Block 10: Module 6-9 Quizzes

d. Learning to perform dressing changes

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? a. Options available for scar removal. b. Joining a community reintegration program c. How to maintain home smoke detectors d. Learning to perform dressing changes

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

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? a. The serum potassium is 4.9 mEq/L. b. The blood urea nitrogen (BUN) level is 67 mg/dL. c. The creatinine level is 3.0 mg/dL. d. Urine output over an 8-hour period is 200 mL.

d. Insert urethral catheter.

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? a. Infuse normal saline at 50 mL/hr. b. Obtain renal ultrasound. c. Draw a complete blood count. d. Insert urethral catheter.

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

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? a. "Many people your age use dialysis and have a good quality of life." b. "It depends on which type of dialysis you are considering." c. "You are the only one who can make the decision about dialysis." d. "Tell me more about what you are thinking regarding dialysis."

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

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. a. Flush the client's eyes with tap water b. Initiate two intravenous lines c. Administer opioid analgesics as prescribed d. Immerse the client in cool water e. Remove as much of the client's clothing as possible

●D. Adrenal cortex

A client with a history of hypertension is diagnosed with primary hyperaldosteronism (Cushing's syndrome). This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which of the following glands? ●A. Adrenal medulla ●B. Pancreas ●C. Parathyroid ●D. Adrenal cortex

●C. Hypoglycemia

A female client with Addison's is admitted to the medical-surgical 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

d. Administration of acetaminophen 650 mg rectal route

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? a. Applying ice packs and cooling blankets on the client b. Placing the client on a continuous cardiac monitor c. Administering normal saline 0.9% 1L IV bolus d. Administration of acetaminophen 650 mg rectal route

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

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? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "We will need to send a stool specimen to the laboratory." c. "Do not take any more of the medication until your stools firm up." d. "You may take an antidiarrheal agent daily for loose stools."

a. Assist the patient to void before the procedure.

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

b. Administer normal saline 0.9% 1L IV bolus (for hypotensive/electrolyte imbalances) c. Place client on continuous cardiac monitor (because tachycardic) d. Apply ice packs and cooling blankets (since heat stroke suspected) e. Apply oxygen via nonrebreather (due to hypoxemia) A wrong because antipyretics do NOT treat heat stroke, contraindicated

A nurse in the ED 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 should the nurse take? SATA a. Administer acetaminophen 650 mg 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

a. Remove wet clothing c. Apply warm blankets e. Infuse warmed IV fluids The room should be WARM (you should be sweating while caring for this pt), no indication for cardioversion based on info given

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

b. Blood in stool.

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? a. Hourly urine output. b. Blood in stool. c. Abdominal circumference. d. Nausea and vomiting.

d. Assist the client to turn to one side.

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? a. Call the health care provider. b. Place an 18-gauge peripheral IV. c. Assess vital signs. d. Assist the client to turn to one side.

c. Varices

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

b. Place the patient on the cardiac monitor immediately.

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? a. Teach the patient to limit high-potassium foods. b. Place the patient on the cardiac monitor immediately. c. Continue to monitor the patient's intake and output. d. Ask to have the laboratory redraw the blood specimen.

d. Check blood pressure before starting dialysis.

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)? a. Teach the patient about fluid restrictions. b. Assess for causes of an increase in predialysis weight. c. Determine the ultrafiltration rate for the hemodialysis. d. Check blood pressure before starting dialysis.

a. Provide O2 at 100% per non rebreather mask B or D next then C

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 implement first? a. Provide O2 at 100% per non rebreather mask b. Initiate continuous ECG monitoring c. Draw blood to type and crossmatch for transfusions D. Insert two large bore IV catheters

c. Administer normal saline 3% 1L IV bolus

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? a. Assess right pedal pulse aevery hour b. Provide oxygen via nonrebreather 15 L/min c. Administer normal saline 3% 1L IV bolus d. Maintain immobilization of the right leg

a. Abdominal pain is decreased.

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? a. Abdominal pain is decreased. b. Bowel sounds are present. c. Grey Turner sign resolves. d. Electrolyte levels are normal.

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

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? a. Place the patient in a high-Fowler's position. b. to monitor vital signs and breath sounds. c. Administer a loop diuretic, such as furosemide. d. Facilitate transfer to intensive care for treatment.

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

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

a. "I need to avoid protein in my diet." Should have moderate protein (it is important that it isnt high protein)

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? a. "I need to avoid protein in my diet." b. "I should not take over-the-counter medications." c. "I cannot drink any alcohol at all anymore." d. "I should eat small, frequent, balanced meals."

●C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m.

Capillary glucose monitoring is being performed every 4 hours for a female client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. The nurse should expect the dose: ●A. Onset to be at 2 p.m. and its peak to be at 3 p.m. ●B. Onset to be at 2:15 p.m. and its peak to be at 3 p.m. ●C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m. ●D. Onset to be at 4 p.m. and its peak to be at 6 p.m.

c. A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C).

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

a. Notify the health care provider immediately

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? a. Notify the health care provider immediately b. Repeat the dose of pain medication c. Apply a heating pad to the right toes d. Remove the cast immediately

d. Internal bleeding.

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? a. Pleural effusion. b. Electrolyte imbalance. c. Pancreatic pseudocyst. d. Internal bleeding.

a. Administer oxygen 2 L/min nasal cannula. c. Place an 18-gauge peripheral IV. d. Place the patient in an upright position. e. Administer normal saline 0.9% 500 mL bolus.

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. a. Administer oxygen 2 L/min nasal cannula. b. Administer morphine 2mg IV push. c. Place an 18-gauge peripheral IV. d. Place the patient in an upright position. e. Administer normal saline 0.9% 500 mL bolus.

a. Call rapid response team d. Prepare for endotracheal intubation Not administering morphine at this time will depress resp function, no indication of PNX

The nurse in the burn ICU 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. Instruct client to take antibiotics as prescribed b. Perform strict hand hygiene to prevent infection d. Restrict fresh fruits, flower, and plants e. Encourage client to increase protein and caloric intake Visitors will be limited due to infection risk

The nurse in the burn unit is caring for a client who has sustained full-thickness burns over their bilateral arms from a charcoal grill accident 40 hours ago. The client's vital signs 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, flower, and plants e. Encourage client to increase protein and caloric intake

a. Magnesium hydroxide.

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? a. Magnesium hydroxide. b. Calcium phosphate. c. Acetaminophen. d. Multivitamin with iron.

b. Administer normal saline 0.9% 1L IV bolus priority due to hypotension/tachycardia wound care is important but not the priority pt has lower O2 and would need a less invasive device such as NC or NRB IV opioids are preferred not ketorolac and lesser priority

The nurse in the emergency department is admitting a client who has sustained full-thickness burns over their bilateral arms from a charcoal grill accident 4 hours ago. The client's vital signs are as follows: BP 110/60, HR 124, RR 20, O2 92%, pain level 8/10 a. Perform wound care to bilateral arms b. Administer normal saline 0.9% 1L IV bolus c. Prepare for endotracheal intubation d. Administer ketorolac 30 mg IV push

B. White blood cell count 16,000 mm3 C. Absent bowel sounds D. Gray blue discoloration of the flanks B could indicate sepsis and indicates an infection, C is indicative a paralytic ileus, D always concerned and flank bruising unless are all EMERGENT findings

The nurse is assessing a client admitted to the hospital with a suspected diagnosis of acute pancreatitis. Which assessment findings are emergent for the nurse to report to the provider? (Select all that apply) A. Diarrhea B. White blood cell count 16,000 mm3 C. Absent bowel sounds D. Gray blue discoloration of the flanks E. Abdominal pain and tenderness

●D. Weight gain in arms and legs ●E. A recent fracture o the left leg

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

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 the clients left foot e. Client reports minimal pain relief with 2nd dose of morphine

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 sec on the clients left toes c. Hard, swollen muscle in the clients left leg d. Burning and tingling of the clients left foot e. Client reports minimal pain relief with 2nd dose of morphine

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

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? Select all that apply: a. The client has a headache 2/10 on the pain scale b. The client is sleepy but easily aroused c. The client cannot remember falling down the stairs d. The client has nystagmus when gazing to the left side of the room e. Glasgow Coma Scale (GCS) score goes from 15 to 13 over an hour

a. Administer fluids to restore fluid and electrolyte balance b. Administer pain meds as needed c. Insert foley catheter to monitor U/O d.Obtain serum labs to monitor renal function

The nurse is assigned to care for a patient with rhabdomyolysis. What are the priority nursing action(s)? SATA a. Administer fluids to restore fluid and electrolyte balance b. Administer pain meds as needed c. Insert foley catheter to monitor U/O d.Obtain serum labs to monitor renal function e. Prepare for CT scan

A. Malaise More likely to see light stools, weight loss and pain on the right side (mid epigastric) pain not left side.

The nurse is caring for a client diagnosed with hepatitis A after eating contaminated oysters. Which assessment finding is consistent with this diagnosis? A. Malaise B. Dark stools C. Weight gain D. Left upper quadrant discomfort

A. Fruits, healthy juices, and pasta Is the best option healthier for them, eggs and milk too much protein for this pt

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

●D. Potassium 3.5 mEq/L A normal potassium tells you a pt is no longer acidotic because the potassium would be high if the pt was acidotic. When we have acidosis we have an excess of potassium ion and they fight for space in the cell and pushes the potassium out of cell and into the bloodstream. A normal pH and bicarbonate and potassium in normal range are the goals.

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/hour. The client is becoming increasingly responsive and the glucose 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

●6. Place a 20g peripheral IV ●2. Administer normal saline at 200mL/hr ●4. Regular insulin continuous IV infusion beginning at 0.1mg/dL/hr ●5. Place the client on a cardiac monitor ●1. Begin D5W at 50mL/hr ●3. Administer acetaminophen 500 mg PO now

The nurse is caring for a client with a blood glucose of 650 mg/dL, increased urine output, a temperature of 103F, and negative ketones. The following orders are prescribed. Place the prescription in order of importance. ●1. Begin D5W at 50mL/hr ●2. Administer normal saline at 200mL/hr ●3. Administer acetaminophen 500 mg PO now ●4. Regular insulin continuous IV infusion beginning at 0.1mg/dL/hr ●5. Place the client on a cardiac monitor ●6. Place a 20g peripheral IV

B. An increase of mean arterial pressure (MAP) from 54 to 67 Blood pressure and U/O are very good indicators of fluid status. This answer is showing improvement in the fluid status which is important because the pt has severe ascites

The nurse is caring for a client with chronic cirrhosis and severe ascites. The client's 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 temperature from 100.5 F to 99.7 F.

A. CBC They are seeing blood in the stool so we need to look at Hgb & Hct to see if they need blood products are really bleeding.

The nurse is caring for a client with chronic cirrhosis of the liver. The client states they have noticed bright red blood in their stool for the last several days. What lab is the priority for the nurse to recommend to the provider? A. CBC B. CMP C. AST and ALT D. Amylase and Lipase

●A. Fluid intake is less than 2500 mL/day4 What goes out must come in, 2500 mL is a normal intake

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/hour ●C. Blood pressure is 90/50 mmHg ●D. Heart rate is 126 beats/minute

d. Deviated trachea to one side

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

d. Auscultate for a bruit at the fistula site.

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? a. Compare blood pressures in the left and right arms. b. Assess the quality of the left radial pulse. c. Irrigate the fistula site with saline every 8 to 12 hours. d. Auscultate for a bruit at the fistula site.

●B. Neck vein distention

The nurse is caring for several client's on a medical/surgical unit. 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

●C. Begin intravenous fluid volume replacement

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 minimum of 64 ounces of water daily ●C. Begin intravenous fluid volume replacement ●D. Notify the dietician of sodium restriction

b. "It is important to wear pressure dressings to prevent contractures."

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 not many support groups, so it is best to go to counseling." d. "There is likelihood of returning to your baseline functioning is low."

A. Maintain NPO status B. Place an NG tube to low intermittent suction E. Give hydromorphone IV as prescribed for pain C is wrong because they are NPO but would be small high calorie bland meals upon discharge, F is wrong because its not enough fluid

The nurse is reviewing the prescriptions for a client admitted to the hospital with acute pancreatitis. Which interventions would the nurse implement? (Select all that apply). A. Maintain NPO status B. Place an NG tube to low intermittent suction C. Give small, frequent high-calorie 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 the vein open

A. The LPN is delivering a vase of flowers to the client

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

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

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

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

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

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

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. a. Have several servings of dairy products daily. b. Choose high-protein foods for most meals. c. Warm the dialysate fluid if cramping occurs. d. Restrict fluid intake to 3000 mL daily. e. Avoid commercial salt substitutes.