Nursing Concepts 2 Questions Midterm

A client presents to an emergency department after experiencing a seizure at home. A nurse pads the client's side rails and ensures that suction equipment is available while waiting for the laboratory results. Which laboratory value could lead to as seizure? a) Calcium 9.2 mg/dl b) Potassium 3.5 mEq/L c) Sodium 119 Meq/L d) Hemoglobin 11g/dL

Sodium 119 Meq/L

The nurse would expect a patient with increased levels of serum calcium to also have _____ levels. A. increased magnesium B. decreased phosphate C. Increased potassium D. decreased sodium

decreased phosphate Serum calcium and phosphate have an inverse relationship. When one is elevated, the other decreases, except in some patients with end-stage renal disease.

A postoperative client has respiratory depression after receiving midazolam for sedation. Which IV-push medication and dose does the nurse prepare to administer? A. Acethylcysteine 50 to 100 mg B. Flumazenil 0.2 to 1 mg C. Naloxone 0.4 to 2 mg D. Protamine Sulfate 1 to 2 mg

Flumazenil 0.2 to 1 mg Flumazenil is a benzodiazepine antagonist and would be the correct drug to use in this situation. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist.

After teaching a client who is prescribed a restricted sodium diet, a nurse assess the client's understanding. Which food choice for lunch indicates the client correctly understood the teaching? a) Grilled chicken breast with glazed carrots and boiled green beans b) Salami and cheese on whole wheat crackers c) Bowl of tomato soup with grilled cheese sandwich d) Slices of smoked turkey ham with potato salad and pickles

Grilled chicken breast with glazed carrots and boiled green beans

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough, although lungs are clear of adventitious sounds. Which action should the nurse take first? a) Provide small quantities of ice and sips of water b) Request a prescription for an antitussive medication c) Apply moist oxygen, pulse oximetry, and monitor the respiratory status. d) Ask the respiratory therapist to provide humidified air.

Apply moist oxygen, pulse oximetry, and monitor the respiratory status.

A patient is admitted for fluid volume deficit associated with decreased fluid intake. Which assessment would be the most accurate way for the nurse to evaluate gain or loss fluids? a) Urine specific gravity b) Daily weight c) Hourly urine output d) Blood pressure and heart rate

Daily weight

The nurse reads in the medical record that a client with diabetic ketoacidosis has Kussmaul's respirations. Which assessment finding is consistent with this condition? a) Respirations with an irregular pattern b) Slow respiration with periods of apnea c) Deep, rapid respirations d) Shallow, grunting respirations

Deep, rapid respirations

During assessment of a client with an intracapsular hip fracture, the nurse should detect: a) Internal rotation b) Numb fractured area c) Muscle flaccidity d) Leg shortening

Leg shortening

If sterile gauze falls to the ground and hits the front of the surgeon's gown on the way down, what does the circulating nurse do to ensure proper infection control? a) Sprays an antimicrobial on the surgeon's gown b) Picks the gauze up with a pair of sterile gloves c) Picks the gauze up without touching the surgeon d) Helps the surgeon change the gown

Picks the gauze up without touching the surgeon

The nurse assessing the IV insertion site finds the vein hard, the skin red, warm and tender, and a blood return in the IV line. The most effective intervention after removing the IV catheter is to: A. apply a warm moist pack B. write an incident report C. clean the site with alcohol and apply cool compress D. administer triple antibiotic ointment

apply a warm moist pack These are signs and symptoms of phlebitis and should be treated with a warm moist pack to increase blood flow to the area.

The nurse anticipates that an order for an isotonic intravenous (IV) solution will read A. 0.9% sodium chloride in 5% dextrose B. 0.45% sodium chloride C. 5% dextrose in water D. 0.9% sodium chloride

0.9% sodium chloride 0.9% sodium chloride is normal saline. It's isotonic

The nurse is choosing an IV cannula for an adult patient and will choose the biggest available size, which is a cannula of: A. 14 gauge B. 22 gauge C. 26 gauge D. 18 gauge

14 gauge The inside diameter, called the gauge, is expressed in reverse numerical order

A female client is brought to the emergency department with second and third degree burns on the whole left arm, left anterior leg, and anterior trunk. Using the rule of nines, what is the total body surface that has been burned? A. 30% B. 36% C. 18% D. 27%

36% 9+9+18=36

The RN is in the patient's room while the charge nurse is obtaining the patient's signature on the surgical consent form. The patient states, "I didn't really understand what my surgeon explained, but I trust him completely". Which response by the charge nurse is correct? A. "I can answer any questions that you might have regarding your surgery" B. "As long as you are comfortable, then you may sign the consent form" C. "I need to contact your surgeon so your questions can be answered" D. "Maybe we should call your surgeon to be sure it is okay to sign the consent form"

"I need to contact your surgeon so your questions can be answered" An informed consent form means that the surgeon has supplied information regarding the procedure itself, as well as the risks and benefits, and that the patient understand this informations.

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion. Which of the following statements indicated that the client knows how to use the device? A. "I should tell the nurse if the pain doesn't stop while using this device" B. "I will ask my son to push the dose button while I am sleeping" C. "I'll wait to use the device until it's absolutely necessary" D. "I'll be careful about pushing the button so I don't get an overdose"

"I should tell the nurse if the pain doesn't stop while using this device"

The nurse is providing discharge teaching. Which statement by the client indicates the need for further teaching regarding increase risk for metabolic alkalosis? a) "I take antacids after every meal to prevent heartburn." b) "I don't drink milk because it gives me gas and diarrhea." c) "I have been taking digoxin every day for the last 15 years." d) "In hot weather, I swear so much that I drink six glasses of water each day."

"I take antacids after every meal to prevent heartburn."

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding to avoid it for happening again. Which statement indicated the client requires reinforcement for teaching? A. "I must drink at least 2-3 liters of water or other liquid each day." B. "I will check for skin turgor on the skin of my chest." C. "I will weigh myself each morning before I eat or drink." D. "I will not drink liquids after 6 PM so I won't have to get up at night"

"I will not drink liquids after 6 PM so I won't have to get up at night" Abstaining of fluids since 6 PM places the patient at risk for dehydration because he/she is going to expend more than 12 hours without fluid intake

A patient with systemic lupus erythematosus (SLE) is preparing for discharge while in low dose of corticosteroids. The nurse knows that the patient has understood health education when the patient makes what statement? a) "I'll reduce the dose of my immune-suppressing steroids if I develop an infection." b) "I'll expect my provider increasing my steroids' dose if I need surgery." c) "I'll make sure I get enough sunlight to raise my vitamin D and avoid osteoporosis.'' d) "I'll try to be as physically and mentally active as possible during flare-ups."

"I'll reduce the dose of my immune-suppressing steroids if I develop an infection."

Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective? a) "I will need the nurse to notify me when it is time for another dose." b) "The pain medication will be delivered by the machine as frequently as I want" c) "Now I know I can't receive an overdose even if I press the button by mistake." d) "This is the only pain treatment I will be allowed to receive."

"Now I know I can't receive an overdose even if I press the button by mistake."

A patient has a parenteral nutrition infusion of 25% dextrose (D25W). A student nurse asks the nurse why a peripherally inserted central catheter (PICC) was inserted to allow the infusion of the D25W. which response by the nurse is the most appropriate? a) "The required blood glucose monitoring is more accurate when samples are obtained from a central line." b) "The 25% dextrose is hypertonic and will be more diluted in the rapid blood flow of the supervisor vena cava." c) "There is less risk for infection when 25% dextrose in infused through a central line." d) "The prescribed infusion can be given much more rapidly without risk of hyperglycemia when the patient has a central line."

"The 25% dextrose is hypertonic and will be more diluted in the rapid blood flow of the supervisor vena cava."

An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive first? a) A 65-year-old conscious male with a head laceration trickling dark blood. b) A 30-year-old distraught mother holding her crying child c) A 26-year-old male who has abdominal pain and pale, clammy skin d) A 48-year-old with an open fracture and deformity of the lower leg

A 26-year-old male who has abdominal pain and pale, clammy skin

Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department. Which of these patients will the nurse need to assess first? a. A patient with a red tag b. A patient with a blue tag c. A patient with a yellow tag d. A patient with a green tag

A patient with a red tag The red tag indicates a patient with a life-threatening injury requiring rapid treatment.

In an industrial accident, a male client that weighs 155 lb. (70kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefitting the client? a) An electrocardiogram (ECG) showing no arrythmias b) A urine output consistently above 30 ml/hour c) Body temperature reading all within normal limits d) A weight gain of 10 lb. (4.54 kg) in 12 hours

A urine output consistently above 30 ml/hour

A patient diagnosed with rheumatoid arthritis (RA) is prescribed methotrexate. To reduce the risk of a common adverse effect of this medication, the healthcare provider should advise the patient to avoid consuming which of the following? A. aged cheese B. alcohol C. caffeine D. green, leafy vegetables

Alcohol Alcohol should be avoided when taking hepatotoxic medications.

The nurse assesses an atopic client with elevated levels of immunoglobulin E and who has has serious type 1 hypersensitivity reactions. The nurse recognizes that the most severe form of a type 1 hypersensitivity reaction is A. dermatitis B. cell-mediated sensitivity C. bronchial asthma D. anaphylaxis

Anaphylaxis Other type 1 hypersensitivity reactions include allergic rhinitis, asthma, and acute allergic drug reactions. The most severe form of type 1 reactions is anaphylaxis. Cell-mediated sensitivity is a type 4 hypersensitivity as is dermatitis.

A client is on a potassium-restricted diet. Which choice by the client indicates a good understanding of the dietary regimen? a) Baked potato b) Apple pie c) 1% low fat milk d) Baked chicken

Apple pie

A 54-year-old female was recently diagnosed with degenerative joint disease. This condition is characterized by wear and tear, and loss of: a) Articular cartilage b) Synovial cartilage c) The joint capsule and ligaments d) The epiphyses' bone

Articular cartilage

The registered nurse is taking care of a 10-year-old male 24 hours after an open reduction and internal fixation (ORIF) of a right tibia fracture. The patient is alert and oriented and is complaining of pain. What is the most appropriate way to assess the pain of this patient? a) Ask the patient to describe the effect of pain on his activities of daily living b) Observe cardiac the patient's body language such as grimacing or crying c) Ask the patient to rate the level of pain and its characteristics

Ask the patient to rate the level of pain and its characteristics

The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate? a) Assess turgor on the client's forehead b) Document the finding and continue to monitor. c) Notify the physician d) Examine dependent body areas

Assess turgor on the client's forehead

The patient's IV has been infusing at a very high rate and now the patient appears to be in fluid volume overload, as indicated by A. bradycardia B. neck vein distention C. kidney failure D. hypotension

B. neck vein distention An IV infusing at a high rate is used to increase intravascular fluid volume , but there is an equalization level, after which the patient goes into fluid overload; strong pulse, increased bp, neck vein distention, and bilateral lung crackles; this results in pulmonary edema

The nurse teaches a client about how to increase dietary potassium. The client says she knows bananas are high in potassium but does not like the taste. The nurse determines teaching is effective if the client states which of the following? A. I should include carrots, apples, and yogurt in my diet B. Eating onions, corn, and oatmeal each day will give me all the potassium I need C. Baked potatoes, spinach, and raisins are high in potassium D. I should eat more rhubarb, tofu and celery

Baked potatoes, spinach, and raisins are high in potassium

The nurse understands the most significant laboratory study for knowing the evolution of a client who is HIV positive is the A. CD4+ count B. enzyme-linked immunosorbent assay (ELISA) test C. total white blood cell count D. Western blot test

CD4+ count The most recent classification system for HIV disease is based on two monitoring parameters used gto follow a client: (1) laboratory date (CD4+ cell count) and (2) clinical presentation (persons clinical manifestations)

A nurse assess bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a) Call the rapid response team and prepare for an emergency airway. b) Document the findings and reassess in 1 hour c) Loosen any constrictive dressing on the chest d) Lower the head of the bed to a Trendelenburg position

Call the rapid response team and prepare for an emergency airway.

The nurse is caring for a patient with hyperkalemia. Which body system would be most important for the nurse to plan to monitor closely? A. gastrointestinal B. cardiac C. renal D. neurological

Cardiac Potassium balance is necessary for cardiac function. Hyperkalemia places the patient at risk for potentially serious dysrhythmias.

The nurse notices yellowing at the corners of the sclera in an African-American client admitted for hepatitis. What does the nurse do next to confirm jaundice? a) Examines the client's hair b) Palpates the liver c) Checks the oral mucosa d) Monitors pulse oximetry

Checks the oral mucosa

A trauma client with multiple fractures and profuse bleeding wounds arrives via helicopter to the trauma center in probable cardiac arrest. Which of the following actions should the nurse take first when deciding to provide advance cardiac life support? a) Ask for medical history and allergies b) Insert a large bore intravenous catheter to initiate fluids c) Don face shield, gown, and gloves d) Assess for airway and respirations

Don face shield, gown, and gloves

An asymptomatic patient consults for a wellness health checkup. The nurse draws a sample of blood for testing with some difficult, and the potassium level is reported 6 mEq/L. The laboratory indicates "the specimen of blood in the tube is hemolyzed". What intervention should the nurse take? a) Obtain a prescription for Na polystyrene b) Notify immediately the health care provider c) Draw a new blood sample to retest d) Initiate immediate cardiac monitoring

Draw a new blood sample to retest

A client develops fluid overload while in the intensive care unit with lung crackles and edema in lower extremities. Which nursing intervention does the nurse perform first? a) Elevates the head of the bed b) Administer oxygen through nasal cannula c) Places the extremities in an elevated position d) Administer furosemide 20mg PO daily as ordered

Elevates the head of the bed Elevating the head of the bed will ease breathing for the client, so it should be done first. Supplemental oxygen may be indicated, the nurse should perform interventions that will help with psychological changes caused by fluid overload first. Diuretics can be administered after easing the patient's breathing capacity.

Which statement about the transmission of hepatitis C is correct? a) Contact precaution are used for the prevention of hepatitis C. b) Equipment or linen soiled with blood or body fluids should be wash with bleach or a disinfectant to prevent infection. c) All healthcare workers should be vaccinated to prevent the disease d) Feces is the most likely body fluid by which to transmit the disease

Equipment or linen soiled with blood or body fluids should be wash with bleach or a disinfectant to prevent infection.

What is a defining characteristic in the composition of hypotonic intravenous saline solutions such as 0.45% NaCl? a) Approximately the same number of dissolved sodium particle as blood serum b) Fewer dissolved of sodium particles than in blood serum c) Contains a mixture of electrolytes and dextrose with low osmolarity d) Higher concentrations of dissolved sodium particles than blood serum

Fewer dissolved of sodium particles than in blood serum

Which situation can cause a client to experience increased "insensible water loss"? Select all that apply a) Nausea b) Diuretics c) Increased respiratory rate d) Dry, hot weather e) Fever f) Diabetes mellitus

Increased respiratory rate Dry, hot weather Fever

Which nursing intervention takes priority for a client admitted with severe metabolic acidosis? a) Assess the client's strength in the extremities b) Administer enteral sodium bicarbonate c) Initiate cardiac monitoring d) Make the patient breath in a paper bag

Initiate cardiac monitoring

The nurse is caring for a postoperative patient on the medical-surgical floor. To prevent venous stasis and the formation of thrombus (DVT) after general anesthesia, the nurse encourages. a) Leg exercises b) Incentive spirometry c) Pursed lip respirations d) Deep breath and coughing

Leg exercises

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent degenerative joint disease (osteoarthritis) of knees and hips? a) Engage in weight-bearing exercise like running b) Maintain body mass index below 25 c) Have a diet plenty of calcium d) Avoid exercise and competitive sports

Maintain body mass index below 25

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88mm Hg, PaCO2 32 mmHg, and HCO3 16 mEq/L. How should the nurse interpret these results? a) Metabolic alkalosis b) Respiratory alkalosis c) Respiratory acidosis d) Metabolic acidosis

Metabolic acidosis

The patient with long-term renal failure has a pH of 7.30, PaCO2 of 33 mm Hg, and HCO3- of 18 mEq/L. From this laboratory information, the nurse assesses the patient is in: A. respiratory alkalosis B. metabolic alkalosis C. respiratory acidosis D. metabolic acidosis

Metabolic acidosis

A nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following? a) Vitamin D and calcium b) Hydromorphone c) Allopurinol d) Methotrexate

Methotrexate In the past, step-wise approach starting with NSAIDs was standard of care. However, evidence clearly documenting the benefits of early DMARD (methotrexate (Rheumatrex), antimalarials, leflunomide (Arava), or sulfasalazine) treatment has changed national guidelines for management.

The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Of the following, which would be the most important nest step? a) Document that the patient had a bath at home this morning b) Ask the nursing assistant to obtain vital signs c) Notify the operating suits that the patient has allergy to natural rubber d) Administer the ordered preoperative intravenous antibiotic

Notify the operating suits that the patient has allergy to natural rubber Patients allergic to fruits like banana, avocado, pineapple, kiwi, etc. have cross allergy with latex, a natural rubber. Innumerable products that contain latex are used in the operating suite and the post-anesthesia care unit (PACU). When preparing for a patient with this allergy, special considerations are required from preparations of the rooms to the types of tubes, gloves, drapes, and instruments utilized.

Which client is at greater risk for dehydration? a) Older adult client receiving hypotonic IV fluid b) Younger adult client receiving hypertonic IV fluid c) Younger adult client on bedrest d) Older adult client with cognitive impairment

Older adult client with cognitive impairment Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk of dehydration.

In which link of the chain of transmission of infection intervenes the use of googles when irrigating a wound infected with vancomycin resistant enterococcus (VRE)? a) Reservoir b) Pathogen agent c) Portal of entry d) Susceptible host

Portal of entry

The nurse is monitoring the fluid status of a 63-year-old woman receiving intravenous (IV) fluids following symptoms would suggest to the nurse that the patient has fluid volume overload? a) Crackles on the left lung apex, cough, fever, and central venous pressure 1 cm H2O. b) Urinary output 600 cc/24 hour, skin tenting, central venous pressure 3 cm H2O, nystagmus. c) Temperature 100, blood pressure 100/60, pulse 70 and thread, dizzy when seats up. d) Pulse 100 and bounding, unable to tolerate flat position, and neck vein distension.

Pulse 100 and bounding, unable to tolerate flat position, and neck vein distension.

A newly admitted client is diagnosed with important hyponatremia in seizure precautions. When admitting the patient, the charge nurse should take which action? a) Avoid soups, pickles, dairy, and processed food in the client's diet b) Remove the water pitcher from the room c) Place the patient on EKG to monitor for U waves d) Assign the patient to a room far from the nurse's station

Remove the water pitcher from the room

In examining a peripheral IV site receiving normal saline, the nurse observes a red streak along the length of the vein, and the vein feels hard and cordlike. What action by the nurse takes priority? a) Continuing to monitor site b) Applying continuous ice packs c) Elevating the extremity d) Removing the catheter

Removing the catheter

A 46-year old male presents with severe pain, redness, and tenderness in the right big toe. He was diagnosed with gouty arthritis. He also at risk for developing. a) Septic arthritis b) Gallstones c) Myocarditis d) Renal Stones

Renal Stones Renal stones are 1000 times more prevalent in individuals with primary gout that in the general populations.

Which acid-base imbalance does the nurse anticipate the client may develop white receiving morphine with patient-controlled analgesia (PCA) and is not responsive to call? a) Metabolic alkalosis b) Respiratory alkalosis c) Respiratory acidosis d) Metabolic acidosis

Respiratory acidosis

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas: pH 7.48, PaO2 85 mm Hg. PaCO2 32mm Hg, and HCO3 25mEq/L? a) Metabolic alkalosis b) Respiratory alkalosis c) Metabolic acidosis d) Respiratory acidosis

Respiratory alkalosis

Deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention? A. First B. Second C. Third D. Mixed

Second Second intention healing is characterized by a cavity-like defect. This requires gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss. There is no such thing as mixed intention healing.

The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal bleeding. It is important for the nurse to utilize ____ precautions. A. standard B. droplet C. protective D. contact

Standard Standard precautions apply to contact with blood, body fluid, non intact skin, and mucous membranes of all patients. Contact precautions apply to individuals with colonization of infection such as MRSA. Protective precautions apply to individuals who have undergone transplantations. Droplet precautions focus on diseases that are transmitted by large droplets.

A patient on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precautions for the staff to take to prevent transmission of this disease? a) Standard and droplet precautions b) Standard and airborne precautions c) Droplet precautions only d) Standard precautions only

Standard and airborne precautions

On a hot humid, an emergency department nurse is caring for a client who is lethargic and has these vital signs: temperature 104.1 F (40.1 C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/56 mm Hg. Which of the following actions should the nurse take? a) Start intravenous line and request the admission to intensive care unit (ICU) b) Draw blood for ordered tests, give a cold bath, and re-assess in 30 minutes c) Encourage the client to drink cold water or sports drinks to lower temperature d) Administer acetylsalicylic acid 1000 mg orally to decrease temperature

Start intravenous line and request the admission to intensive care unit (ICU)

A client undergoing preoperative assessment in the morning informs the nurse that he takes medications for high blood pressure as per MD order. What is the nurse's best action? A. Document the information in the client's record B. tell the client not to take the medication the day of the surgery C. notify the surgeon and the anesthesiologist D. Tell the client to take medications preoperatively with a sip of water

Tell the client to take medications preoperatively with a sip of water Medications for cardiac and respiratory problems usually are given with sips of water before surgery

Which action indicates to the operating room supervisor that the scrub nurse requires additional teaching about sterile technique? a) The sterile saline bottle cap is placed upside down in the center of the sterile field. b) The nurse disposes of any equipment packages that are in poor condition. c) Sterile surgical supplies are placed in the center of the sterile field. d) A small amount of sterile saline is poured out in the garbage bin before it is poured into the basin.

The sterile saline bottle cap is placed upside down in the center of the sterile field.

Which assessment finding would the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? A. lightheadedness when standing up B. decreased deep tendon reflexes C. weak quadriceps muscles D. tingling of the extremities and Trousseau's sign

Tingling of the extremities and Trousseau's sign This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Sodium and potassium values are within their normal ranges: sodium 135-145 mEq/L; potassium: 3.5-5.0 mEq/L. Hypocalcemia causes muscle tetany, positive Trousseau's sign, and tingling of the extremities.

A nurse admits a 10-month-old female infant with bronchiolitis in isolation. Which of the following pediatric clients could be admitted with this infant in the same room? a) A two-year old female with a fracture b) Two-year-old male with Respiratory Syncytial virus c) One-year-old female with rotavirus d) Twelve-month-old male impetigo

Two-year-old male with Respiratory Syncytial virus

An HIV-positive client is admitted to the hospital with Pneumocystis jiroveci pneumonia, an opportunistic infection. Which action by the nurse is most appropriate? a) Place the client on Droplet Precautions b) Initiate Contact Precautions c) Place the client on Airborne Precautions d) Use Standard Precautions consistently

Use Standard Precautions consistently

Emergency medical technicians (EMTs) arrive at the emergency department with an unresponsive client who has oxygen mask in place. The EMT only reports blood pressure 96/60 mmHg and suspects internal bleeding. Which action should the nurse take first? a) Verify the presence of symmetric lung sounds b) Insert a large-bore intravenous line and start isotonic solutions c) Place the client on a cardiac monitor d) Assess the abdomen for signs of internal bleeding

Verify the presence of symmetric lung sounds

The nurse is caring for a patient with osteomyelitis in the right tibia. The plan of care for the patient is to administer antibiotics 2 times a day for 3 weeks while at home. What device will be used to administer these antibiotics? A. a PICC line B. a subclavian catheter with continuous infusion C. a heparin locked peripheral catheter D. an implanted port catheter

a PICC line A PICC line is a type of central venous device that can be introduced into a peripheral vein for administration if IV antibiotics for an extended period, over the course of several weeks. A continuous infusion would not take place if the patient received antibiotics only 2 times daily. A peripheral catheter would not be necessary or heparin locked. An implanted port catheter is intended for long term use of venous access over months, or even years.

The nurse performs Allen's test before obtaining an ABG specimen to determine A. if ulnar circulation is adequate B. the patency of the radial artery C. if an allergy to heparin is present D. the presence of neuromuscular weakness

if ulnar circulation is adequate Before radial puncture to obtain ABG specimens, Allen's test should be performed to ascertain adequate ulnar circulation. Failure to assess ulnar circulation could result in ischemic injury to the clients hand.

A nurse is caring for a client who has the following arterial blood values: pH 7.12, Pa02 56 mm Hg, PaCO2 65 mm Hg, and HCO3- 33 MEq/L. Which clinical situation should the nurse correlate with these values? A. anxiety-induced hyperventilation in an adolescent B. diarrhea for 36 hours in an older, frail woman C. bronchial obstruction related to aspiration of a hot dog D. diabetic ketoacidosis and dehydration

bronchial obstruction related to aspiration of a hot dog Arterial blood gas values indicate that the client has acidosis with normal levels of bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an acute respiratory problem rather than a chronic problem, because no renal compensation has occurred.

A client has low serum calcium level. During a bath the nurse cleans the client's face with a cloth, and the lips, nose, and side of the face contract. The nurse documents the presence of A. trousseau's sign B. tic douloureux C. chvostek's sign D. bell's palsy

chvostek's sign Chvostek's sign is a spasm of the muscles innervated by the facial nerve. It is best elicited by tapping the clients face slightly below the temple.

The nurse is assigned to care for a female client with herpes zoster (Shingles). Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection? A. a generalized body rash B. small blue-white spots with a red base C. clustered skin vesicles D. fiery red, edematous rash on the cheeks

clustered skin vesicles The primary lesions of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome because the lesions follow nerve pathways.

The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjogren's syndrome? A. oxygen saturation B. cornea condition and visual acuity C. renal function studies D. abdominal assessment

cornea condition and visual acuity Sjogren's Syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Corneal ulceration and visual disturbances can occur.

As the nurse is reviewing the chart of a client going into surgery in one hour, it is discovered that the surgical consent form is not signed. What does the nurse do first? A. calls the anesthesiologist to discontinue any preoperative medication B. calls the surgeon to cancel the surgery C. determine if the client already received sedative premedication D. ask an authorized relative to sign the consent

determine if the client already received sedative premedication The nurse may ask the client to sign the consent form if mental altering medication has not been given yet. For that reason this is the first to determine. After that the nurse assesses if the patient was properly informed and then asked him/her to sign. After it is done, the premedication can be administered.

As the nurse is reviewing the chart of a client going into surgery in one hour, it is discovered that the surgical consent form is not signed. What does the nurse do first? A. calls the anesthesiologist to discontinue any preoperative medication B. calls the surgeon to cancel the surgery C. determine if the client already received sedative premedication D. ask an authorized relative to sign the consent

determine if the client already received sedative premedication The nurse may ask the client to sign the consent form if mental altering medication has not yet been given.

A nurse reviews the following data in the chart of a client with burn injuries: Admission notes: 36-year old female with bilateral leg burns NKDA Health history: History of asthma and seasonal allergies Wound assessment: bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize the client's injuries? A. superficial B. partial-thickness C. full thickness D. stage four pressure ulcer

full thickness

Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis? A. administer pain medication only when non pharmacological measure have failed B. provide intravascular bolus as needed for breakthrough pain C. give medications around-the-clock D. administer pain medication before any activity

give medications around-the-clock When a patient with arthritis has chronic pain, the best way to manage pain is to take medication regularly throughout the day to maintain consistent pain relief. "Before activity" is nonspecific, and the medication may not have time to work before activity. If the patient waits until having pain to take the medication, pain relief takes longer. Non Pharmacological measures are used in conjunction with medications unless requested otherwise by the patient.

The nurse is called to a patients room who complains of pain 9/10 and requests pain medication. He is laughing, watching football, and is in conversation with a visitor. Based on the assessment, what intervention should the nurse employ? A. administer a placebo and re-assess pain 30 minutes later B. wait until the visitor leaves to reassess pain C. assess for physiologic manifestations of pain like tachycardia D. give pain medication

give pain medication Pain is a multidimensional phenomenon that is difficult to define. It is personal and subjective and is whatever the patient says it is.

The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which of the following nursing actions would be appropriate given this organism? A. place the patient on droplet precautions B. wear an n95 respirator when entering the patient room C. teach the patient cough etiquette D. instruct assistive personnel to use soap and water rather than sanitizer to clean hands

instruct assistive personnel to use soap and water rather than sanitizer to clean hands Clostridium difficile is a spore-forming organism that can be transmitted through direct and indirect contact. Because C.diff is a spore-forming organism, hand sanitizer is not effective in preventing its transmission. Hands must be washed with soap and water to prevent transmission.

The nurse can record that the compensatory mechanism for the correction of metabolic acidosis is in effect when the nurse observes: A. kussmaul's respirations B. raips and superficial respirations C. patient breath in a paper bag D. cheyne-stoke respirations

kussmaul's respirations kussmaul's respirations, or deep and rapid respirations, are blowing off carbon dioxide reduce an acidotic state

The evening nurse reviews the nursing documentation in the male client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? A. exposed bone, tendon, muscle B. intact skin with non-blanching erythema C. full-thickness skin loss, exposed subcutaneous tissue D. partial-thickness skin loss of the dermis

partial-thickness skin loss of the dermis In the stage I pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open, or ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage 3. Exposed bone, tendon, or muscle is present in stage 4.

A nurse assesses a 52 year old woman with the skin disorder below: A. ecchymoses B. actinic lentigo senile C. petechiae D. senile cherry angiomas

petechiae

A client with human immunodeficiency virus is admitted to the hospital with fever, night sweats, and severe cough with hemoptysis. Laboratory results include a CD4+ cell count of 180/mm3 but had a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? A. initiate contact precautions and notify the provider about the CD4+ results B. place the client under Airborne Precautions and notify provider C. initiate droplet precaution for the client and notify provider D. use standard precautions to provide care and rule out the possibility of TB

place the client under Airborne Precautions and notify provider Since the client's CD4+ cell count is low, he or she may have anergy, the inability to mount on immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which of the following prescriptions should the nurse implement first to promote a shift of extracellular potassium to the intravascular compartment? A. prepare the client for hemodialysis treatment B. prepare to administer dextrose 20% and the 10 units of regular insulin IV push C. prepare to administer sodium polystyrene sulfonate 15 g by mouth D. provide a heart healthy, low-potassium diet

prepare to administer dextrose 20% and the 10 units of regular insulin IV push A client with high serum potassium level and cardiac changes should be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore should be administered with dextrose to prevent hypoglycemia. Kayexalate may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first prescription the nurse should implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level.

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hand. Vital signs are pulse 84, respirations 16, BP 110/70 mm HG. Which action should the nurse take first? A. apply ice packs to both hands B. give diphenhydramine (Benadryl) 50 mg PO C. apply calamine lotion to any itching areas D. remove the patients rings

remove the patients rings The patient's rings should be removed first because it might not be possible to remove them if swelling develops.

Which drug-induced severe skin reaction is characterized by extended vesicles, blistering, erosions, and crusts? A. stevens-johnson syndrome B. urticaria C. basal cell carcinoma D. psoriasis

stevens-johnson syndrome stevens-johnson syndrome is a drug-induced skin reaction, typically characterized by vesicles, erosions, and crusts.

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? A. elevate the extremity on a pillow B. stop the infusion of intravenous fluids C. apply cold compresses to the IV site D. flush the catheter with normal saline

stop the infusion of intravenous fluids Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above site. The nurse should stop the infusion and remove the catheter. Cold compress and elevation of the extremity can be done after the catheter is discontinued to increased patient comfort. Alternatively, warm compresses may be prescribed per institutional policy and may help speed circulation to the area.

A client has an acute case of opioid respiratory depression and successfully receives a dose of naloxone. Which statement is true about this client after receiving the antidote? A. no more than one dose of naloxone is needed B. supplemental pain medication is needed C. the nurse is required to call the rapid response team D. the client will develop severe constipation

supplemental pain medication is needed The client will have breakthrough pain after the opioid antagonist is given, so other interventions to promote pain relief is needed. Several doses of naloxone may be needed because the drug has a short half-life. Opioid depression is a manageable situation by the nurse administering naloxone, not requiring to call RRT. The opioid withdrawal is characterized by abdominal cramps and diarrhea.

The patient refuses to take off her diamond wedding band prior to going to the operating room for a cholecystectomy. The nurse should first: A. alert the surgeon of the presence of the jewelry B. request that the patient sign a waiver to release the hospital of responsibility C. tape the ring to the finger, covering the ring, and document it D. record in the chart that the patient refused to remove jewelry

tape the ring to the finger, covering the ring, and document it Taping the ring will protect the ring and secure it to the finger. Care must be taken not to wrap the tape too tightly. The nurse will also need to document the presence of the ring on the preoperative checklist or in the nurse's notes. There is no need for a signature on a waiver. Most facilities have policies in which the patient signs a release of responsibility for valuables. There is no need to notify the surgical team of the presence of the ring.

Which factor regarding older adults and pain medication is important for the nurse to understand? A. the older adult is more likely to experience drug interactions than the general public B. the older adult feels pain with less intensity due to decreased nerve activity C. older adults have enhanced liver metabolism of analgesic drugs D. older adults require less doses of opioids when taking them for a long time

the older adult is more likely to experience drug interactions than the general public The older adult is more likely to experience drug interactions than the general public due to polymedication and/or decreased liver and kidney function

The nurse is assessing a m ale client admitted with second and third degree burns on arms and chest. Which finding indicates a potential problem is developing? A. rectal temperature of 100 B. urine output of 20 ml/hour C. hemoglobin oxygen saturation 95% D. white pulmonary secretions

urine output of 20 ml/hour Decreased urinary output with increased urine density (specific gravity) is a manifestation of the fluid volume deficit developed in the emergent face of burns