quiz review
A nurse is conducting a class on how to self-manage insulin regimens. A client asks how long a vial of insulin can be stored at room temperature before it "goes bad." What would be the nurse's best answer? "If you are going to use up the vial within 1 month, it can be kept at room temperature." "If a vial of insulin will be used up within 21 days, it may be kept at room temperature." "If a vial of insulin will be used up within 2 weeks, it may be kept at room temperature." "If a vial of insulin will be used up within 1 week, it may be kept at room temperature."
"If you are going to use up the vial within 1 month, it can be kept at room temperature."
The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Put these steps in order in which they occur. 635241 352416 236145 162534
236145
A client who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. What aspect of the client's health history creates a heightened risk of intracardiac thrombi? Atrial fibrillation You Answered Infective endocarditis Recurrent pneumonia Recent surgery
A fib
The nurse is planning the care of a client with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this client's health problem is due to what? Production of inadequate quantities of RBCs Premature release of immature RBCs Injury to the RBCs in circulation Abnormalities in the structure and function of RBCs
Abnormalities in the structure and function of RBCs
Paramedics have brought an intubated client to the RD following a head injury due to acceleration--deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? Keep the head of the bed (HOB) flat at all times Teach the client to perform the Valsalva maneuver Administer benzodiazepines on a PRN basis Perform endotracheal suctioning every hour
Administer benzodiazepines on a PRN basis
The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform? Administer the platelets as rapidly as the client can tolerate Establish IV access as soon as the platelets arrive from the blood bank Ensure that the client has a patent central venous catheter Aspirate 10 to 15 mL of blood from the client's IV immediately following the transfusion
Administer the platelets as rapidly as the client can tolerate
A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? Assess pulse of affected extremity every 15 minutes at first Palpate the affected leg for pain during every assessment Assess the client for signs and symptoms of compartment syndrome every 2 hours Perform Doppler evaluation once daily
Assess pulse of affected extremity every 15 minutes at first
The cardiac monitor alarm alerts the critical care nurse that the client is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how should the nurse describe this initial absence of cardiac rhythm? Pulseless electrical activity (PEA) Ventricular fibrillation Ventricular tachycardia Asystole
Asystole
A client with mitral stenosis exhibits new symptoms of a dysrhythmia. Based on the pathophysiology of this disease process, the nurse would expect the client to exhibit what heart rhythm? Ventricular fibrillation (VF) Ventricular tachycardia (VT) Atrial fibrillation Sinus bradycardia
Atrial fibrillation
A client is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the client's mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should assess for the onset of acute kidney injury by referring to what laboratory findings? Select all that apply. Blood urea nitrogen (BUN) level Urine specific gravity Alkaline phosphatase level Creatinine level Serum albumin level
BUN Urine specific gravity Creatinine
The nurse is caring for a client whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be prescribed to control this? Baclofen Dexamethasone Mannitol Phenobarbital
Baclofen
A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? Acute pain Septicemia Bleeding seizures
Bleeding
The nurse is assessing a client diagnosed with Graves disease. What physical characteristics of Graves disease would the nurse expect to find? Hair loss Moon face Bulging eyes Fatigue
Bulging eyes
A lipid profile has been ordered for a client who has been experiencing cardiac symptoms. When should a lipid profile be drawn in order to maximize the accuracy of results? a) as close to the end of the day as possible b) after a meal high in fat c) after a 12 hour fast d) thirty minutes after a normal meal
C) after a 12 hour fast
A client's recent diagnostic testing included a total lymphocyte count. The results of this test will allow the care team to gauge what aspect of the client's immunity? Humoral immune function Antigen recognition Cell-mediated immune function Antibody production
Cell-mediated immune function
The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? Change the client's position frequently Provide a high-protein diet Provide light massage at least daily Teach the client deep breathing and coughing exercises
Change the client's position frequently
A client's current immune response involves the direct destruction of foreign microorganisms. This aspect of the immune response may be performed by what cells? Suppressor T cells Memory T cells Cytotoxic T cells Complement T cells
Cytotoxic T cells
The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? Disorientation and restlessness Decreased pulse and respirations Projectile vomiting Loss of corneal reflex
Disorientation and restlessness
A client in a hypertensive emergency is admitted to the ICU. The nurse anticipates that the client will be treated with IV vasodilators, and that the primary goal of treatment is what? Lower the BP to reduce onset of neurologic symptoms, such as headache and vision changes Decrease the BP to a normal level based on the client's age Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment Reduce the BP to ≤120/75 mm Hg as quickly as possible
Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment
A client is fighting an active infection. What function will cytokines perform in this immune response? Determining whether a cell is foreign Determining if lymphokines will be activated Determining whether the T cells will remain in the nodes and retain a memory of the antigen Determining whether the immune response will be the production of antibodies or a cell-mediated response
Determining whether the immune response will be the production of antibodies or a cell-mediated response
A diabetes nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic client? Do not eliminate insulin when nauseated and vomiting. Report elevated glucose levels greater than 150 mg/dL (8.3 mmol/L). Eat three substantial meals a day, if possible. Reduce food intake and insulin doses in times of illness.
Do not eliminate insulin when nauseated and vomiting.
An asthma nurse educator is working with a group of adolescent asthma clients. What intervention is most likely to prevent asthma exacerbations among these clients? Encouraging clients to carry a corticosteroid rescue inhaler at all times Educating clients about recognizing and avoiding asthma triggers Teaching clients to utilize alternative therapies in asthma management Ensuring that clients keep their immunizations up to date
Educating clients about recognizing and avoiding asthma triggers
A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool? Monro-Kellie hypothesis Glasgow Coma scale Cranial nerve function Mental status examination
Glasgow Coma scale
When planning the care of a client with an implanted pacemaker, what assessment should the nurse prioritize? Core body temperature Heart rate and rhythm Blood pressure Oxygen saturation level
Heart rate and rhythm
The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage? Hyperthermia Tachycardia Hypertension Bradypnea
Hyperthermia
The home care nurse is conducting client teaching with a client on corticosteroid therapy. To achieve consistency with the body's natural secretion of cortisol, when should the home care nurse instruct the client to take the corticosteroids? In the evening between 4 PM and 6 PM Prior to going to sleep at night At noon every day In the morning between 7 AM and 8 AM
In the morning between 7 AM and 8 AM
The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate response? Inform the care team and assess for further signs of possible increased ICP Administer bronchodilators as prescribed and monitor the client's LOC Increase the client's bed height and reassess in 30 minutes Administer a bolus of normal saline as prescribed
Inform the care team and assess for further signs of possible increased ICP
A client is admitted to the neurologic ICU with a spinal cord injury. In writing the client's care plan, the nurse specifies that contractures can best be prevented by what action? Repositioning the client every 2 hours Initiating range-of-motion exercises (ROM) as soon as the client initiates Initiating (ROM) exercises as soon as possible after the injury Performing ROM exercises once a day
Initiating (ROM) exercises as soon as possible after the injury
The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? Position the client supine Maintain head of bed (HOB) elevated at 30 to 45 degrees Position client in prone position Maintain bed in Trendelenburg position
Maintain head of bed (HOB) elevated at 30 to 45 degrees
A client is undergoing preoperative teaching before his cardiac surgery and the nurse is aware that a temporary pacemaker will be placed later that day. What is the nurse's responsibility in the care of the client's pacemaker? Monitoring for pacemaker malfunction or battery failure Determining when it is appropriate to remove the pacemaker Making necessary changes to the pacemaker settings Selecting alternatives to future pacemaker use
Monitoring for pacemaker malfunction or battery failure
A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the client's bleeding and established that his vital signs are stable. What should be the nurse's next action? Position the client in a prone position to minimize bleeding Establish IV access for the administration of vitamin K Prepare for the administration of factor VIII Administer a normal saline bolus to increase circulatory volume
Prepare for the administration of factor VIII
A nurse is caring for a client with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the client's ability to prepare and self-administer insulin? Ask the client to describe the process in detail. Observe the client drawing up and administering the insulin. Provide a health education session reviewing the main points of insulin delivery. Review the client's first hemoglobin A1C result after discharge.
Observe the client drawing up and administering the insulin.
A client has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? Place the client in the prone position for 30 minutes per day Assist the client in acutely flexing the thigh to promote movement Place a pillow in the axilla when there is limited external rotation Place client's hand in pronation
Place a pillow in the axilla when there is limited external rotation
the nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition? Pneumothorax Cardiac ischemia Acute bronchitis Aspiration
Pneumothorax
The nursing educator is presenting a case study of an adult client who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? P wave T wave QRS complex U wave
QRS complex
A client is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 11/2 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? Risk for impaired skin integrity Risk for injury Risk for autonomic dysreflexia risk for suffocation
Risk for injury
A nurse is admitting a client with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply. Antihypertensives Penicillins Sulfa-containing medications Aspirin-based drugs NSAIDs
Sulfa-containing medications Aspirin-based drugs NSAIDs
The nurse is teaching a client about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply. Transient ischemic attacks (TIAs) Cerebrovascular disease Retinal hemorrhage Venous insufficiency Right ventricular hypertrophy
TIAs CVD retinal hemorrhage
An 87-year-old client has been hospitalized with pneumonia. Which nursing action would be a priority in this client's plan of care? Nasogastric intubation Administration of probiotic supplements Bedrest Cautious hydration
cautious hydration
The nurse is caring for a client recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke? Providing frequent small meals rather than three larger meals Teaching the client to perform deep breathing and coughing exercises Keeping a urinary catheter in situ for the full duration of recovery Limiting intake of insoluble fiber
Teaching the client to perform deep breathing and coughing exercises
Which of the following circumstances would most clearly warrant autologous blood donation? The client has type O blood. The client has sickle cell disease or a thalassemia. The client has elective surgery pending. The client has hepatitis C.
The client has elective surgery pending.
A client with von Willebrand disease (vWD) has experienced recent changes in bowel function that suggest the need for a screening colonoscopy. What intervention should be performed in anticipation of this procedure? The client should not undergo the normal bowel cleansing protocol prior to the procedure. The client should receive a unit of fresh-frozen plasma 48 hours before the procedure. The client should be admitted to the surgical unit on the day before the procedure. The client should be given necessary clotting factors before the procedure.
The client should be given necessary clotting factors before the procedure.
A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction? Antibodies to donor leukocytes remained in the blood. The donor blood was incompatible with that of the client. The client had a sensitivity reaction to a plasma protein in the blood. The blood was infused too quickly and overwhelmed the client's circulatory system.
The donor blood was incompatible with that of the client.
A nurse is explaining how the humoral and cellular immune responses should be seen as interacting parts of the broader immune system rather than as independent and unrelated processes. What aspect of immune function best demonstrates this? The movement of B cells in and out of lymph nodes The interactions that occur between T cells and B cells The differentiation between different types of T cells The universal role of the complement system
The interactions that occur between T cells and B cells
n elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following health care provider prescriptions: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? To decrease cerebral arterial pressure To avoid impeding venous outflow To prevent flexion contractures To prevent aspiration of stomach contents
To avoid impeding venous outflow
The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four clients who might be at risk for a stroke. Which client is likely at the highest risk for a hemorrhagic stroke? White female, age 60, with history of excessive alcohol intake White male, age 60, with history of uncontrolled hypertension Black male, age 60, with history of diabetes Black male, age 50, with history of smoking
White male, age 60, with history of uncontrolled hypertension
The ED nurse is assessing a client complaining of dyspnea. The nurse auscultates the client's chest and hears wheezing throughout the lung fields. What might this indicate about the client? A narrowed airway Pneumonia The need for physiotherapy Hemothorax
a narrowed airway
a critical care nurse is caring for a client with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply. a) pneumothorax b) infection c)atelectasis d) bronchospasm e) air embolism
a) pneumothorax b)infection e) air embolism
The nurse is caring for an older adult client who has been involved in a motor vehicle accident. The client's labs indicate minimally elevated serum creatinine levels. The nurse should assess for signs of what change? a) substantially reduced renal function b) acute kidney injury c) decreased cardiac output d) alterations in ratio of body fluids to muscle mass
a) substantially reduced renal function
In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances? a)fluid volume circulating in the blood vessels decreases b)there is an uncontrolled increase in cardiac output c)Blood pressure regulation becomes irregular d) client experiences tachycardia and a bounding pulse
a)fluid volume circulating in the blood vessels decreases
A client has questioned the nurse's administration of IV normal saline, asking, "Wouldn't sterile water would be a more appropriate choice than saltwater?" Under what circumstances would the nurse administer electrolyte-free water intravenously? a) never, because it rapidly enters the RBC causing them to rupture b) when the client is severely dehydrated resulting in neurologic S&S c) when the client is in excess of calcium and/or magnesium ions d) when a client's fluid volume deficit is due to acute or chronic kidney disease
a)never, because it rapidly enters RBCs causing them to rupture
The nurse is caring for an older adult client who is in cardiac rehabilitation following heart surgery. The client has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The client states that he has cramp-like pain in the legs every time he walks and that the pain gets "better when I rest." The client's care plan should address what problem? Decreased mobility related to VTE Acute pain related to intermittent claudication Decreased mobility related to venous insufficiency Acute pain related to vasculitis
acute pain r/t intermittent claudication
The nurse is caring for a client with hyperparathyroidism. What level of activity would the nurse expect to promote? Complete bed rest Bed rest with bathroom privileges Out of bed (OOB) to the chair twice a day Ambulation and activity, as tolerated
ambulation and activity, as tolerated
The nurse has assessed a client's family history for three generations. The presence of which respiratory disease would justify this type of assessment? Asthma Obstructive sleep apnea Community-acquired pneumonia Pulmonary edema
asthma
A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication? Acute respiratory distress syndrome (ARDS) Atelectasis Aspiration Pulmonary embolism
atelectasis
The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated? Teach the client deep breathing and coughing exercises Administer supplemental oxygen at all times Limit the client's activity level Avoid positioning the client supine
avoid positioning the client supine
A client has been scheduled for cardiovascular computed tomography (CT) with contrast. To prepare the client for this test, what action should the nurse perform? a) keep the client NPO for at least 6 hours prior to the test b) establish peripheral IV access c) limit the client's activity for 2 hours before the test d) teach the client to perform incentive spirometry
b) establish peripheral IV access
A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult client who has been experiencing vital fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis? a) pleurisy b)heart failure c) valve dysfunction d) cardiomyopathy
b) heart failure
The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? a) "I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup." b)"Limiting your fluids can create imbalances that can result in confusion. Maybe we need to adjust the timing of your fluids." c)"It is normal to be a little confused following surgery, and it is safe not to urinate at night." d)"If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress."
b) limiting your fluids can create imbalances that can result in confusion. Maybe we need to adjust the timing of your fluids
During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where should the nurse best palpate the PMI? a) Left midclavicular line of the chest at the level of the nipple b)Left midclavicular line of the chest at the fifth intercostal space c)Midline between the xiphoid process and the left nipple d)Two to three centimeters to the left of the sternum
b)Left midclavicular line of the chest at the fifth intercostal space
The nurse in the medical ICU is caring for a client who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the client have that could cause inadequate ventilation? a) endocarditis b) multiple myeloma c) Guillain-Barre syndrome d) overdose of amphetamines
c) Guillain-Barre Syndrome
The acute care nurse is providing care for an adult client who is in hypovolemic shock. What assessment finding will the nurse likely observe related to the role of antidiuretic hormone during hypovolemic shock? a) increased hunger b) decreased thirst c) decreased Urine output d) increased capillary perfusion
c) decreased urine output
the nurse is assessing the client for the presence of a Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate? a) hypermagnesemia b) hyponatremia c) hypocalcemia d)hyperkalemia
c)hypocalcemia
A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? Cardiac and respiratory status Seizure activity Pain Fluid and electrolyte balance
cardiac and respiratory status
The nurse is caring for a client who has had a dysrhythmic event. What change in status may signal to the nurse a decrease in cardiac output? Increased blood pressure Bounding peripheral pulses Changes in level of consciousness Skin flushing
changes in LOC
A client converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Diltiazem are given. The nurse caring for the client understands that the main goal of treatment is what? Decrease SA node conduction Control ventricular heart rate Improve oxygenation Maintain anticoagulation
control ventricular rate
A client has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation? Expiratory wheezes Inspiratory wheezes Rhonchi Crackles
crackles
The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be the most consistent with the early stage of compensation? a) increased urine output b)decreased heart rate c) hyperactive blood sounds d) cool, clammy skin
d) cool clammy skin
The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the client's health? a) nutritional status b) potassium balance c) calcium balance d) Fluid volume status
d) fluid volume status
The ICU nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that end-organ damage may be occurring? a) urinary output increases b) skin becomes warm and dry c) adventitious lung sounds occur in the upper airway d) Heart and respiratory rates are elevated
d) heart and respiratory rates are elevated
the critical care nurse is preparing to initiate an infusion of a vasoactive medication to client in shock. What goal of this treatment should the nurse identify? A) abscence of infarcts or emboli b) reduced stroke volume and cardiac output c) absence of pulmonary and peripheral edema d) maintenance of adequate mean arterial pressure
d) maintenance of adequate mean arterial pressure
The nurse is caring for a client who is undergoing an exercise stress test. Prior to reaching the target heart rate, the client develops chest pain. What is the nurse's most appropriate response? a) administer sublingual nitroglycerin to allow the client to finish the test b) initiate cardiopulmonary resuscitation c) administer analgesia and slow the test d) stop the test and monitor the client closely
d) stop the test and monitor the client closely
The ED nurse is caring for a client who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform? Place gel pads over the apex and posterior chest for better conduction. Ensure no one is touching the client at the time shock is delivered. Continue to ventilate the client via endotracheal tube during the procedure. Allow at least 3 minutes between shocks.
ensure no one is touching the client at the time shock is delivered
When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client will develop complications of shock. How can the nurse best achieve this goal? a)Provide a detailed diagnosis and plan of care in order to promote the client's and family's coping. b) Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. c)Monitor for significant changes and evaluate client outcomes on a scheduled basis focusing on blood pressure and skin temperature. d)Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.
d)Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.
A client who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse should discuss the importance of antibiotic prophylaxis prior to which of the following? Exposure to immunocompromised individuals Future hospital admissions Dental procedures Live vaccinations
dental procedures
A client is scheduled for catheter ablation therapy. When describing this procedure to the client's family, the nurse should address what aspect of the treatment? Resetting of the heart's contractility Destruction of specific cardiac cells Correction of structural cardiac abnormalities Clearance of partially occluded coronary arteries
destruction of specific cardiac cells
The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding? Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. Inform the physician promptly that there is in imminent leak in the drainage system. Encourage the client to do deep breathing and coughing exercises. Document that the chest drainage system is operating as it is intended.
document that the chest drainage system is operating as it is intended
Following an addisonian crisis, a client's adrenal function has been gradually regained. The nurse should ensure that the client knows about the need for supplementary glucocorticoid therapy in which of the following circumstances? Episodes of high psychosocial stress Periods of dehydration Episodes of physical exertion Administration of a vaccine
episodes of high psychosocial stress
A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? Evidence of hemorrhagic stroke Blood pressure of ≥180/110 mm Hg Evidence of stroke evolution Previous thrombolytic therapy within the past 12 months
evidence of hemorrhagic stroke
A sputum study has been ordered for a client who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample? Immediately after a meal First thing in the morning At bedtime After a period of exercise
first thing in the morning
The nurse is auscultating the breath sounds of a client with pericarditis. What finding is most consistent with this diagnosis? Wheezes Friction rub Fine crackles Coarse crackles
friction rub
The triage nurse in the ED is performing a rapid assessment of a man with reports of severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. When the client collapses, what should the nurse do first? Check for a carotid pulse Apply supplemental oxygen Give two full breaths Gently shake and shout, "Are you OK?"
gently shake and shout "are you ok?"
An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the client is at increased risk for what complication of his injury? Hematoma Skull fracture Embolus Stroke
hematoma
A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the client for which of the following complications of therapy? Immunosuppression Agranulocytosis Anemia Thrombocytopenia
immunosuppresion
A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do? Increase oral fluids unless contraindicated. Call the nurse for oral suctioning, as needed. Lie in a low Fowler or supine position. Increase activity.
increase oral fluids unless contraindicated
The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)? Increased serum sodium Decreased serum potassium Decreased hemoglobin Increased platelets
increased serum sodium
A client's medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect? Drowsiness or lethargy Increased urine output Decreased heart rate Mild agitation
increased urine output
The nurse is caring for a client who is diagnosed with Raynaud phenomenon. The nurse should plan interventions to address what nursing diagnosis? Chronic pain Ineffective tissue perfusion Impaired skin integrity Risk for injury
ineffective tissue perfusion
A postsurgical client has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the client's left leg is visibly swollen and reddened. What is the nurse's most appropriate action? Administer a PRN dose of subcutaneous heparin Inform the health care provider that the client has signs and symptoms of VTE Mobilize the client promptly to dislodge any thrombi in the client's lower leg Massage the client's lower leg to temporarily restore venous return
inform the HCP that the client has S&S of VTE
A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? Hemiplegia Dry mucous membranes Signs of internal bleeding Loss of brain stem reflexes
loss of brain stem reflexes
The nurse is writing a plan of care for a client with a cardiac dysrhythmia. What would be the priority goal for the client? Maintain a resting heart rate below 70 bpm. Maintain adequate control of chest pain. Maintain adequate cardiac output. Maintain normal cardiac structure.
maintain adequate cardiac output
The nurse is caring for an adult client who has gone into ventricular fibrillation. When assisting with defibrillating the client, what must the nurse do? Maintain firm contact between paddles and client skin Apply a layer of water as a conducting agent "all clear" once before discharging the defibrillator Ensure the defibrillator is in the sync mode
maintain firm contact between paddles and client skin
The nurse is caring for a client with a diagnosis of Addison disease. What sign or symptom is most closely associated with this health problem? Truncal obesity Hypertension Muscle weakness Moon face
muscle weakness
A client in hypertensive urgency is admitted to the hospital. The nurse should be aware of what goal of treatment for a client in hypertensive urgency? Normalizing BP within 2 hours Obtaining a BP of less than 110/70 mm Hg within 36 hours Obtaining a BP of less than 120/80 mm Hg within 36 hours ! Normalizing BP within 24 to 48 hours
normalizing BP within 24 to 48 hrs
A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. Post thoracotomy Spontaneous pneumothorax Need for postural drainage Chest trauma resulting in pneumothorax Pleurisy
post thoracotomy spontaneous pneumothorax chest trauma resulting in pneumothorax
A client has been assessed for aldosteronism and has recently begun treatment. What are priority areas for assessment that the nurse should frequently address? Select all that apply. Pupillary response Creatinine and BUN levels Potassium level Peripheral pulses Blood pressure
potassium blood pressure
A cardiac surgery client's new onset of signs and symptoms is suggestive of cardiac tamponade. As a member of the interdisciplinary team, what is the nurse's most appropriate action? Prepare to assist with pericardiocentesis. Reposition the client into a prone position. Administer a dose of metoprolol as prescribed. Administer a bolus of normal saline as prescribed.
prepare to assist with pericardiocentesis
The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids? Presence of a cough and gag reflex Absence of nausea Ability to demonstrate deep inspiration Oxygen saturation of ≥92%
presence of a cough and gag reflex
The nurse is caring for a client who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning, the nurse should anticipate that the weaning of the client will progress in what order? Removal from the ventilator, tube, and then oxygen Removal from oxygen, ventilator, and then tube Removal of the tube, oxygen, and then ventilator Removal from oxygen, tube, and then ventilator
removal from the ventilator, tube, and then oxygen
A client's recently elevated BP has prompted the primary provider to prescribe furosemide. The nurse should closely monitor which of the following? The client's oxygen saturation level The client's red blood cells, hematocrit, and hemoglobin The client's level of consciousness Correct! The client's potassium level
the client's potassium level
A client has undergone diagnostic testing and received a diagnosis of sinus bradycardia attributable to sinus node dysfunction. When planning this client's care, what nursing diagnosis is most appropriate? Acute pain Risk for unilateral neglect Risk for activity intolerance Risk for fluid volume excess
risk for activity intolerance
An older adult client with heart failure is being discharged home on an ACE inhibitor and a loop diuretic. The client's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this client's subsequent care, what nursing diagnosis should be identified? Risk for ineffective tissue perfusion related to dysrhythmia Risk for fluid volume excess related to medication regimen Risk for ineffective breathing pattern related to hypoxia Risk for falls related to hypotension
risk for falls related to hypotension
A client has undergone a successful heart transplant and has been discharged home with a medication regimen that includes cyclosporine and tacrolimus. In light of this client's medication regimen, what nursing diagnosis should be prioritized? Risk for injury Risk for infection Risk for peripheral neurovascular dysfunction Risk for unstable blood glucose
risk for infection
A client suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What will occur during this process? Severed blood vessels constrict. Thromboplastin is released. Prothrombin is converted to thrombin. Fibrin is lysed.
severed blood vessels constrict
The nurse is planning the care of a client with hyperthyroidism. What should the nurse specify in the client's meal plan? A reduced calorie diet, high in nutrients Small, frequent meals, high in protein and calories Three large, bland meals a day A diet high in fiber and plant-sourced fat
small, frequent meals, high in protein and calories
A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? Epidural hemorrhage Hypertensive emergency Spinal shock Hypovolemia
spinal shock
The nurse is caring for a client with a diagnosis of pleurisy. The client begins reporting right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What is the nurse's best action? Teach the client deep-breathing and coughing exercises Contact the respiratory therapist promptly Teach the client to splint their rib cage Teach the client pursed lip breathing
teach the client to splint their rib cage
A 13 year old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. What assessment finding would rule out discharging the client? The client reports a headache. The client reports pain at the site where the ball hits his head. The client is visibly fatigued. The client's speech is slightly slurred.
the client's speech is slightly slurred
The nurse caring for a client with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? Cognition is decreased. Daily arterial blood gases (ABGs) are necessary. Slight tracheal bleeding is anticipated. The cough reflex is depressed.
the cough reflex is depressed
A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? To remove air from the pleural space To drain copious sputum secretions To monitor bleeding around the lungs To assist with mechanical ventilation
to remove air from the pleural space
A 15-year-old child is brought to the emergency department with symptoms of hyperglycemia. Based on the fact that the child's pancreatic beta cells are being destroyed, the client would be diagnosed with what type of diabetes? Type 1 diabetes Type 2 diabetes Non-insulin-dependent diabetes Prediabetes
type I diabetes
A client on corticosteroid therapy needs to be taught that a course of corticosteroids of 2 weeks' duration can suppress the adrenal cortex for how long? Up to 4 weeks Up to 3 months Up to 9 months Up to 1 year
up to 1 year
A nurse is assessing a new client who is diagnosed with PAD. The nurse cannot feel the pulse in the client's left foot. How should the nurse proceed with assessment? Have the primary provider prescribe a CT Apply a tourniquet for 3 to 5 minutes and then reassess Elevate the extremity and attempt to palpate the pulses Use Doppler ultrasound to identify the pulses
use doppler ultrasound to identify the pulses
