Unit 4/3/2 Exam
#50e1 timed out
"""
The nurse is caring for a client who had a resection of the abdominal aorta following a MVC yesterday. The client has an intravenous infusion at a rate of 150 mL/hr, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28mL (28mL is most recent). The client's blood urea nitrogen level is 35 mg/dL (12.6mmol/L). and the serum creatinine level is 1.8 mg/dL (159 mcmol/L) measured this morning. Which nursing action is the priority?
-Call the primary health care provider (PHCP)
23. The nurse assesses a patient who presents with symptoms of hyperparathyroidism Which questions does the nurse ask the patient during the assessment? SATA
-Have you lost or gain any weight recently
A client who is receiving heparin for a history of blood clots has developed heparin-induced thrombocytopenia. His platelet count is 90,000/mcL. Which of the following nursing intervention is most appropriate in this situation?
-Hold the heparin dose and contact the physician
38. Which intervention does the nurse include in the initial plan of care for a patient being evaluated for a possible adrenal crisis?
-IV of 5% dextrose in normal saline (D5NS) to correct the fluid volume
31. The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include BP 110/70, HR 110, RR 30, SpO2 95on supplemental oxygen at 3L, and a T 103.5, What is the priority nursing action?
-Implement seizure precautions
A nurse is caring for a patient with blunt chest trauma after a motor vehicle accident. The patient starts to complain of pain from the chest to the shoulder and a sense of impeding doom. Upon assessing the patient, the nurse notes that the patient has diminished breath sounds on the left side, jugular vein distention, and tracheal deviation to the right. The nurse anticipates which intervention?
-Insertion of a chest tube
12. A nurse is caring for a patient with a closed head injury and increasing ICP. Which of the following manifestations does the nurse report to the health care provider that represents Cushing's triad? SATA
-Irregular respirations -Increasing systolic BP -Bradycardia
The nurse is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, what is the most important nursing intervention?
-Maintain cervical spine precautions
17. A 65 year old male is admitted to the ICU with syndrome of inappropriate antidiuretic hormone as a result of a brain tumor in his frontal lobe. Serum sodium is 115 mEq/L What is the priority of nursing care for the patient?
-Maintaining a safe environment
The nurse is providing care for a newly admitted client diagnosed with hepatic failure. Which interventions should the nurse perform while providing care for the client? SATA
-Monitor BUN, LFTs, PT/PTT levels -Give stool softeners -Take glucometer readings every 2-4 hours -Measure the abdominal girth
A client sustained an injury to the right arm after falling off a motorcycle and is complaining of severe pain and unable to feel the fingers of the right hand. Radial pulse is absent. Identify the nursing priority.
-Notify the physician
The nurse is assessing a patient with a new arteriovenous fistula but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should
-Notify the provider immediately
An elderly male patient in the ICU is diagnosed with acute kidney injury. This patient demonstrates a decreased glomerular filtration rate and lowered urine sodium concentration, as well as increased BUN and serum creatinine levels. The nurse observes that the patient takes several minutes to empty his bladder when he uses the bathroom. His blood pressure and blood glucose levels are normal. What should the nurse suspect as the cause of this patients acute kidney injury?
-Obstruction of the flow of urine due to benign prostatic hypertrophy
A nurse is caring for a client that delivered a fetal demise 3 hours ago is bleeding heavily. The providers believe she has disseminated intravascular coagulation and has ordered labs to be drawn. What results would the nurse expect to see if DIC is occurring? SATA
-PTT 56 seconds -PT 19 seconds -Platelets 50,000
A patient has been admitted with a flail chest. What findings would the nurse expect to observe supporting this diagnosis?
-Paradoxical respiratory movement
A patient has sustained a burn related to spilling a cup of hot liquid onto the right hand. Symptoms include skin that is bright red and mottled at the affected area with a wet and weeping appearance and diffuse blister formation. The burned area is excruciatingly painful and sensitive to air current. What is the appropriate classification of this burn?
-Partial thickness burns
Which symptom would the nurse assess for during a follow-up visit for a patient with a history of traumatic brain injury (TBI) 4 weeks ago? SATA
-Persistent headache -Memory impairment -Nausea -Attention deficits -Dizziness
Nurses in Tennessee, Mississippi, and Arkansas gather for a conference related to improving quality and safety in practice and nursing education. They are awarded continuing education (CE) credit for participation and evaluation of the conference. One nurse from CA states, "I need these CEs to renew my license." The nurse from Mississippi replies, "You do not need CEs for license renewal or advance practice certification renewal." Which statement about CEs would help these nurses?
-The purpose of continuing education is to ensure competence of the workforce after graduation, but each state determines if CEs are required
You are providing education to a patient with CKD about calcium acetate. Which statement by the patient demonstrates they understood your teaching about this medication? SATA
-This medication will help prevent my phosphate level from increasing -I will take this medication with meals or immediately after.
A patient who has undergone stem cell transplantation develops graft-versus host disease (GVHD) and is prescribed cyclosporine. The nurse teaches the patient that this drug is given for what purpose?
-To inhibit immune activity of donor T-cells
The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?
-Train-of-four yields two twitches
The nurse is assessing a client who is admitted with a wound caused by gunshot trauma. What information will help the nurse predict the amount of damage?
-Type of weapon and caliber of bullet
A patient with Stage 5 CKD is experiencing extreme pruritus and has several areas of crystallized white deposits on the skin. As the nurse, you know this is due to excessive amounts of what substance found in the blood?
-Urea
An elderly client is admitted to the critical care unit with a fractured pelvis after falling at home. It is not known how long the client laid on the floor before being discovered. The client is disoriented, complaining of pain and moaning; pulse is 100 and weak; respiratory rate is 24 and shallow; and pain presents on palpation of the abdomen. Which assessment is a priority?
-Urinalysis
A patient requires pancuronium as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes: SATA
-administration of sedatives concurrently with neuromuscular blockade -ensuring that DVT prophylaxis is initiated -providing interventions for eye care, oral care, and skin care
The nurse is caring for a patient who has a Sengstaken-Blakemore tube in place. In caring for this patient, the nurse must:
-deflate the esophageal balloon before the gastric balloon.
The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should
-evaluate the patient's serum creatinine for up to 72 hours after the procedure
Nursing priorities for the management of acute pancreatitis include: SATA
-managing respiratory dysfunction -utilizing supportive therapies aimed at decreasing gastrin release -assessing and maintaining electrolyte balance
Which action would the nurse take to manage acute pain for a patient with a major burn injury? SATA
-monitor pain scale for improvement in pain control -utilize guided imagery as an adjunct to drug therapy -provide analgesic medication before dressing changes -allow the patient control over their pain treatment options
The patient is in the critical care unit and will receive dialysis this morning. The nurse will? SATA
-weight the patient to monitor fluid status -evaluate morning laboratory results and report abnormal results -assess the dialysis access site and report abnormalities
Use the START method to triage the wounded in the following disaster situation: While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned?
-Black
Which nursing interventions are required for hepatitis A?
-Gown and gloves when handling articles contaminated by urine or feces
Continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that
-The process removes solutes and water slowly.
The nurse is caring for a patient with acute pancreatitis. To provide adequate pain control, the nurse should:
-administers pain medication on a routine schedule
A patient with a large painless lymph node has a biopsy that reveals Reed-Sternberg cells. Which form of cancer does this finding indicate?
-Hodgkin's lymphoma
Which action would the nurse take for a patient with multiple myeloma? SATA-Implement infection control measures
-Implement infection control measures -Initiate thrombosis precautions - Implement mobility safeguards
A patient who sustained blunt chest injury is admitted to your unit. The patient develops dyspnea and confusion and confusion and has distant heart tones. Two hours post admission the BP has changed from 140/78 to 92/78. The patient now has visible jugular venous distention. The most likely cause is:
-Cardiac tamponade
The primary survey of a trauma victim in the emergency department reveals the client is awake and tachypneic, is using accessory muscles of respiration, has unequal chest expansion, and is very anxious. There are absent breath sounds on the right and cyanosis on 100% oxygen, and the trachea is deviated to the left. Identify the nursing priority.
-Chest tube insertion
A patient has vague symptoms that indicate an inflammatory bowel disorder. Which symptom is most indicative of Crohn's disease (CD)?
-Chronic diarrhea, abdominal pain, and fever
Which medication is used as an alternative to heparin during continuous renal replacement therapy in patients who are at risk for bleed?
-Citrate
The nurse provides care of a patient with carbon monoxide poisoning. The nurse expects what assessment findings? SATA
-Confusion -Dyspnea
A client with chronic kidney disease (CKD) presents with severe anemia. The nurse administers a dose of epoetin alfa (Procrit) during hemodialysis procedure. Which finding indicates the medication is effective?
-Increase in hemoglobin and hematocrit
A high school football player arrives to the emergency department with full back support and cervical spine support after colliding with another player during a game. The nurse learns the client was flipped into the air and landed on his head. The nurse recognizes the client may have which type of injury related to this incident?
-Crushing
The nurse is reviewing the laboratory results for a patient with acute pancreatitis. Which findings does the nurse expect to find in the report? SATA
-Decrease in albumin level -Increase in serum glucose level -Increase in blood urea nitrogen (BUN)
The patient is admitted for GI bleeding, but the source is unknown. Before ordering endoscopy, the provider orders octreotide to be given intravenously. The purpose of this medication is to:
-Decrease splanchnic blood flow and portal pressure
Which finding would the nurse anticipate for a patient with liver failure experiencing abdominal compartment syndrome?
-Decreased urine output
The nurse is seeking a leadership style that will empower staff to achieve excellence. Which leadership style should the nurse select to achieve this goal?
-Democratic
The nurse is assessing a client diagnosed with hepatitis B. Which assessment questions concerning the past medical history should the nurse ask?
-Do you have a history of sexually transmitted viral infections?
Which statements concerning licensure as a registered nurse are correct? SATA
-Each nurse practice act describes requirements for initial licensure -Candidates for licensure must present proof of graduation as required by the state
A client has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. What intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?
-Early enteral feeding
When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? SATA
-Severity of blood loss -Hemodynamic stability -Necessity for fluid resuscitation
The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan?
-Elevate and immobilize the grafted extremity
In a patient with a head trauma, Battle sign is indicative of which type of injury?
-Skull fracture
A patient is admitted with acute abdominal trauma. The patient has a positive Focused Assessment with Sonography for Trauma (FAST scan) and is hemodynamically unstable. What procedures should the nurse anticipate next?
-Emergency surgery
Which condition would the nurse evaluate for in a patient with a pelvic-fracture who has a low-grade fever, tachycardia, dyspnea, tachypnea, and a petechial rash?
-Fat embolism
Which sign of heparin-induced thrombocytopenia would the nurse monitor for in a patient taking anticoagulants? SATA
-Fever/chills -Decreasing platelet count -Skin lesions at injection site
Which intervention does the nurse add to the plan of care for a patient who was admitted to the critical care unit with acute kidney injury secondary to hemorrhage after a surgical procedure?
-Frequently assess heart rate, breath sounds, and neck veins
A 33-year-old female, who just delivered twins, is transferred to the ICU with hemorrhagic shock and has received 10 units of packed red blood cells via massive transfusion. You should anticipate which of the following interventions next?
-Fresh frozen plasma and platelet infusions
A patient has an emergency escharotomy performed on the right leg. The patient has full-thickness circumferential burns on the leg. Which finding below demonstrates the procedure was successful?
The right foot's capillary refill is less than 2 seconds
A patient is presenting with bright red lips, headache, and nausea. The physician suspects carbon monoxide poisoning. The nurse knows the patient needs:
-100% oxygen via non-rebreather mask
Which score on the Critical Care Pain Observation Tool (CPOT) indicates that a patient needs to receive pain medication?
-8
A patient sustains partial thickness burns to the lower half of the left arm and the lower half of the right arm. Using the rules of nines, determine the percentage of total body surface area (TBSA) that is burned. Record the answer as a whole number in the box provider.
-9
Which assessment finding indicates peritonitis and would be monitored for in a patient undergoing peritoneal dialysis?
-Abdominal pain
A client is admitted to the intensive care unit with hepatic encephalopathy secondary to cirrhosis. The client is lethargic and confused. The healthcare provider prescribes lactulose. Which find indicates a positive response to the medication?
-An increase in alertness and orientation
Following a terrorist attack the people injured in the bomb blast have inhaled anthrax-causing biologic agents. Which treatment strategy would provide effective management of the condition?
-Antibiotics
The nurse places a large-bore nasogastric tube in a client who has acute upper gastrointestinal bleeding. What is the rationale for this intervention? SATA
-Aspiration of gastric contents -Decompression -Lavage of gastric contents
During the postoperative period after surgery for a kidney transplant, the client's creatinine level is 3.1 mg/dL. What should the nurse do first in response to this laboratory result?
-Assess for decreased urine output
Which action would the nurse take to prevent hypothermia in a patient with a major burn injury? SATA
-Assess temperature every 1-2 hours -Use an IV fluid warmer for IV infusions -Minimize skin exposure -Keep the room temperature elevated
A patient involved in a serious hit and run car accident does not want to tell family members about being intoxicated at the time of the accident. Which response would the nurse provide when addressing the patient's concern?
- "Your information will remain confidential; it is up to you to share what you want."
The nurse is caring for a patient with severe pancreatitis and who is orally intubated and on mechanical ventilation. The patient's calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and:
- Places the patient on seizure precautions.
The patient has just returned from having an arteriovenous fistula placed. The patient asks, "when will they be able to use this and take this other catheter out?" The nurse should reply
- The fistula will be usable in about 4 to 6 weeks
The patient is getting neomycin for treatment of hepatic encephalopathy. While the patient is receiving this medication, it is especially important that the nurse:
- evaluate renal function studies daily
The patient is on intake and output as well as daily weights. The nurse notes that output is considerably less than intake over the last shift and daily weight is 1 kg more than yesterday. The nurse should:
-Assess the patient's lungs
What duties are assumed by a state's board of nursing? SATA
-Assures qualified members are appointed to the board -Assigns disciplinary action when the nurse acts in a manner that results in harm to a patient -Grants nursing licensure
A client with lymphoma is preparing to undergo a bone marrow transplant. The client will be using bone marrow taken from their own body. Which type of transplant is this referred to?
-Autologous
Which clinical findings in a patient indicate ulcerative colitis?
-Presence of blood and mucus in the stool
What is the primary purpose of licensure for professional registered nurses?
-Protecting the public from physical and emotional harm
A 54-year-old woman was admitted with deep vein thrombosis and pulmonary emboli. She received a heparin bolus and a continuous heparin infusion. The next day, heparin-induced thrombocytopenia (HIT) was suspected, and the heparin infusion was discontinued. Which of the following assessment findings would be most indicative of HIT?
- petechiae, a platelet count of 50,000
The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient's care to prevent stress ulcers, the nurse would provide: SATA
- proton pump inhibitors -antacids -anticholinergic drugs
Which signs and symptoms indicate rejection of a transplanted kidney? SATA
-+3 edema of the lower extremities -Blood pressure of 164/98 mm Hg -Crackles in the lung fields
A client has been brought into the emergency department via ambulance with resuscitation efforts being performed. It is unlikely that the client will survive the severe injuries sustained. Two adult children of the client are present and are requesting to be with the client at this time. What is the best response by the nurse?
- "You may come in with your parent and I will have someone stay with you to explain what is happening."
Which type of continuous renal replacement therapy would be used for a patient who only needs the removal of excess fluid caused by fluid volume overload?
-Slow continuous ultrafiltration (SCUF)
47. The nurse is planning care for a client with hyperparathyroidism and subsequent hypocalcemia and low bone density. Which information would the nurse provide the UAP to prevent injury?
-Use a lift sheet for transfers
The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? SATA
-Malnutrition -Ascites -Disseminated intravascular coagulation
A nurse and a nursing student are discussing management of the trauma patient. The nurse asks the student what the AVPU method is used for during the primary survey. Which response would indicate for new graduate nurse understood the information?
-Used to assess level of consciousness
15. In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an IV solution that contains dextrose started?
-When the blood sugar reaches 250 mg/dL
37. Which medication is associated with the development of hypothyroidism?
-Metformin
27. A patient diagnosed with syndrome of inappropriate antidiuretic hormone has a serum sodium level of 130 mEq/L and complains of a severe backache. What are the most appropriate nursing intervention? SATA
-Restricting fluid intake to 900 mL/day -Positioning the head of the bed flat -Assessing the patient's weight
You are assessing a patient who was involved in a motor vehicle accident. You notice bruising around her umbilicus. Which of the following clinical manifestations would be consistent with an injury to the liver?
-Right upper quadrant pain, hypotension, hematuria
2. Which of the following interventions would a nurse consider to be inappropriate for a patient with increased ICP?
-administering 5% dextrose/water at 83 mL/hr
An elderly client in the ICU is receiving morphine sulfate 25mg/hr via continuous infusion after undergoing a left hip arthroplasty. On routine assessment, the nurse notes the following: RR 8 breaths/min, BP 110/68, HR 79, otic temp 98.8, SpO2 90%, lethargy; cap refill of 4 sec in both hands and right toes and 6 seconds in the left toes. Identify the nursing priority"
-Administer naloxone
The nurse is admitting a client who has been exposed to the botulism toxin during a terrorist attack. What should the nurse include in the client's immediate interdisciplinary care? SATA
-Administration of antitoxin -Respiratory support
A patient with Hepatitis is extremely confused. The patient is diagnosed with Hepatic Encephalopathy. What lab results would correlate with this mental status change?
-Ammonia 100 mcg/dL
21. A patient taking Tapazole reports feeling dizzing, intolerant to cold, and tired. On assessment, you note the patient's HR 45, BP 70/30 What is the most likely cause
-Antithyroid toxicity
A patient is scheduled to undergo kidney transplant surgery. Which teaching point would the nurse include preoperatively?
-It will be essential for you to wash your hands and avoid people who are ill
Which of the following signs would the patient report as left shoulder pain that is indicative of ruptured spleen?
-Kehr's sign
28. A client with diabetic ketoacidosis is admitted to the intensive care unit and is manifesting respirations that are rapid and deep. Which descriptive term should the nurse use to document the client's breathing pattern?
-Kussmaul's respirations
The nurse is assessing a client after suffering blunt trauma to the abdomen and notes ecchymosis, diffuse pain, and guarding and rigidity to palpation. The nurse suspects which structure is damaged?
-Liver
8. A 23 year old woman was admitted to the emergency department with status epilepticus. Which of the following drugs would most likely be prescribed initially to stop the seizures?
-Lorazepam
9. A 23-year-old man has sustained a head injury. He is in the neurosurgical intensive care unit after being resuscitated in the emergency department. His current Glasgow Coma Scale score is 5. Vital signs are BP 120/64, P 92, RR 28. He is on a ventilator with assist-control mode, tidal volume 700mL, rate 18 breaths/min, and FiO2 0.45. An intraventricular catheter has been inserted, and his intracranial pressure is 40 mm Hg to maintain adequate cerebral perfusion pressure in this patient, the mean arterial pressure must be at least:
-100 mm Hg
22. The patient has been prescribed Lugol's solution. The nurse knows that Lugol's solution helps block _____ of thyroid hormones in thyroid storm and that _____ is a common side effect of this medication.
-1release/synthesis 2taste changes
7. The nurse is caring for a patient with a severe head injury. The patient's Glasgow Coma Scale assessment is as follows: Eye opening: opens eye to pain Verbal response: garbled sounds Motor response: What is this patient's GCS score?
-7
An adult patient weighing 60 kg has sustained a major burn injury to 50% of the total body surface area. Which action would the nurse perform first when following the Parkland fluid resuscitation formula during the first 24 hours?
-Administer LR solution at a rate of 750 mL/hr during the first 8 hours
A patient has been taking benzodiazepines and suddenly develops respiratory depression and hypotension. After careful assessment, the nurse determines that the patient is experiencing benzodiazepine overdose. What is the nurse's next action?
-Administer flumazenil (Romazicon)
19. Which of the following are appropriate nursing interventions for the patient in myxedema coma? SATA
-Administer levothyroxine as prescribed -Initiate passive rewarming interventions -Monitor airway and respiratory effort
40. Mr. M is a 32 year old man brought to the ED by paramedics after a fall from the second story roof of his home. He was placed on a spinal board with a cervical collar to immobilize his spine. After spinal X-rays are obtained, the health care provider determines that he has a spinal cord injury at the C4 to C5 level.The assistive personnel reports that Mr. M's BP is 178/98, HR 50; he is sweating around his face, neck, and shoulders; and he reports a severe headache. What does the nurse suspect when assessing this patient?
-Autonomic dysreflexia
46. A client reports neck stiffness, severe headache, and a decreased level of consciousness. Which condition would the nurse suspect?
-Bacterial meningitis
44. You receive a patient in the ER who has sustained a cervical spinal cord injury. You know this patient is at risk for neurogenic shock. What hallmark signs and symptoms, if experienced by this patient, would indicate the patient is experiencing neurogenic shock? SATA
-Blood pressure of 69/38 -Heart rate of 29 -Temperature of 95 F -Warm and dry extremities
18. A patient is recovering from a thyroidectomy. The patient starts to complain of tingling and numbness in the face, toes, and fingers. Which of the following findings below warrants attention?
-Calcium level 6 mg/dL
1. Which of the following is most important when caring for a patient with meningitis?
-Closely monitor for increased ICP
4. A patient has a craniotomy 2 days ago for removal of a tumor. He is awake and talking to the nurse and demonstrates no neurologic deficit. BP is 110/80, P 92, RR 22, Urine outputs have been 60 ml/hr over the last 2 days, but he has had a recent change. He has had 300-400ml/hr of urine output over the last several hours. The urine has a specific gravity of 1.002. The nurse checks his serum glucose and finds that it is 100mg/dL. The nurse should suspect:
-Diabetes Insipidus
45. Which nursing intervention will be priority when caring for a client with status epilepticus?
-Establish an airway
36. Which action does the nurse take before initiating prescribed insulin therapy to a patient in diabetic ketoacidosis? SATA
-Evaluated the potassium level -Initiate fluid therapy
26. A patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical management of this condition will include:
-Fluid restriction
20. A patient is admitted with thyroid storm. Which signs and symptoms are NOT present with this condition? SATA
-Intolerance to cold -HR of 20 bpm
14. The nurse receives a patient from the ER following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: BP 100/60, P 52, RR 24, SpO2 97 on supplemental oxygen at 45% via Venturi mask, GCS score 4, and ICP of 18. Which provider prescription should the nurse institute first?
-Mannitol 1g intravenous
41. Ms. H is admitted to the acute medical surgical unit for a workup for Cushing's diseaseWhich vital sign value reported to the RN by the UAP is of most concern for a patient with Cushing's disease (hypercortisolism)?
-Oral temperature of 101.8 F (38.8C)
43. The LPN/LVN is assigned to provide care for a patient with a pheochromocytoma. Which physical assessment technique would the RN instruct the LPN/LVN to AVOID?
-Palpating the abdomen in all four quadrants
5. Which laboratory values would differentiate diabetic ketoacidosis from a hyperosmolar hyperglycemic state?
-Positive serum ketones
13. A patient with suspected neurogenic shock after a diving accident has arrived in the ER. A cervical collar is in place. Which actions should the nurse take? SATA
-Prepare to administer atropine IV -Obtain baseline body temperature -Provide high-flow O2 (100%) by nonrebreather mask -Prepare for emergent intubation and mechanical ventilation
30. The nurse is assessing a client who is 12 hours postoperative for the removal of a benign pituitary brain tumor and has been placed in a drug induced coma with normal saline 0.9% infusing a 125 mL/hr. The client's HR 90, BP 100/60, and the indwelling urinary catheter has drained 150 mL of pale-yellow urine in the last 30 min into the collection bag. After reporting these findings to the healthcare provider, which action should the nurse implement?
-Prepare to administer desmopressin (DDAVP)
49. Which hourly assessment would the nurse include in the plan of care for a patient with increased intracrainial pressure (ICP)? SATA
-Pupils -Focal motor -Glasgow Coma Scale
10. A 30 year old woman with type one diabetes mellitus is admitted with complaints of nausea vomiting and diarrhea she has not been eating and she has not taken her insulin for two days she has been taking glargine 45 units daily and aspart with meals (5 units breakfast, 8 units lunch, and 10 units dinner) Her BP is 92/54, P 112, RR 40, T 99.2 Laboratory results include serum glucose of 420, pH 7.1, potassium 4.5, and serum osmolality 320. She is not responding to voice but she does respond to pain. Her mucous membranes are dry and urine output is scant and concentrated. What is the priority of care for this patient at this time?
-Replacement of fluid and electrolytes
35. The nurse receives a report for a patient with syndrome of inappropriate antidiuretic hormone secretion who experiences a seizure 8 hours ago. At the time, the patient's serum sodium was noted to be 108 mEq/L, and a prescription for IV 3% sodium chloride was initiated. During the initial shift assessment, which finding would concern the nurse?
-Serum sodium level 125 mEq/L
32. While doing a neurologic assessment of a patient who sustained a thrombotic stroke, the nurse records the score of a patient as 40 on a National Institutes of Health Stroke Scale What does this score indicate?
-Severe stroke
6. A 25 year old woman is admitted with diabetic ketoacidosis The following laboratory values were reported from blood taken at admission: She has received regular insulin bolus, and an infusion has been initiated. Two liters of normal saline has been administered. The last serum glucose is 215 mg/dL, and the pH is 7.32. Which of the following therapies would be appropriate? SATA
-Slowing the insulin infusion -Changing the intravenous solution to include dextrose -Adding potassium to the intravenous solution
39. Mr. M is a 32 year old man brought to the ED by paramedics after a fall from the second story roof of his home. He was placed on a spinal board with a cervical collar to immobilize his spine. After spinal X-rays are obtained, the health care provider determines that he has a spinal cord injury at the C4 to C5 level. The ED nurse assist the ED HCP in testing the patient's deep tendon reflexes which are all absent. What does the nurse suspect is the likely cause of the absent DTR?
-Spinal shock
33. As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? SATA
-Symptom onset greater than 3 hours prior to admission -Recent intracranial pathology -Current anticoagulation therapy
48. Which hormone level does the nurse expect to be normal within 24 to 48 hours after administering IV levothyroxine sodium to a patient with myxedema coma?
-T4
34. The nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider?
-The client will require full assistance for all aspects of elimination
24. A physician orders Calcium Gluconate IV as treatment for a patient with hypoparathyroidism. The patient's calcium level is 5 mg/dL. Which of the following findings cause you to question this order?
-The patient is taking Digoxin
25. A patient is recovering from a parathyroidectomy. Which of the following finds cause concern and requires nursing intervention?
-The patient's voice is hoarse
42. Ms. H is admitted to the acute medical surgical unit for a workup for Cushing's diseaseThe RN is supervising a nursing student who will assess Ms. H which findings will the RN teach the nursing student to expect in a patient with Cushing's disease? SATA
-Truncal obesity -Moon face
16. The nurse is assigned to care for a patient who presented to the ER with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered. The targeted blood glucose value after the first hour of therapy is:
-a decrease of 35-90 mg/dL compared with admitting values *this was the highly disputed question where everyone put "a decrease of 50-75 mg/dL"
29. Assessment findings the nurse should anticipate for a patient who is in myxedema coma include:
-lethargy, edema, swollen tongue, abdominal distension
3. A 78-year-old man is admitted to the critical care unit with left-sided hemiplegia and a dilated right pupil. He cannot remember falling and has no signs of physical trauma. His family tells you that he is an alcoholic but that he has been "acting differently" for approximately 1 month. This patient's injury is located in the:
-right cerebral hemisphere
11. Which manifestation would the nurse anticipate finding in a patient diagnosed with adrenal insufficiency? SATA
Hyperpigmentation-Hyperkalemia -Vitiligo
Which observation would indicate that a patient has an obstructed airway?
-Stridor
What statement presents accurate information concerning nurse practice acts?
-They are written and passed by state legislators
The nurse is caring for a patient with peptic ulcer disease (PUD). What signs and symptoms in the patient suggest a surgical emergency? SATA
-Tender, rigid, board-like abdomen -Assuming the knee-chest position -Sudden, sharp pain in the mid-epigastrium
A patient has been admitted with muscle trauma and crush injuries. The nurse understands that this patient is at high risk for the development of acute kidney injury secondary to rhabdomyolysis. Which findings would suggest the patient is developing this complication? SATA
-Increase serum creatine kinase level -Decreased urine output -Dark tea-color urine
The healthcare provider prescribed propofol IV and succinylcholine IV for a client who is being prepared for intubation. Which action should the nurse implement to assist the healthcare provider during administration of these two drugs?
-Prepare propofol for sedation before giving succinylcholine, a paralytic
The nurse is caring for a patient who is a recent recipient of a kidney transplant. Which interventions should the nurse perform in the immediate postoperative period? SATA
-Record central venous pressure. -Monitor the patient for hyponatremia and hypokalemia. -Notify the health care provider of a sudden decrease in urine output.
Use the START method to triage the wounded in the following disaster situation: The wounded victim is unable to walk, has respiratory rate of 40, capillary refill is 6 seconds, and can't follow simple commands. The wounded victim is assigned what tag color?
-Red
A patient presents in the emergency department (ED) with burns on the hands and face after handling hydrochloric acid at work. What actions should the nurse perform as part of the patient's burn management? SATA
-Remove all chemical particles on skin -Flush affected area with lots of water -Remove all clothing containing the chemical
A patient with multisystem trauma has been in the ICU for 6 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The patient's vital signs include: BP 92/66 mmHg; HR 118 beats/min; T 38.7 C; and CVP 5 mmHg. What is most likely cause of this hemodynamic picture?
-Septic shock
A nurse has an order to administer heparin to a client. Which steps would the nurse take to minimize the risk of the client developing heparin-induced thrombocytopenia (HIT)? SATA
-Avoid using heparin coated catheters -Note if the client has a history of HIT in his chart -Monitor the client's platelet count -Assess the client's extremities
A nurse is hired to replace a staff member who has resigned. After working on the unit for several weeks, the nurse notices that the unit manager does not intervene when there is conflict between team members, even when it escalates. Which of the following conflict resolution strategies is the unit manager demonstrating?
-Avoidance
