Ameritech COTAC II Winter 2021: Exam 4 quizzes

A client is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? A. Fever, increased heart rate, and decreased blood pressure B. Sudden increase in random blood glucose readings C. Abdominal pain unresponsive to analgesics D. Increased abdominal girth accompanied by decreased level of consciousness

A

A client who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this client knows to immediately report what assessment finding to the health care provider? A. Rigidity of the abdomen B. Drainage of bile-colored fluid onto the abdominal dressing C. Decreased breath sounds D. Acute pain with movement

A

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? A. Respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis

A

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? A. The total body surface area (TBSA) affected by the burn B. The source of the burn C. The length of time since the burn D. The location of burned skin surfaces

A

The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem? A. Diminished deep tendon reflexes B. Cool, clammy skin C. Tachycardia D. Acute flank pain

A

The nurse is planning the care of a client with hyperthyroidism. What should the nurse specify in the client's meal plan? A. Small, frequent meals, high in protein and calories B. Three large, bland meals a day C. A reduced calorie diet, high in nutrients D. A diet high in fiber and plant-sourced fat

A

A 30-year-old female client has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse most likely prioritize when planning the client's care? A. Decisional conflict related to treatment options B. Disturbed body image related to changes in physical appearance C. Spiritual distress related to changes in cognitive function D. Powerlessness related to disease progression

B

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? A. 0.45% NaCl with 20 mEq/L KCl B. Lactated Ringer's C. 0.45% NaCl with 40 mEq/L KCl D. Normal saline

B

A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? A. Low-purine, nutrient-dense foods B. High-fiber foods C. Low-fat foods high in proteins and carbohydrates D. Foods that are low residue and low in fat

C

The nurse is caring for a client diagnosed with hypothyroidism secondary to Hashimoto thyroiditis. When assessing this client, what sign or symptom would the nurse expect? A. Flushed skin B. Palpitations C. Fatigue D. Bulging eyes

C

A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation? A. "Has anyone in your family ever experienced symptoms similar to yours?" B. "Have you ever worked in an occupation where you might have been exposed to toxins?" C. "To the best of your knowledge, are your immunizations up to date?" D. "How many alcoholic drinks do you typically consume in a week?"

D

The nurse is assessing the client for the presence of a Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate? A. Hyponatremia B. Hyperkalemia C. Hypermagnesemia D. Hypocalcemia

D

A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and the left forearm. What extent of burns does the client most likely have, measured as a percentage?

18%

A client is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis? A. Maintain client in a semi- fowlers position whenever possible B. Position the client supine to facilitate diaphragm movement. C. Administer corticosteroids by nebulizer as prescribed. D. Perform oral suctioning as needed to remove secretions

A

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? A. Airway management B. Fluid balance C. Anxiety and fear D. Pain

A

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply. A. Increased total body water B. Decreased renal blood flow C. Increased conservation of sodium D. Decreased kidney mass E. Decreased excretion of potassium

B, D, E

A nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A. Maintenance of bed rest to aid healing B. Administration of beta-adrenergic blockers C. Prevention of venous thromboembolism D. Choosing appropriate splints and functional devices

C

A client with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A> Give the client a cold beverage to promote swallowing ability B. Keep client NPO until the results of test are known. C. Keep client NPO until the client's gag reflex returns D. Administer analgesia until post-procedure tenderness is relieved.

C

A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A. Absence of blood or mucus in stool B. Significant increase in appetite and food intake C. Absence of nausea and vomiting D. Two to three soft bowel movements daily

D

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? A. CNS disturbances B. Respiratory acidosis C. Increased PaCO2 D. Respiratory alkalosis

D