404 ATI B

acute toxicity from acetaminophen OD - admin which med? a. flumenazil b. acetylcysteine c. atropine d. vit K

acetylcysteine

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings? Decreased urine specific gravity Decreased Hgb Increased BUN Increased urine ketones

increased BUN

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? A. Large incisions will be made in the eschar to improve circulation B. I can call the doctor back if you want me to C. A piece of skin will be removed and grafted over the burned area D. Dead tissue will be surgically removed

A. Large incisions will be made in the eschar to improve circulation Relief pressure and remove dead skin

A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? A. Systolic blood pressure is increased B. Cardiac output is reduced C. Apical heart rate is increased D. Urine output is reduced

A. SBP increased

A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer? A. Vitamin K B. Heparin C. Warfarin D. Ferrous sulfate

Answer: A—Vitamin K Rationale: A prothrombin time of 30 seconds indicates the clotting time is prolonged and bleeding could occur. Vitamin K injection increases the synthesis of prothrombin by the liver; therefore, the nurse should plan to administer vitamin k.

A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following? a. Prolonged bleeding b. Cellular hypoxia c. Impaired immunity d. Fluid retention Prolonged bleeding (The client's laboratory results indicate anemia. Thrombocytopenia, rather than anemia, places the client at risk for prolonged bleeding.)-Cellular hypoxia (The client's laboratory results indicate anemia, which places the client at risk for cellular hypoxia.) !!!-Impaired immunity (The client's laboratory results indicate anemia. Leukopenia, rather than anemia, places the clients at risk for impaired immunity.)-Fluid retention (Increased serum sodium, rather than anemia, places the client at risk for fluid retention.)

Answer: cellular hypoxia Prolonged bleeding (The client's laboratory results indicate anemia. Thrombocytopenia, rather than anemia, places the client at risk for prolonged bleeding.) Cellular hypoxia (The client's laboratory results indicate anemia, which places the client at risk for cellular hypoxia.) !!! Impaired immunity (The client's laboratory results indicate anemia. Leukopenia, rather than anemia, places the clients at risk for impaired immunity.) Fluid retention (Increased serum sodium, rather than anemia, places the client at risk for fluid retention.)

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest movement inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? a. Atelectasis b. Flail chest c. Hemothorax d. Pneumothorax

B. Flail chest

A nurse is assessing a client who is receiving a continuous IV infusion of dopamine. Which of the following findings should the nurse recognize as a therapeutic effect? A. Increased pulse B. Increased urine output C. Decreased blood pressure D. Decreased dysrhythmias

B. Increased urine output

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. give morphine IV B. administer oxygen therapy C. start an iv infusion of LR D. initiate cardiac monitoring

B. administer oxygen therapy

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider required clarification? A. Morphine sulfate 2mg IV bolus every 2hr PRN pain B. Laboratory testing of serum potassium upon admission C. 0.9% Normal saline IV at 50ml/hr continuous D. Bumetanide 1mg IV bolus every 12 hr

C. 0.9% Normal saline IV at 50ml/hr continuous Rationale: 0.9% sodium chloride is isotonic and will not cause the fluid shift need in this client to reduce circulatory overload. This prescription requires clarification

A nurse is assessing the depth and extent of a client who has sever burns to the face, neck, and upper extremities. Which of the following factors is the first priority when assessing the severity of the burn? A. Age of the client B. Associated medical history C. Location of the burn D. Cause of the burn

C. Location of the burn

5. Anurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? A. Hypertenion B. Flushing of the skin C. Oliguria D. Bradypnea

C. Oliguria Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys. Hypovolemic shock occurs when there is a large amount of blood loss or there is massive vasodilation resulting in decreased perfusion and oxygenation. This client would be hypotensive. Pallor is a sign of hypovolemic shock. The client may also appear cyanotic or mottled. Tachypnea is a sign of hypovolemic shock.

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? a. Dehydration b. Seizures c. Burns d. Shivering

Correct answer: D Dehydration is a complication that may occur as a result of a fever, however it is not considered a complication of the hypothermia blanket therapy. Seizures are a complication associated with meningitis and should be monitored in this client; however, it is not considered a complication of the hypothermia blanket therapy. Burns are associated with the improper use of heating pads, not a hypothermia blanket.The hypothermia blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption

A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors? A. Pale yellow B. Greenish-brown C. Red D. Dark and foamy

D. Dark and foamyDark and foamy urine indicates the kidneys are filtering excess bilirubin from the blood. Pale yellow = healthy and hydrated, greenish-brown = unexpected, red = urinary tract bleeding.

A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk of renal calculi? a. protein in urine b. dehydration c. iron deficiency d. obesity

Dehydration Dehydration can cause hypercalcemia which increases the risk for renal stone formation. Inadequate fluid intake can result in urinary stasis and promote the formation of calculi.

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

Drop in systolic BP more than 10mm Hg on inspiration.

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? Collect a urine specimen for culture and sensitivity. Continue routine care because the results are within the expected reference range. Decrease the IV fluid infusion rate and limit oral fluid intake. Evaluate urine for amount and for specific gravity.

Evaluate urine for amount and for specific gravity.

A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse? A. Bounding pulsations B. Irregular pulsations C. Tachycardia D. Bradycardia

Irregular pulsations PVCs are early ventricular depolarizations with a pause immediately afterwards. That pause in the usual heart rhythm results in an irregular force and rate on palpation of a peripheral pulse and an irregular beat on auscultation of the apical pulse. PVCs have a wide variety of causes. Clients typically perceive them as "palpitations" and can feel lightheaded if they occur frequently.

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury? a. dextrose in 5% water b. dextrose 5% in 0.9% sodium chloride c. 0.9% sodium chloride d. lactated ringers

Lactated ringers

A nurse in an emergency department is caring for a client who has deep-partial and full-thickness burns to his chest, abdomen and upper arms. what is the nurse's priority intervention for this client during the resuscitation of phase of injury?

Maintaining the airway

A nurse is caring for a client following a CT scan with dye who has an anaphylaxis reaction. Which of the following conditions requires a priority nursing response? A. urticaria B. stridor C. tachypnea D. angioedema

Stridor

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? A. Stridor B. Copious oral secretions C. Hoarseness D. Sore throat

Stridor **This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction.

A nurse is caring for a client who has acute respiratory distress syndrome and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes? A. Decrease chest wall compliance B. Suppress resp effort C. Induce sedation D. Decrease resp secretions

Suppress respiratory effort

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? a. Dyspnea b. GI bloating c. Jugular vein distention d. Confusion e. hypotension

a. Dyspnea c. Jugular vein distention d. Confusion Dyspnea is a clinical manifestation of fluid volume overload. Jugular vein distention is a clinical manifestation of fluid volume overload. Confusion is a clinical manifestation of fluid volume overload.

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? a. hyperactive reflexes b. extreme thirst c. Weak, irregular pulse d. hyperactive BS

Weak, irregular pulse

A nurse is reviewing the medical records of 4 patients who have an acid-base imbalance. The nurse should recognize that which of the following patients is at risk for metabolic acidosis? a. A patient who has diarrhea b. A patient who is vomiting c. a patient taking a thiazide diuretic d. a patient who has salicylate intoxication

a patient who has diarrhea

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? a. Evaluate chest expansion b. Check pupillary response to light c. Assess the capillary refill d. Check client's response to questions about place and time

a. Evaluate chest expansion

A nurse in the ER is caring for a client who has extensive partial and thickness burns of the head, neck and chest. While planning the clients care, the nurse should identify the following risks as the priority for an assessment? a. airway obstruction b. infection c. fluid imbalance d. paralytic ileus

a. airway obstruction

a nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving a lidocaine IV at 2 mg/min when the client asks the nurse why he is receiving that medication the nurse should explain that this has which of the following actions? a. prevents dysrhythmias b. slows intestinal motility c. dissolves blood clots d. relieves pain

a. prevents dysrhythmias

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate (Kayexalate). If this medication is effective, the nurse should expect which of the following corrections on the client's ECG? a. reduction of t-wave amplitude b. shortening of p-wave duration c. widening of qrs complex d. restoration of qrs complex amplitude

a. reduction of t-wave amplitude

A nurse in a cardiac unit is caring for a client with acute right-sided heart failure. which of the following findings should the nurse expect? a. decreased BNP b. elevated CVP c. increased PAWP d. decreased specific gravity

b. Elevated CVP CVP is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure. The BNP is a neurohormone that aids in the regulation of fluid balance by detecting increased stretch of the myocardium and triggering diuresis through sodium excretion via the kidneys. The BNP level is elevated in the client who has acute heart failure.Pulmonary pressure increases in left-sided heart failure because of the increased pressure and volume of blood in the left ventricle.Urinary specific gravity is increased in the client who has heart failure as a result of fluid retention by the body.

A nurse is assessing a client who has acute cocaine toxicity. Which of the following findings should the nurse expect? (Select all that apply) a. Reports of tinnitus b. Fever c. Bradycardia d. Tremor e. Agitation

b. Fever d. Tremor e. Agitation

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? a. Initiate a low-reside diet b. Pantoprazole 80mg IV bolus twice daily c. Ambulate twice daily d. Pancrealipase 500units/kg PO three times daily with meals

b. Pantoprazole 80mg IV bolus twice daily

A nurse is caring for a client who has burns to his face, ears and eyelids. the nurse should identify which of the following is the priority finding to report to the provider? a. urinary output 25 mL/hr b. difficulty swallowing c. HR 122 d. pain 6/10

b. difficulty swallowing

A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations? a. Increased urine output b. Increased heart rate c. Fatigue d. Sneezing

c. Fatigue

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? a. Slow b. Not palpable c. Irregular d. Bounding

c. Irregular With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse. Atrial fibrillation is an abnormal cardiac rhythm in which the atria are unable to effectively contract because of multiple rapid stimuli causing the atria to depolarize in an organized manner. The atrial rate can range from 300 to 600 bpm, with the ventricular rate being 120 to 200 bpm.The heart's contraction is not normal in the client who has atrial fibrillation. The atria quiver rather than contract, and the ventricles contract in a rapid, chaotic fashion. The ventricular response provides the client with a palpable pulse, although it may be difficult to count the rate.With atrial fibrillation, the amplitude of the client's pulse is highly variable. There is a decrease in ventricular filling, resulting in varying stroke volumes.

A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching? a. you may donate blood 6 mos after completing med regimen b. consume high-protein diet c. Rest frequently throughout the day d. take acetaminophen every 4 hr as needed for discomfort

c. Rest frequently throughout the day

a nurse is planning care for client who has acute respiratory distress syndrome. which of the following interventions should the nurse include in the plan? a. admin low-flow O2 cont via nasal cannula b. encourage oral intake of at least 3,000 mL of fluids per day c. offer high protein and high carb foods frequently d. place in prone position

d. place in prone position

A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following? a. to convert atrial fibrillation to sinus rhythm b. to dissolve clots in the bloodstream c. to slow the response of the ventricles to the fast atrial impulses d. to reduce the risk of stroke in clients who have atrial fibrillation.

d. to reduce the risk of stroke in clients who have atrial fibrillation.

A client is about to undergo an abdominal paracentesis. In which of the following positions should the nurse place the client? a. prone b. supine c. lateral d. upright

d. upright

A nurse is monitoring a client who took an overdose of acetaminophen 72 hours ago. The nurse should identify which of the following findings as a manifestation of acetaminophen poisoning? a. constipation b. xerostomia c. tinnitus d. vomiting

d. vomiting

a nurse is reviewing laboratory findings for four clients. which of the following clients has manifestation of acute kidney injury? a. bun 15 b. serum creatinine 6mg/dl c. hgb 16 d. serum K 4.5

serum creat 6

A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? slurred speech bone pain bradypnea pruritus hypotension

slurred speech bone pain pruritus you would expect tachypnea and hypertension