Synthesis Final
- A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the nurse is aware that the functions of the three lumens include: A - Continuous inflow and outflow of irrigation solution. B - Intermittent inflow and continuous outflow of irrigation solution. C - Continuous inflow and intermittent outflow of irrigation solution. D - Intermittent flow of irrigation solution and prevention of hemorrhage.
A
A client with gastroesophageal reflux disease (GERD) is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend? A - Apple B - Orange C - Tomato D - Grapefruit
A
A patient has small cell cancer of the lung. Which of the following findings requires immediate intervention by the nurse? A - Serum sodium of 118 meq/L B - Serum potassium of 5.1 meg/L C - Hematocrit of 45% D - BUN 10 mg/dl
A
A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98 F (36 C), heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects which type of shock? a.) Hypovolemic b.) Cardiogenic c.) Neurogenic d.) Obstructive
A
The nurse is caring for a patient with difficulty breathing. Upon review of the patient's ABG, which results are consistent with Acute Respiratory Failure? Select all that apply. a.PaO2 - 65 mmHg b.SaO2 - 79% c.CO2 - 60 mmHg d.pH - 7.5
A,B,C
The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. A - coffee B - chocolate C - peppermint D - nonfat milk E - fried chicken F - scrambled eggs
A,B,C,E
The nurse would recognize which clinical manifestation as suggestive of sepsis? A. Sudden diuresis unrelated to drug therapy B. Hyperglycemia in the absence of diabetes C. Respiratory rate of seven breaths per minute D. Bradycardia with sudden increase in blood pressure
B
Three days after surgery for cancer of the colon, a nurse introduces the client to colostomy care. Which should the nurse teach the client about skin care around the stoma? A - Apply liberal amounts of Vaseline for 3 inches (7.6 centimeters) around the stoma B - Wash the area with soap and water and then apply a protective ointment C - Pour saline over the stoma and rub the area to remove hard fecal matter D - Rinse the area with peroxide before applying fresh gauze bandages
B
A client is receiving streptomycin in the treatment regimen of TB. The nurse should assess for: A - Decreased serum Creatinine B - Difficulty swallowing C - Hearing loss D - IV Infiltration
C
Which teaching point does the nurse include for a client with pad? •A - "Elevate your legs above your heart to prevent swelling." •B - "Inspect your legs daily for brownish discoloration around the ankles." •C - Walk to the point of leg pain, then rest, resuming when pain stops." •D - "Apply a heating pad to the legs if they feel cold."
C
- A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? A - Urinary output B - Sensation to touch C - Neurologic status D - Respiratory exchange
D
After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? uA) The patient coughs up small amounts of green mucus. uB) Increased tactile fremitus is palpable over the right chest. uC) Bronchial breath sounds are heard at the right base. uD) The patient's white blood cell (WBC) count is 9000/µl.
D
A client is receiving digoxin (Lanoxin) daily. The nurse suspects digoxin toxicity after collecting data noting which signs and symptoms? Select all that apply a.Visual disturbances b.Nausea and vomiting c.Serum digoxin level of 2.3 ng/mL d.Serum potassium level of 3.9 mEq/L e.Apical pulse rate of 63 beats per minute
a,b,c
Your patient has returned from a peripheral artery bypass for the treatment of peripheral arterial disease. The nurse will make it PRIORITY to? A - Assess the surgical site for excessive drainage B - Assess and grade lower extremity pulses bilaterally C - Apply compression stockings D - Elevate the lower extremity above heart level
b
A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider? •a. Hematocrit 46% •b. Hemoglobin 14.1 g/dL (141 mmol/L) •c. Potassium 3.0 mEq/L (3.0 mmol/L) •d. White blood cell 9200/mm3 (9.2 × 109/L)
c
The physician's order says to administered Lasix 40 mg IV twice a day. The patient has the following morning labs: Na+ 148, BNP 900, K+ 2.0, and BUN 10. Which of the following is a nursing priority? •A. Administer the Lasix as ordered •B. Notify the physician of the BNP level •C. Assess the patient for edema •D. Hold the dose and notify the physician about the potassium level
d
What nursing intervention is anticipated for a client with Guillain-Barré syndrome? 1Providing a straw to stimulate the facial muscles 2Maintaining ventilator settings to support respiration 3Encouraging aerobic exercises to avoid muscle atrophy 4Administering antibiotic medication to prevent pneumonia
2. Maintaining ventilator settings to support respiration Guillain-Barré syndrome is a progressive paralysis beginning with the lower extremities and moving upward; mechanical ventilation may be required when respiratory muscles are affected. The use of a straw would not be an effective stimulant for the facial muscles; oral intake may be contraindicated, depending on the extent of the paralysis, because of the risk for aspiration. With progressive paralysis, the client will not be able to perform aerobic exercises. Antibiotics are not given prophylactically; antibiotics will not help if pneumonia is caused by etiologies that are not bacterial.
Captopril, furosemide, and metoprolol are prescribed for a client with systolic hear failure. The clients BP is 136/82 and the HR is 65 bpm. Prior to medication administration at 0900, the nurse reviews the following lab tests: NA 140 K 6.8 BUN 18 Creat 1.0 Hgb 12 Hct 37% What should the nurse do first? 1. Administer the medications 2. Call the HCP 3. Withhold the captopril 4. Question the metoprolol dose
3 (The nurse should withhold the dose of captopril; captopril is an ACE inhibitor, and a side effect of the medication is hyperkalemia. The BUN and creatinine which are normal, should be viewed prior to administration since renal insufficiency is another potential side effect of an ACE-1. The HR is within normal limits. The nurse should question the dose of metoprolol if the clients HR is bradycardic. The hbg and hct are normal for a female. The nurse should report the high K level and that the captopril was withheld.)
A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? 1Urinary output 2Sensation to touch 3Neurologic status 4Respiratory exchange
4. Respiratory exchange The respiratory center in the medulla oblongata can be affected with acute Guillain-Barré syndrome because the ascending paralysis can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurologic status are important, none of them are the priority.
- A client is undergoing fluid replacement after being burned 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats per minute, and a urine output of 25 ml over the past hour. The nurse reports the findings to the physician and anticipates which of the following orders? A - Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour B - Transfusing 1 unit of packed red blood cells. C - Administering diuretic to increase urine output. D - Changing the IV lactated Ringer's solution into dextrose in water
A
- The nurse is monitoring a client during IV nitroglycerin infusion. Which assessment finding will cause the nurse to take action? A - Blood pressure 110/90 mm Hg B - Flushing C - Headache D - Chest pain
A
A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? A.Assessment of vital signs B.Completion of abdominal examination C.Insertion of the prescribed nasogastric tube D.Thorough investigation of precipitating events
A
A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation? A - Physical therapy B - Speech exercises C - Fitting with a vertebral brace D - Follow-up on cataract progression
A
The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessment? A. Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C. Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick secretions
A
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended, and bowel sounds are diminished. Which is the most appropriate nursing intervention? A - Notify the health care provider (HCP). B - Administer the prescribed pain medication. C - Call and ask the operating room team to perform the surgery as soon as possible. D - Reposition the client and apply a heating pad on the warm setting to the client's abdomen.
A
The nurse is obtaining a health history for a client admitted to the hospital with a tentative diagnosis of Guillain- Barre syndrome. Which health history question will best elicit information that supports the diagnosis? A - "Have you experienced an infection lately?" B - "Is there a history of this disorder in your family?" C - "Did you receive a head injury in the past year?" D - "What medications have you taken in the last 3 months?"
A
The nurse monitors for which acid-base disorder that can likely occur in a client with an ileostomy? A - Metabolic acidosis B - Metabolic alkalosis C - Respiratory acidosis D - Respiratory alkalosis
A
Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the appropriate action for the nurse to take? A - Hold the feeding B - Reinstill the amount and continue with administering the feeding (>100 hold, don't reinstill) C - Elevate the client's head at least 45 degrees and administer the feeding D - Discard the residual amount and proceed with administering the feeding
A Unless specifically indicated, residual amounts more than 100 mL require holding the feeding. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics.
During the admission assessment of a client with a small-bowel obstruction, the nurse anticipates which clinical manifestations? Select all that apply. A - Abdominal distention B - Absolute constipation C - Colicky abdominal pain D - Frequent vomiting E - Pain during defecation
A, C, D
- The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. •A - Fever •B - Positive Cullen's sign •C - Complaints of indigestion •D - Palpable mass in the left upper quadrant •E - Pain in the upper right quadrant after a fatty meal • F - Vague lower right quadrant abdominal discomfort
A, C, E
A patient with neurogenic shock has just arrived in the emergency department after adiving accident. He has a cervical collar in place. Which of the following actions shouldthe nurse take (select all that apply)? a. Prepare to administer atropine IV b. Obtain baseline body temperature. c. Prepare for intubation and mechanical ventilation. d. Administer large volumes of lactated Ringer's solution. e. Administer high-flow oxygen (100%) by non-rebreather mask.
A,B,CE
A 70-year-old client is admitted to the hospital with a lower gastrointestinal bleed. After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode. The client is now pale and diaphoretic and reports dizziness. Which action should the nurse perform first? A - Check the vital signs B - Draw hemoglobin and hematocrit C - Lower the head of the bed D - Maintain an IV line with normal saline
A/C
Twenty-four hours after having had surgery a client reports pain in the calf. What should the nurse do when the assessment reveals redness and swelling at the site of discomfort? A - Keep both legs dependent. B - Notify the health care provider. C - Apply a warm soak to the left calf. D - Administer the prescribed analgesic
B
The nurse is caring a client diagnosed with renal calculi is scheduled for lithotripsy. Which post- procedure nursing task would be most appropriate to delegate to the unlicensed nursing assistant (UAP)? A - Monitor the amount, color, and consistency of urine output .B - Teach the client about care of the indwelling Foley catheter. C - Assist the client to the car when being discharged home. D - Take the client's post-procedural vital signs.
C
With which client should the nurse remain alert for the possibility of sepsis and septic shock? A - 41-year-old man who sustained closed depression fractures on the face when hit with a baseball. B - 53-year-old woman who had an open abdominal hysterectomy 3 days ago to remove several large fibroid tumors. C - 67-year-old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago. D - 72-year-old man with severe allergies who is undergoing radiation therapy for early-stage prostate cancer.
C
The nurse receives an obese client in the PACU who underwent a procedure under general anesthesia and notes an O2 sats of 88%. Which is the most appropriate initial intervention? A - Assess pupillary response. B - Auscultate lung sounds. C - Inform anesthesia professional D - Perform head tilt and chin lift
D hence, open occluded airwayhypoxia in obese postop in general anesthesia is due to airway obstruction
A client is experiencing kidney failure. Which is the most serious complication for which the nurse must monitor a client with kidney failure? •A. Anemia •B. Weight loss •C. Uremic frost •D. Hyperkalemia
D Decreased glomerular filtration leads to hyperkalemia, which may cause lethal dysrhythmias such as cardiac arrest. Anemia may occur but is not the most serious complication and should be treated in relation to the client's clinical manifestation; erythropoietin and iron supplements usually are used. Weight loss alone is not life threatening. Uremic frost, a layer of urea crystals on the skin, causes itching but it is not the most serious complication.
Which of the following patients are MOST at risk for developing heart failure? Select-all-that-apply: a.A 69-year-old male with a history of alcohol abuse and is recovering from a myocardial infarction. b.A 55-year-old female with a health history of asthma and hypoparathyroidism c. A 30-year-old male with a history of endocarditis and has severe mitral stenosis. d. A 45-year-old female with lung cancer stage 2. e.A 58-year-old female with uncontrolled hypertension and is being treated for influenza
a,c,e
A client with chest pain is prescribed intravenous nitroglycerin. Which finding is of greatest concern for the nurse initiating the nitroglycerin drip? • a.Serum potassium is 3.5 mEq/L (3.5 mmol/L) b.Blood pressure is 88/46 mmHg c.ST elevation is present on the electrocardiogram d.Heart rate is 61 bpm
b
A nurse is reviewing her shift assignment. Which child should she assess first? A - A 5-month-old infant with I.V. fluids infusing B - An 11-month-old infant receiving chemotherapy through a central venous catheter C - An 8-year-old child in traction with a femur fracture D - A 14-year-old child who is postoperative and has a nasogastric tube and an indwelling urinary catheter
b
There are five clients in the emergency unit. Which client conditions require immediate treatment? Select all that apply a.Skin rash b.Unstable vital signs c.Severe abdominal pain d.Chest pain with diaphoresis e.Multiple complex soft tissue injuries
b,c,d
Patients with rupturing AAA are at risk for hypovolemic shock. Select all that apply the signs and symptoms that may be present in the case of hypovolemic shock. A - Hypertension B - Diaphoresis C - Decreased LOC D - Polyuria e - Loss of pulse distal to rupture
b,c,e
An 18-year-old patient is admitted with appendicitis. Which statement by the patient requires immediate nursing intervention? •A. "The pain hurts so much it is making me nauseous." •B. "I have no appetite." •C. "The pain seems to be gone now." •D. "If I position myself on my right side, it makes the pain less intense."
c
The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take if there is no fluctuation (tidaling) in the water-seal compartment? uA. Obtain an order for a stat chest x-ray. uB. Increase the amount of wall suction. uC. Check the tubing for kinks or clots. uD. Monitor the client's pulse oximeter reading.
c
- A client in shock develops a central venous pressure (CVP) of 2 mm Hg. Which prescribed intervention should the nurse implement first? a.Increase the rate of O2 flow b.Obtain arterial blood gas result c.Insert an indwelling urinary catheter d.Increase the rate of intravenous (IV) fluids
d
A client recently diagnosed with heart failure is being discharged on Lisinopril. Which client teaching related to the new medication is important to review? A - instruct client to report for monthly blood work to monitor drug levels. B - review foods high in potassium that client should include in diet. C - teach client to count own pulse for one minute, hold medication if pulse below 60 bpm D - teach client to rise slowly and sit on side of bed for several minutes before rising
d
The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? a.Exhales slowly b.Stay very still c.Inhale and exhale quickly d.Perform the Valsalva maneuver
d
The nurse is caring for an infant with bronchiolitis in the hospital pediatric unit. During breastfeeding, the nurse observes the infant's oxygen saturation decreasing from 95% to 92%. Which intervention should the nurse implement first? A - Stop the feeding and replace the infant in the crib. B - Slightly increase oxygen flow through the nasal cannula and observe the infant's response. C - Initiate NPO measures and notify the infant's healthcare provider. D - Request that the provider prescribe nasogastric gavage feedings for the infant.
B
- What observation should the nurse instruct the client with an ileostomy to report immediately? A - Passage of liquid stool from the stoma B - Occasional presence of undigested food in the effluent C - Absence of drainage from the ileostomy for 6 or more hours D - Temp of 99.8
C
. Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a client with TB. A nurse reviews the medical record of the client. Which of the following, if noted in the client's history, would require physician notification? A. Heart disease B. Allergy to penicillin C. Hepatitis B D. Rheumatic fever
C
A client is admitted with a marginal placenta previa. Which item should the nurse have readily available? A - One unit of freeze-dried plasma B - Vitamin K for intramuscular injection C - Two units of typed and screened blood D - Heparin sodium for intravenous injection
C
A patient who has pericarditis related to radiation therapy, becomes dyspneic, and has a rapid, weak pulse. Heart sounds are muffled, and a 12 mmHg drop in blood pressure is noted on inspiration. The healthcare provider's interventions are aimed at preventing which type of shock? a.) Distributive b.) Neurogenic c.) Obstructive d.) Cardiogenic
C
The client is diagnosed with a uric acid stone. Which foods should the client eliminate from the diet to help prevent re-occurrence? A - Beer and colas B - Asparagus and cabbage. C - Venison and sardines. D - Cheese and eggs.
C
The client is on CPAP for weaning from a mechanical ventilator. Assessment reveals a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles. What should the nurse anticipate will occur? A. The FiO2 will be increased. B. Weaning will continue. C. The client will be placed back on full ventilator support. D. The client will be extubated.
C
- The nurse caring for a child who is awake and alert in the post anesthesia care unit (PACU) immediately after a tonsillectomy should implement which interventions? Select all that apply A - Observe for continuous swallowing B - Administer prescribed oral pain medications C - Offer ice pops D - Encourage throat clearing and coughing
A,B,C
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? •a. Administer lidocaine, 75 mg intravenous push. •b. Perform synchronized cardioversion. •c. Defibrillate the client as soon as possible. •d. Administer atropine, 0.4 mg intravenous push.
B
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. Which assessment finding indicates to the nurse that the client is experiencing magnesium toxicity? A - Proteinuria of +3 B - Sudden drop in FHR C - Presence of DTR D - Serum magnesium level of 2.5 mEq/L
B
Before surgery to remove an ectopic pregnancy and the fallopian tube, which signs or symptoms would alert the nurse to the possibility of tubal rupture? A - Amount of vaginal bleeding and discharge B - Profuse sweating C - Slow, bounding pulse rate of 80 bpm D - Marked abdominal edema
B
The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client? a) Cool moist skin b) Bradycardia c) Wheezing d) Decreased Bowel sounds
B
The client is scheduled to have an abdominal CT scan with IV contrast. Before the procedure, the nurse should assess the patient for: A - peptic ulcer disease B - Shellfish allergies C - Reactions to blood products D - Egg allergies
B
The nurse is assessing a 7 -day- old infant at home. The infant is breastfeeding, and the mother is concerned about whether the baby is receiving breastmilk during the feedings. Which question is most important for the nurse to ask the mother, when assessing the infant's breastmilk intake? A - "Is the baby sleeping through the night?" B - "Do you hear swallowing noises while the baby is nursing?" C - "How many minutes is the baby suckling on your nipple?" D - "Are you eating a balanced, high protein diet each day?"
B
The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage? A - Infant birth weight of 9lb 2oz b - Labor and birth without pain medication c - Labor that lasted 8 hours d - Third stage of labor lasting 20 minutes
A
The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? Select All that apply a.Diarrhea b.Bradycardia c.Rebound tenderness d.Diminished bowel sounds e.Rigid, board-like abdomen
C,D,E
A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? A. Acute pain B. Impaired tissue integrity C. Decreased cardiac output D. Ineffective tissue perfusion
D
A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond a. "You may have difficulty believing this, but the paralysis caused by this disease is temporary." b. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." c. "It must be hard to accept the permanency of your paralysis." d. "You'll first regain use of your legs and then your arms."
a
8 - A client is admitted to the hospital with severe flank pain, nausea, and hematuria caused by a ureteral calculus. What should be the nurse's initial intervention? A - Strain all urine output B - Increase oral fluid intake C - Obtain urine specimen for culture D - Administer prescribed analgesic
B
The healthcare provider is caring for a patient who has a pneumothorax. When assessing the patient and the chest tube drainage system, a large fibrin clot is noted in the tubing. Which additional assessment finding requires immediate action by the healthcare provider? A - Fluctuations in the water seal chamber B - A downward trend in blood pressure C - Increasing pain at the insertion site D - Decreased water in the suction control chamber
B
The healthcare provider is conducting teaching during a health fair about the causes of pneumonia. The healthcare provider demonstrates understanding of the causes when she states that community acquired pneumonia (CAP) can be caused by all of the following except: A - Mycoplasma B - Human papillomavirus C - Influenza D - Streptococcus pneumonia
B
The nurse conducts a program about strategies for preventing community-acquired pneumonia at a center for senior citizens. Which statement made by a participant indicates the need for further instruction? A - "I got the flu vaccine, and it can help to prevent pneumonia." B - "I got the one-time pneumonia shot, so I won't need it again." C - "I stopped smoking a year ago, so that should help me a lot." D - "I try to avoid going to the mall during the winter months."
B
The nurse received report on the following children on the inpatient pediatric unit. Which child should the nurse assess first? A - 8 year old who just returned from the post-anesthesia recovery unit, spitting up small amounts of brown-flecked saliva B - 3 year old with newly diagnosed asthma, with diminished right lower lobe breath sounds C - 6 month old with isotonic dehydration, full fontanel, and no skin tenting D - 14 year old with periorbital cellulitis, no discomfort and oral temperature of 99.9°F
B
Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock? A - Serum sodium of 130 mEq/L (130 mmol/L) B - Metabolic acidosis validated by arterial blood gases C - Serum lactate of 3 mmol/L D - SvO2 greater than 80%
B
Which measure is likely to provide the most relief from the pain associated with renal calculi? A - Applying moist heat to the flank area B - Administering morphine C - Encouraging high fluid intake D - Maintaining complete bed rest
B
Which of the following nursing interventions is of the highest priority in helping a patient expectorate thick secretions related to pneumonia? A.Humidify the oxygen as able B.Increase fluid intake to 3L/day if tolerated. C.Administer cough suppressant q4hr. D.Teach patient to splint the affected area.
B
The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? A - Check the client for peripheral edema and make sure the client takes a diuretic early in the day. B - Monitor the client's potassium level and assess the client's intake of bananas and orange juice. C - Determine if the client has gained weight and instruct the client to keep the legs elevated. D - Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.
B Rationale: The most probable cause of the leg cramping is potassium excretion as a result of the diuretic medication. Bananas and orange juice are foods that are high in potassium.
Which information about a patient who is receiving vasopressin (Pitressin) to treat septicshock is most important for the nurse to communicate to the heath care provider? a. The patient's heart rate is 108 beats/min. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak .d. The patient's urine output is 15 mL/hr.
B Vasopressin- a vasoconstrictor->can cause chest pain
A nurse is caring for a client with a ureteral calculus. Which are the most important nursing actions? Select all that apply. A - Limiting fluid intake at night B - Monitoring intake and output C - Straining urine at each voiding D - Recording the client's blood pressure E - Administering the prescribed analgesics
B, C,E
A primary healthcare provider diagnoses a client with acute cholecystitis with biliary colic. Which clinical findings should the nurse expect when performing a health history and physical assessment? Select all that apply. •a. Diarrhea with black feces •b. Intolerance to foods high in fat •c. Vomiting of coffee-ground emesis •d. Gnawing pain when stomach is empty •e. Pain that radiates to the right shoulder
B, E
A patient with a fever is lethargic and has a blood pressure of 89/56. The patient's white blood cell count is elevated. The physician suspects the patient is developing septic shock. What other findings indicate this patient is in the "early" or "compensated" stage of septic shock? Select all that apply: A. Urinary output of 60 mL over 4 hours B. Warm and flushed skin C. Tachycardia D. Bradypnea
B,C In the early or compensated stage of septic shock, the patient is in a hyperdynamic state. This is different from the other types of shock like hypovolemic or cardiogenic (vasoconstriction is occurring in these types of shock). In septic shock, vasodilation is occurring and this leads to WARM and FLUSHED skin in the early stage. However, in the late stage the skin will be cool and clammy. Tachycardia and TACHYpnea (not bradypnea) occurs in the early stage too as a compensatory mechanism. Oliguria (option A) is in the late stage or uncompensated when the kidneys are starting to fail.
- What will the nurse identify as symptoms of hypovolemic shock in a patient? Select All That Apply A - Temperature of 97.6°F (36.4°C) b - Restlessness c - Decrease in blood pressure of 20 mm Hg when the patient sits up d - Capillary refill time greater than 3 seconds e - Sinus bradycardia of 55 beats per minute
B,C,D
-20 - The nurse assessing a child admitted to the pediatric floor for dehydration observes that the child has varicella lesions. Which nursing intervention has the highest priority? A - Apply the prescribed calamine lotion topically to the lesions. B - Order a soft diet for the next meal. C - Implement airborne precautions. D - Collect additional health history data.
C
The nurse is assessing 4 clients in the emergency department. Which client should the nurse prioritize for care? A - Client with liver cirrhosis and ascites who has increasing abdominal distension and needs therapeutic paracentesis B - Client with new-onset ascites for a suspected ovarian mass who needs paracentesis for diagnostic studies C - Client with ulcerative colitis who has a fever, bloody diarrhea, and abdominal distension and needs an abdominal x-ray D - Nursing home client with dementia who has stool impaction and abdominal distension and needs stool disimpaction
C
The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestation would support the diagnosis of bacterial meningitis? A - Positive Babinski's sign and peripheral paresthesia B - Negative Chvostek's sign and facial tingling C - Positive Kernig's sign and nuchal rigidity D - Negative Trousseau's sign and nystagmus
C
The nurse is caring for a hospitalized child with leukemia, experiencing bone marrow depression from chemotherapy. The nurse should contact the health care provider to question which prescribed medication? A - Amoxicillin, clavulanic acid (Augmentin) B - Epoetin intravenous (Epogen) C - Measles, Mumps, Rubella vaccine (MMR) D - Odansetron (Zofran)
C
The nurse observes the cardiac rhythm for a client who is being admitted with a myocardial infarction. What should the nurse do first?- V-TACH A - Prepare for immediate cardioversion B - Begin cardiopulmonary resuscitation (CPR) C - Check for a pulse D - Prepare for immediate defibrillation
C
Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup
C
You're caring for a patient who is experiencing shock. Which lab result below demonstrates that the patient's cells are using anaerobic metabolism? A. Ammonia 18 µ/dL B. Potassium 4.5 mEq/L C. Serum Lactate 9 mmol/L D. Bicarbonate 23 mEq/L
C
The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. a. Excessive bubbling in the water seal chamber B. Vigorous bubbling in the suction control chamber c. Drainage system maintained below the client's chest d. 50 mL of drainage in the drainage collection chamber e. Occlusive dressing in place over the chest tube insertion site F . Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
C,D,E,F
A client in shock develops a central venous pressure (CVP) of 2 mm Hg. Which prescribed intervention should the nurse implement first? A - Increase the rate of O2 flow B - Obtain ABG results C - Insert an indwelling urinary catheter D - Increase the rate of intravenous fluids
D
The nurse should include which of the following instructions when developing a teaching plan for clients receiving INH and rifampin for treatment for TB? A. Take the medication with antacids B. Double the dosage if a drug dose is forgotten C. Increase intake of dairy products D. Limit alcohol intake
D
Within minutes of giving birth to a healthy infant, the client displays symptoms of respiratory distress. An amniotic fluid embolism is suspected. In addition to respiratory distress, for what other complication should the nurse assess the client? A - Hypertension B - Uterine atony C - Thrombophlebitis D - Uncontrolled bleeding
D
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? A - "My ankles are swollen." B - "I am tired at the end of the day." C - "When I eat a large meal, I feel bloated." D - "I have trouble breathing when I walk rapidly."
D Rationale: Dyspnea on exertion often occurs with left ventricular heart failure because the heart is unable to pump enough oxygenated blood to meet the energy requirements for muscle contractions related to the activity. The statement "My ankles are swollen" is more likely with right ventricular heart failure. The statement "I am tired at the end of the day" is not specific to left ventricular heart failure. The statement "When I eat a large meal, I feel bloated" is not specific to left ventricular heart failure.
A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and reports itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which interventions are a priority? Select all that apply. a.Stop the infusion. b.Raise the head of the bed. c.Administer protamine sulfate. d.Administer diphenhydramine. e.Call for the Rapid Response Team (RRT).
a,d,e
The nurse caring for a client after a bowel resection notes that the client is restless. The nurse takes the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped significantly since the previous readings. The nurse suspects that the client is going into shock and should take which immediate action? A - Check the client's oxygen saturation level. B - Recheck the vital signs to verify the findings. C - Raise the client's legs above the level of the heart. D - Slow the rate of the intravenous (IV) fluid infusing.
a.d In addition to hypotension, manifestations of shock include tachycardia; restlessness and apprehension; and cold, moist, pale, or cyanotic skin. If a client develops signs of shock the nurse should immediately raise the client's legs above the level of the heart to improve venous return and immediately notify the surgeon. The nurse should also check the client's pulse oximetry reading, plan to administer oxygen, increase the rate of IV fluids (unless contraindicated), administer medications as prescribed, and continue to monitor the client and the client's response to interventions.
An older adult with peripheral vascular disease has stopped smoking, and the client's children want to make the home environment safe. What should the home healthcare nurse emphasize when providing instructions? A - Observe for evidence of blurred vision B - Use measures that can prevent thermal injuries C - Reduce fluid intake to prevent peripheral edema D - Limit activities to reduce the workload on the heart
b
The nurse has provided instructions to a client receiving enalapril maleate for hypertension. Which statement by the client indicates a need for further instruction? A - "I need to rise slowly from a lying to a sitting position." B - "I need to notify the primary health care provider if fatigue occurs." C - "I need to notify the primary health care provider if a sore throat occurs." D - "I know that several weeks of therapy may be required for the full therapeutic effect."
b
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water seal chest tube drainage system. The nurse notes that the fluid in the water seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? ua. an obstruction is present in the chest tube ub. the client is developing subcutaneous emphysema uc. the chest tube system is functioning properly ud. there is a leak in the chest tube system
c
The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? ·A. Place the patient in supine position and clamp the tubing. ·B. Notify the physician immediately. ·C. Disconnect the drainage system and get a new one. ·D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
d
- The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which snack is most appropriate? A - A gelatin dessert B - Yogurt C - An orange D - Peanuts
A
A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first? A - Begin intravenous fluids B - Check the pulses with a Doppler device C - Obtain a complete blood count (CBC) D - Obtain a electrocardiogram (ECG)
A
A nurse is caring for a client with a temperature of 100.4° F, crackles at the right lung base, pain with deep inspiration, and dyspnea. Which of the following orders is the nurse's priority? A.Sputum specimen for culture and sensitivity B.Codeine 15 mg orally every 6 hours as needed C. Incentive spirometer every 2 hours while awake D.Amoxicillin (Amoxil) 500 mg orally 4 times a day
A
A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is due to: A - Reduced cardiac output B - Increased stroke volume C - Reduced blood volume D - Blood flow blocked in the pulmonary circulation
A
The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse knows that which observation of the client's clinical condition is most favorable? A - Urine out put of 40 ml/hr B - HR of 110 beats/minute C - Frequent PVCs D - CVP = 15
A
- The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock? SATA A - Hypotension B.Bradycardia c - Warm dry skin d - Abdominal cramps e - Palpitations
A,B,C Neurogenic is a distributive type of shock Rationale 1: Hypotension is a manifestation of neurogenic shock because of the loss of autonomic reflexes. Rationale 2: Bradycardia occurs because of the loss of sympathetic innervation. Rationale 3: Warm dry skin occurs because of a loss of cutaneous control of sweat glands.
You are assessing your patient load for the patients who are at MOST risk for seizures. Select all the patients below that are at risk: A. A 32-year-old with a blood glucose of 20 mg/dL. B. A 63-year-old whose CT scan shows an ischemic stroke. C. A 72-year-old who is post opt day 5 from open heart surgery. D. A 16-year-old with bacterial meningitis. E. A 58-year-old experiencing ETOH withdrawal.
A,B,D,E
A nurse is reviewing a care plan for an adolescent girl who's receiving chemotherapy for leukemia who was admitted for pneumonia. The adolescent's platelet count is 50,000 μl. Which item in the care plan should the nurse revise? (Sata) A - Keep a sign over the bed that reads "NO NEEDLE STICKS AND NOTHING PER RECTUM." B - Use two peripheral I.V. intermittent infusion devices, one for blood draws and one for infusions. C - Administer oxygen at a rate of 4 L/minute using a nonhumidified nasal cannula. D - Use a tympanic membrane sensor to measure her temperature at the bedside.
A,C
The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. a.Activities should be resumed gradually b.Avoid contact with other individuals, except family members, for at least 6 months c.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated d.Respiratory isolation is not necessary because family members already have been exposed e.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags f.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment
A,C,D,E
When creating a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply A.Suction the oral cavity whenever needed. B.Change the ventilator circuit tubing every 2 hours. C.Maintain the client in a supine position at all times. D.Practice frequent oral hygiene, including teeth brushing. E.Wear gloves when suctioning or handling the endotracheal tube.
A,D,E
