Physiological Adaptation

The nurse at the wellness clinic is teaching a client newly diagnosed with insulin-dependent diabetes mellitus. The client asks about beginning an exercise program. The nurse bases her response on the fact that exercise has what effect on the body? Select all that apply: 1. Lowers the blood glucose 2. Provides more energy 3. Increases insulin need 4. Reverses complications of diabetes 5. Increases the workload of the liver

1. & 2. Correct: In the presence of adequate insulin, exercise lowers the blood glucose. Exercise releases endorphins, providing the client with increased energy and feelings of well-being.

The nurse is monitoring a client in DKA. Which arterial blood gas value would be expected? 1. pH 7.32 2. PCO2 47 3. HCO3 25 4. PO2 78

1. Correct: The pH should be acidotic so less than 7.35.

For a client with a major burn, which evaluation criteria identified by the nurse best indicates that fluid resuscitation has been effective during the first 24 hours of care? Select all that apply: 1. Urine output of 860 mL / 24 hours. 2. Increase in weight from preburn weight. 3. Heart rate of 122 beats per minute 4. Central venous pressure of 18 mm

1. Correct: Urine output is the best indicator of adequate fluid replacement during the first 24 hours.

An elderly client has suffered a cerebrovascular accident (CVA) and as a result has left homonymous hemianopia. Based on this fact, what measures will the nurse include in the client's initial plan of care? Select all that apply: 1. Approach the client from his left side. 2. Place the client's meal on the right side of the over bed table. 3. Request a consult for an ophthalmologist. 4. Stand directly in front of the client when addressing. 5. Have client look at the left side of the body.

2. & 5. Correct: Hemianopia is blindness in half of the visual field. The client has lost half of the visual field in the left eye. To avoid startling the client and so the client can better view the food, the nurse should approach the client from the right side. Neglect of the left side can occur. Encourage client to look at the left side of the body to avoid neglect.

The client has been diagnosed with cutaneous anthrax in a cut on the right hand. What measure should be implemented by the nurse to prevent further spread of the disease? 1. Wear mask only. 2. There are no precautions necessary. 3. Universal precautions. 4. Limit interactions with client.

3. Correct: Cutaneous anthrax is typically not contagious; however, it can be spread to others in rare events if the wound is draining. Universal precautions should protect the individual.

What independent nursing interventions should the nurse include when planning care for a client who is in a fluid volume excess? Select all that apply: 1. Monitor CVP 2. Administer diuretic 3. Monitor for orthopnea 4. Raise HOB to 45 degrees 5. Elevate edematous extremities

3., 4. & 5. Correct: These are independent nursing actions that will increase venous return and decrease edema. Also the nurse should assess for crackles, changes in respiratory pattern, SOB, orthopnea.

A client with cancer of the larynx undergoes radiation therapy for 5 weeks prior to a neck dissection and tumor excision. The client asks the nurse how long the post surgical recovery time will be. How should the nurse reply? 1. "I really don't know. It is different for everyone, but speak to your surgeon." 2. "Your medical insurance will cover the whole length of your stay, so don't worry." 3. "You shouldn't worry about how long you are going to stay. You should focus on getting better." 4. "It may be a little longer than average. The radiation you received sometimes delays tissue healing."

4. Correct: This is the best, most accurate response.

What is the first nursing action that should be taken in caring for this client with symptoms of tuberculosis? 1. Identify the client's symptoms promptly. 2. Instruct the client to cover the mouth and nose with tissues when sneezing. 3. Isolate the client in a negative pressure room. 4. Place a surgical mask on the client.

1. Correct: The first action that should be taken is to identify the client's symptoms promptly.

The nurse is caring for a client with questionable loss of consciousness in the emergency department following a motor vehicle crash. Which action should the nurse take first? 1. Assess airway patency, breathing, and circulation. 2. Assess level of consciousness and movement. 3. Measure vital signs and check extremities. 4. Stabilize neck and check for signs of neck injury.

1. Correct: The nurse should assess airway patency, breathing, and circulation prior to initiating the other interventions.

A client is admitted to the hospital due to alcohol poisoning. Which interventions should the nurse initiate? Select all that apply: 1. Pad side rails 2. Attach client to pulse oximeter 3. Monitor closely for hyperthermia 4. Place in recovery position 5. Monitor intake and output

1., 2., 4. & 5. Correct: Client is at risk for seizures so pad the siderails. Client is at risk for hypoventilation and may stop breathing. Pulse oximeter will measure oxygen levels. The recovery position decreases the risk for aspiration. Alcohol has a diuretic effect, so I&O should be monitored.

Which assessment findings does the nurse expect to find when assessing a client admitted to the emergency department with left sided congestive heart failure? Select all that apply: 1. Ascites 2. Bibasilar crackles 3. Orthopnea 4. Hepatomegaly 5. Anorexia

2. & 3. Correct: Bibasilar crackles that do not clear with coughing occur with left sided heart failure. Fluid backs up into the lungs. Orthopnea occurs in left sided heart failure when the client lies flat. Fluid backs up into the lungs.

The nurse should teach the client with chronic pancreatitis how to monitor for which problem that can occur as a result of the disease? 1. Hypertension 2. Diabetes 3. Hypothyroidism 4. Graves disease

2. Correct: Insulin is produced in the pancreas. When the client has chronic pancreatitis, the pancreas becomes unable to produce insulin, thus resulting in diabetes.

A client will be undergoing a thoracentesis for a large right pleural effusion. The nurse knows that further teaching is necessary when the client makes which statement? 1. "It is important that I do not cough during the procedure." 2. "This procedure will require me to be placed on a ventilator." 3. "I will be in a sitting position leaning forward." 4. "The primary healthcare provider knows from the x-ray where the fluid is"

2. Correct: The client will not need to be on a ventilator during a thoracenteses. This is a false statement.

The nurse is caring for a client who receives hemodialysis three times a week. What dietary education should the nurse provide for this client? Select all that apply: 1. Increase protein intake 2. Restrict fluids 3. Decrease sodium 4. Increase phosphorus 5. Decrease potassium

2., 3., & 5. Correct: The client will get dialyzed every other day so restrict fluid intake. Restrict sodium to decrease thirst and fluid excess. Restrict potassium to decrease the risk of heart arrhythmias associated with hyperkalemia.

A nurse attaches a client to continuous cardiac monitoring due to a potassium level of 2.8 mEq (2.8 mmol). The nurse should monitor for which dysrhythmia? 1. Third degree heart block 2. Atrial fibrillation 3. Premature atrial contractions 4. Premature ventricular contractions

4. Correct: Hypokalemia is reflected by the EKG. The earliest EKG change is often premature ventricular contractions (PVCs), which can deteriorate into ventricular tachycardia or fibrillation (VT/VF) without appropriate potassium replacement.

Which statement, by a client, would indicate to the nurse that education about gastroesophageal reflux disease (GERD) has been successful? 1. It would be better for me to eat 3 small meals a day. 2. I need to avoid eating foods high in purine. 3. When going to sleep, I should lie on my side. 4. My last daily meal should not be within 2 hours of bedtime.

4. Correct: To avoid reflux the client should not eat within a 2-hour period of bedtime.

A client requires external radiation therapy. The nurse knows external radiation may cause which problems? Select all that apply: 1. Pancytopenia 2. Edema 3. Erythema 4. Fever 5. Fatigue

1., 3. & 5. Correct: Radiation may cause fatigue, loss of appetite, erythema, skin problems and pancytopenia.

The nurse is providing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider? Select all that apply: 1. Difficulty waking up 2. Headache (3/10 on the pain scale) 3. Blurry vision 4. Achy feeling all over 5. Vomiting

1., 3. & 5. Correct: Yes! This are signs of increasing intracranial pressure (post-concussion syndrome).

A 65 year old client is admitted for management of dehydration with an IV infusion of LR @ 125 mL/hr. What assessment findings would be of concern to the nurse? Select all that apply: 1. Anxiety 2. BP 140/80 3. CVP 5 mmHg 4. Crackles noted right posterior lung field 5. S3 heart sound

1., 4. & 5. Correct: Volume overload is an adverse effect of IV therapy in the elderly. Anxiety is an early sign of hypoxia due to FVE. Crackles to the bases are an early sign of FVE. S3 heart sounds are also an indication of FVE.

The emergency responders enter the emergency department with a client in cardiac arrest. One of the responders is performing chest compressions. What is the best assessment for the nurse to determine if the responder is compressing with enough force and depth? 1. Dilated pupils after 1 minute of CPR 2. Presence of a carotid pulse with each compression 3. Cardiac rhythm on the monitor 4. Rise and fall of client's chest with ventilations

2. Correct: If chest compressions are being given with enough force and depth, a pulse will be felt with each compression.

The emergency department pediatric nurse is assigned to care for four pediatric clients with varying symptoms. Which client should the nurse examine first? 1. 12 year old reporting a severe headache 2. 6 month old with respiratory rate of 52/min 3. 2 year old with a broken arm who is crying and appears in pain 4. 8 year old with cellulitis of the left leg and an elevated body temperature

2. Correct: Yes! Most life threatening, respiratory, airway. Normal respiratory rate for 6 month old is 30-45/min.

The nurse should question which prescription for a client diagnosed with acute heart failure? 1. 2 gm NA diet. 2. Digoxin 0.25 mg IV q 4 hours times 3 doses. 3. Furosemide 40 mg IVP stat. 4. Start IV with NS at 125 mL/hr.

4. Correct: The client is in fluid overload and does not need the NS at 125 mL/hr. The other prescriptions are acceptable.

A client asks the nurse, "What causes hypermagnesemia?" The nurse should explain to the client that hypermagnesemia can occur secondary to what health problem? 1. Cardiac contractility 2. Hypokalemia 3. Liver failure 4. Renal insufficiency

4. Correct: The incidence of hypermagnesemia is rare in comparison with hypomagnesemia, and it occurs secondary to renal insufficiency or iatrogenic overtreatment.

The nurse in the clinic would recognize which client statement most indicative of gallbladder disease? 1. "Yesterday, when I ate a hamburger and french fries, my belly really hurt." 2. "I have been gaining a lot of weight lately." 3. "My stools are darker. Sometimes they are even black." 4. "When I start hurting, it helps if I drink milk or have a small snack."

1. Correct: The gallbladder assists in digestion of fat. When foods high in fat are ingested, bile is released from the gallbladder to assist in digestion. If gallstones are formed in the gallbladder or blocking the outlet to the gallbladder, the client may experience epigastric discomfort after a meal high in fat.

What assessment data would a nurse expect to find in a client diagnosed with acute inflammatory bowel disease? Select all that apply: 1. Bloody stools that contain mucus 2. Pallor 3. Anorectal excoriation 4. Urine output below 30 ml/hr 5. Increased serum prealbumin

1., 2., 3., & 4. Correct: Stools are bloody and contain mucus with this client. The client will be malnourished, thus will be pale due to anemia. Anemia is related to folate deficiency. Anorectal excoriation and pain can occur. Hypotension and low urine output indicate possible fluid volume deficit.

A 37 week pregnant woman presents to triage complaining of a headache and begins to have a seizure. What actions should the nurse take? Select all that apply: 1. Place in right recumbent position 2. Administer oxygen 3. Monitor tonic-clonic activity 4. Lower siderails to avoid injury to extremities 5. Administer diazepam

2. & 3. Correct: Oxygen is needed to ensure supply of oxygen to mom and fetus. Seizure activity should be monitored for tonic and clonic phases of seizure.

The nurse is teaching the family of a newly diagnosed diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client? 1. It is not necessary to treat mild hypoglycemia indicated by irritability. 2. Treat a mild episode with 10-15 grams of carbohydrate. 3. The client should consume 12 ounces of regular cola. 4. The client should consume 2 cups of orange juice without added sugar.

2. Correct. 10-15 grams of carbohydrate should raise the blood sugar 40 - 50 mg/dL.

The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What assessment question is most important? 1. Have you traveled out of the United States recently? 2. Have you recently worked with any farm animals or any animal-skin products? 3. Have you experienced any gastrointestinal upset recently? 4. Have you eaten any home-canned foods recently?

2. Correct: Cutaneous anthrax may be contracted by working with contaminated animal-skin products. Anthrax is found in nature and commonly infects wild and domestic hoofed animals.

Which prevention measure should the nurse include when instructing a client on avoidance of otitis externa? 1. Gently cleaning the ear canal with a cotton tipped applicator daily. 2. Use of astringent drops after bathing. 3. Taking preventative antibiotics prior to swimming in lakes or ponds 4. Routine use of nasal saline to clear the sinuses and eustachian tubes.

2. Correct: Prevention and avoidance measures for otitis externa include thorough ear canal drying and use of acidifying or astringent drops after swimming or bathing.

The nurse is caring for a client that was admitted to the hospital 48 hours ago for complications resulting from an automobile accident. The nurse observes an increase in vital signs, increased sweating, and tremors of the extremities. The client further reports feeling extremely anxious. The client's physical condition does not seem to be consistent with the symptoms noted. Which item in the admission assessment may be crucial, given the symptoms noted? 1. Routinely takes vitamin supplements at home. 2. Drinks several alcohol beverages daily. 3. Has a history of myocardial infarction. 4. Has been diagnosed with renal failure.

2. Correct: The client is at risk for alcohol withdrawal delirium. The most likely time for symptoms to occur is 48 to 72 hours after the last drink.

A client's last two central venous pressure (CVP) readings were 23 cm of water. The nurse would expect the client to manifest which associated signs and symptoms? Select all that apply: 1. Dry oral mucus membranes 2. Tachypnea 3. Orthostatic hypotension 4. Rales in the posterior chest 5. Jugular vein distention 6. Weight gain

2., 4., 5. & 6. Correct: The CVP is high and correlates with fluid volume excess. These signs and symptoms correlate with fluid volume excess.

The nurse is caring for a client with acute renal failure. The morning assessment findings indicate the client has become confused and irritable. Which finding is most likely responsible for the change in behavior? 1. Hyperkalemia 2. Hypernatremia 3. Elevated BUN 4. Limited fluid intake

3 Correct: Elevated blood urea nitrogen levels can cause confusion as urea is neurotoxic.

Which signs and symptoms will the nurse include when teaching a client about the signs and symptoms of recurrent nephrotic syndrome? Select all that supply: 1. Dysuria 2. Hematuria 3. Foamy urine 4. Periorbital edema 5. Weight loss

3. & 4. Correct: Foamy urine, which may be caused by excess protein in the urine, is seen with nephrotic syndrome. Swelling (edema), particularly around the eyes (periorbital) and in the ankles and feet ,are symptoms of nephrotic syndrome.

The nurse is caring for a female client who is at risk for renal failure. The nurse has completed the initial assessment of the most recent lab results so that any concerns can be reported to the primary healthcare provider. Which assessment finding warrants further action? 1. Hemoglobin of 12 g/dl (120 g/L) 2. Hematocrit of 38% (0.38) 3. Potassium levels of 5.2mEq/L (5.2 mmol/L) 4. BUN of 15 mg/dl. (5.35 mmol/L)

3. Correct. In clients who have renal failure, the potassium level is increased. The normal value is 3.5 - 5.0 mEq/L (3.5 - 5.0 mmol/L).

The nurse is caring for a client diagnosed with type 2 diabetes who was brought to the emergency department in an unresponsive state. A diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse prepares for the administration of which initial therapy? 1. Oxygen by nasal cannula 2. Long-acting IV insulin 3. Normal saline 4. IV dextran

3. Correct: Clients in HHNS diurese due to a high glucose load in the vascular space. The client becomes severely volume depleted and is at risk for developing shock. Therapy is focused on combating shock.

When caring for a client with hepatitis A, the nurse should take what special precaution? 1. Wear gloves when handling blood and body fluids. 2. Wear a mask and gown before entering the room. 3. Use gloves when removing the client's bedpan. 4. Use caution when bringing food to the client.

3. Correct: Hepatitis A is transmitted by the fecal/oral route.

A client in the manic phase of bipolar disorder is constantly walking around the day room and refuses to sit down to eat the spaghetti and meatballs sent by the kitchen. Which food should the nurse request from dietary? 1. Carrots and apples 2. Donuts 3. Pizza sticks 4. Strawberry pastry

3. Correct: High protein, high calorie, nutritious finger foods are required when the client will not sit down to eat.

The nurse is caring for a client who is experiencing a severe exacerbation of asthma. Which intervention takes priority? 1. Inhaled short-acting beta2-agonist 2. Intravenous fluids 3. Oxygen 4. Systemic corticosteroids

3. Correct: Owing to the life-threatening nature of severe exacerbations of asthma, treatment should be started immediately once the exacerbation is recognized. All clients with a severe exacerbation should immediately receive oxygen.

The nurse is performing CPR on an adult client with facial and neck trauma. Following the administration of rescue breaths, where is the best location for the nurse to assess for a pulse in this client? 1. Apical area 2. Carotid artery 3. Femoral artery 4. Radial artery

3. Correct: Pulses that are best palpated are large and close to the trunk of the body. The femoral artery is large and at the trunk (proximal) of the body.

The nurse is caring for a client admitted to the emergency department with a history of asthma. Which assessment findings would the nurse anticipate? Select all that apply: 1. Coughing 2. Chest tightness 3. 3 + pitting edema to ankles 4. Kussmaul respirations 5. Increased respiratory rate

1., 2., & 5. Correct: The client with asthma has a pattern of dyspnea (shortness of breath), chest tightness, coughing, wheezing, and increased respiratory rate.

The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessments by the nurse suggests that the client is developing this complication? Select all that apply: 1. Asterixis 2. Lethargy 3. Amnesia 4. Behavioral changes 5. Kussmaul respirations

1., 2., 3. & 4. Correct: All are complications of hepatic encephalopathy.

The son of an elderly diabetic client complains that his mother is frequently having low blood sugar. What should the nurse teach this family member about symptoms of hypoglycemia in the elderly? Select all that apply: 1. Elders may not be aware that blood sugar is dropping due to decreased release of epinephrine in response to the lowered blood sugar. 2. Suggest that the client and family check with primary healthcare provider to see if the medication prescribed has low incidence of hypoglycemic episodes. 3. Symptoms of hypoglycemia may be averted if the client maintains regular meal schedules. 4. Dry, warm skin is an indicator of low blood sugar. 5. Check blood glucose levels if client becomes unsteady, has difficulty concentrating, or is tremulous.

1., 2., 3. & 5. Correct. Elders may not recognize early symptoms of hypoglycemia. Blood sugar levels should be checked frequently. Some oral medications are more likely to cause hypoglycemia episodes. If the client has frequent episodes, perhaps a medication change is warranted. The elderly must maintain regular meal schedules and adequate food intake. This may present challenges for the elder who lives alone. If an elder develops unsteady gait, loss of concentration, lightheadedness, the blood glucose levels should be checked. These symptoms are typical in a hypoglycemic episode.

A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? Select all that apply: 1. Elevate HOB 30 degrees 2. Pad side rails 3. Provide sponge bath if temperature greater than 101 degrees F (38.3 degrees C) 4. Initiate airborne isolation precautions 5. Darken room

1., 2., 3. & 5. Correct: An acute onset of fever, headache, stiff neck, n/v, and mental status changes are consistent with bacterial meningitis. HOB elevated to promote comfort and decrease ICP. Increased risk for seizures, so pad the side rails. Sponge bath is appropriate for fever. Darken room as client with meningitis usually has photophobia.

Which symptoms should the nurse anticipate when caring for a client with acute cholecystitis? Select all that apply: 1. Chills 2. Fever 3. Nausea and vomiting 4. Increased appetite 5. Rigidity of upper right abdomen.

1., 2., 3. & 5. Correct: Many clients with acute cholecystitis present with acute onset of right upper quadrant pain associated with nausea and vomiting. Epigastric pain may also be present. Additional symptoms may include fever, chills, and anorexia. A physical examination often reveals right upper quadrant tenderness and rigidity of upper right abdomen that may radiate to midsternal area or right shoulder. Rebound and guarding are present in some cases.

A nurse is caring for a client admitted with chronic fatigue and weakness. During the physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling in the legs and ankles, and bruises in various stages of healing throughout the body. What nursing interventions should the nurse initiate? Select all that apply: 1. Measure abdomen 2. Monitor intake and output 3. Obtain daily weight 4. Place on fall precautions 5. Provide six small meals per day 6. Elevate legs

1., 2., 3., 4., 5. & 6. Correct: Measuring abdominal girth will indicate accumulating ascitic fluid. Clients with liver disease have fluid volume problems, so daily weight, I&O are indicated. This client is at risk for injury related to chronic fatigue and weakness, so fall prevention is indicated. Poor tolerance to larger meals may be due to abdominal distension and ascites. Client may need help eating if fatigue is severe. Elevating legs enhances venous return and reduces edema in extremities.

A nurse notes that a client with end-stage chronic renal failure has dry, itchy skin, white crystals on the skin and uremic halitosis. Which nursing interventions would be appropriate for this client? Select all that apply: 1. Encourage use of cotton gloves during sleep 2. Apply emollients to the skin 3. Bathe in cold water 4. Cut fingernails short 5. Provide mouth care prior to meals

1., 2., 4. & 5. Correct: Gloves reduce the risk of dermal injury. Emollients and lotion will aid dry, itchy skin. Apply after bathing. Cutting nails short will decrease risk of skin breakdown when scratching. Uremic halitosis occurs from a build-up of urea in the body. It produces a metallic taste in the mouth. Mouth care prior to meals will help in eliminating this taste.

The nurse recognizes which manifestations as signs of community-acquired pneumonia? Select all that apply: 1. Cough 2. Decreased respiratory rate 3. Fever 4. Myalgia 5. Pleuritic chest pain

1., 3., 4. & 5. Correct: Signs of community-acquired pneumonia include cough, crackles, egophony, tactile fremitus, fever, dyspnea, sputum production, myalgias, and pleuritic chest pain.

A 37 week pregnant woman presents to triage complaining of a headache and begins to have a seizure. What actions should the nurse take? Select all that supply: 1. Place in right recumbent position. 2. Administer oxygen. 3. Monitor tonic-clonic activity. 4. Lower siderails to avoid injury to extremities. 5. Administer diazepam.

2. & 3. Correct: Oxygen is needed to ensure supply of oxygen to mom and fetus. Seizure activity should be monitored for tonic and clonic phases of seizure.

The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate to the nurse that the client should not be advanced to the next level? 1. Facial flushing 2. A complaint of chest heaviness 3. Heart rate increase of 10 beats/min. 4. Systolic blood pressure increase of 10 mm Hg

2. Correct: Onset of chest pain indicates myocardial ischemia which can be life threatening. The client should not be advanced to the next level of activity.

A client who has a history of intolerance to fatty foods is admitted to the hospital with a sudden onset of severe right upper quadrant pain radiating to the right shoulder. What should be included in the nurse's initial focused assessment of this client? 1. "Do you have pain in the middle of your stomach that is relieved by vomiting?" 2. "Have you noticed any red splotches on your skin?" 3. "Please describe your bowel habits and stool." 4. "Tell me how often you eat high fat meals."

3. Correct: Clay-colored stools are a sign of biliary obstruction and are due to lack of bile in the stool. Bile adds a darker color to the stool. Asking the client to describe stool is open ended and will give the nurse more detail.

The occupational health nurse is caring for an employee after a chemical explosion at the local tire factory. The client reports a foreign body in the right eye. The right eye is watery, and the client reports photophobia. Which nursing action takes priority? 1. Evert eyelid and examine for foreign body. 2. Measure visual acuity. 3. Notify the receiving hospital immediately for transfer of the client. 4. Place an eye shield over eye.

4. Correct: If a foreign body is the result of explosion or blunt or sharp trauma, the eye should be protected from further damage by placing an eye shield over the eye (or if a shield is not available, a paper cup to prevent rubbing of the eye). After this is done, arrangements should be made to transport the client for emergency care by an ophthalmologist.

A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important nursing measure to include in the nursing care plan for this client? 1. Observation and support of ventilation 2. Insertion of Foley catheter 3. Nasogastric suctioning 4. Frequent assessments of level of consciousness

1. Correct: Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis.

The nurse in the emergency department is caring for a client who is admitted in diabetic ketoacidosis (DKA). Which central venous pressure (CVP) reading would the nurse anticipate? 1. 0 mm of Hg 2. 3 mm of Hg 3. 6 mm of Hg 4. 12 mm of Hg

1. Correct: This is a CVP reading that would indicate fluid volume deficit. A client in DKA will have polyuria.

The nurse is planning an educational seminar on ophthalmic health. Which risk factors for cataract formation should be included in the discussion? Select all that apply: 1. Diabetes mellitus. 2. Cigarette smoking. 3. Increased intraocular pressure. 4. Long-term use of corticosteroids. 5. Thin cornea.

1., 2. & 4. Correct: All these factors put a client at greater risk for development of cataracts.

A nurse is caring for a client admitted with chronic fatigue and weakness. During the physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling in the legs and ankles, and bruises in various stages of healing throughout the body. What nursing interventions should the nurse initiate? Select all that apply: 1. Measure abdomen 2. Monitor intake and output 3. Obtain daily weight 4. Place on fall precautions 5. Provide three meals per day 6. Dangle legs

1., 2., 3., 4., Correct: Measuring abdominal girth will indicate accumulating ascitic fluid. Clients with liver disease have fluid volume problems, so daily weight, I&O are indicated. This client is at risk for injury related to chronic fatigue and weakness, so fall prevention is indicated. Client may need help eating if fatigue is severe.

The nurse is caring for a client in end-stage renal disease with an arterio-venous dialysis access. What assessment by the nurse indicates patency of the access? Select all that apply: 1. Ascultate for a bruit 2. Warm and dry skin 3. Presence of a thrill 4. Positive trousseau's 5. Capillary refill within 3 seconds

1. & 3. Correct: Yes! The nurse palpates the thrill and listens for the bruit to ensure patency of the access device

The client is concerned about renal complications that may result from long- term hypertension. Which comment by the client indicates adequate understanding of the disease process and possible complications? 1. I would like to have my serum creatinine checked at this visit. 2. I would like to stop taking one of my medications for a few days. 3. I have slacked off on watching my sodium intake recently. 4. I don't like the taste of water, so I drink coffee all day.

1. Correct. The client understands that renal function is reflected by serum creatinine levels. This request demonstrates understanding of the disease and possible complications.

The nurse is planning care for a client admitted to the burn unit with full thickness burns over 30% of the body. Which client need should the nurse identify as the priority during the first 24 hours? 1. Fluid volume loss. 2. Infected burn areas. 3. Increased nutritional deficit 4. Pain and loss of function.

1. Correct: Although all are appropriate needs, this client is at risk for fluid volume deficit within the first 24-48 hours when the fluid shifts out of the vascular space and into the interstitial space because of increased capillary permeability.

A client with type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What instruction would the nurse give the client? 1. Take their blood sugar around 2am for several days. 2. Decrease bedtime snacking. 3. Decrease intermediate acting insulin. 4. Increase intermediate acting insulin.

1. Correct: Morning hyperglycemia may be the result of dawn's phenomenon or the Somogyi effect. The client must take their blood sugar between two and three o'clock in the morning for several days to determine the cause of morning hyperglycemia. If the client has decreased blood sugar between two and three o'clock in the morning, suspect Somogyi effect.

A client has arrived in the emergency department with partial thickness burns to 52 percent of the body. Which central venous pressure (CVP) reading would the nurse anticipate? 1. 1 mm of Hg 2. 2 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

1. Correct: This is a CVP reading that would indicate fluid volume deficit. A client with 52 percent of the body burned with partial thickness burns would lose fluid from the vascular space out into the tissues. The client would have a deficit of fluid in the vascular space.

The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women identify which hormone as causing amenorrhea? 1. Progesterone 2. Estrogen 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG)

1. Correct: Yes! In the presence of progesterone amenorrhea results.

When performing a post-surgical neurovascular assessment of a client with a hip fracture, the nurse notes a left dorsalis pedis pulse amplitude of +1 and a right dorsalis pedis pulse amplitude of +2. What other assessment findings would the nurse expect to find? Select all that apply: 1. The left foot is ashen in color. 2. Capillary refill is 6 seconds in the left extremity; 3 seconds in right extremity 3. The skin is cooler on the left extremity 4. Blanching disappears quicker on the left side than on the right side 5. The client has decreased sensation on the right side

1., 2. & 3. Correct: When the circulation is impaired to one extremity, the affected extremity will be cooler to touch, capillary refill will be longer than 3 seconds, and the skin will be cooler to the touch and ashen in color as compared to the unaffected extremity.

A client's central venous pressure (CVP) reading has changed significantly from the last hourly reading. Which data would the nurse assess that reflect changes in the CVP reading? Select all that apply: 1. Heart sounds 2. Skin turgor 3. Temperature 4. Nail bed color 5. EKG rhythm 6. Urinary output

1., 2. & 6. Correct: The CVP reading reflects the client's fluid volume status. If the CVP is elevated, indicating FVE, then the nurse is likely to hear S3 sounds when auscultating the heart sounds. The client's skin turgor and urine output would reflect the client's fluid volume status.

A client who has diabetes calls the nurse hot-line reporting shakiness, nervousness, and palpitations. Which questions would yield information that would help the nurse distinguish if this is a hypoglycemic episode? Select all that apply: 1. What have you eaten today and at what times? 2. Are you using insulin as a treatment of diabetes, and if so, what kind? 3. Do you feel hungry? 4. Do you have access to a glucose monitor to check your current glucose level? 5. Does your skin feel hot and dry?

1., 2., 3. & 4. Correct. This question will give the nurse information about how much time has elapsed since the last meal and will indicate the amount of protein and carbohydrates consumed at the last meal. Even a minor delay in meal times may result in hypoglycemia. Insulin type will give the nurse information about duration of action and peak time. Hunger is a symptom of hypoglycemia.If the client has a glucose monitor, an accurate reading would give the nurse valuable information about how much food the client should consume now.

The nurse, caring for a client who has chronic renal failure, suspects that the client is experiencing anxiety. Which statements by the client would validate the nurse's suspicion? Select all that apply: 1. "I do not think I can continue working." 2. "My husband has taken over the house cleaning and cooking." 3. "I fear I am dying." 4. "I have an "uneasy" feeling most of the time." 5. "Most of the time I feel very 'down and blue'."

1., 2., 3. & 4. Correct: The inability to maintain employment is of concern to most clients who have been used to working. With a chronic illness, the client is unlikely to be able to return to work. Anxiety related to role strain is common. The client may not be able to perform the duties that she once did, thus causing others to have to assume their roles. Death is a possible outcome if transplant does not occur. Fear may be a later diagnosis as the client's condition deteriorates. Clients with anxiety often report feeling uneasy or on edge.

The nurse, caring for a client who has chronic renal failure, suspects that the client is experiencing anxiety. Which statements by the client would validate the nurse's suspicion? Select all that supply: 1. "I do not think I can continue working." 2. "My husband has taken over the house cleaning and cooking." 3. "I fear I am dying." 4. I have an "uneasy" feeling most of the time. 5. "Most of the time I feel very 'down and blue'."

1., 2., 3. & 4. Correct: The inability to maintain employment is of concern to most clients who have been used to working. With a chronic illness, the client is unlikely to be able to return to work. Anxiety related to role strain is common. The client may not be able to perform the duties that she once did, thus causing others to have to assume their roles. Death is a possible outcome if transplant does not occur. Fear may be a later diagnosis as the client's condition deteriorates. Clients with anxiety often report feeling uneasy or on edge.

A nurse is educating a group of community citizens about risk factors for developing peripheral neuropathy. Which risk factors should the nurse include? Select all that supply: 1. Uncontrolled diabetes 2. Alcohol abuse 3. Vitamin B deficiency 4. Rheumatoid arthritis 5. Varicella-zoster virus

1., 2., 3., 4. & 5. Correct: All are risk factors for peripheral neuropathy.

The nurse is caring for a client with a casted right arm due to a fractured radius. The client begins to report severe pain in the right arm accompanied with edema in the fingers. What does the nurse suspect is developing? 1. Carpal tunnel syndrome. 2. Compartment syndrome. 3. Subsequent ulnar fracture. 4. Ulnar nerve palsy.

2. Correct: This situation best describes compartment syndrome. Compartment syndrome is when edema within a closed space may result in vascular compromise and decreased blood flow with eventual neurologic compromise. There are five Ps of compartment syndrome: pallor, pulselessness, pain, paresthesias, and paralysis.

A nurse notes that a client with end-stage chronic renal failure has dry, itchy skin, white crystals on the skin and uremic halitosis. Which nursing interventions would be appropriate for this client? Select all that apply: 1. Encourage use of cotton gloves during sleep 2. Apply emollients to the skin 3. Bathe in tepid water 4. Cut fingernails short 5. Provide mouth care prior to meals

1., 2., 3., 4. & 5. Correct: Gloves reduce the risk of dermal injury. Emollients and lotion will aid dry, itchy skin. Apply after bathing. A tepid bath will remove the crystals and decrease itching. This will make the client more comfortable. Cutting nails short will decrease risk of skin breakdown when scratching. Uremic halitosis occurs from a build-up of urea in the body. It produces a metallic taste in the mouth. Mouth care prior to meals will help in eliminating this taste.

Which signs/symptoms does the nurse expect to note when caring for a client with a suspected cystitis? Select all that apply: 1. Incontinence 2. Urgency 3. Frequency 4. Hematuria 5. Nocturia

1., 2., 3., 4. & 5. Correct: Signs and symptoms of cystitis include burning on urination, nocturia, incontinence, suprapubic or pelvic pain, hematuria, and back pain. 6. Incorrect: Flank pain is seen when the urinary tract infection progresses to the kidneys,

A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform? Select all that apply: 1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 3. Position client upright. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min.

1., 2., 3., 4. & 5. Correct: This client exhibits signs of cardiogenic shock, a complication of myocardial infarction. Hypotension accompanied by clinical signs of increased peripheral resistance (weak, thready pulse and cool, clammy skin) and inadequate organ perfusion (altered mental status and decreased urinary output) are found in this client. Initiate cardiac monitoring, watching for dysrhythmias, Monitor I&O hourly to make sure kidneys are perfused. Position upright to promote optimal ventilation by reducing venous return and lessen pulmonary edema. Limit activity to decrease oxygen demand. Dopamine is administered to increase BP and cardiac output.

A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform? Select all that apply: 1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 3. Position client in recumbant position. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min.

1., 2., 4. & 5. Correct: This client exhibits signs of cardiogenic shock, a complication of myocardial infarction. Hypotension accompanied by clinical signs of increased peripheral resistance (weak, thready pulse and cool, clammy skin) and inadequate organ perfusion (altered mental status and decreased urinary output) are found in this client. Initiate cardiac monitoring, watching for dysrhythmias, Monitor I&O hourly to make sure kidneys are perfused. Limit activity to decrease oxygen demand. Dopamine is administered to increase BP and cardiac output.

The nurse is preparing to speak to a group of clients at the community center about influenza. Which risk factors for post-influenza complications would be included in the session? Select all that apply: 1. Age over 65 years. 2. Middle age client living alone 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home.

1., 3., 4. & 5. Correct: Clients who are over the age of 65, have diabetes, have renal disease, or who reside in a nursing home are all at risk for post-influenza complications.

The nurse is caring for a client in the emergency department who presents with hematemesis. What information is most important for the nurse to obtain during the initial assessment? Select all that apply: 1. Vital signs 2. History of prior bleeding episodes 3. Medications the client is taking 4. Urinary output 5. Level of consciousness

1., 4., & 5. Correct: A set of vital signs and assessment for hypovolemic shock take priority for this client. S/S of shock include thready, rapid pulse, decreased LOC, shortness of breath, cold and clammy skin, and decreased urinary output.

A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation? 1. Are you having trouble sleeping at night? 2. Do you have periods of muscle jerking? 3. Are you having any sexual dysfunction? 4. Is your mood improving?

2. Correct: Myoclonus, shaking chills, and mental confusion are symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction.

An elderly client is admitted to the outpatient unit with anemia and is receiving a blood transfusion. What is the nurse's priority assessment? 1. Monitor for peripheral edema 2. Assess breath sounds 3. Keep bedrails up at all times 4. Monitor hemoglobin every 6 hours

2. Correct: The elderly client receiving a blood transfusion is at greater risk for fluid volume overload. Assessing breath sounds is the priority.

A client has been prescribed chlorpromazine for the treatment of schizophrenia. The nurse makes afternoon rounds and finds the client's temperature to be 104.7ºF/40.4ºC. The client has extreme muscle rigidity, and the vital signs have been fluctuating for the last four hours. What should the nurse do first? 1. Provide a tepid sponge bath. 2. Notify the primary healthcare provider immediately. 3. Administer an antipyretic immediately. 4. Administer the chlorpromazine as ordered.

2. Correct: These symptoms are consistent with neuroleptic malignant syndrome, a medical emergency. Immediate action should be taken.

When assessing a client, the nurse finds that in response to painful stimuli the upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb while the lower extremity exhibits extension, internal rotation, and plantar flexion. How would the nurse accurately document this finding? 1. Decerebrate posturing 2. Decorticate posturing 3. Reflex posturing 4. Superficial posturing

2. Correct: This describes decorticate posturing.

Which factors should the nurse include when teaching a parent about risk factors for otitis media? Select all that apply: 1. Breast-feeding 2. Contact with siblings 3. Day care attendance 4. Season of the year 5. Age over 5

2., 3. & 4. Correct: Contact with siblings, day care attendance, and season of the year all increase a child's risk of developing otitis media.

The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment goals have not been met? Select all that apply: 1. Diuresis 2. Dyspnea on exertion 3. Persistent cough 4. Warm, dry skin 5. Heart rate irregular at 118/min 6. Alert and oriented

2., 3. & 5. Correct: When the cardiac output decreases, renal perfusion decreases, which leads to decreased urine output and fluid retention. This leads to difficulty breathing. Increasing HR and irregularity is a sign of FVE and decreased output. Persistant cough, wheezing, pink blood tinged sputum are all signs that the client is still sick.

The school nurse has identified a large outbreak of viral conjunctivitis among one middle school class and plans to educate these students on this illness. Which data should the nurse be sure to include? Select all that apply: 1. Viral conjunctivitis is only contagious for 24 hours. 2. Light cold compresses over the eyes several times a day will ease discomfort. 3. Do not share towels or linens. 4. Discard all makeup and use new makeup after infection resolves. 5. Wash hands frequently with soap and water. 6. Use personal handkerchief to wipe the eye of discharge.

2., 3., 4. & 5. Correct: All of these measures will promote comfort and decrease risk of transmitting infection.

The nurse is caring for a client with a long history of emphysema. Which clinical signs/symptoms, if noted by the nurse, would support a history of emphysema? Select all that supply: 1. Atelectasis 2. Increased AP diameter 3. Breathlessness 4. Use of accessory muscles with respiration. 5. Leans backwards to breathe. 6. Clubbing of fingernails

2., 3., 4., & 6. Correct: Emphysema is described as a permanent hyperinflation of lung beyond the bronchioles with destruction of alveolar walls. Airway resistance is increased, especially on expiration. Inspection reveals dyspnea on exertion, barrel chest, tachypnea, and use of accessory muscles with respiration. Clubbing of fingernails is due to decreased oxygen levels.

The nurse is caring for a client with a T4 lesion on the neuro rehabilitation unit. The client suddenly complains of a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What interventions should the nurse initiate? Select all that apply: 1. Place client supine with legs elevated. 2. Assess bladder and bowel for distention. 3. Examine skin for pressure areas. 4. Eliminate drafts. 5. Remove triggering stimulus. 6. Administer hydralazine if BP does not return to normal.

2., 3., 4., 5. & 6. Correct: This is autonomic dysreflexia. The cause of these symptoms is a noxious stimulus and must be promptly treated.

What interventions should the nurse initiate to keep the airway free of secretions in a client with pneumonia? Select all that apply: 1. Evaluate results of ABG's, and report abnormal findings. 2. Increase oral intake to at least 2000 mL/day. 3. Administer a cough suppressant medication. 4. Educate client on incentive spirometry. 5. Perform percussion to affected area.

2., 4., & 5. Correct: Liquify secretions by increasing oral intake to at least eight, 8 ounce glasses of liquid/day. Incentive spirometry helps keep lungs open and prevent further pneumonia and atelectisis. Prescribed percussion can assist with loosening secretions.

The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which assessment findings? Select all that apply: 1. Continued lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP 114/78 5. Increased thirst

3. & 4. Correct: Urinary output should increase with decreasing shortness of breath as hydration is corrected and BP should be normal.

The nurse is caring for a client with pneumococcal pneumonia. Which nursing observations would indicate a therapeutic response to the treatment regime for the infection? Select all that apply: 1. Dyspnea on exersion with nonproductive cough 2. Tachypnea with use of accessory muscles 3. Expectorating moderate amounts of thin, white sputum 4. White blood cell count of 18,000 5. Crackles clearing with cough

3. & 5. Correct: The client has no signs of active infection. A cough with thin, white sputum is expected for a while, but it is infection free. Crackles clearing with cough are signs of an effective cough effort.

Two days after a myocardial infarction, a client begins reporting orthopnea and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The urine output has steadily declined over the past 12 hours. What should the nurse do first? 1. Notify the primary healthcare provider. 2. Increase the IV rate. 3. Elevate the head of the bed. 4. Observe for cardiac arrhythmias.

3. Correct: Elevate the head of the bed first. The client is complaining they cannot breathe. (Orthopnea means the client needs to sit up to breathe better.) With ANY client having difficulty breathing, the first intervention for the nurse is to sit the client up. This client is showing s/s of heart failure.

The nurse is caring for a client with a closed head injury. Three days after admission, urinary output for 8 hours was 1800 mL. In response to this data, what would be the appropriate nursing action? 1. Hydrate the client with 500 mL of IV fluid in the next hour. 2. Monitor BUN and creatinine. 3. Check urine specific gravity. 4. Recognize this as a side effect of dexamethasone.

3. Correct: For any client with a head injury and abnormally high urinary output, the nurse knows the client is at risk for ADH (anti-diuretic hormone) problems. The pituitary gland is located in the brain. ADH is produced in the pituitary gland. In head injured clients, ADH can get messed up. If the client does not have enough ADH large volumes of water will be lost in the urine. The name of this disease is diabetes insipidus (DI). Large volume losses place the client at risk for shock. The nurse knows to further investigate the problem by checking a urine specific gravity. For clients in DI, the urine specific gravity will be very, very low because they are losing so much water. When you see the letters DI, think of the "D" for diuresis and think SHOCK first.

The nurse evaluates an electrocardiogram (EKG) and notices a U-wave. The nurse suspects that this occurrence is caused by which electrolyte imbalance? 1. Hypermagnesemia 2. Hypocalcemia 3. Hypokalemia 4. Hyponatremia

3. Correct: Hypokalemia impairs myocardial conduction and prolongs ventricular repolarization. This can be seen by a prominent U-wave (a positive deflection following the T-wave on the EKG). The U-wave is not totally unique to hypokalemia, but its presence is a signal for the clinician to check the serum potassium level.

The nurse is caring for a newly admitted diabetic client. The initial assessment reveals that the client is unresponsive, BP is 98/64, Resp 38, HR 100, T 97.2ºF/36.2ºC. The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

3. Correct: Kussmaul respirations occur due to excess ketones in the body causing metabolic acidosis. A diabetic client who is unresponsive with fruity ketone breath is assumed to be in acidosis. The respiratory rate indicates that the lungs are trying to fix the metabolic acidosis with Kussmaul breathing.

The nurse is caring for a client with renal failure. The client has a 24 hour intake of 2500 mL and a 24 hour urinary output of 200 mL. What is the priority nursing assessment? 1. Assess for dependent edema 2. Monitor for cardiac arrhythmias 3. Auscultate breath sounds 4. Monitor sodium and potassium levels

3. Correct: The nurse is "worried" about fluid volume excess. In fluid volume excess, the number one concern is heart failure with resultant pulmonary edema. In FVE, you can stress the heart so much that the heart begins to fail. With heart failure, the cardiac output decreases. With decreased cardiac output, there is decreased forward flow out of the heart. With decreased forward flow there is backflow. Backflow from the left ventricle results in fluid accumulation in the lungs. The best assessment for heart failure is to auscultate lung sounds.

Which arterial blood gas (ABG) results would the nurse expect on a client who has overdosed on aspirin (ASA)? 1. pH 7.54, pCO2 41, p02 63, Sa02 91, HC03 36 2. pH 7.24, pCO2 37, p02 83, Sa02 95, HC03 18 3. pH 7.49, pC02 30, p02 68, Sa02 92, HC03 28 4. pH 7.12, pC02 28, p02 72, Sa02 93, HC03 10

3. Correct: This ABG result indicates respiratory alkalosis. Aspirin stimulates the respiratory center and causes an increase in respiratory rate and depth. This causes respiratory alkalosis by blowing off C02 and causing the pH to increase.

The nurse is providing post-operative care to the craniotomy client. Hourly urinary output increases from 100 mL last hour to 500 mL this hour. What action by the nurse takes priority? 1. Elevate HOB 90 degrees 2. Auscultate apical pulse 3. Obtain a blood pressure 4. Assess Glasgow Coma Score

3. Correct: This is the best answer because we are "worried" this client is going into SHOCK due to diabetes insipidus. So, you better be checking a BP. This is a time where checking the BP is appropriate. If we "assume the worst" I better check a blood pressure. It could have dropped out the bottom.

A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. Which intervention takes priority? 1. Triage victims and tag according to injury. 2. Assess the immediate area for electrical wires on the ground and in vicinity of victims. 3. Activate the community emergency response team. 4. Begin attending to injuries as they are encountered.

3. Correct: With mass casualties, community response teams are needed.

The nurse is caring for a child who has partial thickness burns to the right arm and leg that are open to air. The child has a pain score of 8/10. The nurse administers morphine 2 mg IVP, and reassesses the pain 15 minutes later. The child reports the pain to be 7/10. What should the nurse do next? 1. Notify the primary healthcare provider 2. Administer morphine 2 mg IVP 3. Apply a moist cloth. 4. Coat burn with petroleum ointment

3. Correct: Yes moisture will soothe the burn and provide comfort

One week ago a client was involved in a motor vehicle crash and was brought to the Emergency Department. The client received two sutures to the forehead and was sent home. Today, the client's spouse notes the client "acts like he is drunk" and cannot control his right foot and arm. Based on this data, what should the nurse suspect? 1. Meningitis 2. Transient ischemic attack 3. Subdural hematoma 4. Meniere's disease

3. Correct: Yes! Subacute subdural hematoma is a head injury with slow venous bleed and the body does not have symptoms until compensation is exhausted.

The emergency department nurse is assuming care of a client with full thickness burns to both legs. Which primary healthcare provider prescription should be implemented first? 1. Administer IV morphine 2. Insert oropharyngeal airway 3. Start two large bore IVs 4. Apply silver sulfadiazine to burn area

3. Correct: Yes! This client will have lots of fluid loss through the burn wound and also there is a fluid shift.

What signs or symptoms should the nurse assess for when monitoring a client who has a brain injury? Select all that apply: 1. Increased pulse 2. Glasgow coma score of 15 3. BP 150/60 4. Papilledema 5. Projectile vomiting

3., 4. & 5. Correct: The pulse pressure of 150/60 is 90 (greater than 40 is a sign of increased ICP). Signs of increased intracranial pressure also include papilledema, elevated systolic pressure, wide pulse pressure, decreased pulse, and slow respirations. Projectile vomiting is classically associated with increased ICP.

A client has received 850 mL of an isotonic solution intravenously in less than 60 minutes. Which central venous pressure (CVP) reading noted by the nurse indicates a problem related to the amount of intravenous fluids infused? 1. 1 mm of Hg 2. 3 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

4. Correct: This CVP reading indicates fluid volume overload.

The nurse approaches a client that entered the emergency department following a fall down a flight of stairs. The client is unresponsive with snoring and wheezes with respirations. How would the nurse best open the client's airway? 1. Endotracheal tube (ET) 2. Head tilt-chin lift maneuver 3. Oropharyngeal airway 4. Jaw thrust maneuver

4. Correct: This is a trauma client that could possibly have a C-spine injury. The jaw thrust maneuver will open the client's airway without manipulating the client's C-spine.

After making rounds on clients, a primary healthcare provider hands the nurse a client record and gives the following verbal order: Administer cisplatin 1 mg IV over 6 hours. What should be the first action by the nurse following this verbal prescription? 1. Write down the prescription immediately. 2. Repeat the prescription back to the primary healthcare provider. 3. Ask the primary healthcare provider to spell the drug name for clarification. 4. Inform the healthcare provider that this medication requires a written prescription.

4. Correct: Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety.

When assessing a client's fluid status, the nurse associates weight gain and peripheral edema with which problem? 1. Dehydration 2. Hyperosmolality 3. Volume depletion 4. Volume overload

4. Correct: Volume overload is manifested by an increase in weight and peripheral edema. A history of increased dietary sodium intake and use of medications that affect the renin angiotensin system should be sought.

The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client? 1. Increase carbohydrate intake. 2. Increase fluid intake. 3. Avoid shellfish. 4. Increase fiber.

4. Correct: Yes! Low thyroid clients have constipation so increased fiber.

What is most important for the nurse to do prior to initiating peritoneal dialysis? 1. Aspirate for placement. 2. Have the client void. 3. Irrigate the catheter for patency. 4. Warm the fluids.

4. Correct: Yes, we want to promote vasodilation for good exchange, so warm the fluids.