AH2 Quiz Questions (canvas + zoom)

A nurse cares for a patient who is prescribed lactulose. The patient states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? "You may take an antidiarrheal agent daily for loose stools." "We will need to send a stool specimen to the laboratory." "Diarrhea is expected; that's how your body gets rid of ammonia." "Do not take any more of the medication until your stools firm up."

"Diarrhea is expected; that's how your body gets rid of ammonia."

After teaching a patient who has alcohol-induced cirrhosis, a nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional teaching? "I should eat small, frequent, balanced meals." "I should not take over-the-counter medications." "I cannot drink any alcohol at all anymore." "I need to avoid protein in my diet."

"I need to avoid protein in my diet." With hepatitis you avoid protein for short time. But cirrhosis is chronic so you can't cut it out, should have mod protein diet. Only decreasing if noticing signs of hepatic encephalopathy. Pancreatitis you want more protein.

Which statement made by the client indicates a correct understanding of steroid therapy for Addison's disease? "I'll take the same amount from now on". "I'll take the medicine in the morning because if I take it at night, it might keep me awake." "This medicine probably won't affect my blood pressure". "I'll increase my potassium by eating more bananas".

"I'll take the medicine in the morning because if I take it at night, it might keep me awake." Medications always change based on s/s Never stop abruptly and notify provider of any symptoms on steroid therapy

Which statement made by the client with Cushing's syndrome indicates a need for further teaching? "I realize I will have to begin an exercise program slowly and gradually". "I'll be eating food low in carbohydrates and salt". "I'm not really worried about getting pneumonia this winter". "I'm going to have to keep a close eye on my blood pressure".

"I'm not really worried about getting pneumonia this winter" cortisol suppress immune system

A 74-yr-old patient who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis?" Which initial response by the nurse is best? "It depends on which type of dialysis you are considering." "Many people your age use dialysis and have a good quality of life." "Tell me more about what you are thinking regarding dialysis." "You are the only one who can make the decision about dialysis."

"Tell me more about what you are thinking regarding dialysis."

Prioritization 4 steps

1) ABCs 2) Acute before Chronic 3) Stable vs Unstable 4) Actual vs Potential problem

5 teaching points for PERT

1) Take with meals 2) Take with full glass of water 3) Wipe mouth after eating 4) Low fat diet, normal protein 5) Take H2 blocker or PPI before eating to lower acid

Esophageal varices, vomiting blood interventions

1) turn on side 2) IV fluids and blood - fill the tank before meds 3) vasopressor (norep, epi) - titrate depending on BP, never STOP drip without order, it will tank UAP can go get blood, take vitals

The nurse is caring for a client with a blood glucose of 650 mg/dL, increased urine output, temp 103, and negative ketones. The following orders are prescribed. Place the prescription in order of importance. 1) Begin D5W at 50 ml/hr 2) Administer normal saline at 200ml/hr 3) Administer acetaminophen 500 mg PO now 4) Regular insulin continuous IV infusion beginning at 0,1 mg/dL/hr 5) Place client on cardiac monitor 6) Place a 20g peripheral IV

6) Place a 20g peripheral IV 2) Administer normal saline at 200ml/hr 4) Regular insulin continuous IV infusion beginning at 0,1 mg/dL/hr 5) Place client on cardiac monitor 1) Begin D5W at 50 ml/hr 3) Administer acetaminophen 500 mg PO now pt is in HHS and fluids and insulin are priority!

During change-of-shift report, the nurse learns about the following four patients. Which patient should the nurse see first? A 36-yr-old patient with post-operative surgical site pain rated 3 out of 10. A 58-yr-old patient who has compensated cirrhosis and reports anorexia. A 40-yr-old patient with chronic pancreatitis who has gnawing abdominal pain A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C).

A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C). (displays signs of peritonitis = infection risk ) anorexia is common s/s with cirrhosis bc buildup of toxins (bilirubin and ammonia) causing nausea

Which client is the priority to assess immediately after hand-off/shift report? A client with superficial thickness burns of the bilateral hands and presents with contractures A client who has partial thickness burns on the back complaining of pain 9/10 A client with full thickness burns to the chest who is complaining of chest pain A client who is scheduled for a dressing change partial thickness burns to bilateral legs

A client with full thickness burns to the chest who is complaining of chest pain

A patient with a right femur fracture arrives in the ED with dyspnea; cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider should the nurse implement first? A) Provide O2 100% non-rebreather B) initiate continuous ECG monitor C) Draw blood to type and crossmatch for transfusion D) Insert 2 large-bore IV catheters

A) Provide O2 100% non-rebreather Initial actions always focus on ABC order

A nurse in the ED is assessing a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? SATA A) Remove wet clothing B) Maintain normal room temp C) Apply warm blankets D) Prepare for synchronized cardioversion E) Infuse warmed IV fluids

A) Remove wet clothing C) Apply warm blankets E) Infuse warmed IV fluids Want the room very warm!! And there is no indication for cardiovert (no SVT, V-tach)

Which complications can arise from the progressive stage of septic shock? (Select all that apply) A. Acute respiratory distress syndrome B. Extreme edema C. Elevated ammonia and lactate levels D. GI bleeding and ulcers E. Dysrhythmias F. Myocardial infarction G. Acute tubular necrosis H. Disseminated intravascular clotting

A. Acute respiratory distress syndrome (high risk with septic shock bc widespread inflammation occuring in lungs) B. Extreme edema (vessels vasodilate and become leaky from cytokines causing third spacing, no matter how much fluid given pt still lacking INTRAvascularly) C. Elevated ammonia and lactate levels (just worry about lactate, but yes ammonia inc too) D. GI bleeding and ulcers (septic shock = DIC risk, DIC = bleeding everywhere [eyes, nose, IV sites, etc.], including in stomach) E. Dysrhythmias (inadequate perfusion to tissues, heart is tissue = heart not receiving enough oxygen) F. Myocardial infarction (same for dysrhythmias) G. Acute tubular necrosis (tubules in kidneys, in shock there is decreased perfusion to ALL organs aka MODS) H. Disseminated intravascular clotting (duh sepsis can lead to DIC) progressive = pt still trying to compensate and very close to MODS (multiple organ dysfunction syndrome) and SIRS (systemic inflammatory respiratory syndrome)

The nurse is assigned to care for a patient with rhabdomyolysis. What are the priority nursing actions? SATA A. Administer fluids to restore fluid and electrolyte balance B. Administer pain medications as needed C. Insert Foley Catheter to monitor urine output D. Obtain serum labs to monitor renal function E. Prepare patient for CT scan

A. Administer fluids to restore fluid and electrolyte balance B. Administer pain medications as needed C. Insert Foley Catheter to monitor urine output D. Obtain serum labs to monitor renal function treat like pre renal acute injury. can be painful with muscle spasms and cramps, will have low urine output or have coca cola urine, order labs to monitor renal function

Client has chronic cirrhosis of the liver. The client has bright red blood in stool for last several days. What lab is priority for nurse to draw? A.CBC B.CMP C. AST and ALT D. Amylase and Lipase

A. CBC (q says bleeding, CBC shows Hgb and HCT, tells us how we must intervene) AST and ALT will obv be elevated bc cirrhosis. Amylase and lipase for pt with pancreatitis.

The nurse is caring for a client with diabetes insipidus who is being treated with desmopressin. What outcome indicates that treatment has been effective? A. Fluid intake is less than 2500 mL/day B. Urine output is greater than 200 ml/hr C. Blood pressure is 90/50 mmHg D. Heart rate is 126 bpm

A. Fluid intake is less than 2500 mL/day We should drink 2-3L/day so if they're drinking less than 3L than they are doing well. DI pt always takes in what they put out, so this means they are putting out normal urine volumes. yeeeeet Tachy is a sign of fluid overload and low BP would mean desmopressin isn't working

The nurse is caring for a client diagnosed with hep C. What diet would be most appropriate for this client? A. Fruits, healthy juice, pasta B. Steak, chicken, pork C. Rise, milk, eggs D. Alcohol and fast food

A. Fruits, healthy juice, pasta impaired liver function = lower protein

The nurse is assessing a client who had an external fixation device applied two hours ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of acute compartment syndrome? SATA A. Intense pain when the client's left foot is passively moved B. Cap refill of 3 seconds on the client's left toes C. Hard, swollen muscle in the clients left leg D. Burning and tingling of of the client foot E. Client reports minimal pain relief with second dose of morphine

A. Intense pain when the client's left foot is passively moved C. Hard, swollen muscle in the clients left leg D. Burning and tingling of of the client foot E. Client reports minimal pain relief with second dose of morphine they have increased pain and altered sensation

The nurse is reviewing prescriptions for client admitted to hospital with acute pancreatitis. Which interventions would the nurse implement? SATA A. Maintain NPO status B. Place an NG tube to low intermittent suction C. Give small, frequent high cal feedings D. Maintain the client in a supine and flat position E. Give hydromorphone IV as prescribed for pain F. Maintain IV fluids at 10mL/hr to keep vein open

A. Maintain NPO status B. Place an NG tube to low intermittent suction E. Give hydromorphone IV as prescribed for pain (dilaudid) not C bc they should be NPO rn, true for discharge teaching pancreatitis pts like fetal position on side for pain IV fluids at 10mL too low, standard maintenance 100ish mL.hr.

The nurse is caring for a client diagnosed with hep A after eating contaminated oysters. Which assessment is consistent with this dx? A. Malaise B. Dark stools C. Weight gain D. LUQ discomfort

A. Malaise would have light stools, weight loss, and liver pain is on right side

A client comes to the emergency department after sustaining burns from a house fire. The client has 27% total body surface area that is affected. What are the priority nursing actions? Select all that apply. Administer opioid analgesics as prescribed Initiate two intravenous lines Remove as much of the client's clothing as possible Flush the client's eyes with tap water Immerse the client in cool water

Administer opioid analgesics as prescribed Initiate two intravenous lines Remove as much of the client's clothing as possible

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? Grey Turner sign resolves Electrolyte levels are normal. Bowel sounds are present. Abdominal pain is decreased

Abdominal pain is decreased NPO and suction removes excess gastric acid which decreases production of amylase and lipase = less pain

A diabetic patient is admitted to the hospital with a blood glucose of 748 mg/ml and urinary output of 320 ml in the first hour. The client's vital signs are Blood pressure 72/62; pulse 128, irregular and thready; respirations 38; and temperature 97° F. The patient is disoriented and lethargic with cold, clammy skin, and cyanosis in the hands and feet. What is the priority nursing action? Hang one unit of packed red blood cells (RBCs). Administer intravenous normal saline. Continue to assess vital signs. Decrease the amount of oxygen therapy the client is receiving.

Administer intravenous normal saline. this is HHS resulting in shock (fluids is best first priority)

The nurse documents the vital signs of a patient with chronic cirrhosis: Heart rate = 121 beats/min Respirations = 27 breaths/min Blood pressure = 94/52 mmHg Oxygen saturation: 90% What priority interventions does the nurse anticipate? Select all that apply. Administer normal saline 0.9% 500 mL bolus. Place the patient in an upright position. Administer morphine 2mg IV push. Administer oxygen 2 L/min nasal cannula. Place an 18-gauge peripheral IV.

Administer normal saline 0.9% 500 mL bolus. (low BP needs fluid but sparingly bc cirrhosis is risk for ascites) (would still pick if it said 1000mLs tho) Place the patient in an upright position. Administer oxygen 2 L/min nasal cannula. Place an 18-gauge peripheral IV.

A patient with a right femur fracture arrives in the emergency department with dyspnea; cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider should the nurse question? Maintain immobilization of the right leg Administer normal saline 3% 1L IV bolus Provide oxygen via nonrebreather 15 L/min Assess right pedal pulse every hour

Administer normal saline 3% 1L IV bolus

A nurse is caring for a client with alcohol dependence who was admitted for abdominal pain. The client begins to have dark brown "coffee-like" emesis. What is the priority intervention? Assess vital signs. Assist the client to turn to one side. Call the health care provider. Place an 18-gauge peripheral IV.

Assist the client to turn to one side. coffee bleed = GI tract bleed bright red = esophageal Notify HCP is priority if saw in STOOL

A nurse cares for a patient who is scheduled for a paracentesis. Which intervention would the nurse delegate to an unlicensed assistive personnel (UAP)? Get the patient into a chair after the procedure. Help the patient lie flat in bed on the right side. Assist the patient to void before the procedure. Have the patient sign the informed consent form.

Assist the patient to void before the procedure. UAP shouldn't help pt lie flat during procedure (not clear here , but assist to void is safe answer)

The nurse is caring for a patient with an arteriovenous (AV) fistula in the left arm. What is the most important action to include in the plan of care for AV fistula patency? Assess the quality of the left radial pulse. Auscultate for a bruit at the fistula site. Compare blood pressures in the left and right arms. Irrigate the fistula site with saline every 8 to 12 hours.

Auscultate for a bruit at the fistula site.

A nurse in the ED admitted client who was hiking on a hot July afternoon. the client is lethargic, orientated to person only, hypotensive, hypoxemic, and tachycardia. Which of the following actions should the nurse take? SATA A) Administer acetaminophen 650mg rectal route B) Administer normal saline 0.9% 1L IV bolus C) Place client on continuous cardiac monitor D) Apply ice packs and cooling blankets E) Apply oxygen via nonrebreather

B) Administer normal saline 0.9% 1L IV bolus C) Place client on continuous cardiac monitor (fluid and electrolyte imbalances) D) Apply ice packs and cooling blankets E) Apply oxygen via nonrebreather Exertional cause. No antipyretics bc will not treat heat stroke, not infection related

The nurse is caring for a client with chronic cirrhosis and severe ascites. The clients condition is noted to be deteriorating. The nurse begins to infuse the ordered IV albumin. Which change indicates the effectiveness of the treatment? A. An increase of fine bilateral crackles B. An increase of mean arterial pressure (MAP) from 54 to 67 C. A decrease in urine output from 45 to 23 ml/hr D. A decrease in temp from 100.5 to 99.7

B. An increase of mean arterial pressure (MAP) from 54 to 67 Ascites deteriorating prob means hypotensive. Albumin given to raise osmotic pressure and increase vol in vessels

A 74-year-old client is extremely confused and does not respond to commands or stimulation. The patient respiratory rate is 28 and labored, oxygen saturation 86%, heart rate 120, blood pressure 70/40, mean arterial pressure is 50 mmHg, and temperature is 102 'F. The patient's heart rhythm is atrial fibrillation. The patient's urinary output is 5 mL/hr. The patient's labs: blood pH 7.15, serum lactate 15 mmol/L, BUN 55 mg/dL, Creatinine 6 mg/dL. In addition, the patient is now starting to have slight oozing of blood around puncture sites. What complication is this client experiencing? A. Necrotizing pancreatitis B. Disseminated intravascular coagulation C. Refractory stage hypovolemic shock D. Late stage hepatopulmonary syndrome What is the treatment for this complication?

B. Disseminated intravascular coagulation (late complication of septic shock) Give clotting factors (FFP) and Heparin! And blood product for active bleed. DIC pt uses up all clotting factors in microvascular areas of tissues, so all these clots form and further decrease perfusion. Clotting factors get used up by forming little clots, so must replace clotting factors lost but also do not want clots to get bigger. So give Heparin to avoid those clots growing and save perfusion to tissues and organs. Necrotizing pancreatitis can lead to DIC, so watch pts with acute pancreatitis. Pt in refractor stage of SEPTIC shock, not hypovolemic shock.

During the _______ stage of shock, signs and symptoms are subtle, however cells are experiencing ____________ due to lack of perfusion which causes the cells to switch from ___________ metabolism to _____________ metabolism. A. Proliferative, hyperoxia, anaerobic, aerobic B. Initial, hypoxia, aerobic, anaerobic C. Compensatory, hypoxia, anaerobic, aerobic D. Fibrotic, hypoxia, aerobic, anaerobic

B. Initial, hypoxia, aerobic, anaerobic Lactate values should be less than 2, an increase means they are using anaerobic metabolism, indicating shock.

The nurse is caring for several clients. Which of these signs suggests that the client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications? A. Tetanic contractions B. Neck vein distention C. Weight loss D. Polyuria

B. Neck vein distention Fluid overload baby

The nurse is assessing client with suspected acute pancreatitis. Which assessment findings are emergent for the nurse to report to the provider? SATA A. Diarrhea B. WBC 16,000 C. Absent bowel sounds D. Gray blue discoloration of flanks E. Abdominal pain and tenderness

B. WBC 16,000 (indication of sepsis) C. Absent bowel sounds (indication of paralytic ileus, has decreased blood flow to gut, definitely needs NG tube decompression to avoid obstruction) D. Gray blue discoloration of flanks (Gray Turners sign, discoloration = bruise = internal bleeding) pain is expected

Which of the clinical findings would the nurse document in the chart, report to the health care provider, and include in the plan of care for the client with Addison's disease? (Select all that apply). Weight gain of over 2 lbs. over 2 days. Temperature: 97.8 F (36.6 C). Blood glucose 51. Spiked T waves on ECG monitor. Blood pressure: 98/64

Blood glucose 51. Spiked T waves on ECG monitor. (hyperkalemia) Blood pressure: 98/64

A nurse is caring for a client admitted to the hospital for acute gastritis and ascites secondary to chronic alcohol use and cirrhosis. What is most important to assess for? Blood in stool. Abdominal circumference Nausea and vomiting. Hourly urine output.

Blood in stool. Circulation issue, worry about GI bleed risk from acute gastritis and cirrhosis (liver damage = low clotting factors). Does not show signs of infection, so ascites is not priority here. But ACUTE gastritis is.

The nurse is caring for the client with diabetes insipidus. Assessment findings include restlessness, agitation, flushed skin and dry tongue. What is the priority intervention? A. monitor daily weights B. Ensure the client drinks a min of 64 ounces of water daily C. Begin intravenous fluid volume replacement D. Notify the dietician of sodium restriction

C. Begin intravenous fluid volume replacement Pt is losing fluids, showing signs of dehydration and hypernatremia. Giving fluids fixes hypernatremia. DI = dry inside!!

The nurse is assessing a client with Cushing's syndrome. What assessment findings would the nurse expect to document in the medical record? A. Hypotension B. Thick, course skin C. Deposits of adipose tissue in the trunk and dorsocervical area D. Weight gain in arms and legs E. A recent fracture to the left leg

C. Deposits of adipose tissue in the trunk and dorsocervical area E. A recent fracture to the left leg You get hypertension in Cushing's bc fluid overload. You get thin skin. They get muscle wasting in arms and legs.

The nurse is caring for a client at home with a peritoneal port secondary to liver and gallbladder cancer. Assessment includes temperature 100.2, heart rate 110 beats/minute, respirations 22 breaths/minute, blood pressure 110/76 mmHg, and pain 3 on a 1-10 scale. A. Give the client intravenous medication for pain B. Assess the clients level of consciousness C. Evaluate the insertion site of the peritoneal port and abdomen D. Determine if the client has jaundice

C. Evaluate the insertion site of the peritoneal port and abdomen You have enough assessment info about perfusion (impaired) to inspect further for infection (plus brings up port in question, hint). There isn't anything in the q indicating altered LOC, so checking for infection first is better option here.

A female client with Addisons is admitted to the med-surg unit. During the admission assessment, the nurse notes that the client is agitated and irritable, has poor memory, reports increase of appetite, and appears disheveled. These findings are consistent with which problem? A. Depression B. Neuropathy C. Hypoglycemia D. Hyperthyroidism

C. Hypoglycemia

The main goal of treating septic shock is: A. Preserving the myocardium. B. Restoring adequate fluid status. C. Identification and elimination of the cause of infection. D. Identification and elimination of the cause of allergy.

C. Identification and elimination of the cause of infection Can't treat s/s with fluids forever, must target the cause. *Within first hour of septic shock we do cultures, antibiotics, and fluids.

The nurse is caring for a client with metastatic liver cancer. Initial assessment findings include delayed skin turgor, dry mucous membranes, and cloudy urine. The client reports that they are no longer able to walk without severe pain. Lab results include sodium 148 mEq/L, potassium3.2 mEq/L, calcium 13.8 mg/dL, glucose 134 mg/dL, BUN 24 mg/L. What is the priority nursing intervention? A. Administer 5mg of morphine orally B. Insert urinary catheter to monitor urine output C. Initiate intravenous fluids with sodium chloride D. Replace potassium with 20 mEq/L intravenously

C. Initiate intravenous fluids with sodium chloride Increased sodium indicates dehydration. LR would be better option but sodium chloride is fine bc point is pt needs fluids and has high sodium BC they're dehydrated.

A patient who is in hypovolemic shock has the following clinical signs: HR 120 bpm, blood pressure 80/55, and urine output 20 mL/hr. After administering IV fluid bolus, which of these signs is best indication of improved perfusion? A. Heart rate drops to 100 beats/minute. B. Right atrial pressure increases. C. Urine output increases to 30mL/hour. D. Systolic blood pressure increases to 85 mmHg.

C. Urine output increases Urine output and BP are most sensitive indicators of perfusion. HR is good for telling you there is a problem, it's the first reaction so it won't give a clear picture of your pt. in this situation.

A patient has arrived for a scheduled hemodialysis session. Which nursing action is appropriate for the registered nurse (RN) to delegate to the unlicensed assistive personnel (UAP)? Teach the patient about fluid restrictions. Determine the ultrafiltration rate for the hemodialysis. Check blood pressure before starting dialysis. Assess for causes of an increase in predialysis weight.

Check blood pressure before starting dialysis.

Shock compensated vs uncompensated

Compensated: initial and compensatory -BP staying somewhat normal Uncompensated: progressive and refractory -BP dropped : Systolic below 85/ MAP below 65 -late sign

A client with a history of hypertension is dx with primary hyperaldosteronism (Cushings). This dx indicates that the clients hypertension is caused by excessive hormone secretion from which of the following glands? A. Adrenal medulla B. Pancreas C. Parathyroid D. Adrenal cortex

D. Adrenal cortex

Patients receiving fluid replacement therapy should be frequently monitored for: A. Adequate urinary output. B. Changes in mental status. C. Vital sign stability. D. All of the above.

D. All of the above strict I/O, decline in LOC hella concerning, monitor HR and BP closely

The nurse is caring for a client in DKA. An IV insulin drip is infusing at a continuous rate along with NS infusion at 250 ml/hr. The client is becoming increasingly responsive and the glycose level has decreased each hour. Which finding would indicate that the client's metabolic acidosis is improving? A. Glucose 132 mg/dL B. HCO3 20 mEq/L C. PaCO2 26 mmHg D. Potassium 3.5 mEq/L

D. Potassium 3.5 mEq/L Hydrogen pushes Potassium out of cells and causes hyperkalemia. So this means they are no longer metabolically acidotic, PaCO2 has nothing to do with metabolic acidosis

Physiologic responses to all types of shock include the following except: A. Activation of the inflammatory system. B. Activation of the coagulation system. C. Hypo-perfusion of tissues. D. Vasoconstriction.

D. Vasoconstriction (technically untrue bc shows up in late shock) In all types of shock first thing activated is SNS, causing inflammation (septic shock most common) Activation of coagulation system can be with all shocks (hemorrhagic and DIC most common) Hypo-perfusion common for all shocks First vasodilation happens in septic shock, then as SNS is stimulated you see vasoconstriction.

A nurse is caring for a client with DKA. What finding does the nurse expect to see on the ABG? Decreased HCO3. Increase pCO2. Decreased pO2 Increase pH.

Decreased HCO3. metabolic issue, should see decreased pH and HCO3 (bicarb)

The nurse is caring for a client with multiple injuries sustained during a head-on motor vehicle collision. Which assessment finding is the priority? Unequal pupils Ecchymosis in the flank area Irregular apical pulse Deviated trachea to one side

Deviated trachea to one side

A 72-yr-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? Infuse normal saline at 50 mL/hr. Insert urethral catheter. Obtain renal ultrasound. Draw a complete blood count.

Insert urethral catheter.

The nurse is caring for a 66-year-old client who had a meningioma removed yesterday. The nurse monitors for complications of cranial surgery, including diabetes insipidus(DI). To determine if DI occurs, what assessment findings would the nurse anticipate? (Select all that apply) Dilute urine. Increased urine specific gravity. Hypotension. Acute confusion. Bradycardia. Weak peripheral pulses. Poor skin turgor. Dry mucous membrane. Increased urine output.

Dilute urine. Hypotension. Acute confusion. Weak peripheral pulses. Poor skin turgor. Dry mucous membrane. Increased urine output. will see tachycardia and decreased urine spec gravity with DI

A nurse is caring for a client with a history of Cushing's. The nurse should identify this client is at increased risk for which of the following? (Select all that apply). Dysphagia Nephrolithiasis Gastric Ulcer. Infection. Bone Fracture.

Gastric Ulcer. Infection. Bone Fracture. steroids suppress the immune system,

The nurse is assessing a client who is in the emergency department with a concussion after falling down the stairs at home. What assessment findings require immediate follow-up by the nurse? Glasgow Coma Scale (GCS) score goes from 15 to 13 over an hour The client has a headache 2/10 on the pain scale The client cannot remember falling down the stairs The client is sleepy but easily aroused The client has nystagmus when gazing to the left side of the room

Glasgow Coma Scale (GCS) score goes from 15 to 13 over an hour The client has nystagmus when gazing to the left side of the room

Which of these clinical findings indicate the priority outcome for the treatment of syndrome of inappropriate antidiuretic hormone (SIADH)? Serum osmolality - 310 mOsm Serum sodium - 149mg/dL Specific gravity - 1.029 Hemoglobin13g/dL, Hematocrit 39 %

Hemoglobin13g/dL, Hematocrit 39 % you want to see sodium and H&H in normal range for SIADH bc they are at risk for low in both

The nurse documents the vital signs of a patient with acute pancreatitis: Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 mmHg What complication of acute pancreatitis does the nurse suspect the patient may have? Electrolyte imbalance. Pleural effusion. Pancreatic pseudocyst. Internal bleeding.

Internal bleeding. necrotizing pt/ hemorrhagic pancreatitis = bleed, sepsis, DIC risk watch for flank bruising and high HR low BP

LPN/ UAP

LPN: -oral meds, IM, SubQ -tasks like VS, ADL wound care UAP: -tasks like VS, ADL NEVER does first assessment/reassessment ,no IV meds, no teaching

A 23-year-old client with a full thickness burn is being prepared for discharge from the hospital. Which patient education is most important for the nurse to provide prior to discharge? Options available for scar removal. How to maintain home smoke detectors Learning to perform dressing changes Joining a community reintegration program

Learning to perform dressing changes

Labs for cirrhosis pt

Liver enzymes :AST and ALT Albumin: risk low protein Ammonia :before lactulose Bilirubin Coagulation/CBC CMP (common hypernatremia)

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? Magnesium hydroxide. Calcium phosphate. Acetaminophen. Multivitamin with iron.

Magnesium hydroxide.

The client has a long leg cast on the right leg. Assessment reveals that the right foot is pale and cool to touch, and the right leg pain is still severe with no relief from the pain medication administered 45 minutes ago. What is the priority action? Notify the health care provider immediately Remove the cast immediately Apply a heating pad to the right toes Repeat the dose of pain medication

Notify the health care provider immediately

After receiving change-of-shift report, which patient should the nurse assess first? Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange. Patient who has just returned from having hemodialysis with a heart rate of 110/min. Patient with stage 4 chronic kidney disease who has an elevated phosphate level.

Patient who has just returned from having hemodialysis with a heart rate of 110/min.

A patient with chronic kidney disease is restless, anxious, and short of breath. The nurse hears crackles that begin at the base of the lungs. The pulse rate is increased and the patient has frothy, blood tinged sputum. What action does the nurse perform first? Continue to monitor vital signs and breath sounds. Administer a loop diuretic, such as furosemide. Facilitate transfer to intensive care for treatment. Place the patient in a high-Fowler's position.

Place the patient in a high-Fowler's position.

A patient has a serum potassium level of 6.5 mEq/L, a serum creatinine level of 2 mg/dL, and urine output of 350 ml/day. What is the best action by the nurse? Place the patient on the cardiac monitor immediately. Continue to monitor the patient's intake and output. Teach the patient to limit high-potassium foods. Ask to have the laboratory redraw the blood specimen.

Place the patient on the cardiac monitor immediately.

A nurse is caring for a client with Addison's disease. Which of the following manifestations will the nurse expect? (Select all that apply). Bradycardia Postural hypotension. Diarrhea Constipation. Weakness. Hypopigmentation.

Postural hypotension. (orthostatic) Weakness. constipation diarrhea will be tachycardia and have hyperpigmentation

Which action by the LPN requires the nurse to intervene immediately while caring for a client on protective isolation for a burn injury? The LPN is providing the client with clean sheets and linens The LPN is wearing gloves and a gown when assisting with wound dressing changes. The LPN is delivering a vase of flowers to the client The LPN is performing strict handwashing technique

The LPN is delivering a vase of flowers to the client

Which assessment indicates the expected outcome of the fluid resuscitation for a client with a burn injury? Bilateral +1 radial pulses Heart rate increased from 58 to 110 beats/minute Urine output increased from 28 mL/hour to 60 mL/hour Decreased level of consciousness

Urine output increased from 28 mL/hour to 60 mL/hour

A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? The serum potassium is 4.9 mEq/L. The creatinine level is 3.0 mg/dL. Urine output over an 8-hour period is 200 mL. The blood urea nitrogen (BUN) level is 67 mg/dL.

Urine output over an 8-hour period is 200 mL.

A nurse is caring for a client with chronic cirrhosis. Which potential complication would cause the nurse the most concern? Fetor hepaticus. Ascites. Asterixis. Varices.

Varices. Fetor hepaticus is musty smelling bad breath associated with cirrhosis. (would pick if asked for assessment findings, not complication)

Which information will be included when the nurse is teaching self-management to a chronic kidney disease (CKD) patient who is receiving peritoneal dialysis? Select all that apply. Have several servings of dairy products daily. Warm the dialysate fluid if cramping occurs. Choose high-protein foods for most meals. Restrict fluid intake to 3000 mL daily. Avoid commercial salt substitutes.

Warm the dialysate fluid if cramping occurs. Choose high-protein foods for most meals. Avoid commercial salt substitutes.

Which clinical findings indicate a complication from diabetes insipidus? Weight loss of 2 lbs. Serum sodium - 135mEq/L Urine output > than 200 ml/hr. Urine specific gravity - 1.001

Weight loss of 2 lbs. (in 1 day!) low urine spec gravity is an expected finding, not complication

The nurse is caring for a client with multiple injuries sustained during a head on car collision. Which assessment finding takes priority? a) A hoarse voice and prominent seat belt mark on the neck b) Unequal pupils, GCS of 14 c) Ecchymosis in the flank area and pain level 4 out of 10 d) Irregular apical pulse and stable blood pressure

a) A hoarse voice and prominent seat belt mark on the neck (airway obstruction)

The nurse in the burn intensive care unit is caring for a client who sustained full thickness burns over 50% of the total body surface area (TBSA), mainly on the chest and neck, from a house fire. The client develops a hoarse and brassy cough and O2 sat is 78% and continues to decrease. What are the immediate nursing actions? SATA a) call rapid response team b) administer morphine 4mg IV push c) prepare for chest tube insertion d) prepare for endotracheal intubation e) encourage client to cough and deep breathe

a) call rapid response team d) prepare for endotracheal intubation Chest and neck burn involves airway, chest, and heart.. Not giving opioids at this time bc respiratory function depression risk and not priority for ABC support and management. Chest tube is for pneumothorax and pt doesn't have that. Pulmonary toileting (cough and deep breathe) will NOT fix airway obstruction from injury, will happen once pt is stable.

The nurse in the ED is admitting a client who has sustained full-thickness burns over their bilateral arms from a charcoal grill accident 40hrs ago. VS are stable. What actions are important for the nurse to implement in this phase? SATA a) instruct client to take antibiotics as prescribed b) perform strict hand hygiene to prevent infection c) allow visitors of all ages to provide emotional support d) restrict fresh fruits, flowers, and plants e) encourage client to increase protein and caloric intake

a) instruct client to take antibiotics as prescribed b) perform strict hand hygiene to prevent infection d) restrict fresh fruits, flowers, and plants e) encourage client to increase protein and caloric intake

The nurse is admitting a trauma client who nearly drowned in a lake during the winter. Which interventions should the nurse implement? a) remove the client's wet clothing b) prepare to give several units of uncrossed matched blood c) insert an 18g IV and administer warmed fluids d) decrease the temp in the trauma room e) use the jaw thrust maneuver to open the airway f) place the client on cardiac monitor

a) remove the client's wet clothing c) insert an 18g IV and administer warmed fluids e) use the jaw thrust maneuver to open the airway f) place the client on cardiac monitor

The nurse in the ED is admitting a client who has sustained full-thickness burns over their bilateral arms from a charcoal grill accident 4hrs ago. The clients VS: BP 100/60, HR 124, RR 20, O2 92%, pain 8/10. What is priority action? a) perform wound care to bilateral arms b) administer normal saline 0.9% 1L IV bolus c) prepare for endotracheal intubation d) administer ketorolac 30mg IV push

b) administer normal saline 0.9% 1L IV bolus ETT is too invasive for this pt. Ketorolac is a steroidal anti-inflammatory and not strong enough, IV OPIODS are preferred x2. But pain is not as important as ABCs

The nurse is working in triage of the emergency dep and four client approach triage desk at same time. List the order in which the nurse will assess clients. a) 25 yo man who is alert and ambulatory with a bandaged head wound b) 85 yo with a fever, projectile vomiting, and new lethargy c) 35 yo jogger with a twisted ankle who has a pedal pulse and no deformity d) 50 yo woman with mod abdominal pain and occasional vomiting

b) 85 yo with a fever, projectile vomiting, and new lethargy (dec LOC = airway risk) a) 25 yo man who is alert and ambulatory with a bandaged head wound (head trauma = d) d) 50 yo woman with mod abdominal pain and occasional vomiting c) 35 yo jogger with a twisted ankle who has a pedal pulse and no deformity

The nurse is educating the client about burn self-management and support. Which education will the nurse include? a) You will need plastic surgery to remove scars and restore appearance b) It is important to wear pressure dressings to prevent contractures c) There are many support groups, so it is best to go to counseling d) The likelihood of returning to your baseline functioning is low

b) It is important to wear pressure dressings to prevent contractures There ARE many support groups. ACD are not therapeutic.

It is summer season, and clients with signs and symptoms of heat-related illness come to the ED. Which client needs to be seen first? a) The elderly person with dizziness and syncope after standing in the sun for several hours to watch a parade. b)A marathon runner who reports severe leg cramps and nausea, is tachycardia, diaphoretic, and weak c) A healthy female who reports that the air conditioner has been broken for several days and is tachypneic, hypotensive, fatigued, and diaphoretic d) An older adult left in the car for an unknown length of time who is disoriented, has hot and dry skin, and poor muscle tone

d) An older adult left in the car for an unknown length of time who is disoriented, has hot and dry skin, and poor muscle tone

The nurse is triaging clients complaining of abdominal pain. In what order should the nurse see the clients? a) A 35 yo man reporting severe intermittent cramps w/ 3 episodes of watery diarrhea after eating b) 42 yo w/ cirrhosis who states their abdomen now feels rigid and painful c) 40 yo w/ moderate RUQ pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the past week d) 65 yo w / LUQ pain radiating to the back and shoulder w/ bruising around the umbilicus and L. flank e) 80 yo reporting dizziness and severe abdominal pain who states they vomited bright red blood in the parking lot f) 50 yo who reports gnawing mid epigastric pain that is worse between meals and during the night

e) 80 yo reporting dizziness and severe abdominal pain who states they vomited bright red blood in the parking lot (possible aspiration risk) d) 65 yo w / LUQ pain radiating to the back and shoulder w/ bruising around the umbilicus and L. flank (circulation issue) b) 42 yo w/ cirrhosis who states their abdomen now feels rigid and painful (infection) c) 40 yo w/ moderate RUQ pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the past week (urgent due to abd pain) a) A 35 yo man reporting severe intermittent cramps w/ 3 episodes of watery diarrhea after eating (less urgent, only intermittent cramps) f) 50 yo who reports gnawing mid epigastric pain that is worse between meals and during the night (prob GERD)

Hypovolemia signs

low sodium and high H&H

A graduate nurse in the emergency department is admitting a client who was hiking on a hot July afternoon. The client is lethargic, oriented to person only, hypotensive, hypoxemic, and tachycardic. Which of the following actions by the graduate nurse requires the charge nurse to intervene? Administering normal saline 0.9% 1L IV bolus Applying ice packs and cooling blankets on the client Placing the client on a continuous cardiac monitor Administration of acetaminophen 650 mg rectal route

q seen twice!! Administration of acetaminophen 650 mg rectal route

Prioritization: one pt has rectal pain and one has new onset of confusion

see confusion first bc new onset, UNLESS rectal pain pt stated bleeding

Prioritization: 2 pts left paracentesis 2hrs ago; one has bp 105/75 and one has hard abdomen

see hard abdomen first bc peritonitis risk. Low bp is expected after paracentesis bc just removed hella fluids.