Adult Health Final!

After receiving a change of shift report, which should the nurse assess first?

A 7--year-old who recently started levothyroxine (Synthroid) to treat hypothyroidism and has an irregular pulse of 134

A client is admitted after MVA the HCP diagnosis is pelvic fractures, bilateral femur fractures, the BP is falling from 120/76 to 60/40, with increased HR

Hypovolemic shock

ECG indicating ischemia

ST segment depression

A nurse is caring for a client after a craniotomy for a pituitary tumor and has developed DI. The client is receiving vasopressors (Pitressin). The desired response of the the medication is what?

Urine output to decrease

Which information should the nurse include in the teaching plan of female with bilateral adrenalectomy?

The client will need to take steroid replacement the rest of her life

A PT who has cardiac surgery has a urine output of 20 mL/hr for 2 hours. They receive a single bolus of 500 mL IV. The urine output over the next hour was 25 mL. Daily lab results indicate that the BUN is 45 and serum creatinine is 2.2. Based on these findings, the nurse will anticipate that the client is at risk for developing which?

acute kidney injury

PT with thorax aneurysm. Which intervention should nurse include in plan of care

administration of antihypertensive meds

A client with a family history of cancer asked what the single most important risk factor for cancer. What risk factor should the nurse discuss?

age

18 year old involved in MVA with pneumothorax. Chest tube with constant bubbling in water sealed chamber most likely a result of?

air leak

A client is beginning external beam therapy to the right axilla after a lumpectomy after breast cancer. Which of the following should the nurse include in client teaching?

apply deodorant only under the left arm

PT develops following rhythm (V tach). Which intervention should nurse do first

assess PT for pulse

After cardiac cath, PT has a lot of blood under butt. nurse should

assess the site

PT with pulmonary embolus. Which assessment data requires immediate intervention?

client O2 is 90%

PT with ARDS in prone position for 30 mins. Which of the following will require discontinue of position?

client is tachycardic with drop in BP

What action should nurse do first with asystole?

confirm in another lead

Which outcome is a priority for the client with addison's disease?

continue therapy

1st degree heart block on ECG strip

continue to monitor

During hemodialysis the PT becomes lightheaded and nauseous. What should the nurse do first?

decrease the rate of fluid removal and infuse NS

Low pressure alarm sounds on vent. Cause for alarm may be?

displaced tube

client with pneumothorax has chest tube. Gentle bubbling in suction control chamber. Which action is appropriate?

do nothing, expected in chamber

High pressure alarm goes off. Which action should the nurse take?

empty excess accumulated water in tube

A PT with hyperparathyroidism has a serum phosphorous level of 1.7 and calcium of 14. Which nursing action should be included in the plan of care?

encourage 3000-4000 mL of oral fluids daily

a client with advanced small lung cell cancer presents with complaining of SOB and weakness, a serum sodium of 116 is reported by the lab. The nurse can anticipate which order from the physician?

fluid restriction and 3% saline

A nurse is providing care to a client with left radial arterial line, which assessment data obtained by the nurse indicates a need for the nurse to take action?

hands are cool to touch

The nurse is caring for a client with partial and full thickness burns to 65% of the body. When planning additional interventions, what choices should the nurse implement?

high calorie and high protein

Pulmonary embolus, when suction nurse should do what?

hyperoxygenate before and after suctioning

Which signs and symptoms would make the nurse suspect that the client is experiencing a thyroid storm?

hyperpyrexia and extreme tachycardia

The nurse is reviewing past medical history of a PT diagnosed with chronic renal failure. Which part of PT's medical history most likely contributed to the PT getting chronic renal failure?

hypertension

Another PT with inhalation injury comes to the ER on initial assessment they are very confused. The nurse determines that the PT is most likely experiencing?

hypoxia

Pacemaker malfunction- failure to capture

inability to produce contraction

A client receiving chemotherapy for breast cancer develops myelosuppression. The nurse should include all of the following in the PT's discharge planning except

increase in fresh vegetables

This person has fluid replacement LR's at 375 mL/hr. They were burned 10 hours ago, their temperature is 99.0, HR 122, BP 84/42, CBB 2, and urine output of 25 mL from the last 2 hours. Using the SBAR the nurse calls the HCP with which recommendation?

increase the IV rate

Caring for a client immediately after insertion of permanent pacemaker via right subclavian vein

limiting movement/abduction in Right arm

Performing assessment of Pt with Left HF, which component will elicit specific information related to CHF?

listening to lung sounds

The nurse is teaching a client to perform peritoneal dialysis, the nurse reviews which essential action that will help prevent further complications?

maintain strict aseptic technique

The ambulance reports that you are transporting a PT to the ER is experiencing full thickness burns from a grill. What manifestations should the nurse expect?

no pain, waxy white skin, and no blanching with pressure

A PT is scheduled to undergo hemodialysis. What is the highest priority action the nurse should plan prior to the start of dialysis?

obtain their weight

The nurse receives one at the ER with extensive electrical burns. The nurse understands that this type of burn illustrates what priority?

place the pt on a cardiac monitor

PT with increased capillary permeability. Which finding does nurse anticipate in PT?

pulmonary edema

The nurse is preparing for a burn client for a escharotomy procedure being performed for a 3rd degree circumferential burn. The nurse understands that which finding is the anticipated therapy outcome?

relief of pressure

Bedridden PT with sacral edema. What contributes to the edema

right sided heart failure

To provide oral hygiene for a client with recovering transsphenoidal hypophysectomy the nurse should instruct the client to

rinse the mouth with NS

Pt is experiencing acute pulmonary- how should nurse position PT for max ventilation

sitting straight up

Nurse is suctioning client via intratracheal tube. HR is increasing. Which nursing intervention is appropriate?

stop procedure and reoxygenate PT

PT immediately after removal of ET, which symptom is reported immediately?

stridor

Following surgery a radical neck dissection for laryngeal cancer, the priority of the nursing care is?

suction the laryngeal tube as much as needed

client with acute respiratory failure. considered for weaning. high pressure alarm keeps going off. vent inoperable alarm sounds. nurse should do what

take off and ventilate them manually

A PT undergoing chemotherapy has a WBC of 2,300, a hemoglobin of 9.8, platelets of 80,000, and potassium of 3.8. What finding should take priority?

temp of 101

A client is receiving high dose chemotherapy for a large rapidly dividing tumor. What is the person developing?

tumor lysis syndrome

The nurse is providing care to a PT that had bilateral adrenalectomy. Which assessment information requires the most rapid action by the nurse?

BP is 88/50

A female client who has undergone replacement radiation therapy asks if she can with her husband to the lounge at the end of the hall. Which response is the most appropriate?

Because of the treatment you are receiving you need to remain in your room

Permanent demand ventricular pacemaker, proper pacemaker function by looking at ECG, looking for pacemaker spikes where?

Prior to QRS wave

A nurse caring for a client admitted with a diagnosis of hyperthyroidism, the client report a weight loss of 12 pounds in the past 2 months despite increased appetite. The additional symptoms include increased perceptions, menstrual irregularities, and restlessness. Which of the following measures should the nurse include in the plan of care to prevent a thyroid crisis?

Provide a quiet low stimulus environment

Nurse in telemetry observes this rhythm- P wave normal, PR lengthen progressively, until no QRS

Wenckebach, 2nd degree type 1 heart block

post op for CABG, monitor for what common complication?

atrial dysrhythmias

Which meal would indicate the PT understands recommended diet with CAD

baked fish, steamed broccoli, garden salad

What is the primary nursing intervention indicated for a symptomatic PT with a wedge pressure of 3?

begin volume replacement

Pulmonary artery catheter has been inserted. What is the nurses primary intervention for using the device

call for chest x ray

Cardioversion ECG picture, ECG indicates what

cardioversion was successful

PT complains of sudden dizziness, ECG reveals the following (tachycardia). The nurse understands that the dizziness is a results of

decreased CO

Nurse assessing client on vent with ET. Which data confirms tube has migrated too far into trachea?

decreased breath sounds over left side of chest

ABG's of someone that has renal failure, the nurse should expect what result?

pH 7.30, PaCO2 35, HCO3 18

Which of the fluids should you give for...

lactated ringer's

A client has treatment for lymphoma complains of headaches, vomiting fatigue, and constipation, serum electrolyte testing reveals calcium of 14. The appropriate treatment is?

normal saline

Aortic aneurysm repair with graft placement 30 mins ago. Posterior tibial pulse not palpable. Nurse priority action is

notify surgeon

Aortic aneurysm repair with graft placement 30 minutes ago. Posterior tibial pulse not palpable. Nurse priority action

notify surgeon

The client is diagnosed with Addison's disease is admitted to the ED after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should be the emergency room nurse's firs action?

Start an IV with an 18 gauge needle to infuse NS rapidly

The nurse is caring for a client immediately after renal transplant, IV fluids are administered as prescribed. The nurse recognizes that the hourly calculi glomerulus of what?

The number of mL in the previous hour's urine output

The physician orders a patient with septic shock receive an IV bolus. How will the nurse know if the treatment was successful?

The patient's BP changed from 70/48 to 110/82

A client newly diagnosed with chronic kidney disease has recently begun hemodialysis knowing that the client is at risk for disequilibrium syndrome. The nurse should assess the client for which associated manifestations?

decreased LOC

During the initial chemo client with leukemia develops hyperkalemia and hyperuricemia. The nurse recognizes that these symptoms are an oncological emergency and anticipates which priority treatment?

increase urine output with hydration therapy

A client with a diagnosis of MI is admitted to the ICU and a pulmonary artery catheter is inserted, therapy is administered to maintain the pulmonary wedge pressure at 16-20 to optimize stroke volume. The pulmonary wedge pressure increases to 24. What does the nurse consider as the most likely reason for this change?

increased intravascular volume

The client with chronic renal failure tells the nurse that he takes magnesium hydroxide for constipation. The nurse suggests the client switch to Psyllium Metamucil because?

it can cause magnesium toxicity

Which info collected by nurse suggest pain is caused by MI

occurs longer than 30 minutes

The nurse is admitting a client with chronic kidney disease to the unit that has a potassium level of 6. The nurse should plan for which action as a priority?

put them on a cardiac monitor

The nurse receives report on assigned clients. One client is reported to be at nadir for his cancer chemotherapy. How will this affect the nursing care plan?

reinforce precautions for decreasing infections

To obtain an accurate CVP reading what position should the patient be in

supine

This person had an MI and they developed cardiogenic shock despite treatment in the ER. Which client response are related to neurogenic shock

tachycardia, increased CBC, decreased CO

The nurse is administering IV fluids prescribed to someone who sustained superficial partial thickness burns along the back and legs. In evaluating the adequacy of fluid resuscitation the nurse should understand that which assessment finding would provide the most reliable indicator for determining the action of fluid replacement?

urine output

PT with complaints of chest pain, SOB, hypotension. Connected to monitor, nurse observes this rhythm (SVT). what is the appropriate intervention for this rhythm?

Adenosine

Nurse is assessing PT given opiod analgesic. Which ABG value indicates PT is at risk for respiratory failure?

CO2 of 80

"Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for:

CSF leakage

A physician has decided to use renal replacement therapy to remove large bodies of fluid from someone who is hemodynamically unstable in the ICU. The nurse would expect which treatment?

CVVH

This person has a burn on 20% of her body. BP 90/50, HR 110, urine output 20 mL. The nurse reports the findings to the health care provider and anticipates what?

Increasing the IV lactated ringer's solution administered per hour

The nurse asks the client to state her name as soon as she regains consciousness post- operatively after a subtotal thyroidectomy at each assessment. The nurse does this to assess for what?

Laryngeal nerve damage

PT admitted to CCU artrial fib and rapid ventricular response, nurse prepares for cardioversion. What nursing action is essential to prevent danger of producing V fib during cardioversion?

Make sure sync button is on

planning urgent care for a PT wth suspected MI, the nurse will administer

O2, nitroglycerin, morphine

Charge nurse making shift assignment. Which PT should to the most experienced nurse?

PT with sudden onset pulmonary edema

The nurse is assessing the patency of a client's left arm AV fistula prior to administering hemodialysis. Which finding indicates that the fistula is patent?

Palpation of thrill

a PT with heart failure has tachypnea, severe dyspnea, and a SpO2 of 84%. The nurse identifies a nursing diagnosis of impaired gas exchange related to increased preload and mechanical failure. An appropriate nursing intervention is

Place PT in high fowlers position with the legs horizontal

PT arrives in the ED and is unable to give a health history die to altered mental status. The family reports the PT has gained over 10 pounds in a week and says its mainly water weight. In addition, they report the PT has not been able to urinate or eat within the past week, as well as recently diagnosed with small cell lung cancer. On assessment you know that their HR is 115, BP 180/92, and sodium level is 90. Which of the following conditions do you suspect the PT is most likely experiencing?

SIADH

During a check-up with a diabetic client who has proteinuria on urine analysis. The nurse assesses the client and knows that further teasing will need to assess the health of the kidney. Which test is considered the most accurate indicator of kidney function?

Serum creatinine

PT with pulmonary embolus. Which assessment data requires immediate intervention?

The client's ABG's are pH 7.36, PaCO2 38, HCO3 24

A client is hospitalized for possible SIADH, the client is confused and reports having muscle cramps and twitching. The nurse would expect which lab results to report what?

a decreased sodium

Person was admitted to the burn center with burns to the face and upper chest and hands after fireworks exploded in the garage. The nurse noes the PT coughing up black sputum, singed hairs, and dark oral and nasal membranes and decreased breathes. Increasing SOB and hoarseness. Which action would be most appropriate for the nurse to take next?

plan the need for endotracheal tube

A patient has sustained thermal injuries on 30% of their TBSA. What action should the nurse take first?

airway, breathing, circulation

You have a patient with septic shock and the physicians orders titration of hypophed to maintain the MAP at 65, the drips presently diffuse at 3 mcg/min. The client's current BP is 94/56. What do you do

continue to monitor

The nurse should monitor the patient for Cushing's disease for which finding?

decreased calcium levels

The nurse is suspecting a patient of septic shock, due to untreated cellulitis in the lower extremities. What findings would the nurse expect to learn on assessment?

decreased urine output

The nurse is teaching a 17 year old client and the clients family about what to expect with high dose chemotherapy and the effects of neutropenia. What should the nurse teach as the most reliable early indicator of infection in a neutropenic client?

fever

What is an acute renal failure diet?

gelatin dessert

65 year old comes to ER with crushing substernal chest pain, diagnosis of acute MI. Orders include O2, blood work, chest x-ray, ECG, 2mg morphine. Which to do first

give morphine

The nurse is caring for a PT with autograph on the right knee. What would the nurse anticipate to be prescribed?

keep the extremity above the lines

Nurse performs assessment on PT with complaints of chest pain, which indicates chronic stable angina?

pain with jogging, subside at rest

The rate at which the IV fluids to be infused is based on the compliance of what?

parkland formula

ECG of PT with suspected MI, which is most indicative of prolong or complete coronary occlusion

pathologic P wave

A PT has undergone a sub thyroidectomy is subject to complications in the first 48 hours. The nurse should obtain and keep at the bedside equipment to do what?

perform a tracheostomy

A PT admitted to critical care after left pneumonectomy receives 40% O2 via simple facemask. Dx with right lower lobe pneumonia. After eating breakfast, PT aspirates and vomits. Becomes agitated, decreased LOC, inability to maintain saturation, nurse anticipates which next action?

placement of PT on vent

Which of the following should raise suspicion to the nurse that a had injury is experiencing DI?

urine specific gravity is low

Low pressure alarm. Nurse assesses client then attempts to determine cause. If can't determine cause of alarm, what action should be priority?

ventilate PT manually