CC Exam 4 quiz questions

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

54%

a patient presents in hyperkalemia. what should the nurse look for on the EKG monitor based on this finding? A. peaked T waves B. depressed T waves C. ST depression D. ST elevation

A

what is the first line treatment for PEA and aystole? a. CPR and epi 1 mg q 3-5 min b. defibrillation c. atropine 0.5 mg q 3-5 min d. synchronized cardioversion

A

which ABG is associated with acute respiratory failure? A. ph 7.28, pCO2 74, pO2 74, HCO3 28 B. ph 7.38, pCO2 44, pO2 52, HCO3 22 C. pH 7.48, pCO2 32, pO2 84, HCO3 22 D. pH 7.17, pCO2 35, pO2 58, HCO3 12

A

which are the following are the 3 effects of septic shock? a. vasodilation, maldistribution of blood flow, and myocardial depression b. vasodilation, myocardial depression, and increased blood production c. increased blood production, vasoconstriction, and increased cardiac output d. maldistribution of blood flow, myocardial depression, and vasoconstriction

A

which intravenous fluid should the nurse prepare when a patient requires an isotonic solution? A. 0.9% normal saline B. dextrose 2.5% C. 0.33% normal saline D. D5LR

A

The nurse is caring for a patient with liver failure notes a change in mental status and elevated ammonia level. Which ordered interventions are most directly related to treating these clinical manifestations? A. diuretics B. lactulose C. high protein diet D. coumadin E. insulin F. low protein diet

B F

adenosine

SVT only, crash cart in the room

The nurse is caring for a client with acute pancreatitis. The physician has ordered gentamicin, 3 mg/kg/day, in three divided doses. The patient weighs 264 lb. How many mg of gentamicin will the patient receive per dose? ________mg/dose (round to whole number)

120 mg/dose

Following a liver biopsy, in which order should the complete the following tasks. 1. oxygen 2. assess site for bleeding 3. monitor blood pressure 4. change empty bag of normal saline

1234

partial thickness burns on the patients right anterior leg, left anterior and posterior leg, and anterior torso

45%

an unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. which nursing intervention will be included in the plan of care? A. elevated HOB to 30 degrees B. position the patient prone C. encourage the patient to cough and deep breathe to promote oxygenation D. incentive spirometer use Q1 hour

A

in planning care respiratory acidosis. which intervention does the nurse include A. perform chest physiotherapy B. reduce environmental stimuli C. administer intravenous sodium bicarbonate D. administer intravenous sodium bicarbonate

A

the nurse in the outpatient clinic notes that a patient has a decreased magnesium level. what should the nurse ask the patient about? a. daily alcohol intake b. daily protein intake c. multivitamin use d. over the counter laxative

A

the nurse is conducting a primary survey during an emergency assessment. which is the priority nursing action related to breathing in response to this assessment? A. having suction available B. assessing pupil size and reactivity C. immobilizing any obvious deformities D. obtaining blood samples for type and crossmatch

A

the nurse monitors for which finding in the patient admitted in neurogenic shock? A. bradycardia B. increased CVP C. increased CO D. hyperventilation

A

what action after noticing a rise in the water seal chamber with client inspiration with a chest tube? a. continue to monitor the client b. immediately notify the provider c. reposition the client toward the left side d. clamp the chest tube near the water seal

A

You are providing care for a patient who was just flown in from the Boston Mountains and upon arrival you the patient hypotensive, bradycardic. The report from the flight crew is that he has received 2 liters of NS with no response. They state the patient was climbing a tree to get into a deer stand when he fell to the ground and was knocked unconscious. They state rescue personnel on scene had already immobilized him upon their arrival with a cervical collar and long back board. The patients only complaints at this time is tingling in his hands and a burning sensation to the backs of this arms. a. hypovolemic shock due to suspected internal bleeding b. the patient is young and may always have a low heart rate and blood pressure c. neurogenic shock due to suspected spinal cord injury d. the pt is at risk for fluid volume overload and pulmonary edema secondary to the 2 liters of NS given by the flight crew

C

what is the first line IV med for treatment of SVT? a. atropine b. dopamine c. adenosine d. saline

C

what is the first line of treatment for unstable (symptomatic) SVT? a. adenosine 6 mg rapid IV push b. beta blockers c. synchronized cardioversion d. vagal maneuvers

C

A patient is being treated for diabetes insipidus (DI). Which medication should the nurse prepare to administer? A. calcium B. synthroid C. vitamin D D. Desmopresin (DDAVP)

D

D5NS

fluid and electrolyte replenishment and caloric supply used as a source of water, electrolytes and calories

lactulose

help increase the number of bowel movements per day and the number of days on which bowel movements occur

furosemide

helps body get rid of excess water

Hepatitis E

is transmitted via the fecal-oral route primarily through water that is contaminated in areas of poor sanitation.

3% NS

used with severe hyponatremia, IV administration calls for very close monitoring with constant neuro assessment

a nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. what EKG changes can be seen? a. peaked t waves b. ST elevation c. increased PR interval d. inverted QRS

A

you arrive on duty and assess that your trauma patient that has a heparin drip running at 11 ml/hr. the bag contains 25,000 units per 250 mL. how much heparin (units/hr) is your patient currently recieving?

1,100

which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (osmitrol) has been effective for an unconscious patient? A. hematocrit B. blood pressure C. oxygen saturation D. intracranial pressure

D

atropine

bradycardia only

A dose of Levophed 2mcg/min has been ordered for a septic patient to maintain a MAP of 65. The infusion concentration is 4mg of levophed in 250 mlD5W. Calculate the rate in mL/hr. Answer with number only. Round to the nearest tenth. ________ml/hr

7.5

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. airway obstruction B. infection C. fluid imbalance D. paralytic illeus

A

A patient who recently recevied a liver transplant had a liver biopsy. Upon returning from the biopsy, how should the nurse position the patient? A. right side lying B. left side lying C. prone D. supine

A

what is the treatment for a pt in sustained vtach with a pulse? a. amiodarone b. chest compressions c. close monitoring d. beta blockers

A

ABG results show a pH of 7.3 and a PaCO2 of 50 mmHg a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

C

defibrillation is appropriate for this type of rhythm a. SVT b. rapid afib c. asystole d. vfib

D

While observing another nurse caring for a patient with a chest tube, which of the following actions would require intervention and additional teaching? (Select all that apply) a. Loosely coiling tubing below the level of the chest. b. Changing chest tube dressing using medical aseptic or sterile technique, based on facility protocol. c. Elevating drainage system to the level of the patient's chest. d. Stripping the chest tube with each assessment. e. Checking for a leak in the system when there is continuous bubbling.

DC

Hepatitis B

is spread by blood and body fluids or secretions such as semen. The virus can be spread through mucous membranes, contact with infected fluids, during childbirth, or through the puncture of a contaminated needle or other instrument.

amiodarone

all rhythms vtach and awake meds I must take

Insulin sub q

consistently effective

Mannitol

diuretic which helps make more urine and to lose salt and excess water from your body. it treats swelling from heart, kidney, or liver disease

insulin infusion

preferred for patients with type 1 diabetes

propranolol

slows down your heart rate and makes it easier for your heart to pump blood around your body

metformin

used for type 2 diabetes and used to treat high blood sugar levels

Toresemide

used to help treat fluid retention and swelling that is caused by congestive heart failure, liver disease, kidney disease

vasopressin

used to treat DI that is less expensive than desmopressin

Mrs. heart had a new onset atrial flutter at 150s. she is stable. which is the priority treatment? a. cardioversion b. amiodarone c. cardene d. adenosine

B

Based on the below scale. If your patient's blood sugar is 187 and they are on the average before meal sliding scale. How many units would they receive? _____ units Answer with the number only. Round to the nearest tenths.

4 units

A patient has been admitted to the ICU in diabetic ketoacidosis. The patient is receiving normal saline, 0.9%, and a regular insulin drip. What is a priority assessment for this patient? A. ECG B. skin turgor C. blood cultures D. time of last insulin dose

A

A patient on the Intensive Care Unit receives a blood draw at the beginning of your shift. When lab work returns results show a pH of 7.23, HCO3 of 18, PO2 of 80, and PCO2 of 37. After analyzing the results it is clear that this patient is experiencing which of the following? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

A

An intubated patient receiving mechanical ventilation requires all of the following should be readily available but which piece of equipment absolutely has to be with the patient at all times, even during transport? a. Self-inflating bag-valve mask (e.g Ambu bag) b. IV pump c. Suctioning equipment d. Patent IV access

A

When reviewing the patient's medication administration record (MAR) the notes the medication atropine listed. The nurse understands that this medication is administered for which problem? a. Symptomatic bradycardia b. Symptomatic tachycardia c. Supraventricular tachycardia d. Ventricular dysthymias

A

a patient is admitted after losing consciousness while fasting, ketones in the urine. what do you suspect? A. metabolic acidosis B. metabolic alkalosis C. respiratory acidosis D. respiratory alkalosis

A

which of the following measures would be taken to decrease a patients ICP? A. increase RR on ventilator B. mannitol administration C. nitroglycerine administration D. increase stimulation

AB

which assessment findings would indicate to the nurse that a patient is exhibiting early symptoms of shock? a. restlessness b. increased respiratory rate c. pallor d. increased bowel sounds e. decreased blood glucose

ABC

which of the following parameters are included in a GCS assessment? A. eye opening B. motor response C. verbal response D. cranial nerves

ABC

which of the following parameters are included in a neurologic assessment? A. vital signs B. LOC/orientation C. peripheral pulses D. GCS E. cardiac assessment

ABD

Which should the nurse include in the plan of care for a mechanically ventilated patient who is receiving care based on a ventilator bundle? Select all that apply. a. Elevating the head of the bed b. Conducting a readiness to wean assessment c. Avoiding the use of compression stockings during immobility d. Administering a prescribed peptic ulcer prophylactic regimen e. Ensuring a sedation vacation each day

AEBD

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A. Urinary Output 25 Ml/ Hr B. Difficulty swallowing C. Heart rate 122 bpm D. Pain 6 out of 10

B

A patient with liver disease is being evaluation for varices. The nurse prepares the patient for which procedure? A. liver biopsy B. EGD C. ERCP D. TIPS

B

A patient with type 1 diabetes mellitus has not taken insulin for several days. Which observation indicates that diabetic ketoacidosis (DKA) could be developing? A. slow heart rate B. deep rapid respirations C. decreased urine output D. increased blood pressure

B

The nurse is providing care to a patient who has been vomiting for several days. Which acid-base disorder does the nurse assess for in this patient? a. Respiratory acidosis b. Metabolic alkalosis c. Respiratory alkalosis d. Metabolic acidosis

B

a client has hypertension and has potassium level of 6.8 mEq/L. which action should the nurse take? a. suggest that the client use a salt substitute b. obtain a 12-lead ECG c. advise the client to add citrus juices and bananas to their diet d. obtain a blood sample for a serum sodium level

B

a nursing student is helping care for a patient on the ventilator with posttraumatic brain swelling, which causes him to have an increased ICP. which action by the student would require intervention by the nurse? A. the student positions the head of the patients bed at 30 degrees B. the student suctions the patient for 10 seconds, three times in a row to ensure all secretions have been cleared from the patients airway C. the student leaves the light on in the room after she is finished giving a medication D. the student repositions and turns the patient every 2 hours

B

how does the nurse interpret an arterial pH of 7.47? a. acidosis b. alkalosis c. compensation d. homeostasis

B

the nurse is assessing a patients level of consciousness after a brain injury using the Glasgow Coma Scale. the patients eyes open to painful stimuli only, but he does not respond verbally to the painful stimuli. He is also decorticate posturing. approximately what should the nurse rate his GCS score? A. 2-3 B. 5-6 C. 9-10 D. 13-14

B

the nurse is caring for a patient with a large epidural hematoma who is intubated and on the ventilator. the physician instructs the nurse to hyperventilate the patient. the nurse understands the best rationale for this action is which of the following? A. increase the patients PaCO2 to lower intracranial pressure B. decrease the patients PaCO2 to lower intracranial pressure C. increase the patients PaCO2 to increase intracranial pressure D. decrease the patients PaCO2 to increase intracranial pressure

B

the nurse is providing care to a patient who has been vomiting for several days. what does the nurse assess for? A. metabolic acidosis B. metabolic alkalosis C. respiratory acidosis D. respiratory alkalosis

B

the nurse monitors for clinical manifestation of metabolic alkalosis in the patient with which disorder? A. diarrhea B. prolonged vomiting C. acute kidney injury D. overdose of tylenol

B

the nurse provides care for a patient admitted for anaphylactic shock after eating shellfish. which family member statement indicates the need for additional teaching regarding this condition? a. we will have an epipen on hand wherever we go b. my spouse requires a prescription for diphenhydramine prior to discharge c. a scratchy throat indicates the need for prompt intervention d. we will inform our doctor that contrast dye should be avoided in the future

B

the nurse provides care for a patient who is 4 hr post op to correct a herniated nucleus pulposus. which assessment finding causes the nurse to notify the health care provider? A. the patient is drowsy but arousable B. the patients respiratory rate is nine breaths per minute C. the patient reports relief of pain following medication administration D. the patients dressing is intact with small amount of serosanguinous drainage noted

B

what meds are used for v fib and vtach? a. amiodarone and digoxin b. amiodarone or lidocaine c. epinephrine or lidocaine d. digoxin or adenosine

B

which of the following interventions should the nurse implement to prevent complications related to mechanical ventiliation? a. apply restraints if the client becomes agitated b. administer pantoprazole as prescribed c. elevate the HOB to degrees d. keep patient comfortable sedated

B

which of the following lab results warrants immediate attention? A. sodium 145 B. Potassium 6 C. BiCarb 27 D. creatinine 5

B

which of the following medications should the nurse have available to reverse heparins effects? a. vitamin K b. protamine sulfate c. acetylcysteine d. defasirox

B

you are caring for a patient with a recent spinal cord injury. the patient develops a sudden, pounding, headache and HTN. what is your best first action? A. administer metoprolol 5 mg IVP B. elevate the HOB to at least 45 degrees or place the patient in a sitting position C. administer acetaminophen (tylenol) 650 mg PO D. assess for and relieve bladder distention

B

a client who has a chest tube needs to be transported to the xray department. which action should the nurse take? a. clamp the chest tube prior to transferring the client to a wheelchair b. disconnect the chest tube from the drainage system during transport c. keep the drainage system below chest at all times d. empty the collection chamber prior to transport

C

a patient in the emergency room has hypovolemic shock. which assessment finding indicates that fluid resuscitation has been successful? a. hemoglobin of 13.5 g/dL b. mean arterial pressure of 50 mmHg c. urine output of 55 mL/hr d. blood pressure 85/52

C

A patient is admitted for evaluation of a bowel obstruction and has a nasogastric tube placed to low intermittent suction. The physician orders arterial blood gases, and the following results are reported: What is the nurse's interpretation of these results? pH - 7.37PaCO2 - 33 mm HgPaO2 - 94 mm HgHCO3 - 19 mm HgSaO2 - 98% a. Uncompensated metabolic acidosis b. Uncompensated respiratory alkalosis c. Fully compensated metabolic acidosis d. Partally compensated respiratory alkolosis

C

Interpret the following pH 7.31; PaCO2 48 mm Hg; and HCO3 24 mEq/L A. metabolic acidosis B. metabolic alkalosis C. respiratory acidosis D. respiratory alkalosis

C

Susan is taking care of a patient with acute respiratory failure and respiratory acidosis is suspected. Which combination of values is indicative of respiratory acidosis? a. pH 7.5; HCO3 32; PaCO2 30; PaO2 80 b. pH 7.30, HCO3 20; PaCO2 30; PaO2 85 c. pH 7.25; HCO3 22; PaCO2 47; PaO2 79 d. pH 7.48, HCO3 28; PaCO2 43; PaO2 75

C

The nurse is providing care for an adult patient who is admitted to the emergency department (ED) after losing consciousness. The patient has been fasting and currently has ketones in the urine. The nurse monitors for which acid-base imbalance? a. Respiratory acidosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory alkalosis

C

The nurse is providing care to a patient who is admitted after a morphine overdose. Which acid-base imbalance does the nurse assess for in this patient? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

C

The nurse is providing care to patient with the following laboratory values: pH 7.31; PaCO2 48 mm Hg; and HCO3 24 mEq/L. The nurse correlates these values to which acid-base disorder? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

C

The nurse is reviewing the latest arterial blood gas results for a patient with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated? a. pH 7.32 b. HCO3 8 mEq/L c. PaCO2 48 mm Hg d. PaCO2 18 mm Hg

C

The nurse observes asystole on the patient's telemetry monitor. What is the nurse first action? a. Carry out defibrillation. b. Notify the physician. c. Assess the patient. d. Administer atropine IV.

C

You are working in the ICU and are caring for a patient who has just arrived from the inpatient floor with new onset changes in their ECG and difficulty breathing. There is no acute myocardial event on ECG which would require intervention but when assessing the patient you notice audible crackles bilaterally in the lower lobes of the lungs. You also obtain a set of vital signs which are as follows; BP 96/54, HR 118, RR 24, SP02 93% on 2 liters nasal cannula. Which of the following would be of primary concern at this point in your decision making? a. the changes in ECG rhythm b. the patients blood pressure c. potential cardiogenic shock d. potential distributive shock

C

the nurse is caring for a patient with a suspected head injury who is scheduled for a CT scan with contrast. Prior to the procedure, the nurse notes the patients creatinine is 1.9 mg/dL. what is the priority intervention by the nurse? A. notify the physician and request the CT scan be cancelled B. send the patient for the CT scan with no further action C. notify the physician and request orders for a bicarbonate infusion D. inform the CT tech of the patients lab results as the only action

C

the nurse is providing care to a patient who is admitted after a morphine overdose. what does the nurse anticipate? A. metabolic acidosis B. metabolic alkalosis C. respiratory acidosis D. respiratory alkalosis

C

the nurse monitors for which therapeutic effect in the patient receiving sodium polystyrene sulfonate (Kayexalate) A. decreased sodium B. decreased phosphorus C. decreased serum potassium D. increase dextrose

C

the nurse provides care to a patient who is admitted for a MI. when planning for this patient, the nurse includes interventions that address which type of shock? a. obstructive b. distributive c. cardiogenic d. hypovolemic

C

the nurse recognizes that which disorder increases a patients risk for distributive shock? A. burns B. tension pneumothorax C. spinal cord injury D. valvular disease

C

the nurse works in an emergency department in a city that experiences an earthquake. which patient injury does the nurse prepare to treat based on this information? A. drowning B. electrocution C. crush injuries D. open brain injuries

C

which intravenous fluid should the nurse prepare when a patient requires a hypotonic solution? A. 0.9% normal saline B. dextrose 2.5 W with 20 KCl C. 0.33% normal saline D. D5LR

C

which of the following pulse characterisitics should the nurse expect in a client who has atrial fibrillation? a. slow b. non palpable c. irregular d. bounding

C

The nurse is providing care to a patient who is admitted to the hospital with sudden, severe abdominal pain. Which arterial blood gas supports the patient's current diagnosis of respiratory alkalosis? a. pH is 7.33 and PaCO2 is 36 b. pH is 7.30 and HCO3 is 30. c. pH is 7.35 and PaO2 is 88. d. pH is 7.47 and PaCO2 is 25

D

The nurse provides care to a patient admitted for a traumatic brain injury. The patient's arterial blood gas (ABG) analysis indicates respiratory acidosis. Which action by the nurse is best when providing care to this patient? a. Monitoring peripheral vascular status b. Administering sodium bicarbonate, per prescription c. Reassuring the patient to decrease anxiety d. Assessing respiratory rate and depth closely

D

While caring for a patient with the later stage of acute respiratory failure, which arterial blood gas (ABG) results would the nurse anticipate for this patient? a. pH, 7.45; HCO3-, 23 mEq/L; PCO2, 25 mm Hg; PO2, 82 mm Hg b. pH, 7.30; HCO3-, 26 mEq/L; PCO2, 35 mm Hg; PO2, 75 mm Hg c. pH, 7.50; HCO3-, 30 mEq/L; PCO2, 38mm Hg; PO2, 66 mm Hg d. pH, 7.32; HCO3-, 22 mEq/L; PCO2, 55 mm Hg; PO2, 96 mm Hg

D

a 85 year old female has been admitted to the ICU with severe nausea, vomiting, and diarrhea with hypokalemia. the nurse has an order to infuse 40 mEq of potassium chloride via IV infusion. What is the most appropriate method for the nurse to use to infuse this medication? a. infuse at a rate of 40 mEq per hour b. infuse at a rate of 30 mEq per hour c. remix the 40 mEq in 1000 mL of d5w and infuse over 12 hours d. infuse at a rate of 10 mEq per hour

D

a clients heart rate is 28 bpm, atropine didnt work, what is the next treatment? a. ablation b. cardioversion c. defibrillation d. pacemaker

D

a nurse is preparing to administer warfarin to a client who has atrial fib. the purpose of this medication is a. to convert atrial fib to sinus rhythm b. to dissolve clots in the bloodstream c. to slow the response of the ventricles to the fast atrial impulses d. to reduce the risk of stroke in clients who have atrial fib

D

a patient with a severe fluid deficit, which prescribed intravenous solution does the nurse recognize as most? A. 0.9% normal saline B. dextrose 10% C. 0.45% normal saline D. albumin

D

closed chest drainage - slow, steady bubbling in the suction control chamber with each breath. what next action? a. check the tubing connections for leaks b. check the suction control outlet on the wall c. clamp the chest tube d. continue to monitor the clients respiratory status

D

joe smith is 100 kg who comes to the ED with burns to his face, anterior trunk, and bilateral upper extremities. he has singed nasal hairs and carbonaceous sputum but has no difficulty swallowing or breathing. the burns are pale and dry and the patient is not complaining of any pain except around the edge of the wounds. A. superficial B. superficial partial thickness C. deep partial thickness D. full thickness

D

patient is SOB and dizzy, what is the first treatment after IV is placed and O2 applied? a. pacing b. ASA and nitro c. nothing, monitor and transport d. atropine 0.5 mg IVP

D

recommended treatment of unstable patient with afib? a. diltiazem b. metoprolol c. adenosine d. synchronized cardioversion

D

the nurse is caring for a patient with cardiogenic shock. which intervention is included in the plan of care? a. assess vital signs every 2 hours b. assess skin for dryness and pruritus c. maintain HOB at <10 degrees d. monitor breath sounds every 2-4 hours

D

the nurse is reviewing the laboratory results of patients. the nurse expects an order for fluid restriction related to which a. blood glucose 90 mg/dL b. potassium level 3.8 mEq/L c. magnesium level 2.1 mg/dL d. sodium level 123 mEq/L

D

what do you do first when the vtach alarm starts sounding for your patients room? a. print a strip b. call the MD c. tell the charge nurse d. check the patient

D

which intravenous fluid should the nurse prepare when a patient requires a hypertonic solution? A. 0.9% normal saline B. dextrose 2.5% C. 0.33% normal saline D. D5LR

D

DDAVP (desmopressin)

drug of choice in patients with DI and is available in subcutaneuous, intranasal, and oral preparations

Hepatitis C

is spread through blood or body fluids and from mother to child during childbirth.

Hepatitis A

is the most common type of hepatitis and is primarily spread through the oral route from food, water, or shellfish that has been infected with the virus.

Lasix

used to treat excessive fluid caused by congestive heart failure, liver failure, renal failure, and nephritic syndrome