CM-extra
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is pending an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
"large incisions will be made in the eschar to improve circulation"
63. The nurse is caring for a client diagnosed with ARDS who is on a ventilator. Which interventions should the nurse implement. Select all
*A Assess the client's level of consciousness *B Monitor clients urine output *C Perform passive range of motion exercise *D maintain intravenous fluids as ordered
59. The client is admitted to the ED with chest trauma. Which signs/symptoms would the nurse expect to assess that supports the diagnosis of pneumothorax?
*B Absent breath sounds and tachypnea
61. A client has a total serum calcium level of 7.5 mg/dl. Which clinical manifestations would the nurse expect to note on assessment of the client? Select all
*B Muscle twitches *D Hyperactive deep tendon reflexes *E Positive Trousseau's sign and positive Chvostek's sign *F. Prolong ST interval and QT interval on ECG
54. A client with and ECG reading showing sinus bradycardia has a blood pressure of 47/28 mmhg. Which drugs does the nurse expect the physician to order for this client?
*B. Atropine sulfate
60. A nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse includes which interventions in the plan? Select all that apply
*B. Changing the client's position frequently *C. Maintaining the collection chamber below the client's waist *D. Adding water to the suction control chamber as it evaporates. *E Taping the connection between the chest tube and the drainage system.
58. The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action?
*C Ventilates the client manually
56. A nurse assesses a comatose, head-injured client and finds flexion of the arms, wrists, and fingers and adduction of the upper extremities. Which of the following describes these findings?
*C. Decorticate posturing
55. Chemical cardioversion is prescribed for the client with atrial fibrillation. The nurse who is assisting in preparing the client would expect that which medication specific for chemical cardioversion will be needed?
*D. Amiodarone (Cordarone)
72.Order rocephen 1g over 30minutes Q6H. Supply 1g/100mL. How many mL per hour will the nurse infuse? Round the nearest whole number.
200 ml/hr
67. If dietary trays are usually brought to the nursing unit at 8:00am the nurse should plan to administer intermediate- acting insulin (Humlin N) 40 units SQ to the client between?
630am and 700 am
6. A nurse is caring for a client who came the emergency dept reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client's troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is
A heart muscle protein that appears in the bloodstream when there is damage to the heart
47. After receiving change-of-shift report, which of these patients should the nurse assess first?
A patient with smoke inhalation who has wheezes and altered mental status
68.A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases ??? to 110min and becomes irregular. The nurse should know that the client requires?
OXYGENATE PRIOR TO SUCTIONING
16. A triage nurse in an emergency dept is caring for a client who has gunshot wound to the right side of chest. The nurse notices thick dressing on the chest and sucking noise coming from the wound. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take initially?
Administer oxygen via nasal cannula
80.The client is admitted the ED with chest trauma. Which signs and symptoms would the nurse expect to assess that supports the diagnosis of pneumothorax?
ABSENT BREATHS SOUNDS TACHYPNEA
75.The nurse is monitoring a client receiving pertional dialysis notes that the client's outflow is less than inflow. What action should the nurse take? Select all that apply?
ANSWER- (SELECT ALL ANSWERS EXPCEPT - CONTACT THE HEALTH CARE PROVIDER & INCREASE THE FLOW- DO NOT SELECT THOSE TWO ANSWERS)
52. The nurse is assessing the patency of an arteriovenous fistula and suspects clotting in the fistula if which finding are noted? Select all that apply
Absence of a bruit on auscultation over the fistula *D. Complaints of tingling or discomfort in the extremity
11. A nurse in the ICU is caring for a client who has acute respiratory distress syndrome (ARDS) and is receiving mechanical via an endotracheal tube. The provider plans to extubate her within the next 24 hour. Which of the following is an important criterion for extubating the client?
Adequate tidal volume without manually assisted breaths
19. A client with a diagnosis of disseminated intravascular coagulation (DIC) has the following assessment findings: blood pressure of 76/56, temperature 102.6degrees, resp. 24 breath/min., with complaints of severe neck and back pain. Which nursing action should the nurse implement first?
Administer acetaminophen (Tylenol) PO.
13. A nurse is caring for a female client who came in to the ED reporting SOB and pain in the lung area. Her heart rate is 110/min, resp. rate 40/min, and blood pressure 140/80 m8juiimHg. Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority intervention
Administer oxygen via face mask
77.The nurse is caring for a client diagnosed with ARDS who is on a ventilator. Which intervention should the nurse implement? Select all that apply
Assess the client's level of consciousness. B. Monitor the client's urine output C. Perform passive range of motion (ROM) exercise. D. Maintain intravenous fluids as ordered.
57. The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first
Assess the respiratory status and pulse oximeter reading.
24. Norepinephrine (Levophed) has been ordered for a client in hypovolemic shock. Before administering the drug, the nurse should make sure that the client has:
Been receiving adequate IV fluid replacement
100.A nurse assess a client who 8 score using the Glasgow coma scale to elevate of consciousness. Describe the score
C. Client in deep coma
94.A nurse observing a close chest tube drainage system is postop 1 day thoracotomy Continue bubbling in the suction chamber?
C. Continue to monitor client respiratory status
34) A new employee at a facility needs a hepatitis vaccine. Which statement reflects accurate understanding of the immunization?
C. I will receive 3 injections over a period of months, which should protect me from hep B
68. What ECG changes would reflect myocardial ischemia in a client who has been admitted for observation after experiencing an episode of chest pain?
ST segment elevation or depression
25. The client returns to his room after a thoracotomy. What will the nursing assessment reveal if hypovolemia from excessive blood loss is present?
CVP of 3 cm H20 and urine output of 20 mL/hr
4. A nurse is assessing the depth and extent of a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the first priority when assessing the severity of the burn?
Cause of the burn
33) What ECG changes would reflect myocardial ischemia in a client who has been admitted for observation after experiencing an episode of chest pain?
ST- Segment elevation or depression
69.A client comes into the ER with complains of midsternal chest pain radiating to the neck and left arm which is unrelieved by sublingual nitroglygen. An electrocardiogram (ECG) is obtained. What observation on the ECG or on the cardiac monitor would indicate to the nurse the need to immediately notify the physician?
D. An ST segment elevation from the isoelectric baseline.
50) A client with T6 spinal cord injury is being discharged. The PT is concerned about autonomic dysreflexia. S/S include the following:
D. Diaphoresis above the level of the lesion
99. A nurse admitted morphine 2 mg IV push after client report pain and evaluate client 15 min. later injection. Which follow adverse effect?
D. RR 8 bpm
95.A client admit to hospital report recurrent flank pain, nausea, and vomiting within 24 hours. Which of the following priority nursing action?
D. Strain urine
23. The nurse is monitoring an IV infusion of sodium nitroprusside (Nirpride). Fifteen minutes after the infusion is started, the client's BP goes from 190/120 mm Hg to 120/90 mm Hg. What is the priority nursing action?
Decrease the infusion rate and recheck the blood pressure in 5 minutes
21. The nurse is assessing a client who is on a ventilator and has an endotracheal tube in place. What data confirms that the tube has migrated too far into the trachea?
Decreased breath sounds are heard over the left side of the chest
9. A nurse in a cardiac care unit is caring for a client with acute heart failure. Which of the following findings should the nurse expect?
Elevated central venous pressure (CVP)
49) A client with cervical neck fracture is admitted to the intensive care unit. Which findings would the nurse recognize as indicative of spinal shock?
Flaccidity and lack of sensation below the level of spinal cord lesion.
38. A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous and pulmonary artery wedge pressure are 4. Which of these orders by the health care provider will the nurse question?
Give furosemide (Lasix) 40 mg IV
62. The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?
Have the client sit down immediately
51) A woman has been recently diagnosed with systemic lupus and shares with the nurse, I want to get pregnant, but I don't know how I will tolerate pregnancy because I have lupus. Which response is best?
How long have you been in remission?
35) While talking with a client with a diagnosis of end stage liver disease. The nurse notices the client is unable to stay awake and seems to fall asleep in the middle of a sentence. The nurse recognizes these symptoms to be indicative of what condition?
Increased blood ammonia levels
7. A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following should the nurse expect in the findings?
Increased clotting factors
14. A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations indicate a complication that requires notifying the provider immediately?
Increased heart rate
10. A client comes into the ED reporting nausea and vomiting that worsens when lying down and without relief from antacids. The provider suspects acute pancreatitis. Which of the following lab test results should the nurse expect to see if the client has acute pancreatitis?
Increased serum amylase
65. When teaching a client about the expected outcomes after intravenous administration of furosemide, the nurse would include which outcome?
Increased urine output
22. What is the desired action of dopamine (Intropin) when administered in the treatment of shock?
It increases myocardial contractility
53. Epoetin alfa (Epogen) is prescribed for a client diagnosed with chronic renal failure. The client asks the nurse about the purpose of the medication. The appropriate response would be which of the following?
It is used to treat anemia
8. A nurse is about to administer warfarin (Coumadin) to a client who has atrial fibrillation. When the client asks what his medication will do, which of the following is an appropriate nursing response?
It prevents strokes in clients who have atrial fibrillation
67.The nurse is caring for a client who underwent cardiac catherization 1 hour ago. What is an important nursing measures at this time?
MAINTAIN PRESSURE OVER CATHETER INSERTION SITE AND DETERMINE DISTAL CIRCULATION STATUS.
5. A client arrives at the emergency dept following an explosion at the chemical plant. He has deep partial and full-thickness chemical burns over more than 25 % of his body surface area. What is the nurse's priority intervention?
Maintain a patent airway
31) The nurse is caring for a client who underwent cardiac catheterization 1 hour ago. What is an important nursing measure at this time?
Maintain pressure over catheter insertion site and determine distal circulation status.
98.A nurse is performing teaching for client who have recently diagnosis type 2 DM. nurse should recognize that the client understood the teaching. Identify hypoglycemia? Select all
Moist, clammy skin Tachycardia
41. Which interventions will the nurse include in the plan of the care for a patient who has cardiogenic shock?
Monitor breath sounds frequently
96.A nurse is caring for client who have type 1 DM. The nurse misread client morning blood glucose level at 210 mg/dL instead of 120 mg/dL base on this error. She admitted insulin dose of 200 mg/dL before client breakfast. Which of the nursing priority?
Monitor client for hypoglycemia
78.The nurse is performing an assessment on a client who has returned from dialysis unit following hemodialysis. The client is complaining of headache, nausea, and is extremely restless. Which of the following ?? the most appropriate nursing action?
NOTIFY THE PHYSICANS
39. After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of which of the following?
Norepinephrine (Levophed)
45. A patient is admitted to the burn unit with burns the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased ad no wheezes are audible. What is the best action for the nurse to take?
Notify the HCP and prepare for endotracheal intubation
29) An older adult client comes into ER stating that he has no appetite, is nauseated, his heart feels funny and has noticed a haziness in his vision. The client states that he has been taking an antihypertensive drug and digitalis for more than a year. Based on the presenting symptoms, what would be the priority nursing action?
Obtain an order for an EKG and serum potassium and digitalis levels
42. Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective?
Oxygen saturation
73.The nurse is caring for client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40 percent. The 02 saturation measured by pulse oximeter was 83 ABG results are pH 7.31, PACO2 93mmHg, HCO3 25 meq/L. Which of the following is an appropriate action by the nurse?
POSITION CLIENT IN HIGH- FOWLERS AND ENCOURAGE USE OF INCENTIVE SPIROMETER AND COUGHING.
92.T2-T3:
Paraplegia
69. The client with acute renal failure has a serum potassium level of 6.0 mEq/L. The nurse would plan which of the following as a priority action?
Place the client on a cardiac monitor
30) the nurse is administering alteplase to a client who has been diagnosed with acute coronary syndrome. What are important nursing implications for this medication?
Place the client on bleeding precautions
17. A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the client requires which of the following?
Pre-oxygenation prior to suctioning
28) The V/S of a client with Cardiac disease are as follows: BP 102/76 mm/hg, Pulse 52, RR 16. Atropine is administered IV push. What nursing assessment indicates a therapeutic response to the medication?
Pulse rate has increased to 70 beats/min
71. The vital signs of a client with cardiac disease are as follows blood pressure of 103/78 mm Hg, heart rate ??? beats/min, and respiratory rate of 16 breaths/min. Atropine (atropine???? Administered IV push. What nursing assessment indicates a therapeutic response to the medication?
Pulse rate has increased to 70 beats/min
76.The nurse is obtaining a health history from a client who is visiting the clinic with complaints of a severe headache. The client provides the following data to the nurse based on a review of systems. The nurse identifies the following as a modifiable risk for stroke? Select all the apply.
SMOKING B. ALCOHOL CONSUMPTION C. DECREASED PHYSICAL ACTIVITY D. OBESITY
43. When caring for the patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider? (TB ch.67 Q.17)
Skin cool and clammy
91.Cranial nerve II:
Snellen test
66. A client arrives at the emergency department with deep partial thickness and burns over 15% of his body. At admission his vital signs are blood pressure 100/50 mm Hg, heart rate 130 beats/minute and respiratory rate 20 breaths/minute. Which nursing intervention are appropriate for this client? Select all that apply
Starting an IV infusion of lactated Ringers solution B. Administering 6mg of morphine IV C. Administering tetanus prophylaxis as ordered
18. The nurse is caring for a client who is receiving a blood transfusion. The transfusion started 30 minutes ago at a rate of 100 mL/hr. The client begins to complain of low back pain and headache and is increasingly restless. What is the first nursing action?
Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of normal saline solution
81.The nurse is caring for hospitalized clients. Which of the following clients is at greatest risk for fluid volume deficit?
THE CLIENT WHO HAS JUST BEEN ADMITTED HAS SEVERE DIARRHEA AND IS febrile.
70. A client begins complains of chills and discomfort after about 50ml of blood has packed red blood cells. The best nursing action at this time is to
TOP THE TRANSFUSION AND MAINTAIN A PATENT LINE WITH NORMAL SALINE solution and new tubing
74.The diabetic educator is teaching a class on Diabetes Type 1 and is discussing sick day rules. Which interventions should the diabetes counselor include in the teaching? Select all that apply
Take diabetic medication even if unable to eat the client's normal diet. B) If unable to eat, drink liquids equal to the client's normal diet. D) Test the blood glucose levels and test the urine ketones once a day and keep a record.
48. The RN observes all of the following actions begin taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene?
The nurse uses latex gloves when applying antibacterial cream to a burn wound
97.A nurse is caring a client who is schedule of colonoscopy. The client ask the nurse if there will be a lot of pain during procedure. Which of the following is appropriate nursing response?
You may be sedated but you will feel discomfort during the instrument insertion
32. The nurse in a cardiac stepdown unit has received a hand-off shift report for these clients. Which client should be assess first?
a client who has just returned from a coronary artierogram with placement of an intracoronary stent.
90.Planning rehabilitation for a stroke patient
a. Assess functional status before developing plan (Walking, speaking, eating, ADLs )
20. The nurse administering albuterol (Proventil) via a metered-dose inhaler (MDI) to a client who has a history of coronary artery disease is now in congestive heart failure. What side effects will be particularly important to observe for when the client takes the medication
a.Tremors and central nervous system stimulation
37. A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock?
apical heart rate of 48 beats/min
86.P wave:
atrial depolarization
27. The nurse applies a Nitro-Dur patch on a client who has undergone cardiac surgery. What nursing observation indicates that a Nitro-Dur patch is achieving the desired effect?
b. Client performs activities of daily living without chest pain
40. Which of these findings is the best indicators that the fluid resuscitation for a patient with hypovolemic shock has been successful?
b.Urine output is 60 mL over the last hour
26. The nurse is performing an assessment and finds the client has cold, clammy skin, pulse of 130 beats/min and weak, blood pressure of 84/56 mm Hg, and urinary of 20 mL for the past hour. The nurse would interpret these findings as suggestive of which pathophysiology?
d. Decrease in the cardiac output and inadequate tissue perfusion
46. During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion?
d. Measures hourly urine output
44. During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which findings is most important for the nurse to report to the HCP?
d.New onset of confusion and agitation
88.HbA1c considerations for about 3 months of glucose monitoring
diabetic controlled should be less than 7%
15. A group of college students was attending a weekend football rally when one of the students stumbled and fell into the bonfire. Although several friends quickly intervened, the client sustained partial-thickness burns to both lower legs, chest, and both forearms. Which of the following is priority nursing action when the client is brought to the ED?
inspect mouth for signs of inhalation
79.The nurse determines that a client with diabetes- mellitus is experiencing fat breakdown for conversion to glucose if the client has elevated levels of which substance in the urine?
ketones
2. A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids is used in the first 24 hours following a burn injury?
lactated ringers
87.Assessing response in an unconscious patient:
nail bed pressure (peripheral)
93.ICP:
no lumbar puncture
3. A nurse is caring for a client who has full-thickness burns all over 75% of his body. Which of the following methods is appropriate to accurately monitor the cardiovascular system?
obtain a central venous pressure
64. The nurse is assessing a client experiencing motor loss as a result of a left sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document?
paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, paralysis would affect the right side.
12. A nurse is caring for a client following a CT scan with dye who suffered from an anaphylactic reaction. Which of the following conditions requires a priority nursing response?
stridor
36) The nurse is caring for a client with chronic hep B. What will the teaching plan for this client include?
use a condom for sexual intercourse
