OMG Final

Positioning: Pulmonary Embolism

high fowler

A client with a pulmonary embolism is being discharged home on warfarin (Coumadin). Which response suggests the client requires additional teaching about warfarin therapy by the nurse prior to discharge? 1 "I will not participate in my soccer club games until I'm off the warfarin." 2 "I can use a rectal suppository if I become constipated." 3 "I will have to buy myself an electric shaver." 4 "I will call my provider before I go to the dentist.

"I can use a rectal suppository if I become constipated." Several safety precautions important for the client to understand about bleeding when being discharged on warfarin. The client should take stool softeners to prevent hard stools or straining but should not insert a rectal suppository (unless they are prescribed and well-lubricated) or enema, as they can cause bleeding. Avoiding contact sports, contacting the provider before going to the dentist, and using an electric shaver demonstrate appropriate knowledge about warfarin safety upon discharge.

The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms should the nurse assess? Select all that apply. 1 Dizziness and fainting 2 Shortness of breath (SOB) worsening over the last 2 weeks 3 Inspiratory chest pain 4 Productive cough 5 Pink, frothy sputum

- Dizziness and fainting - Inspiratory chest pain Syncope, hypotension, and fainting are symptoms associated with PE. Sharp, pleuritic, inspiratory chest pain is also characteristic of PE. Sudden, not gradual, SOB occurs with PE. Productive cough is associated with infection; PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema; PE may cause hemoptysis.

A nurse is reviewing the assessment findings for a client who was admitted to the hospital with a diagnosis of diabetes insipidus. The nurse understands that which manifestations are associated with this disorder? (SATA) 1. Polyuria 2. Polydipsia 3. Concentrated urine 4. Complaints of excessive thirst 5. Specific gravity lower than 1.005

1, 2, 4, 5 ~ A triad of clinical symptoms-polyuria, polydipsia, and excessive thirst-often occurs suddenly in the client with diabetes insipidus. The urine is dilute, with a specific gravity lower than 1.005, and the urine osmolality is low (50 to 200 mOsm/L).

The nurse is developing a plan of care for a client with Addison's disease. The nurse has identified a problem of risk for deficient fluid volume and identifies nursing interventions that will prevent this occurrence. Which nursing interventions should the nurse include in the plan of care? (SATA) 1. Monitor for changes in mentation. 2. Encourage an intake of low-protein foods. 3. Encourage an intake of low-sodium foods. 4. Encourage fluid intake of at least 3000 mL per day. 5. Monitor vital signs, skin turgor, and intake and output.

1, 4, 5 ~ The client at risk for deficient fluid volume should be encouraged to eat regular meals and snacks and to increase intake of sodium, protein, and complex carbohydrates and fluids. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required. Mentation, vital signs, skin turgor and intake and output should be monitored for signs of fluid volume deficit.

The nurse is assessing a postoperative client who is recovering from a partial gastrectomy. The nurse is aware that the client is at risk for developing: 1. anemia 2. polycythemia 3. purpura 4. thrombocytopenia

1. anemia Surgery is a risk factor for anemia. Polycythemia can occur from severe hypoxia due to congenital heart and pulmonary disease. Purpura and thrombocytopenia may result from decreased bone marrow production of platelets and do not result from surgery.

The nurse is developing a care plan for a client with leukemia. The plan should include which of the following? Select all that apply. 1. Monitor the temperature and report elevation. 2. Recognize signs and symptoms of infection. 3. Avoid crowds. 4. Maintain integrity of skin and mucous membranes. 5. Take a baby aspirin each day.

1. Monitor the temperature and report elevation. 2. Recognize signs and symptoms of infection. 3. Avoid crowds. 4. Maintain integrity of skin and mucous membranes.

What determines the neuromuscular status of a patient who underwent endoscopic nasal hypophysectomy for hyperpituitarism? 1 Level of consciousness 2 Pupillary response to light 3 Ability to read a seven-word sentence 4 Orientation to time, place, and person

2 Pupillary response to light Pupillary response to light determines the neuromuscular status of a patient after hypophysectomy. The patient's cognition and mental status are determined by assessing the level of consciousness. The patient's cognition is also determined by the ability to read a seven-word sentence with each word not having more than three syllables. The patient's mental status is evaluated by checking orientation to time, place, and person.

Platelets should not be administered under which of the following conditions? 1. The platelet bag is cold. 2. The platelets are 2 days old. 3. The platelets bag is at room temperature. 4. The platelets are 12 hours old.

1. The platelet bag is cold. Platelets cannot survive cold temperatures. The platelets should be stored at room temperature and last for no more than 5 days

The nurse should teach the client with neutropenia and the family to avoid which of the following? 1. Using suppositories or enemas. 2. Using a high-efficiency particulate air filter mask. 3. Performing perianal care after every bowel movement. 4. Performing oral care after every meal.

1. Using suppositories or enemas. neutropenic client is at risk for infection, especially bacterial infection of the respiratory and gastrointestinal tracts. Breaks in the mucous membranes, such as those that could be caused by the insertion of a suppository or enema tube, would be a break in the first line of the body's defence and a direct port of entry for infection.

The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? (SATA) 1. Anxiety 2. Leukocytosis 3. Chvostek's sign 4. Urinary output of 800 mL/hour 5. Clear drainage on nasal dripper pad

2, 4, 5 ~ Acromegaly results from excess secretion of growth hormone, usually caused by a benign tumor on the anterior pituitary gland. Treatment is surgical removal of the tumor, usually with a sublingual transsphenoidal complete or partial hypophysectomy. The sublingual transsphenoidal approach is often through an incision in the inner upper lip at the gum line. Transsphenoidal surgery is a type of brain surgery and infection is a primary concern. Leukocytosis, or an elevated white count, may indicate infection. Diabetes insipidus is a possible complication of transsphenoidal hypophysectomy. In diabetes insipidus there is decreased secretion of antidiuretic hormone and clients excrete large amounts of dilute urine. Following transsphenoidal surgery, the nasal passages are packed and a dripper pad is secured under the nares. Clear drainage on the dripper pad is suggestive of a cerebrospinal fluid leak. The surgeon should be notified and the drainage should be tested for glucose. A cerebrospinal fluid leak increases the postoperative risk of meningitis. Anxiety is a nonspecific finding that is common to many disorders. Chvostek's sign is a test of nerve hyperexcitability associated with hypocalcemia and is seen as grimacing in response to tapping on the facial nerve. Chvostek's sign has no association with complications of sublingual transsphenoidal hypophysectomy.

What is the earliest clinical manifestation of a client with acute disseminated intravascular coagulation (DIC)? 1. Severe shortness of breath. 2. Bleeding without history or cause. 3. Orthopnea. 4. Hematuria.

2. Bleeding without history or cause. there is no well-defined sequence for acute DIC other than that the client starts bleeding without a history or cause and does not stop bleeding.

A client with disseminated intravascular coagulation develops clinical manifestations of microvascular thrombosis. The nurse should assess the client for: 1. Hemoptysis. 2. Focal ischemia. 3. Petechiae. 4. Hematuria.

2. Focal ischemia manifestations of microvascular thrombosis are those that represent a blockage of blood flow and oxygenation to the tissue that results in eventual death of the organ. Examples of microvascular thrombosis include acute respiratory distress syndrome, focal ischemia, superficial gangrene, oliguria, azotemia (Presence of nitrogenous bodies espec. uria in increased amount, in the blood), cortical necrosis, acute ulceration, delirium, and coma.

The nurse should instruct the client with a platelet count of less that 150,000/uL to avoid which of the following activities? 1. Ambulation. 2. Valsalva's maneuver. 3. Visiting with children. 4. Semi-Fowler's position.

2. Valsalva's maneuver When the platelet count is less that 150,000/uL., prolonged bleeding can occur from trauma, injury, or straining such as with Valsalva's maneuver. Clients should avoid any activity that causes straining to evacuate the bowel.

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse would instruct the client to: 1. lie supine with his neck extended. 2. sit upright, leaning slightly forward. 3. blow his nose and then put lateral pressure on it. 4. hold his nose while bending forward at the waist.

2. sit upright, leaning slightly forward.

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? 1. Lower the head of the bed. 2. Test the drainage for glucose. 3. Obtain a culture of the drainage. 4. Continue to observe the drainage.

2. ~ After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. Cerebrospinal fluid contains glucose, and if positive, this would indicate that the drainage is cerebrospinal fluid. The head of the bed should remain elevated to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.

A client is diagnosed with Cushing's syndrome. When reviewing the recent laboratory results, the nurse should expect an excess of which substance? 1. Calcium 2. Cortisol 3. Epinephrine 4. Norepinephrine

2. ~ Cushing's syndrome is characterized by an excess of cortisol, a glucocorticoid. Glucocorticoids are produced by the adrenal cortex. Calcium would be decreased in this disorder. Epinephrine and norepinephrine are produced by the adrenal medulla.

Which clinical manifestation may be evident in the initial stage of hypovolemic shock? 1 Decrease in urine output 2 Decrease in cardiac output 3 Increase in heart and respiratory rate 4 A 2%-5% decrease in oxygen saturation

3 Increase in heart and respiratory rate The initial stage of hypovolemia can be detected only by an increase in heart and respiratory rates. Reduction in urine output is a manifestation of the nonprogressive stage. Antidiuretic hormone increases water reabsorption in the kidneys which results in decreased urine output. In the initial stage of hypovolemia, the compensatory mechanisms are efficient in maintaining cardiac output, so there is no overall decrease in cardiac output. A 2%-5% decrease in oxygen saturation indicates the nonprogressive stage of hypovolemia.

Which assessment data indicates that antibiotic therapy has been effective for treating a patient with sepsis? 1 Serum creatinine increases from 1.2 to 1.8 mg/dL 2 White blood cell count decreases from 15,000 to 13,500/mm3 3 Serum lactate level decreases 2.3 to 0.9 mmol/L 4 Serum glucose increases from 112 to 146 mg/dL

3 Serum lactate level decreases 2.3 to 0.9 mmol/L No single laboratory test confirms the presence of sepsis, but one of the hallmarks of sepsis is an increasing serum lactate level. The return of abnormal labs to normal range and stabilization of the patient's presentation are used to evaluate treatment effectiveness. An increase in serum creatinine clearance does not indicate the effective sepsis treatment. A decrease (not increase) in serum glucose would be expected in a non-diabetic patient. The slight decrease in white blood cells does not yet signify the effectiveness of antibiotic therapy.

nurse is reviewing the assessment findings and laboratory data for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The nurse understands that which symptoms are associated characteristics of this disorder? (SATA) 1. Hypernatremia 2. Signs of water deficit 3. High urine osmolality 4. Low serum osmolality 5. Hypotonicity of body fluids 6. Continued release of antidiuretic hormone (ADH)

3, 4, 5, 6 ~ SIADH is characterized by inappropriate continued release of ADH. This results in water intoxication, manifested as fluid volume expansion, hypotonicity of body fluids, and hyponatremia as a result of the high urine osmolality and low serum osmolality.

Which of the following is an assessment finding associated with internal bleeding with disseminated intravascular coagulation? 1. Bradycardia. 2. Hypertension. 3. Increasing abdominal girth. 4. Petechiae.

3. Increasing abdominal girth. As blood collects in the peritoneal cavity, it causes dilation and distention, which is reflected in increased abdominal girth. The client would be tachycardic and hypotensive. Petechiae reflect bleeding in the skin.

A client has been diagnosed with Cushing's syndrome. The nurse should assess the client for which expected manifestations of this disorder? 1. Dizziness 2. Weight loss 3. Hypoglycemia 4. Truncal obesity

4. ~ The client with Cushing's syndrome may exhibit a number of different manifestations. These may include moon face, truncal obesity, and a "buffalo hump" fat pad. Other signs include hyperglycemia, hypernatremia, hypocalcemia, peripheral edema, hypertension, increased appetite, and weight gain. Dizziness is not part of the clinical picture for this disorder.

The nurse is instructing a client with Cushing's syndrome on follow-up care. Which of these client statements would indicate a need for further instruction? 1. "I should avoid contact sports." 2. "I should check my ankles for swelling." 3. "I need to avoid foods high in potassium." 4. "I need to check my blood glucose regularly."

3. ~ Hypokalemia is a common characteristic of Cushing's syndrome, and the client is instructed to consume foods high in potassium. Clients with this condition experience activity intolerance, osteoporosis, and frequent bruising. Fluid volume excess results from water and sodium retention. Hyperglycemia is caused by an increased cortisol secretion.

The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? 1. A platelet count of 200,000 mm3 (200 × 109/L) 2. A blood glucose level of 110 mg/dL (6.28 mmol/L) 3. A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L) 4. A white blood cell (WBC) count of 6000 mm3 (6 × 109/L)

3. ~ The client with Cushing's syndrome experiences hypokalemia, hyperglycemia, an elevated WBC count, and elevated plasma cortisol and adrenocorticotropic hormone levels. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids in the body. The laboratory values listed in the remaining options would not be noted in the client with Cushing's syndrome.

The nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. Which health care provider's (HCP's) prescriptions, if noted on the record, would indicate the need for clarification? 1. Assess vital signs and neurological status. 2. Instruct the client to avoid blowing his nose. 3. Apply a loose dressing if any clear drainage is noted. 4. Instruct the client about the need for a MedicAlert bracelet.

3. ~ The nurse should observe for clear nasal drainage; constant swallowing; and a severe, persistent, generalized, or frontal headache. These signs and symptoms indicate cerebrospinal fluid leak into the sinuses. If clear drainage is noted after this procedure, the HCP needs to be notified. Therefore, clarification is needed regarding application of a loose dressing. The remaining options indicate appropriate postoperative interventions.

The nurse is caring for a patient who is prescribed desmopressin (DDAVP) nasal spray for diabetes insipidus. What is a potential side effect of this intranasal drug? 1 Anuria 2 Drowsiness 3 Weight gain 4 Chest tightness

4 Chest tightness

The nurse is caring for a client with a diagnosis of Cushing's syndrome. Which expected signs and symptoms should the nurse monitor for? Select all that apply. 1. Anorexia 2. Dizziness 3. Weight loss 4. Moon face 5. Hypertension 6. Truncal obesity

4, 5, 6 ~ A client with Cushing's syndrome may exhibit a number of different manifestations. These could include moon face, truncal obesity, and a buffalo hump fat pad. Other signs include hypokalemia, peripheral edema, hypertension, increased appetite, and weight gain. Dizziness is not part of the clinical picture for this disorder.

1. The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the client's recent history? a. Pyelonephritis b. Myocardial infarction c. Bladder cancer d. Kidney stones

ANS: B Pre-renal causes of AKI are related to a decrease in perfusion, such as with a myocardial infarction. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI related to urine flow obstruction.

The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? 1. Agitation 2. Diaphoresis 3. Restlessness 4. Severe abdominal pain

4. ~ Addisonian crisis is a serious life-threatening response to acute adrenal y a major stressor. insufficiency that most commonly is precipitated client in addisonib The an crisis may demonstrate any of the signs and symptoms of Addison's disease, but the primary problems are sudden profound weakness; severe abdominal, back, and leg pain; hyperpyrexia followed by hypothermia; peripheral vascular collapse; coma; and renal failure. The remaining options do not identify clinical manifestations associated with addisonian crisis.

The nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which should the nurse expect to note on assessment of the client? 1. Skin atrophy 2. The presence of sunken eyes 3. Drooping on 1 side of the face 4. A rounded "moonlike" appearance to the face

4. ~ With excessive secretion of adrenocorticotropic hormone (ACTH) and chronic corticosteroid use, the person with Cushing's syndrome develops a rounded moonlike face; prominent jowls; red cheeks; and hirsutism on the upper lip, lower cheek, and chin. The remaining options are not associated with the assessment findings in Cushing's syndrome.

A client is recovering from a kidney transplant. The client's urine output was 1500 mL over the last 12-hour period since transplantation. What is the priority assessment by the nurse? a. Checking skin turgor b. Taking blood pressure c. Assessing lung sounds d. Weighing the client

ANS: B By taking blood pressure, the nurse is assessing for hypotension that could compromise perfusion to the new kidney. The nurse then should notify the provider immediately. Skin turgor, lung sounds, and weight could give information about the fluid status of the client, but they are not the priority assessment.

A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first? a. Cardiac rate and rhythm b. Skin and mucous membranes c. Musculoskeletal strength d. Level of orientation

ANS: A Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be present. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should be monitored if the acidosis worsens. Skin and mucous membrane assessment is not a priority now, but will change as acidosis worsens.

A patient arrives to the ER and is unable to give you a health history due to altered mental status. The family reports the patient has gained over 10 lbs in 1 week and says it is mainly "water" weight. In addition, they report the patient hasn't been able to urinate or eat within the past week as well and was recently diagnosed with small cell lung cancer. On assessment, you note the patient's HR is 115 and BP 180/92. Patient sodium level is 90. Which of the following conditions do you suspect the patient is most likely presenting with?* A. SIADH B. Diabetes Insipidus C. Addison's Disease D. Fluid Volume Deficient

A

The patient with acute pancreatitis experiences abdominal pain. What is the best intervention to begin management of this pain? a. IV opioids by means of patient-controlled analgesia (PCA) b. Oral opioids such as morphine sulfate given as needed c. Intramuscular opioids given every 6 hours d. Oral hydromorphone (Dilaudid) given twice a day

A

Which abnormal laboratory findings are cardinal findings in acute pancreatitis? (Select all that apply.) a. Elevated serum lipase b. Increased serum amylase c. Decreased serum trypsin d. Elevated serum elastase e. Elevated serum glucose

A, B, D

A patient is admitted to the ER. The patient is unconscious on arrival. However, the patient's family is with the patient and reports that before the patient became unconscious she was complaining of severe pain in the abdomen, legs, and back, and has been experiencing worsening confusion. In addition, they also report the patient has not been taking any medications. The patient was recently discharged from the hospital for treatment of low cortisol and aldosterone levels. On assessment, you note the patient's blood pressure is 70/45. What disorder is this patient most likely experiencing? A. Addisonian Crisis B. Cushing Syndrome C. Thyroid crisis D. Hashimoto thyroiditis

A. Addisonian Crisis Note the patient is experiencing the signs and symptoms of Addisonian Crisis. The red flag in this scenario are the patient's symptoms, recent hospitalization diagnosis, and that she is not taking any medications. Remember that patients who have Addision's disease are at risk for Addisonian Crisis, especially if they are not taking their prescribed hormone therapy replacement.

After a hypophysectomy for acromegaly, what should be the priority of postoperative nursing care? A. Frequent monitoring of serum and urine osmolarity B. Parenteral administration of a growth hormone receptor antagonist C. Keeping the patient in a recumbent position for 2 days D. Patient teaching relate to lifelong ACTH and TSH hormone replacement

A. Frequent monitoring of serum and urine osmolarity A possible postoperative complication after hypophysectomy is transient diabetes insipidus (DI). This may occur because of loss of antidiuretic hormone (ADH), which is stored in the posterior lobe of the pituitary, or cerebral edema related to manipulation of the pituitary during surgery. To assess for DI, monitor urine output and serum and urine osmolarity closely.

Which laboratory result is most likely for a patient diagnosed with Cushing disease? A. Hypokalemia B. Decreased serum cortisol level C. Eosinophilia D. Thrombocytopenia

A. Hypokalemia The excessive adrenocortical activity produces hyperglycemia, hypokalemia, hypercalcemia, and elevated plasma cortisol levels.

A nurse contacts the health care provider after reviewing a client's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity

ANS: A Normal BUN is 10 to 20 mg/dL. Normal creatinine is 0.6 to 1.2 mg/dL (males) or 0.5 to 1.1 mg/dL (females). Creatinine is more specific for kidney function than BUN, because BUN can be affected by several factors (dehydration, high-protein diet, and catabolism). This client's creatinine is normal, which suggests a non-renal cause for the elevated BUN. A common cause of increased BUN is dehydration, so the nurse should anticipate giving the client more fluids, not placing the client on fluid restrictions. Hemodialysis is not an appropriate treatment for dehydration. The lab results do not indicate an infection; therefore, a urine culture and sensitivity is not appropriate.

nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the clients nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

ANS: A The client has experienced a combination of metabolic and acute respiratory acidosis through heavy skeletal muscle contractions and no gas exchange. When the seizures have stopped and the client can breathe again, the fastest way to return acid-base balance is to administer oxygen. Applying a paper bag over the clients nose and mouth would worsen the acidosis. Sodium bicarbonate should not be administered because the clients arterial bicarbonate level is normal. Glucose and insulin are administered together to decrease serum potassium levels. This action is not appropriate based on the information provided.

A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful? a. Arrange a dietary consult. b. Increase fluid intake. c. Limit the client's foods. d. Make the client NPO.

ANS: A The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to the registered dietitian will be extremely helpful. Food and fluid intake is complicated and needs planning. The client should not be NPO.

A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this client's history? a. "Have you been taking any aspirin, ibuprofen, or naproxen recently?" b. "Do you have anyone in your family with renal failure?" c. "Have you had a diet that is low in protein recently?" d. "Has a relative had a kidney transplant lately?"

ANS: A There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the client since both the serum creatinine and BUN are elevated, indicating some renal problems. A family history of renal failure and kidney transplantation would not be part of the questioning and could cause anxiety in the client. A diet high in protein could be a factor in an increased BUN.

A marathon runner comes into the clinic and states "I have not urinated very much in the last few days." The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority? a. Give the client a bottle of water immediately. b. Start an intravenous line for fluids. c. Teach the client to drink 2 to 3 liters of water daily. d. Perform an electrocardiogram.

ANS: A This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the client to drink 2 to 3 liters of water each day. An intravenous line may be ordered later, after the client's degree of dehydration is assessed. An electrocardiogram is not necessary at this time.

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.) a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis d. Firefighter with severe burns e. Young woman with lupus

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

A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) a. Canned unsweetened apricots b. Coffee cake c. Milk shake d. Potato soup e. Steamed broccoli

ANS: A, D Canned apricots and potato soup are appropriate selections as they are part of a high-protein, high-fat, low- to moderate-carbohydrate diet. Coffee cake and other sweets must be avoided. Milk products and sweet drinks such as shakes must be avoided. Gas-forming foods such as broccoli must also be avoided.

The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding? a. Woman with a blood pressure of 158/90 mm Hg b. Client with Kussmaul respirations c. Man with skin itching from head to toe d. Client with halitosis and stomatitis

ANS: B Kussmaul respirations indicate a worsening of chronic kidney disease (CKD). The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs. Hypertension is common in most clients with CKD, and skin itching increases with calcium-phosphate imbalances, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis.

A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values? a. Diabetic ketoacidosis in a person with emphysema b. Bronchial obstruction related to aspiration of a hot dog c. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman

ANS: B 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 nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client's plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 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.

ANS: B The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results? a. Diarrhea and vomiting for 36 hours b. Anxiety-induced hyperventilation c. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema

ANS: B The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to respiratory acidosis, and the client with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.

A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess? a. Agitation b. Kussmaul respirations c. Seizures d. Positive Chvosteks sign

ANS: B The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvosteks sign are manifestations of the electrolyte imbalances that accompany alkalosis.

A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this client's care? a. Edema and pain b. Electrolyte and fluid imbalance c. Cardiac and respiratory status d. Mental health status

ANS: B This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance is essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the client's cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.

A nurse cares for a client with a urine specific gravity of 1.018. Which action should the nurse take? a. Evaluate the client's intake and output for the past 24 hours. b. Document the finding in the chart and continue to monitor. c. Obtain a specimen for a urine culture and sensitivity. d. Encourage the client to drink more fluids, especially water.

ANS: B This specific gravity is within the normal range for urine. There is no need to evaluate the client's intake and output, obtain a urine specimen, or increase fluid intake.

A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately? a. Albumin: 2.1 g/dL b. Hematocrit: 28% c. Hemoglobin: 8.1 mg/dL d. International normalized ratio (INR): 4.2

ANS: D An INR as high as 4.2 poses a serious risk of bleeding during the operation and should be reported. The albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in gastric cancer.

A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

ANS: D Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin.

A nurse cares for a client with a urine specific gravity of 1.040. Which action should the nurse take? a. Obtain a urine culture and sensitivity. b. Place the client on restricted fluids. c. Assess the client's creatinine level. d. Increase the client's fluid intake.

ANS: D Normal specific gravity for urine is 1.005 to 1.030. A high specific gravity can occur with dehydration, decreased kidney blood flow (often because of dehydration), and the presence of antidiuretic hormone. Increasing the client's fluid intake would be a beneficial intervention. Assessing the creatinine or obtaining a urine culture would not provide data necessary for the nurse to make a clinical decision.

4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide (Lasix) intravenously. c. Encourage the client to take deep breaths. d. Teach the client fall prevention measures.

ANS: D The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.

A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? Select all that apply. 1 Ask family members to stay with the client. 2 Call the health care provider. 3 Increase IV and oxygen rates. 4 Remain with the client. 5 Reassure the client that everything is being done for him or her.

Ask family members to stay with the client. Remain with the client. Reassure the client that everything is being done for him or her. Having a familiar person nearby may provide comfort to the client. The nurse should remain with the client who is demonstrating physiologic deterioration. Offering genuine reassurance supports the client who is anxious. The health care provider should be notified, and increasing IV and oxygen may be needed, but these actions do not support the client's psychosocial integrity.

A ventilated client in the intensive care unit begins to pick at the bedcovers. Which action should the nurse take next? 1 Increase the sedation. 2 Assess for adequate oxygenation. 3 Explain to the client that he has a tube in his throat to help him breathe. 4 Request that the family leave to decrease the client's agitation

Assess for adequate oxygenation Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia. Increasing sedation is not indicated for this client and may mask symptoms like hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease the chances of "ICU psychosis" and anxiety, but it does not take priority over assessing for hypoxemia.

The nurse is evaluating electrolyte values for a patient with acute pancreatitis and notes that the serum calcium is 6.8 mEq/L. How does the nurse interpret this finding? a. Within normal limits considering the diagnosis of acute pancreatitis b. A result of the body not being able to use bound calcium c. A protective measure that will reduce the risk of complications d. Full compensation of the parathyroid gland

B

Which nursing action should be done for a patient with DI? A. Monitor levels of urine ketones. B. Administer desmopressin acetate (DDAVP). C. Administer prednisone by intravenous push (IVP). D. Monitor blood glucose levels hourly.

B. Administer desmopressin acetate (DDAVP). Patients with DI have decreased production and secretion of ADH and increased urine output with low specific gravity. DDAVP is used for ADH replacement. DI is not related to glucose metabolism and ketones and does not need close monitoring. Prednisone is not used to treat DI.

A patient with a head injury develops SIADH. What symptoms do you expect to find? A. Hypernatremia and edema B. Low urinary output and thirst C. Muscle spasticity and hypertension D. Weight gain and decreased glomerular filtration rate

B. Low urinary output and thirst Excess ADH increases the permeability of the renal distal tubule and collecting duct, which leads to the reabsorption of water into the circulation. Consequently, extracellular fluid volume expands, plasma osmolality declines, the glomerular filtration rate increases, and sodium levels decline (dilutional hyponatremia). Hyponatremia causes muscle cramping, pain, and weakness. Initially, the patient displays thirst, dyspnea on exertion, and fatigue.

You are providing discharge instructions to a patient with DI. Which patient teaching regarding DDAVP is most appropriate? A. The patient can expect to experience weight loss because of increased diuresis. B. The patient should alternate nostrils during administration to prevent nasal irritation. C. The patient should monitor for symptoms of hypernatremia as a side effect of this drug. D. The patient should report any decrease in urinary elimination to the health care provider.

B. The patient should alternate nostrils during administration to prevent nasal irritation. DDAVP is used to treat DI by replacing the ADH that the patient is lacking. DDAVP can cause nasal irritation, headache, nausea, and other signs of hyponatremia.

The patient had pituitary surgery yesterday. Which symptom is most important for you to monitor? A. Urine specific gravity: 1.005 B. Voids 10 L/day C. Crackles auscultated in lung bases D. Temperature: 100.4° F (38° C)

B. Voids 10 L/day Diabetes insipidus (DI) is a deficiency of production or secretion of antidiuretic hormone (ADH) or a decreased renal response to ADH. It is characterized by polydipsia (5 to 20 L/day) with low specific gravity (less than 1.005). The last two options are more likely related to atelectasis and are less important than DI.

The nurse is administering continuous intravenous infusion of norepinephrine (Levophed) to a client in shock. Which finding causes the nurse to decrease the rate of infusion? 1 Blood pressure 170/96 mm Hg 2 Respiratory rate 22 breaths/min 3 Urine output of 70 mL/hr 4 Heart rate 98 beats/min

Blood pressure 170/96 mm HgSigns of excess vasoconstricting drugs include headache, hypertension, and decreased renal perfusion manifested by oliguria. While vasoconstricting medications and the shock state may cause tachycardia (heart rate greater than 100 beats/min), this client's heart rate is within normal range. Vasoconstricting drugs do not affect the respiratory rate; shock itself causes an increased respiratory rate in an effort to deliver more oxygen to the tissues.

A patient with acute pancreatitis is at risk for the development of paralytic (adynamic) illeus. Which action provides the nurse with the best indication of bowel function? a. Observing contents of the nasogastric drainage b. Weighing the patient every day at the same time c. Asking the patient if he or she has passed flatus or had a stool d. Obtaining a computed tomography (CT) scan of the abdomen with contrast medium

C

The anti-diuretic hormone is __________ in Diabetes Insipidus and _________ in SIADH. A. high, low B. absent, absent C. low, high D. low, low

C

The patient comes to the emergency department (ED) with severe abdominal pain in the midepigastric area. The patient states that the pain began suddenly, is continuous, radiates to his back, and is worst when he lies flat on his back. What condition does the nurse suspect? a. Acute cholecystitis b. Pancreatic cancer c. Acute pancreatitis d. Pancreatic pseudocyst

C

Which clinical manifestation is most important for you to monitor in a patient with Cushing disease? A. Periorbital edema B. Pitting pedal edema C. Flu with a temperature of 100.4° F (38° C) D. Blood glucose level of 150 mg

C. Flu with a temperature of 100.4° F (38° C) Patients with Cushing disease are immunosuppressed and have a blunted response to infection

A patient with Addison's Disease should consume which of the following diets? A. High fat and fiber B. Low potassium and high protein C. High protein, carbs, and adequate sodium D. Low carbs, high protein, and increased sodium

C. High protein, carbs, and adequate sodium

The patient has SIADH with a serum sodium level of 128 mEq/L. What action do you anticipate? A. Increase sodium-rich foods. B. Rapidly infuse hypertonic intravenous (IV) fluids. C. Restrict fluids. D. Administer calcitonin.

C. Restrict fluids. When symptoms of SIADH are mild and the serum sodium level is more than 125 mEq/L, the only treatment may be restriction of fluids to 800 to 1000 mL per day. Severe hyponatremia (less than 120 mEq/L) may be treated with slow infusion of hypertonic saline.

Which selection indicates the teaching regarding nutrition was effective in a patient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)? 1 Apple 2 Chicken breast 3 Frozen French fries 4 Canned green beans

Canned green beans Patients with SIADH have low sodium and need to implement foods higher in sodium. Canned green beans would have higher sodium because of preservatives. An apple, chicken breast, and frozen French fries would have low sodium content.

18. The nurse is evaluating electrolyte values for a patient with acute pancreatitis and notes that the serum calcium is 6.8 mEq/L. How does the nurse interpret this finding? a. Within normal limits considering the diagnosis of acute pancreatitis b. A result of the body not being able to use bound calcium c. A protective measure that will reduce the risk of complications d. Full compensation of the parathyroid gland

b

A patient with SIADH is undergoing IV treatment of a hypertonic IV solution of 3% saline and IV Lasix. Which of the following nursing findings requires intervention?* A. Sodium level of 136. B. Patient reports urinating more frequently. C. Potassium level of 5.0. D. Assessment finding of crackles throughout the lung fields.

D

Disseminated intravascular coagulation (DIC) is a complication of pancreatitis. What pathophysiology leads to this complication? a. Hypovolemia b. Peritoneal irritation and seepage of pancreatic enzymes c. Disruption of alveolar - capillary membrane d. Consumption of clotting factors and microthrombi formation

D

Addison's Disease is: A. Increased secretion of cortisol B. Increased secretion of aldosterone and cortisol C. Decreased secretion of cortisol D. Decreased secretion of aldosterone and cortisol

D. Decreased secretion of aldosterone and cortisol

When caring for a client with septic shock who has disseminated intravascular coagulation (DIC), the nurse anticipates which finding? 1 Polycythemia 2 Thrombocytosis 3 Elevated d-dimer levels 4 Elevated fibrinogen levels

Elevated d-dimer levels Plasma d-dimer levels rise during DIC as multiple fibrin clots break down. A reduction in red blood cells, hemoglobin, and hematocrit, rather than an increase (polycythemia), occur in DIC. Thrombocytopenia (a reduction of platelets) rather than thrombocytosis (an increased number of platelets) occurs along with reduced fibrinogen levels as these components are incorporated into the multiple small clots that develop in DIC.

A client in the progressive or intermediate stage of hypovolemic shock will exhibit which manifestation? 1 Polyuria 2 Metabolic alkalosis 3 Moist, warm skin 4 Feeling of impending doom

Feeling of impending doom As shock progresses, tissue perfusion to the brain continues to be reduced, causing a sense of anxiety or that "something bad" is about to happen. Oliguria or anuria occurs in the nonprogressive stage rather than polyuria. A lack of perfusion to the skin results in cool, moist skin rather than warm skin. Due to decreased tissue perfusion, buildup of lactic or metabolic acid occurs; the arterial blood gases reflect metabolic acidosis at this time.

Which menu selection indicates the teaching regarding nutrition was effective in a patient diagnosed with diabetes insipidus (DI)? 1 Pizza 2 Cold cuts 3 Frozen French fries 4 Canned green beans

Frozen french fries Patients diagnosed with DI have to reduce sodium intake. Frozen French fries are low in sodium and indicated for this patient. Pizza, cold cuts, and canned green beans all have high sodium content.

What finding in a patient that is 4 hours post-hypophysectomy should be reported to the health care provider immediately? 1 Increased swallowing 2 Dry mucous membranes 3 Blood-tinged nasal drainage 4 Urine specific gravity of 1.028

Increased Swallowing Increased swallowing is a sign of CSF leakage and should be reported to the surgeon. Dry mucous membranes are a normal finding with the surgery and is related to mouth breathing. Blood-tinged nasal drainage is normal. A urine specific gravity of 1.028 is a normal finding.

Which are cardiovascular manifestations of hypovolemic shock? Select all that apply. 1 Narrow pulse pressure 2 Postural hypotension 3 Decreased pulse rate 4 Decreased cardiac output 5 Bounding peripheral pulses

Narrow pulse pressure, decreased cardiac output, postural hypotenion In hypovolemic shock, total body fluid is reduced; therefore, the difference between systolic and diastolic pressure (pulse pressure) is decreased. Blood pressure in the body drops also causing postural hypotension. The decrease in blood volume causes a simultaneous decrease in cardiac output. There is a compensatory increase in pulse rate to restore cardiac output in shock. Peripheral pulses become weak in hypovolemic shock.

Which term best describes the symptoms that occur in the nonprogressive (compensatory) phase of shock? 1 Hypoxemia 2 Oliguria 3 Decreased tissue perfusion 4 Blood loss related to hemorrhage

Oliguria Compensatory mechanisms in the nonprogressive stage of shock result from increased sympathetic nervous stimulation and release of antidiuretic hormone (ADH); vasoconstriction and water retention to maintain fluid volume occur with oliguria as a result. Problems such as reduction in mean arterial pressure and tissue perfusion, hypoxemia, and acid-base imbalances occur in the compensatory phase, but compensatory mechanisms keep the pulse oximetry reading within 2-5% of baseline. Blood loss may occur in hemorrhagic or hypovolemic shock; this question addresses the overall shock state.

Which signs/symptoms does the nurse expect to assess in a client diagnosed with cardiogenic shock? Select all that apply. 1 Oliguria 2 Bradycardia 3 Hypokalemia 4 Change in mental status 5 Vesicular breath sounds 6 Low mean arterial blood pressure

Oliguria Change in mental status Low mean arterial blood pressure Cardiogenic shock results when 40% of the left ventricle has been infarcted, resulting in severe loss of cardiac output. Tachycardia, hypotension, blood pressure less than 90 mm Hg, oliguria, cold and clammy skin, pulmonary congestion, and tachypnea as well as chest pain or discomfort occur. Hypokalemia may be a complication of diuretic therapy used in heart failure, but is not a manifestation of cardiogenic shock. Vesicular breath sounds are normal sounds heard over most of the lung fields; crackles or wheezes are manifestations of the pulmonary congestion of cardiogenic shock.

A client with chronic obstructive pulmonary disease (COPD) reports acute difficulty breathing and right-side pleuritic pain. Auscultation reveals decreased breath sounds in the right lung field compared to the left lung field. Which possible condition does the nurse contact the provider for based on these assessment data? 1 Tension pneumothorax 2 Flail chest 3 Pneumothorax 4 Pulmonary embolism

Pneumothorax Clients with COPD may have a spontaneous pneumothorax. Assessment findings frequently include reduced breath sounds on auscultation over the collapsed lung region, hyperresonance on percussion, deviation of the trachea, pleuritic pain, tachypnea, and subcutaneous emphysema. The provider or Rapid Response Team must be contacted immediately to evaluate the need for a chest tube to reexpand the lung.

Which assessment data suggest that antibiotic therapy may be effective in the treatment of a client with sepsis? 1 Serum creatinine increases from 1.2 to 1.8 mg/dL 2 White blood cell count decreases from 15,000 to 13,500/mm3 3 Serum lactate level decreases to 3.3 from 4.2 mmol/L 4 Serum glucose increases from 112 to 146 mg/dL

Serum lactate level decreases to 3.3 from 4.2 mmol/L No single laboratory test confirms the presence of sepsis, although one of the hallmarks of sepsis is an increasing serum lactate level. The return of abnormal labs to normal and stabilization of the client's presentation are used to evaluate treatment effectiveness. An increase in serum creatinine clearance does not indicate the effectiveness of treatment for sepsis. A decrease in serum glucose would be expected, not an increase. The slight decrease in white blood cells may not signify the effectiveness of antibiotic therapy.

What laboratory finding is most important to monitor in a patient diagnosed with diabetes insipidus (DI)? 1 Serum sodium 2 Serum glucose 3 Serum potassium 4 Serum liver function

Sodium Serum sodium is the priority laboratory value to evaluate in patients diagnosed with DI. The inability of the kidneys to respond to ADH leads to increased sodium levels. Glucose, potassium, and liver function labs are not priority in these patients.

Which are key assessment findings in a patient suspected of having diabetes insipidus? Select all that apply. 1 Tachycardia 2 Hemodilution 3 Increased thirst 4 Dry mucous membranes 5 High specific urine gravity

Tachycardia, Increased Thirst, Dry mucous membranes Tachycardia, increased thirst, and dry mucous membranes are findings typical of diabetes insipidus. The patient's blood is hemoconcentrated as a result of the significant fluid loss. The urine is diluted resulting in a low specific gravity.

Which is a serious side effect associated with positive end-expiratory pressure (PEEP)? 1 Lung infection 2 Ventilatory failure 3 Pulmonary embolism 4 Tension pneumothorax

Tension pneumothorax PEEP is used to prevent the alveoli from collapsing at the end of expiration. The most serious side effect of PEEP is tension pneumothorax, in which the alveoli rupture and air accumulates in the pleura. Infection is not associated with application of PEEP. PEEP is used for prevention of ventilatory failure. PEEP does not affect the clotting mechanism of the body; pulmonary embolism is not a side effect associated with PEEP.

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? a. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min b. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain c. Middle-aged client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography d. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL

a Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min Acute respiratory distress syndrome is a possible complication of acute pancreatitis. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.

A patient with acromegaly is treated with a transphenoidal hypophysectomy. Postoperatively, the nurse: a. ensures that any clear nasal drainage is tested for glucose b. maintains the patient flat in bed to prevent cerebrospinal fluid leak c. assists the patient with toothbrushing Q4H to keep the surgical area clean d. encourages deep breathing and coughing to prevent respiratory complications

a. ensures that any clear nasal drainage is tested for glucose (Rationale- a transphenoidal hypophysectomy involves entry into the sella turcica through an incision in the upper lip and gingiva into the floor of the nose and the sphenoid sinuses. Postoperative clear nasal drainage with glucose content indicates CSF leakage from an open connection to the brain, putting the patient at risk for meningitis. After surgery, the patient is positioned with the head elevated to avoid pressure on the sella turcica, coughing and straining are avoided to prevent increased ICP and CSF leakage, and although mouth care is required Q4H toothbrushing should not be performed for 7-10post sx.)

The client suffers a deep thickness burn injury. The nurse cares for the client during the shock phase. The nurse understands which finding is expected during this phase? a. Increased blood pressure b. Decreased urine output c. Hypokalemia d. Decreased pulse

a. the emergent phase (shock phase) of a burn occurs during the first 24-48 hours; fluid is lost through open wounds or extravasation into deeper tissues; blood pressure is decreased b. CORRECT - due to fluid shift during emergent phase, urine output is decreased and urine is concentrated and has a high specific gravity; accurate intake and output is measured and is one of the parameters used to determine the amount of IV fluids; output should be maintained at 30-50 mL/hour c. potassium increased due to tissue destruction and hemolysis of red blood cells d. pulse is increased due to decreased cardiac output

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? a. Measure intake and output every shift. b. Do not administer food or fluids by mouth. c. Administer opioid analgesic medication. d. Assist the client to assume a position of comfort.

c Administer opioid analgesic medication. For the client with acute pancreatitis, pain relief is the highest priority. Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.

The nurse suspects that a client may have acute pancreatitis as evidenced by which group of laboratory results? a. Deceased calcium, elevated amylase, decreased magnesium b. Elevated bilirubin, elevated alkaline phosphatase c. Elevated lipase, elevated white blood cell count, elevated glucose d. Decreased blood urea nitrogen (BUN), elevated calcium, elevated magnesium

c Elevated lipase, elevated white blood cell count, elevated glucose Elevated lipase is more specific to a diagnosis of acute pancreatitis. Many pancreatic and nonpancreatic disorders can cause increased serum amylase levels. Bilirubin and alkaline phosphatase levels will be increased only if pancreatitis is accompanied by biliary dysfunction. Usually, calcium and magnesium will be increased and BUN increased, not decreased, in acute pancreatitis.

Which set of assessment findings indicates to the nurse that a client may have acute pancreatitis? a. Absence of jaundice, pain of gradual onset b. Absence of jaundice, pain in right abdominal quadrant c. Presence of jaundice, pain worsening when sitting up d. Presence of jaundice, pain worsening when lying supine

d Presence of jaundice, pain worsening when lying supine Pain that worsens when lying supine and the presence of jaundice are the only assessment findings indicative of acute pancreatitis. Pain associated with acute pancreatitis usually has an abrupt onset, is located in the mid-epigastric or upper left quadrant, and lessens with sitting up; also, jaundice is present.

The nurse is attempting to position a client having an acute attack of pancreatitis in the most comfortable position possible. In which position does the nurse place this client? a. Supine, with a pillow supporting the abdomen b. Up in a chair between frequent periods of ambulation c. High-Fowler's position, with pillows used as needed d. Side-lying position, with knees drawn up to the chest

d Side-lying position, with knees drawn up to the chest The side-lying position with the knees drawn up has been found to relieve abdominal discomfort related to acute pancreatitis. No evidence suggests that supine position, sitting up in a chair, or high-Fowler's position have any effect on abdominal discomfort related to acute pancreatitis.

Positioning: Head Injury

elevate HOB 30 degrees to decrease intracranial pressure

Positioning: pneumothorax, contussion

high fowler

Positioning: Increased ICP

high fowlers

Positioning: spinal cord injury

immobilized on spinal back board, head in neutral position and immobilized to prevent any movement with a firm, padded cervical collar patient must be log-rolled without allowing any twisting or bending movement

Positioning: Post Lumbar Puncture

patient should lie flat in supine to prevent headache and leaking of CSF.

Positioning: Autonomic Dysreflexia

place client in sitting position (elevate HOB) first before any other implementation