury over the first 8 hours. So 5200/2 = 2600 mL 2600 mL/8 hr = 325 mL/hr

A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? A. Insert urethral catheter B. Draw a complete blood count C. Obtain renal ultrasound D. Infuse normal saline at 50 mL/hr

A client diagnosed with Addison's disease is admitted to the unit after a day at the lake. The client is lethargic, forgetful and weak. Which intervention should the nurse implement? A. Start an IV with 18-gauge needle and infuse normal saline rapidly B. Have the client wait until you are done with the morning medications C. Obtain a consent for the client to receive a blood transfusion D. Collect urinalysis and blood samples for a CBC and calcium level

What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department? A. Determine the acuity of the client's condition to determine priority of care. B. Assess the status of the airway, breathing, circulation, or presence of deficits. C. Determine whether the client is responsive enough to provide needed information. D. Evaluate the emergency department's resources to adequately treat the patient.

A ED triage is an organized system for sorting and classifying clients into priority levels depending on illness or injury severity. The primary goal of the triage system is to facilitate the ED nurse's ability to prioritize care according to the acuity of the patient, having the clients with the more severe illness or injury seen first. Airway, breathing, and circulation are part of the primary survey. Determining responsiveness is done during the disability phase of the primary survey and is not the primary goal. Evaluating the ED's resources is also not a goal of triage.

The nurse gets the hand-off report on four clients. Which client would the nurse assess first? A. Client with a blood pressure change of 128/74 to 110/88 mm Hg B. Client with oxygen saturation unchanged at 94% C. Client with a pulse change of 100 to 88 beats/min D. Client with urine output of 40 mL/hr for the last 2 hours

A This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of worsening perfusion status and possible shock. The nurse would assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate that the client's pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is above the normal range, which is 30 mL/hr.

A nurse is caring for a client who has cirrhosis. Which of the following medication can the nurse expect to administer to this client? Select all that apply. A. Diuretic B. Beta-blocking agent C. Opioid analgesic D. Lactulose E. Sedative

A, B, D Diuretics to facilitate excretion of excess fluids. Beta blocking agents to prevent bleeding from cirrhosis. Lactulose to aid in elimination of ammonia in stool. Opioids and sedatives are metabolized in the liver and should not be given.

A client is undergoing hemodialysis. The client's blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions would the nurse perform to maintain blood pressure? (Select all that apply.) A. Adjust the rate of extracorporeal blood flow. B. Place the patient in the Trendelenburg position. C. Stop the hemodialysis treatment. D. Administer a 250-mL bolus of normal saline. E. Contact the primary health care provider.

A, B, D Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the primary health care provider contacted.

A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? Select all that apply. A. Assess blood glucose levels B. Assess for neck vein distention C. Monitor for an irregular heartbeat D. Monitor for postural hypotension E. Weigh the client daily

A, B, E Cushing's syndrome affects blood glucose levels by causing increased release of glucose from the liver and decreased sensitivity of insulin receptors. This can result in elevated blood glucose levels.

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? Select all that apply. A. Color B. Temperature C. Ecchymosis D. Skin integrity E. Sensation

A, B, E These are all parts of a neurovascular check. This rationale is dope, I know.

A client diagnosed with Cushing's disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client? Select all that apply. A. Instruct the client to take the glucocorticoid and mineralocorticoid medications as prescribed B. Teach the client regarding sexual functioning and androgen replacement therapy C. Explain the signs and symptoms of infection and when to call the health care provider D. Demonstrate turn, cough, and deep-breathing exercises the client should perform every 2 hours

A, C

Which clients would the triage nurse classify as emergent, needing to been immediately? Select all that apply. A. Client w/ crushing substernal chest pain and shortness of breath B. Client with a generalized skin rash who had shellfish for dinner yesterday C. Client with active hemorrhage after a motor vehicle crash D. Clients with back pain and hematuria w/ a hx of kidney stones E. Client with a dislocated shoulder F. Client with dysuria from a long term care facility

A, C

For which causes will the nurse monitor clients for development of intrarenal (intrinsic) acute kidney injury (AKI)? SATA A. Glomerulonephritis B. Bladder cancer C. Exposure to nephrotoxins D. Embolism in renal blood vessels E. Severe dehydration F. Kidney stones

A, C, D Examples of disorders causing intrinsic AKI include allergic disorders, embolism or thrombosis of the renal vessels, and nephrotoxic agents. Severe dehydration would be prerenal. Bladder cancer and kidney stones cause postrenal.

The nurse is assessing a client who had external fixation device applied two hours ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of acute compartment syndrome? Select all that apply. A. Intense pain when the client's left foot is passively moved B. Capillary refill of 3 seconds on the client's left toes C. Hard, swollen muscle in the client's left leg D. Burning and tingling of the client's left foot E. Client reports minimal pain relief with second dose of morphine

A, C, D, E

A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? Select all that apply. A. Alopecia B. Tremors C. Moon face D. Purple striations E. Buffalo hump

A, C, D, E These are all common findings

The nurse is assessing a client who is in the emergency department with a concussion after falling down the stairs at home. What assessment findings require immediate follow-up by the nurse? Select all that apply. A. The client has nystagmus when gazing to the left side of the room B. The client is sleepy but easily aroused C. The client cannot remember falling down the stairs D. Glasgow Coma Scale (GCS) score goes from 15 to 13 over an hour E. The client has a headache 2/10 on the pain scale

A, D

A nurse is in charge of a first-aid tent at an all-day outdoor sports event on a hot and humid day. A participant comes to the tent reporting a headache, weakness, and nausea. What actions would the nurse take? (Select all that apply.) A. Have the client lie down in a cool place. B. Force fluids with large quantities of plain water. C. Administer acetaminophen and send home. D. Apply cold packs to neck, arm pits, and groin. E. Encourage drinking a sports drink. F. Remove all clothing and cover with a towel.

A, D, E Heat exhaustion manifests as flulike symptoms with headache, weakness, nausea, and/or vomiting. Treatment includes stopping the activity, moving to a cool place, and using cooling measures such as cold packs, cool water soaks, or fanning while spraying cool water on skin. Sodium deficits may occur from drinking plain water, so sports drinks or an oral rehydration therapy solution would be provided. The nurse would remove constrictive clothing only.

The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from the client? A. Current range of motion in all extremities B. Heart rate and rhythm C. Respiratory rate and pulse oximetry reading D. Orientation to time, place, and person

B "We want to see if the electricity has affected the electrical conductivity of the heart"

A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take? A. Provide a low-carbohydrate diet B. Weigh the client daily C. Administer oral corticosteroids D. Restrict fluid intake

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? A. Insert an oral airway B. Administer the abdominal thrust maneuver C. Turn the client to the side D. Perform a blind finger sweep

B The nurse should immediately begin applying abdominal thrusts to a conscious client who has an airway obstruction and should continue until the obstruction is clear of the client loses consciousness

A nurse is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should the nurse include in the teaching? A. Limit intake of potassium rich foods B. Restrict sodium intake C. Increase carbohydrate intake D. Decrease protein intake

B The nurse should recommend the client restricts sodium intake to control fluid volume. This restriction can range from "no added salt" to table foods to a restriction of 2 g/day.

A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching? A. "I should consume most of the fluid during the evening." B. "I will make a list of my favorite beverages." C. "I will put beverages in large containers to give the appearance of drinking a lot." D. "I will not add ice cream to the amount of fluid intake."

B The nurse should work with the client to develop a schedule for fluid restrictions, and should attempt to include the client's favorite beverages when possible to promote satisfaction.

A nurse cares for a patient who is prescribed lactulose. The patient states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? A. "We will need to send a stool specimen to the laboratory." B. "Diarrhea is expected; that's how your body gets rid of ammonia." C. "Do not take any more of the medication until your stools firm up." D. "You may take an antidiarrheal agent daily for loose stools."

A nurse plans care for a client with acute pancreatitis. Which intervention would the nurse include in this client's plan of care to reduce discomfort? A. Administer morphine sulfate intravenously every four hours as needed B. Maintain nothing by mouth (NPO) and administer intravenous fluids C. Provide small, frequent feedings with no concentrated sweets D. Place the client in Semi-Fowler's position with the head of bed elevated

The nurse is caring for a client with a new diagnosis of chronic kidney disease. Which priority complications would the nurse anticipate? (Select all that apply.) A. Dehydration B. Anemia C. Hypertension D. Dysrhythmias E. Heart failure

B, C, D, E The client who has CKD has fluid overload and electrolyte imbalances, especially hyperkalemia, that can cause hypertension, heart failure, and dysrhythmias. Anemia results because erythropoietin production by the kidneys is decreased.

The nurse is caring for a 66-year-old who is admitted for hyperglycemic hyperosmolar nonketotic syndrome. Which of the following clinical manifestations would the nurse expect to see? Select all that apply. A. Increased urine specific gravity B. Hypotension C. Bradycardia D. Dilute urine E. Increased urine output F. Dry mucous membrane G. Poor skin turgor from dehydration H. Weak peripheral pulses I. Acute confusion

B, D, E, F, G, I

A 23-year-old client with a full thickness burn is being discharged from the hospital. Which patient education is most important for the nurse to provide prior to discharge? A. Joining a community reintegration program B. How to maintain home smoke detectors C. Options available for scar removal D. Learning to perform dressing changes

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? A. Evaluate chest expansion B. Check pupillary response to light C. Assess the capillary refill D. Check client's response to questions about place and time

A When using the ABC approach to client care blahblahblah making sure they can breathe is the most important.

A 40-year-old male client who was burned was admitted under your care. Assessment reveals he has crackles, respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first? A. Administer digoxin B. Perform chest physiotherapy C. Monitor urine output D. Place the client in an upright position

D "They're coughing up blood-tinged sputum, right? You don't want them to aspirate"

A client who has cirrhosis and esophageal varices is being treated with propranolol. Which finding is the best indicator to the nurse that the medication has been effective? A. The apical pulse is 68 beats/min B. Blood pressure is 130/80 mmHg C. The client reports no chest pain D. Emesis tests negative for occult blood

D "We're not actually using it for the blood pressure, the actual answer is D because that shows signs that they're not bleeding."

A nurse is providing teaching to a client who has a history of pancreatitis. Which of the following food choices should the nurse instruct the client to avoid? A. Noodles B. Vegetable soup C. Baked fish D. Cheddar cheese

D Clients who have pancreatitis should avoid foods high in fat. Cheddar cheese is high in fat content and the client should avoid this food choice.

A client who is admitted after a thermal burn injury has the following vital signs: blood pressure 70/40, heart rate 140 beats/min, respiratory rate 25/min, He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first? A. Start intravenous fluids B. Check pulses using a doppler device C. Obtain a complete blood count (CBC) D. Obtain an electrocardiogram (ECG)

A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload? A. The client has a 5 lb weight gain since yesterday B. Flattened neck veins C. Oxygen saturation 93% D. Return of skin to previous position when the client's shin is palpated

A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect? A. Hyper pigmentation B. Weight gain C. Hirsutism D. Purple striations

A patient with a right femur fracture arrives in the emergency department withs dyspnea; cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed the health care provider should the nurse implement first? A. Provide O2 at 100% per non-rebreather mask B. Initiate continuous electrocardiogram (ECG) monitoring C. Draw blood to type and crossmatch for transfusions D. Insert two large-bore IV catheters

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? A. Abdominal pain is decreased B. Electrolyte levels are normal C. Grey Turner sign resolves D. Bowel sounds are present

A patient with chronic kidney disease is restless, anxious, and short of breath. The nurse hears crackles that begin at the base of the lungs. The pulse rate is increased and the patient has frothy, blood tinged sputum. What action does the nurse perform first? A. Place the patient in a high-Fowler's position B. Administer a loop diuretic, such as furosemide C. Facilitate transfer to intensive care for treatment D. Continue to monitor vital signs and breath sounds

During change-of-shift report, the nurse learns about the following four patients. Which patient should the nurse see first? A. A 55-year-old patient with cirrhosis and ascites who has an oral temperature of 102 degrees F (38.8 C) B. A 40-year-old patient with chronic pancreatitis who has gnawing abdominal pain C. A 58-year-old patient who has compensated cirrhosis and reports anorexia D. A 36-year-old patient with post-operative surgical site pain rated 3 out of 10

For a client who has cirrhosis, which nursing action can the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? A. Providing oral hygiene after a meal B. Teaching the client the prescribed diet C. Palpating the abdomen for distention D. Assessing the client for jaundice

Ten hours after the client with 50% burns is admitted, her blood glucose level is 142 mg/dL. What is the nurse's best action? A. Document the finding B. Obtain a family history of diabetes C. Repeat the glucose measurement D. Stop the IV fluids containing dextrose

A "With burns they have a big fluid shift and they actually have a fluctuation in their blood sugar. If this was a blood sugar of like 200 or 250, then I would stop the dextrose, but this is just an expected finding."

A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appress anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority? A. Administer high-flow oxygen at 5 L/min by facemask to the client B. Place the client in high-Fowler's position with legs dependent C. Give the client sublingual nitroglycerin D. Reassure the client

A A client who has pulmonary edema is critically ill and is hypoxic. The first action the nurse should take when using the ABC approach to client care is to administer high-flow oxygen at 5 L/min by facemark to the client.

A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect? A. Widened QRS complexes B. Hyperactive deep tendon reflexes C. Bounding peripheral pulses D. Warm, flushed skin

A A client who has respiratory acidosis is likely to have cardiac changes from delayed electrical conduction through the heart, such as widened QRS complexes, tall T waves, prolonged PR intervals, and a heart rate that ranges from bradycardia to heart block.

A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect? A. Hyperkalemia B. Hypernatremia C. Hypercalcemia D. Hypophosphatemia

A AKI is a loss of renal function that results in a failure to maintain homeostasis. Fluid and electrolyte balance, as well as acid-base balance, are disrupted. The nurse should expect the client to have hyperkalemia due to protein breakdown and the subsequent release of intracellular potassium in to the circulation. The kidneys' inability to filter and excrete potassium results in hyperkalemia.

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood? A. Elevated blood urea nitrogen (BUN) B. Elevated HbA1c C. Decreased chloride D. Decreased bilirubin

A As the body digests blood, BUN rises. An elevated BUN is an indication of GI bleeding

A nurse is caring for a client following his first hemodialysis treatment. The client reports a headache, nausea, and restlessness. The nurse should identify these findings as manifestations of which of the following complications? A. Dialysis disequilibrium B. Air embolism C. Peritonitis D. Septicemia

A Dialysis disequilibrium syndrome can develop during or after hemodialysis. The syndrome is caused by the rapid decrease in fluid volume and BUN levels during dialysis. The change in urea levels can cause cerebral edema and increased intracranial pressure. Manifestations include headache, nausea, vomiting, restlessness, seizures, and coma.

How does the nurse best interpret a condition when a client is undergoing hemodialysis (HD) and develops symptoms including headache, nausea, vomiting and fatigue? A. Mild dialysis disequilibrium syndrome B. Adverse reaction the dialysate solution C. Transient symptoms in a client new to hemodialysis D. Expected manifestations of end stage kidney disease

A Dialysis disequilibrium syndrome may develop during HD or after HD has been completed. It is characterized by mental status changes and can include seizure or coma, although rare to get that severe. A mild form of disequilibrium syndrome includes symptoms of nausea, vomiting, headaches, fatigue, and restlessness. It is thought to be the result of a rapid reduction in electrolytes and other particles.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? A. "High glucose is common in shock and needs to be treated." B. "Some of the medications we are giving are to raise blood sugar." C. "The IV solution has lots of glucose, which raises blood sugar." D. "The stress of this illness has made your spouse a diabetic."

A High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the range of 140 to 180 mg/dL (7.7 to 10 mmol/L. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not "made" the client diabetic.

The client has a long leg cast on the right leg. Assessment reveals that the right foot is pale and cool to touch, and the right leg pain is still severe with no relief from the pain medication administered 45 minutes ago. What is the priority action? A. Notify the health care provider immediately B. Remove the cast immediately C. Apply a heating pad to the right toes D. Repeat the dose of pain medication

A It's giving compartment syndrome

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention? A. Daily weight B. Sodium level C. Tissue turgor D. Intake and output

A Obtaining a client's daily weight and comparing it to previous weights is a reliable method for measuring a client's fluid volume over time.

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history? A. Gallstones B. Hypolipidemia C. COPD D. Diabetes mellitus

A The client's history might reveal biliary obstruction from a gallstone causing bile to inflame the pancreas

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority? A. Blood pressure 92/50 mmHg B. Heart rate 72/min C. Abdominal pain rated 4 on a scale of 0 to 10 D. Respiratory rate 20/min

A The expected reference range for blood pressure in an adolescent is 110/65 to 120/80 mmHg. A blood pressure 92/50 mmHg indicates the adolescent is hypotensive and unstable. Therefore, this finding is the priority. Blunt abdominal trauma can cause internal hemorrhage that leads to hypotension.

At the beginning of a shift, a nurse is assessing a client who has Cushing's disease. Which of the following findings is the priority? A. Weight gain B. Fatigue C. Fragile skin D. Joint pain

A The greatest risk to a client who has Cushing's disease is fluid retention, which can lead to pulmonary edema, hypertension, and heart failure; therefore, this is the priority finding.

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? A. Increased heart rate B. Widening pulse pressure C. Increased deep tendon reflexes D. Pulse oximetry 96%

A The nurse should anticipate an increased heart rate as an early indication of shock because the body attempts to compensate for decreased circulatory volume.

A The nurse should identify that a gain of 2 lb per day is unstable. A gain more than 2 lb per day or 5 lb per week is an indication of fluid overload.

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care? A. Decrease the client's fluid intake B. Increase the client's saturated fat intake C. Increase the client's sodium intake D. Decrease the client's carbohydrate intake

A The nurse should restrict fluids for a client who has cirrhosis and ascites due to the client's risk for increased fluid retention

A The nurse should restrict fluids for a client who has cirrhosis and ascites due to the client's risk for increased fluid retention.

A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? A. Systolic blood pressure is increased B. Cardiac output is reduced C. Apical heart rate is increased D. Urine output is reduced

A When dopamine has a therapeutic effect, it causes vasoconstriction peripherally and increases systolic blood pressure

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. Airway obstruction B. Infection C. Fluid imbalance D. Paralytic ileus

A When using the ABC approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.

How will the nurse position a client with a burn wound to the posterior neck to prevent contractures? A. Have the client turn the head from side to side B. Keep the client in a supine position without the use of pillows C. Keep the client in semi-Fowler's position with his or her arms elevated D. Place a towel roll under the client's neck or shoulder

A You want to prevent them from keeping their head in one position

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions would the nurse include in this client's plan of care? Select all that apply. A. Elevate heels off the bed with a pillow. B. Ambulate the client on the first postoperative day. C. Push the client's patient-controlled analgesia button. D. Re-position the client every 2 hours. E. Use pillows to encourage subluxation of the hip.

A, B, D Postoperative care for a client who has ORIF of the hip includes elevating the client's heels off the bed and re-positioning every 2 hours to prevent pressure and skin breakdown. It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse would teach the client to use the patient-controlled analgesia pump, but the nurse would never push the button for the client.

The nurse in the burn unit is caring for a client who has sustained full-thickness burns over their bilateral arms from a charcoal grill accident 40 hours ago. The clients vital signs are stable. What action(s) are important for the nurse to implement in this phase? Select all that apply. A. Instruct client to take antibiotics as prescribed B. Perform strict hand hygiene to prevent infection C. Allow visitors of all ages to provide emotional support D. Restrict fresh fruits, flowers, and plants E. Encourage client to increase protein and caloric intake

A, B, D, E

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the assistive personnel (AP)? Select all that apply. A. Bringing the client warm blankets B. Giving the client hot tea to drink C. Massaging the client's painful legs D. Reorienting the client as needed E. Sitting with the client for reassurance

A, B, D, E The AP can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. If the nurse assesses the client is safely able to swallow, small amounts of fluids would be allowed. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

When the nurse provides care for a client with Chronic Kidney Failure, what assessments will be made that support a finding of fluid overload? SATA A. Weigh the client and compare to baseline B. Compare current BP to baseline C. Measure for residual urine with a bladder scanner D. Auscultate the lung fields to determine if fluid is present E. Check for pedal and periorbital swelling F. Obtain a sterile urine specimen by catheterization

A, B, D, E To assess fluid overload, the nurse looks at skin and tissue which may show edema associated with kidney disease, esp pedal (foot), pretibial (shin), periorbital (eyes), and sacral tissues. A stethoscope is used to listen to the lungs to determine whether fluid is present. The client is weighed and blood pressure measured as a baseline for later comparisons. A client with chronic kidney failure does not make much urine, thus checking for residual urine with a bladder scanner is not necessary. A sterile sample is not needed unless infection is suspected.

A nurse is caring for a client with a history of Cushing's. The nurse should identify this client is at increased risk for which of following? Select all that apply. A. Bone fracture B. Dysphagia C. Infection D. Gastric ulcer E. Nephrolithiasis

A, C, D

A nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instructions are important to discuss with the client? Select all that apply. A. Refer the client to the American Diabetic Association for resources B. Do not take any over-the-counter medications C. Take the prescribed insulin even when unable to eat because of illness D. Explain the need to get the annual flu and pneumonia vaccines

A, C, D

A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? Select all that apply. A. Administer furosemide B. Administer warfarin C. Implement a low-sodium diet D. Measure the client's abdominal girth E. Encourage weight lifting during physical therapy

A, C, D A is correct because the nurse should administer furosemide to the client to reduce fluid accumulation in the abdomen C is correct because the nurse should implement a low-sodium diet to control fluid accumulation in the abdomen D is correct because just yeah. Cool rationale this one.

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). The nurse should instruct the client to limit which of the following nutrients? Select all that apply. A. Protein B. Calcium C. Calories D. Phosphorous E. Sodium

A, D, E Protein is correct. (A client who has CKD should restrict protein intake to prevent uremia that can develop as a result of the kidneys' inability to remove the waste products of protein.)Phosphorous is correct. (A client who has CKD is at risk for hyperphosphatemia due to a reduction in excretion of phosphorous by the kidneys.)Sodium is correct. (A client who has CKD is at risk for hypernatremia, edema, and hypertension due to sodium retention.)

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement? A. Droplet B. Contact C. Airborne D. Standard

D Hepatitis C is a blood borne pathogen that is commonly spread by needle stick injury, sharing of IV drug paraphernalia and sexual contact. The nurse should implement standard precautions when in contact with blood, body fluids (except sweat), broken skin, and mucous membranes. The nurse should wear additional personal protective equipment if there is possible blood contact or a risk for splashes or sprays of blood or body fluids

A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect? A. Weight loss B. Hypotension C. Diaphoresis D. Hyperpigmentation

D Hyperpigmentation, bruising, and striae or stretch marks, are manifestations of Cushing's syndrome

After teaching a patient who has alcohol-induced cirrhosis, a nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional teaching? A. "I should eat small, frequent, balanced meals." B. "I should not take over-the-counter medications." C. "I cannot drink any alcohol at all anymore." D. "I need to avoid protein in my diet."

After receiving change-of-shift report, which patient should the nurse assess first? A. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange B. Patient who has just returned from having hemodialysis with a heart rate of 110/min C. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L D. Patient with stage 4 chronic kidney disease who has an elevated phosphate level

The nurse in the emergency department is admitting a client who has sustained full-thickness burns over their bilateral arms from a charcoal grill accident 4 hours ago. The clients vital signs are as follows: blood pressure 100/60 mmHg, heart rate 124 beats/min, respiratory rate 20 breaths/min, oxygen saturation 92%, pain level 8/10. What is the priority nursing action? A. Perform wound care to bilateral arms B. Administer normal saline 0.9% 1L IV bolus C. Prepare for endotracheal intubation D. Administer ketorolac 30mg IV push

The nurse is caring for a client who has pheochromocytoma. What is the priority nursing intervention for this client? A. Monitor the client's intake and output and urine specific gravity B. Monitor blood pressure for severe hypertension C. Monitor blood pressure for severe hypotension D. Administer medication to increase cardiac output

Which assessment information will be the most important for the nurse to report to the health care provider about a client who has acute cholecystitis? A. The client reports chronic heartburn B. The client's stools are tan colored C. The client's urine is bright yellow D. The client has increased pain after eating

Which client is the priority to assess immediately after hand-off/shift report? A. A client who has partial thickness burns on the back complaining of pain 9/10 B. A client with full thickness burns to the chest who is complaining of chest pain C. A client with superficial thickness burns of the bilateral hands and presents with contractures D. A client who is scheduled for a dressing change partial thickness burns to bilateral legs

Which statement made by the client with Cushing's syndrome indicates a need for further teaching? A. "I realize I will have to begin an exercise program slowly and gradually." B. "I'm not really worried about getting pneumonia this winter." C. "I'll be eating food low in carbohydrates and salt." D. "I'm going to have to keep a close eye on my blood pressure."

A client with acute pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate? A. Providing the client with plenty of P.O fluids B. Reserving an antecubital site for a peripherally inserted central catheter (PICC) C. Limiting I.V. fluid intake according to the physician's order D. Providing generous servings at mealtime

B "That's because these patients might need TPN for nutrition. They're gonna need strong pain medications, and they're probably gonna be in the hospital for a little while so the PICC line is a good option for them.

A nurse cares for a client who has cirrhosis of the liver. What action would the nurse take to decrease the presence of ascites? A. Monitor intake and output B. Provide a low-sodium diet C. Increase oral fluid intake D. Weigh the client daily

B "They think sometimes [low sodium] will help with the fluid shift a little bit. It'll maybe help with the minimal ascites. Then they'll do diuretics and paracentesis is the gold standard."

A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take? A. Provide a low carbohydrate diet B. Weigh the client daily C. Administer oral corticosteroids D. Restrict fluid intake

B Addison's disease is an endocrine disorder that causes weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin. Obtaining the client's daily weight will alert the nurse that dehydration is developing, which could indicate an impending crisis A is incorrect because clients who have Addison's disease are prone to hypoglycemia. They should follow a high protein diet, high carbohydrate diet to ensure adequate caloric intake and avoid weight loss, which is common with Addisonian crisis. C is incorrect because the nurse should administer IV corticosteroids to manage Addisonian crisis until the client is no longer at risk for dehydration, hypotension, and shock. D. Nah

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? A. "It is caused by the lack of production of insulin by the pancreas." B. "It is caused by the lack of production of aldosterone by the adrenal gland." C. "It is caused by the overproduction of growth hormone by the pituitary gland." D. "It is caused by the overproduction of parathyroid hormone by the parathyroid gland."

B Addison's disease is caused by a lack of production of the adrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland

A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following statements should the nurse take? A. "You should decrease your caloric intake when abdominal pain is present." B. "You should increase your daily intake of protein." C. "You should increase fat intake when experiencing loose stools." D. "You should limit alcohol intake to 2-3 drinks per week."

B Clients who have chronic pancreatitis should consume a diet that is high in protein

A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following statements should the nurse make? A. "You should decrease your caloric intake when abdominal pain is present." B. "You should increase your daily intake of protein C. "You should increase fat intake when experiencing loose stools." D. "You should limit alcohol intake to 2-3 drinks per week."

B Clients who have chronic pancreatitis should consume a diet that is high in protein A is incorrect because patients with chronic pancreatitis are at risk for malnutrition and should increase their caloric intake in order to maintain weight

Which priority teaching will the nurse provide to the client receiving peritoneal dialysis (PD) when the effluent becomes cloudy? A. The change means that more waste products are being removed from the blood B. The presence of cloudiness is an early sign of an infection called peritonitis and is very serious C. Effluent cloudiness is the result of eating foods that contain too much protein electrolytes D. The effluent is expected to be cloudy because it has spent time (dwelled) in the abdomen, in close contact with the intestines

B Cloudy or opaque effluent is an early indication of peritonitis

A nurse is assessing a client who is receiving a continuous IV infusion of dopamine. Which of the following findings should the nurse recognize as a therapeutic effect? A. Increased pulse B. Increased urine output C. Decreased blood pressure D. Decreased dysrhythmias

B Dopamine is used for the treatment of shock and heart failure. It increases cardiac output by increasing myocardial contractility. This medication also dilates renal blood vessels, which increases renal perfusion and leads to an increase in the client's urinary output. This finding should indicate to the nurse a therapeutic effect has been achieved.

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury? A. Atorvastatin B. Metformin C. Nitroglycerin D. Carvedilol

B Metformin interacts with contrast dye and can cause acute kidney damage

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to providing advanced cardiac life support? A. Contact the on-call orthopedic surgeon. B. Don personal protective equipment. C. Notify the Rapid Response Team. D. Obtain a complete history from the paramedic.

B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions would be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers. It is not known if this client has orthopedic injuries. The Rapid Response Team is not needed in the ED. A complete history is needed but the staff's protection comes first.

A nurse is developing a plan of care for a client who is to begin receiving peritoneal dialysis. Which of the following interventions should the nurse implement to ensure proper dialysate exchange? A. Monitor vital signs every 2 hours during the procedure B. Warm the dialysate solution prior to instillation C. Place the drainage bag above the level of the client's abdomen D. Maintain the client in a left lateral position during dialysis

B Pain during inflow of the dialysate is a common adverse effect when client begin peritoneal dialysis. Warming the solution decreases discomfort.

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis? A. Hyperactive bowel sounds B. Nausea and vomiting C. Bradycardia D. Increased urinary output

B Peritonitis is an inflammation of the peritoneum and is a potential complication of peritoneal dialysis. The nurse should monitor the client for manifestations such as abdominal tenderness or pain, anorexia, nausea, vomiting, restlessness, and confusion.

A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? A. Insert an indwelling catheter B. Inspect the mouth for signs of inhalation injuries C. Administer intravenous pain medication D. Draw blood for a complete blood cell (CBC) count

B Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the ABC priority setting framework, this is the priority concern at this time.

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take? A. Encourage the client to drink cool water or sports drinks. B. Start an intravenous line and infuse 0.9% saline solution. C. Administer acetaminophen (Tylenol) 650 mg orally. D. Encourage rest and reassess in 15 minutes.

B The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the patient, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this patient's temperature or improve the patient's symptoms. The client needs immediate medical treatment; therefore, rest and reassessing in 15 minutes are inappropriate.

A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching? A. "Test your blood glucose level every 8 hours." B. "Check your urine for ketones when blood glucose levels are greater than 240 mg/dL." C. "Withhold your usual daily dose of insulin." D. "Drink 240 to 360 milliliters of calorie-free liquids every 8 hours."

B The client should check his urine for ketones when blood glucose levels are greater than 240 mg/dL in order to detect DKA. The client should contact the provider if he has moderate or large amounts of ketones in his urine. A is incorrect because they should check their blood glucose levels every 4 to 6 hours when they are experiencing anorexia, nausea, and vomiting C is incorrect because just no. D is incorrect because the client should drink 240 to 360 mL (8 to 12 oz) of calorie-free and caffeine-free liquids every hour. If the client's blood glucose level is below his expected reference range he should drink fluids that contain sugar.

A nurse cares for a client with a recently fractured tibia. Which assessment would alert the nurse to take immediate action? A. Pain of 4 on a scale of 0-10 B. Numbness in the extremity C. Swollen extremity at the injury site D. Feeling cold while lying in bed

B The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.

A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first? A. Apply a tourniquet just below the elbow B. Apply direct pressure over the wound C. Clean the wound D. Elevate the limb after the bleeding is controlled

B The greatest risk to the client is injury from hemorrhage. Therefore, the first action the nurse should take is to apply firm pressure with a thick, dry dressing material directly over the wound to stop bleeding

B The greatest risk to the client is injury from hemorrhage. Therefore, the first action the nurse should take it to apply firm pressure with a thick, dry dressing material directly over the wound to stop bleeding.

A nurse is caring for a client in the emergency department who, 2 hours earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first? A. Client's history of previous accidents B. Date of the clients' last tetanus immunization C. Client's blood alcohol level D. Signs of wound infection

B The greatest risk to this client is injury from infection with Clostridium tetanus; therefore, the priority assessment the nurse should perform is to determine whether the client will require a tetanus immunization by identifying the date the client last received one. An adult should have a tetanus booster immunization every 10 years and after any severe or dirty wound.

A nurse is collecting the medical history from a client who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if he has a history of which of the following conditions that can cause SIADH? A. Osteoarthritis B. Lung cancer C. Liver cirrhosis D. Dyspepsia

B The nurse should ask the client if he has a history of lung cancer because some of the treatment options for small cell lung cancer can cause secretion of antidiuretic hormone. This results in the body retaining water and can cause SIADH

A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur. Which of the following interventions should the nurse include in the plan? A. Instruct the client to flex and extend the ankle twice daily B. Monitor the client's pedal pulses every hour C. Remove the weights every four hours D. Evaluate pressure points daily

B The nurse should assess the neuromuscular status of the client's affected extremity including assessing pulses, color, and capillary refill hourly for the first 24 hours following the placement of skeletal traction to prevent complications such as compartment syndrome or circulatory compromise. A is incorrect because it should be every hour while awake to prevent DVT C is incorrect because you don't remove the weights ever D. is incorrect because you should monitor pressure points at least every eight hours

A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate? A. Hypernatremia B. Oliguria C. Weight loss D. Increased thirst

B The nurse should expect a client who has developed SIADH following a craniotomy to manifest oliguria. The decrease in urine output can be dramatic with output less than 20 mL/hr

A nurse is caring for a client who has cirrhosis and a new prescription for lactulose. Which of the following manifestations indicates an adverse effect of the medication? A. Dry mouth B. Vomiting C. Headache D. Peripheral edema

B The nurse will monitor for vomiting as an adverse effect of lactulose.

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mmHg. Her arterial blood gases are pH 7.50, PaCO2 29 mmHg, PaO2 60 mmHg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? A. Prepare for mechanical ventilation B. Administer oxygen via facemask C. Prepare to administer a sedative D. Assess for indications of pulmonary embolism

B The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client's oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation.

A nurse is caring for a client after surgery who is restless and apprehensive. The assistive personnel (AP) reports the vital signs and the nurse sees that they are only slightly different from previous readings. What action does the nurse delegate next to the AP? A. Assess the client for pain or discomfort. B. Measure urine output from the catheter. C. Reposition the client to the side. D. Stay with the client and reassure him or her.

B Urine output changes are a sensitive early indicator of shock. The nurse would delegate emptying the urinary catheter and measuring output to the AP as a baseline for hourly urine output measurements. The AP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A. Urinary output 25 mL/hr B. Difficulty swallowing C. Heart rate 122/min D. Pain of 6 on a scale of 0 to 10

B Using the ABC approach to client care, the nurse should determine that the priority finding is difficulty swallowing as this can be an indication that the client's airway is obstructed.

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? A. BP B. Heart rate C. Urine output D. Weight

B When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as an indication of adequate fluid replacement

A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first? A. Place the client in a rigid cervical collar B. Open the client's airway using the jaw-thrust maneuver C. Evaluate the client for other injuries D. Complete a neurological check on the client

B When using the ABC approach to client care, the nurse determines that the priority action is opening the client's airway using the jaw-thrust maneuver to protect the clients' cervical spine. The priorities of care at an accident scene, and when using the ABC approach to client care... are ABC... oy.

A 23-year-old male client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge? A. How to maintain home smoke detectors B. Joining a community reintegration program C. Learning to perform dressing changes D. Options available for scar removal

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? A. Imbalanced nutrition: less than body requirements related to biliary inflammation B. Deficient knowledge related to prevention of disease recurrence C. Acute pain related to biliary spasms D. Anxiety related to unknown outcome of hospitalization

A nurse cares for a client with acute pancreatitis. The client states "I am hungry." How would the nurse reply? A. "Is your stomach rumbling or do you have bowel sounds?" B. "I need to check your gag reflex before you can eat." C. "Have you passed any flatus or moved your bowels?" D. "You will not be able to eat until the pain subsides."

A nurse cares for a patient who is scheduled for a paracentesis. Which intervention would the nurse delegate to an unlicensed assistive personnel (UAP)? A. Have the patient sign the informed consent form B. Get the patient into a chair after the procedure C. Assist the patient to void before the procedure D. Help the patient lie flat in bed on the right side

A nurse is caring for a client on the medical floor. Which client should be assessed first? A. The client diagnosed with syndrome of inappropriate anti-diuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterday B. The client diagnosed with pituitary tumor who had developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours C. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having a muscle twitching and irritability within the past 4 hours D. The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to get up at night

A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving? A. "I know that I will get a kidney transplant. I am a good candidate." B. "I can now eat whatever I want. The dialysis will remove it from my system." C. "I just can't believe that this dialysis is going to ruin my whole life." D. "I know that kidney disease runs in my family, but I can prevent it."

A nurse is caring for a client with alcohol dependence who was admitted for abdominal pain. The client begins to have dark brown "coffee-like" emesis. What is the priority intervention? A. Assess vital signs B. Call the healthcare provider C. Assist the client to turn to one side D. Place an 18-gauge peripheral IV

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? A. Calcium phosphate B. Multivitamin with iron C. Magnesium hydroxide D. Acetaminophen

The nurse is caring for a client with acute pancreatitis. Which nursing action is the highest priority? A. Teach about the need to avoid scratching any pruritic area B. Offer high-calorie, high-protein dietary choices C. Administer prescribed opioids to relieve pain as needed D. Offer psychologic support for depression

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? A. Provide the client with nonprescription laxatives B. Ask the client about food intake C. Measure abdominal girth according to a set routine D. Report the condition to the physician immediately

Which assessment indicates the expected outcome of the fluid resuscitation for a client with a burn injury? A. Heart rate increased from 58 to 110 beats/minute B. Decreased level of consciousness C. Urine output increased from 28 mL/hour to 60 mL/hour D. Bilateral +1 radial pulses

Which client will you see first? A. A client with portal hypertension and bulging hemorrhoids. B. A client with jaundice and severe itching. C. A client that just vomited 300cc of frank blood and distended abdomen. D. A client that needs a paracentesis due to their ascites.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? A. Ascites and orthopnea B. Dyspnea and fatigue C. Purpura and petechiae D. Gynecomastia and testicular atrophy

C "If they don't have the vitamin K factors then they're not clotting and they have a high potential for bleeding." "Just remember this for assessment purposes that purpura and petechiae are bad signs."

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification? A. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain B. Laboratory testing of serum potassium upon admission C. 0.9% normal saline IV at 50 mL/hr continuous D. Bumetanide 1 mg iV bolus every 12 hr

C 0.9% sodium chloride is an isotonic and will not cause the fluid shift needed in this client to reduce circulatory overload. This prescription requires clarification D. is incorrect because bumetanide is a loop diuretic, and is administered as a first-line drug of choice for the client in acute heart failure. This prescription does not require clarification

A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take? A. Ambulate the client four times per day B. Encourage the client to consume clear liquids C. Provide frequent oral and nares care D. Keep the client in a supine position

C A client who has a Senga-Bkajfjds tube in place is unable to swallow. If the client is alert, the nurse should encourage the client to spit saliva into a tissue or a basin. If the client is not alert, gentle suctioning of the oral cavity and nares might be required to remove secretions.

A nurse is triaging clients in the emergency department. Which client would be considered "urgent"? A. A 20-year-old female with a chest stab wound and tachycardia B. A 45-year-old homeless man with a skin rash and sore throat C. A 75-year-old female with a cough and a temperature of 102° F (38.9° C) D. A 50-year-old male with new-onset confusion and slurred speech

C A client with a cough and a temperature of 102° F (38.9° C) is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech would be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that which of the following laboratory findings indicate a therapeutic effect of the medication? A. Serum sodium 146 mEq/L B. Blood glucose 80 mg/dL C. Urine specific gravity 1.015 D. Blood urea nitrogen (BUN) 15 mg/dL

C A therapeutic effect of the medication would be urine specific gravity within the expected reference range, which is 1.010 - 1.025

For which condition does the nurse suspect a client with CKD is attempting to compensate for when respirations increase in rate and depth? A. Hypoxia B. Alkalosis C. Acidosis D. Hypoxemia

C As CKD worsens and acid retention increases, increased respiratory action is needed to keep the blood pH normal. The resp system adjusts or compensates for the increased blood hydrogen ion levels (acidosis or decreased pH levels) by increasing rate and depth of breathing to excrete carbon dioxide through the lungs.

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? A. "DIC is controllable with lifelong heparin usage." B. "DIC is characterized by an elevated platelet count." C. "DIC is caused by abnormal coagulation involving fibrinogen." D. "DIC is a genetic disorder involving vitamin K deficiency."

C DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage.

A client with DKA presents to the emergency department. What nursing action is the priority for treatment? A. Educate the client about the cause of DKA B. Inject intermediate NPH insulin immediately C. After assessing labs administer an insulin bolus D. Insert an IV and hang D5W fluid bolus

C Don't want to do B because an intermediate insulin isn't going to act fast enough. We also don't have enough data to know how much insulin to give.

A nurse is teaching a client who has an acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching? A. Renal function is reestablished B. BUN and creatinine levels decrease C. Urine output is less than 400 mL per 24 hr D. The glomerular filtration rate (GFR) recovers

C Inadequate urinary output is associated with the oliguric phase of acute kidney injury. The minimum amount of urine needed to rid the body of metabolic waste products is 400 mL. Therefore, a client who is producing less than 400 mL of output in 24 hr is manifesting acute kidney injury.

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior? A. He is hard of hearing B. Pain C. Confusion D. Language barrier

C Since the client was manifesting signs of confusion before coming to the emergency department and currently seems unable to understand or respond to speech, the nurse should determine that the client has confusion

A nurse is assessing a client who has diabetes insipidus. Which of the following findings is a manifestation of this diagnosis? A. Hypertension B. Bounding peripheral pulses C. Tachycardia D. Hyperglycemia

C Tachycardia is a manifestation of diabetes insipidus due to dehydration from fluid loss.

A nurse reviews the laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L Potassium 5 mEq/L Blood urea nitrogen (BUN) 44 mg/dL Serum creatinine 2.5 mg/dL What initial intervention would the nurse anticipate? A. Start hemodialysis immediately. B. Discuss the need for peritoneal dialysis. C. Increase the dose of immunosuppression. D. Return the client to surgery for exploration.

C The client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point.

The nurse documents the vital signs of a patient with acute pancreatitis: Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 mmHg What complications of acute pancreatitis does the nurse suspect the patient may have? A. Electrolyte imbalance B. Pleural effusion C. Pancreatic pseudocyst D. Internal bleeding

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache? A. Administer pain medication B. Darken the client's room and close the door C. Increase fluid intake D. Elevate the head of the bed 30 degrees

C The client who has had a lumbar puncture is at risk for continued leaking of CSF from the puncture site. This results in a decreased amount of circulating CSF. Increasing fluids is helpful in quickly replacing the cerebrospinal fluid that was removed during the procedure and increasing fluids will facilitate resolution of the headache. The client should also be instructed to remain in a prone position for 6 hours to prevent leaking of CSF fluid.

An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first? A. A 30-year-old distraught mother holding her crying child B. A 65-year-old conscious male with a head laceration C. A 26-year-old male who has pale, cool, clammy skin D. A 48 year old with a simple fracture of the lower leg

C The client with pale, cool, clammy skin may be in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

The nurse is teaching assistive personnel (AP) about fluid restriction for a client who has acute kidney injury (AKI). The client's 24-hour urinary output is 120 mL. How much fluid would the client be allowed to have over the next 24 hours? A. 380 mL B. 500 mL C. 620 mL D. 750 mL

C The general principle for fluid restriction for clients is that they may have a daily fluid intake of 500 mL plus the amount of their urinary output. In this case, 120 mL urinary output plus 500 mL equals 620 mL fluid allowance.

A nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse should identify which of the following findings as an indication that the medication is effective? A. A decrease in blood sugar B. A decrease in blood pressure C. A decrease in urine output D. A decrease in specific gravity

C The major manifestations of diabetes insidious are excessive urination and extreme thirst. Vasopressin is used to control frequent urination, increased thirst, and loss of water associated with diabetes insidious. A decreased urine output is the desired response

A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the potency of this graft? A. Measure the client's blood pressure to ensure it is higher in the left arm than the right B. Check the brachial and radial pulses of the left arm simultaneously C. Auscultate the site for a bruit D. Auscultate the antecubital fossa using a doppler stethoscope

C The nurse should auscultate the AV graft site for the presence of a bruit or palpate the site for a thrill every 4 hours to assess for blood flow

A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection? A. Temperature 36.1 C (97.0 F) B. Insomnia C. Oliguria D. Weight loss

C The nurse should identify little to no urine output as possible manifestations of kidney rejection.

A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include? A. A family history increases your risk for acquiring hepatitis A B. Hepatitis A infects the kidneys C. Manifestations of the virus are similar to flu-like symptoms D. The incubation of the virus is 5 days

C The nurse should include in the teaching that the manifestations of hepatitis A are similar to having the flue or a gastrointestinal illness. Often the client is unaware that they have acquired the virus

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan? A. Include foods high in starch and proteins B. Include foods high in fiber C. Avoid foods high in fat D. Avoid foods high in sodium

C The nurse should instruct the client to follow a low-fat diet to decrease episodes of biliary colic. A client who has chronic cholecystitis has intolerance to fatty foods.

A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include? A. "Withhold insulin dose if feeling nauseous." B. "Notify the provider if blood glucose levels are over 350 milligrams/deciliter" C. "Test the urine for ketones." D. "Limit fluid intake during meal time."

C The parent or child should test the urine for ketone and report the presence of them in the urine. Ketonuria can indicate that the child does not have enough close for energy and is breaking down fats to provide glucose to cells. B is incorrect because the parents should notify the provider if BG levels are >250 mg/dL

An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient? A. A full set of vital signs B. Cardiac rhythm C. Neurologic status D. Client history

C The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. Injuries from this type of fall have a high risk for cervical spine injuries. In addition, with the loss of consciousness at the scene the client would be at risk for head trauma. A full set of vital signs is obtained as part of the secondary survey. The cardiac rhythm is important but not specifically related to this client's presentation. Client history would be obtained as able.

Which problem or complication does the nurse suspect when a client with chronic kidney disease develops anorexia, nausea and vomiting, muscle cramping and pruritus? A. Client has oliguria B. Client has anuria C. Client has uremia D. Client has azotemia

C Uremia is the build of nitrogenous waste in blood from inadequate elimination as a result of kidney failure. Symptoms include anorexia , nausea and vomiting, muscle cramps, Pruritus, fatigue, and lethargy. Anuria is failure to produce urine; oliguria is production of abnormally small amounts of urine and azotemia is the build up of nitrogenous waste products in the blood.

The nurse is caring for a patient with an arteriovenous (AV) fistula in the left arm. What is the most important action to include in the plan of care for AV fistula patency? A. Assess the quality of the left radial pulse B. Irrigate the fistula site with saline every 8 to 12 hours C. Compare blood pressures in the left and right arms D. Auscultate for a bruit at the fistula site

A 74-year-old patient who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis?" Which initial response by the nurse is best? A. "Many people your age use dialysis and have a good quality of life." B. "You are the only one who can make the decision about dialysis." C. "It depends on which type of dialysis you are considering." D. "Tell me more about what you are thinking regarding dialysis."

A patient has a serum potassium level of 6.5 mEq/L, a serum creatinine level of 2 mg/dL, and urine output of 350 mL/day. What is the best action by the nurse? A. Ask to have the laboratory redraw the blood specimen B. Teach the patient to limit high-potassium foods C. Continue to monitor the patient's intake and output D. Place the patient on the cardiac monitor immediately

A patient has arrived for a scheduled hemodialysis session. Which nursing action is appropriate for the registered nurse (RN) to delegate to a dialysis technician? A. Assess for causes of an increase in pre dialysis weight B. Teach the patient about fluid restrictions C. Determine the ultrafiltration rate for the hemodialysis D. Check blood pressure before starting dialysis

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? A. Decrease in the respiratory rate from 20 to 16/min B. Decrease in the urinary output from 50 mL to 30 mL per hour C. Increase in the temperature from 37.5 C (99.5 F) to 38.6 C (101.5 F) D. Increase in the heart rate from 88 to 110/min

D Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of blood loss or inadequate blood volume. In an effort to compensate for this, the heart rate increases steadily. In the first stage of shock (compensatory), the heart rate is > 100/min. As shock progresses, the heart rate continues to accelerate to more than 150/min. In the final (irreversible or refractory) stage, the heart rate becomes very erratic and may develop asystole.

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. The patient has tachypnea, and shortness of breath. Which of the following assessments should take the highest priority? A. Unequal pupils B. Irregular pulse C. Ecchymosis in the flank area D. Deviated trachea

D It's giving collapsed lung

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? A. The client's bilirubin level decreases B. The client has at least one stool daily C. The client denies nausea or anorexia D. The client is alert and oriented

D Lactulose is used for binding ammonia that occurs due to hepatic encephalopathy

The nurse recognizes that teaching a client following a laparoscopic cholecystectomy has been effective when the patient makes which statement? A. "I need to limit my activities and not return to work for 4 weeks." B. "I can expect yellowish drainage from the incision for a few days." C. "I will follow a low-fat diet for life because I do not have a gallbladder." D. "I can take a shower and walk around the house tomorrow"

D Laparoscopic cholecystectomy surgery makes small incisions and they recover very quickly. C is incorrect because the body will eventually adapt to not having a gallbladder and you can incorporate fats back into your diet after one to two months.

A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin site? A. Serosanguineous drainage B. Mild erythema C. Warmth D. Fever

D Manifestations of inflammation and infection at the pin sites include fever, purulent drainage, odor, loose pins, and tenting of the skin around the pin sites

A 21-year-old patient has been urinating excessively for the past 2 days after falling off a bicycle and hitting his head. He presents to the ED with BP 96/58, dizziness, fatigue, respirations 24, SaO2 95%, temperature 99, pulse 102. What is the priority nursing action? A. Test his blood glucose B. Ask him about medication consumption C. Administer fast acting insulin per doctor's order D. Begin an IV and 0.9% NS bolus 500 mL

D My dude is giving diabetes insipidus due to hitting his head. We gotta get him fluids.

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? A. Cryoprecipitates B. Platelets C. Albumin D. Packed RBCs

D Packed RBCs are given to restore blood volume and replace hematocrit and hemoglobin levels in clients who have hypovolemic shock

A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values? A. RBC count B. Protein C. Calcium D. Potassium

D Potassium levels are reduced by the process of diffusion during dialysis.

A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? A. NPH insulin B. Insulin glargine C. Insulin detemir D. Regular insulin

D Regular insulin is classified as short-acting insulin. It can be given intravenously with an onset of action of less than 30 minute. This is the insulin that is most appropriate in emergency situations of severe hyperglycemia or diabetic ketoacidosis

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mmHg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A. Raise the foot of the bed to a 90 degree angle B. Remove the dressing to inspect the wound C. Prepare to insert a central line D. Administer oxygen via nasal cannula

D The client has an increased respiratory rate and heart rate, indicating that she is having respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a hemothorax. Administer oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues

A nurse in an emergency department is caring for a client who has deep partial and full thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation phase of injury? A. Initiate fluid resuscitaiton B. Medicate for pain C. Insert an indwelling urinary catheter D. Maintain the airway

D The client is at risk for respiratory obstruction. Using the ABC approach to client care is the first action the nurse should take to ensure that the client has a patent airway.

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? A. "I drink at least 2 quarts of fluid every day." B. "The last time I voided it was painful and red tinged." C. "My period ended 2 days ago." D. "I don't eat shellfish because it gives me hives."

D The client says she experiences hives after eating shellfish, which indicates a sensitivity. The contrast dye typically used for an IVP is an iodine derivative, and the client with a shellfish sensitivity may have cross-sensitivity to iodine and a serious iodine allergy. This nurse should report these findings to the client's provider.

A nurse is caring for a client who has meningitis, a temperature of 39.7 C (103.5 F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? A. Dehydration B. Seizures C. Burns D. Shivering

D The hypothermia blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstrictor in an attempt to reduced heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption.

A nurse is reviewing the laboratory values of a client who is at risk for disseminated intravascular coagulopathy. Which of the following values should the nurse report to the provider? A. Platelets 156,000/mm^3 B. PT 12 seconds C. PTT 64 seconds D. Fibrinogen 85 mg/dL

D This fibrinogen level is below the expected reference range and should be reported to the provider. A decreased fibrinogen level can result from its depletion during the blood clotting process.

A nurse in an emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? A. Clean and dress the wound B. Administer pain medication C. Administer a tetanus booster D. Administer IV fluids

D Using the ABC framework, the priority action the nurse should take is to initiate fluid resuscitation to maintain blood volume and preserve cardiac output. The nurse can utilize large bore peripheral IV cannulas. However, in extensive burns a central line should be inserted to allow for rapid infusion of fluids

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremity. Which of the following interventions should the nurse perform first? A. Clean and dress the wound B. Administer pain medication C. Administer a tetanus booster D. Administer IV fluids

A nurse in the emergency department is assessing a newly admitted client who has facial trauma. Which of the following assessments is the nurse's priority? A. Soft-tissue edema B. Facial asymmetry C. Active bleeding D. Altered respirations

D When using the ABC approach to client care, the nurse determines that the priority is to assess the client's respirations, because edema from the client's injuries could cause airway obstruction. The nurse should assess the client's airway for stridor, shortness of breath, and dyspnea.

NURS 306 MC questions part dos

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