E1 Adult ATI
A nurse is caring for a client. A nurse is caring for a 26-year-old client who has abdominal pain. Click to highlight the findings below that the nurses should report to the provider.
- client reports abdominal pain for the last two days that is now moving to the right lower quadrant - the pain has started to increase over the last hour and is a 9 on a 0 to 10 scale - respiratory rate 22/min - heart rate 110/min - blood pressure 88/58 mm Hg while lying down
a nurse is caring for a client who is scheduled for surgery. a nurse is providing preoperative teaching to a client about pain management using a patient controlled analgesia (PCA) system. - your family member should push the PCA button for you while you are sleeping - using the PCA regularly will provide a consistent level of pain relief - you will still have to request pain medication from the nurse from time to time - there is minimal risk of an overdose of pain medication while using the PCA pump - push the button on the PCA prior to your pain level becoming severe so you can remain comfortable
- using the PCA regularly will provide a consistent level of pain relief - there is minimal risk of an overdose of pain medication while using the PCA pump - push the button on the PCA prior to your pain level becoming severe so you can remain comfortable
A nurse is documenting the intake for a client who is scheduled for an abdominal computed axial tomography (CT) scan. prior to the scan, the client consumes 12 oz sodium diatrizoate and meglumine diatrizoate. The client has an IV of D5 1/2 NS running at 75 ml/hr from 0700 until 1200. The IV runs at 30ml/hr from 1200 to 1500, the client has 6 oz juice. How many mL should the nurse document as the client's intake for the shift?
1,005 mL (1 oz ~ 30 mL)
a nurse is preparing to admin 40 of KCL in 45% NaCl 500 mL IV to infuse 10/hr. the nurse should set the IV pump to deliver how many mL/hr?
125 ((10 X 500)/40)
A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first? A- Airway patency B- Tissue integrity C- Wound drainage D- Pain severity
A
a nurse is an ED is caring for a client. complete teh diagram
Action: teach client pursed-lip breathing, plan to admin a bronchodilator Condition: COPD Monitor: RR, O2 sat
A nurse is caring for a client who is postoperative from a colon resection for a complete bowel obstruction. Complete the diagram
Actions to take: ventilate w/ oxygen, administer naloxone Problem: respiratory depression Monitor: vital signs, level of consciousness
A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing the pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? A. It decreases the client's level of anxiety. B. It facilitates the client's deep breathing. C. It enhances the client's ability to sleep. D. It reduces the client's blood pressure.
B
a nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. which of the following surgical procedure places the client at risk for a deep-vein thrombosis A. Myringotomy b. Laparoscopic appendectomy c. Hip arthroplasty d. Cataract extraction
C (Clients who are postoperative following orthopedic procedures of the lower extremities and clients who were placed in the lithotomy position for a procedure, such as for gynecological or urological surgeries, are at a higher risk of developing deep-vein thrombosis postoperatively.)
a 74 year old female is admitted to the ED with increasing dyspnea, productive cough and fatigue. for each client finding, click to indicate if the finding is consistent with COPD, pneumonia, or pulmonary edema
COPD: dyspnea, barrel chest, antibiotics Pneumonia: dyspnea, antibiotics Pulmonary Edema: dyspnea, diuretics
A nurse is monitoring a postoperative client who is unable to respond to questions, which of the following nonverbal behaviors should the nurse identify as indication that the client is in pain? Restlessness Grimacing Moaning Clenching Drowsiness
Restlessness Grimacing Clenching
A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? a. Apply the bag for 30 min at a time b. Reapply the bag 10 min after removing it. c. Allow room for some air inside the bag. d. Place the bag directly on the skin.
a
A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. which of the following client statements indicates an understanding of pain control? a. i will call for pain medication before the previous dose wears off b. i will call for pain medications as my pain starts to increase again c. i will wait for you to evaluate my pain before asking for more medication d. i will ask for less medication to avoid addiction
a
a 74 year old female is admitted to the ED with increasing dyspnea, productive cough and fatigue. which condition is the client most likely experiencing? a. COPD exacerbation b. pulmonary edema c. community acquired pneumonia d. pneumonia
a
a nurse in an emergency department is caring for a client who has 2 day history of vomiting and an elevated temperature. which of the following should the nurse recognize as the most reliable indicator of fluid loss? a. body weight b. skin integrity c. headache d. respiratory rate
a
a nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. which of the following findings should the nurse expect during the initial assessment? a. lethargy b. hyperactive deep tendon reflexes c. prolonged ST segment d. hyperactive bowel sounds
a
a nurse is assessing a client who is postoperative and finds the client's abdominal incision has eviscerated. which of the following actions should the nurse take? a. cover the wound with a sterile saline-soaked dressing b. place the client in high-Fowler's position c. auscultate all quadrants of the abdomen for bowel sounds d. gently re-insert the protruding tissue
a
a nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. the client reports chills and back pain, and the client's blood pressure is 80/64. which of the following actions should the nurse take first? a. stop infusion of blood b. inform provider c. obtain urine specimen d. notify laboratory
a
a nurse is assessing a client who reports acute pain. the nurse should anticipate which of the following findings? a. increased HR b. decreased RR c. hyperactive bowel sounds d. decreased BP
a
a nurse is caring for a client 1 day postoperative following a subtotal thyroidectomy. the client reports a tingling sensation in the hands, the soles of the feet, and around the lips. for which of the following findings should the nurse assess the client? a. chvostek's sign b. babinski's sign c. brudzinski's sign d. kernig's sign
a
a nurse observes mild hand tremors in a client who has diabetes mellitus. which of the following actions should the nurse take after obtaining a glucose meter reading 60 mg/dL a. administer 15g of carbs b. retest blood glucose level c. administer 1 mg of glucagon IM d. administer IV dextrose
a
a nurse working for a home health agency is teaching a client who has diabetes about disease management. which of the following glycosylated hemoglobin values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels? a. 6.3% b. 7.8% c. 8.5% d. 10%
a
client is admitted to ED w RR of 7. ABG reveal 7.22, CO2 68, base excess -2, O2 78, sat 80%, bicarb 26. analysis? a. respiratory acidosis b. metabolic acidosis c. metabolic alkalosis d. respiratory alkalosis
a
A nurse is caring for a client who had a total thyroidectomy and a serum calcium level of 7.6 mg/dl. Which of the following findings should the nurse expect? a. tingling of extremeities b. hypoactive deep tendon reflexes c. shortened QT intervals d. constipation
a (hypocalcemia - at risk for parathyroid injury which can lead to hypocalcemia - nurse should monitor client for reports of tingling and numbness of the extremities and around the mouth, muscle tremors, cramps, and cardiac dysrhythmias)
a nurse is caring for a client who has low magnesium level and is being treated with magnesium sulfate IV. the client's respiratory rate is 10, and deep tendon reflexes are absent. which of the following actions should the nurse take? a. discontinue the med infusion b. make client NPO c. assess BG d. place client in trendelenburg position
a (mag. toxicity is manifested by bradypnea (RR < 12 and absent DTR) stop infusion and admin calcium gluconate via IV)
a nurse is reviewing the ABG results of a client who the provider suspects has metabolic acidosis. which of the following results should the nurse expect to see? a. pH below 7.35 b. HCO3 above 26 c. PaO2 below 70 d. PaCo2 above 45
a (pH should be lower than 7.35; the pH alone doesn't indicate whether the problem is metabolic or respiratory. a pH above 7.45 indicates alkalosis)
a nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury. which of the following electrolyte imbalances should the nurse expect? a. hyperkalemia b. hypernatremia c. hypercalcemia d. hypophosphatemia
a (protein breakdown and subsequent release of intracellular K+ in circulation and kidney can't filter and excrete it)
a nurse is assessing a client who is taking chlorothiazide sodium. the nurse recognizes which of the following as manifestations of hypokalemia. a. shallow respirations b. hypertensive crisis c. diarrhea d. hyperreflexia
a (sign of weakness in accessory muscles of breathing due to hypokalemia)
a nurse is assessing a client who has type 1 diabetes and finds the client lying in bed, sweating, and reporting feeling anxious. which of the following complications should the nurse suspect? a. hypoglycemia b. nephropathy c. hyperglycemia d. ketoacidosis
a (sweating, tachy, tremors, palpitations, hunger, anxiety)
A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.) A. Offer the client a back rub. B. Remind the client to use incisional splinting C. Identify the client's pain level D. Assist the client to ambulate. E. Change the client's position.
a, b, c, e
a nurse is preparing a teaching session about reducing the risk of complications of diabetes. which of the following info should the nurse plan to include in the teaching (SATA) a. reduce cholesterol and saturated fat intake b. increase physical activity and daily exercise c. enroll ina. smoking-cessation program d. sustain hyperglycemia to reduce deterioration of nerve cells e. maintain optimal blood pressure to prevent kidney damage
a, b, c, e
the nurse is reviewing the client's assessment data to prepare the client's plan of care. complete the diagram by dragging from the choices below to specify what condition the client is mostly likely experiencing (54 year old male with hx of type 1 diabetes)
action: administer normal saline bolus, administer IV insulin condition: diabetic ketoacidosis monitor: capillary glucose level, potassium level
a nurse is caring for a client who is being admitted to the medical-surgical unit from the ED. the nurse is reviewing the client's medical records. complete the diagram
action: teach the client about the signs of hyperglycemia, access the client's feet for sensation condition: type 1 diabetes mellitus monitor: fingerstick blood glucose, urinary output
a nurse is caring for a male client who reports abdominal pain. for each potential provider's prescription, click to specify if the potential prescription is anticipated, non essential, or contraindicated for the client
anticipated: administer antibiotics, CT scan of abdomen w/ contrast, change IV fluids, administer analgesic contraindicated: admin of 1 unit of packed RBCs, admin enema now X1
A nurse is caring for a client is receiving hydromorphone HCL (a type of narcotic) via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first? a. administer a bolus of medication b. check the display of the PCA pump c. obtain an order for another pain medication for breakthrough pain d. encourage the client to administer a demand dose
b
A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the clients morning blood glucose level as 210mg/dL instead of 120mg/dL. Based o;n this error, she administered the insulin dose appropriate for a reading over 200 mg/ dL before the clients breakfast. Which of the following error? A. give the client 15 to 20 g of carbohydrates B. monitor the client for hypoglycemia C. complete an incident report D. notify the nurse manager
b
A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain? a. vital sign measurement b. client's self report of pain severity c. visual observation for nonverbal signs of pain d. the nature and invasiveness of the surgical procedure
b
A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching? a. expect ringing in your ears b. take the medication with food c. store the medication in the refrigerator d. monitor for weight loss
b
a nurse is caring for a client who is 5hr postoperative following a transurethral resection of the prostate. the nurse notes that the client's indwelling urinary catheter has not drained in the past hour. which of the following actions should the nurse take first? a. notify provider b. check tubing for kinks c. adjust rate of bladder irrigant d. irrigate the catheter
b
a nurse is providing a client who is newly diagnosed with type 2 diabetes and has a prescription for glipizide. which of the following statements by the nurse best describes the action of glipizide? a. glipizide absorbs the excess carbs in your system b. stimulates your pancreas to release insulin c. replaces insulin that isn't being produced by your pancreas d. prevents your liver from destroying your insulin
b
a nurse is providing teaching about foot care for a client who has type 2 diabetes. which of the following statements by the client indicates an understanding of the teaching? a. i should soak my feet before trimming my nails b. i should buy new shoes late in the day c. i should wear a clean pair of nylon socks every day d. i should use a heating pad at night when my feet feel cold
b
a nurse is teaching a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. which of the following foods should the nurse advise the client to increase in her diet? a. carrots b. broccoli c. cabbage d. potatoes
b
a nurse is collaborating on care for a client who has COPD. which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance? a. instructing how to measure O2 sat b. instructing how to use kitchen tools to prepare a meal c. instruction how to plan a diet based on individual caloric needs d. instructing how to perform pursed-lip breathing
b (fine motor skills and coordination)
a nurse is planning a community diabetes mellitus management program. which of the following goals should the nurse include for the program a. proper foot care will be demonstrated during the program b. clients will have a decreased incidence of foot amputations c. a facility will be reserved for the program d. handouts and teaching materials will be distributed at the program
b (goal is desired result toward which effort is directed)
a nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in past hour. which of the following electrolyte imbalances should the nurse monitor the client for? a. elevated sodium level b. decrease potassium level c. elevated magnesium level d. decreased calcium level
b (hypokalemia is an electrolyte imbalance in which serum potassium is less than 3.5 and can be result of diuretic use, diarrhea, vomiting, prolonged nasogastric suctioning)
a nurse is caring for a female client in the ED who reports shortness of breath and pain in lung area. she states that she started taking birth control pills 3 wks ago and she smokes. her HR is 110, RR 40, BP 140/80, ABG 7.50, PaCo2 29, PaO2 60, HCO3 20, SaO2 86. which of the following is the priority nursing intervention? a. prepare for mechanical vent b. admin O2 via face mask c. prepare to admin a sedative d. assess for indications of pulmonary embolism
b (pH reflects alkalosis and low PaCO2 indicates the lungs are involved = respiratory alkalosis)
a nurse is preparing to administer lispro insulin to a client who has type 1 diabetes. which of the following actions should the nurse take? a. assess for hypoglycemia 4 hr after the insulin injection b. inject the insulin 15min before a meal c. monitor for polyuria d. administer with short-acting insulin
b (rapid acting that has an onset w/in 15-30min and can develop hypoglycemia quickly if they don't eat)
a nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. after administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times? a. 0720 b. 0730 c. 0745 d. 0815
b (regular insulin should be given 20-30min before eating because the onset of action is 30min)
a home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. the client reports difficulty breathing. which of the following actions is the nurse's priority a. increase the O2 flow to 3L/min b. assess the client's respiratory status c. call emergency services for the client d. have the client cough and expectorate secretions
b (so you can determine appropriate interventions)
A nurse is teaching a patient who has COPD about ways to facilitate eating, which of the following statements indicates a need for further teaching? a. "I will rest for at least 30 minutes before eating b. I will take my bronchodilators after meals c. I will eat five or six small meals each day d. I will choose foods that are not gas-forming
b (take before not after to reduce SOB)
a nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes. when mixing the two types of insulin, which of the following actions should the nurse take first? a. inject 10 units of air into the regular insulin vial b. inject 20 units of air into the NPH insulin vial c. withdraw 10 units of insulin from the regular insulin vial d. replace the needle of withdrawal with a safety needle
b (the first action is to do this b/c the insulin is the intermediate-acting insulin which will be drawn up last in order to avoid contaminating the regular insulin with NPH insulin; the nurse will inject 10 units of air into the regular insulin vial after injecting air into the NPH insulin vial after the first action)
a nurse is teaching a client who has COPD and is to start using fluticasone by MDI twice daily. which of the following instructions should the nurse include? a. check your HR before each dose b. inspect your mouth for lesions daily c. this med is to relieve an acute attack d. skip the morning dose if you don't have any symptoms
b (this is a corticosteroid that reduces client's immunity and increases risk for infection - Candida albicans)
a nurse is providing dietary teaching for a client who has COPD. which of the following instructions should the nurse include? a. eat 3 large meals each day b. limit water intake with meals c. reduce protein intake d. use a bronchodilator 1 hour before eating
b (to prevent early satiety and increase the intake of nutrient dense foods, bronchodilator should be administered 30 min before)
a nurse is caring for a client admitted who reports increased urination and thirst. the nurse has assisted the client back to bed and should first address ? followed by ?
blood pressure, sodium level
a nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. the nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia (SATA) polyuria blurred vision polydipsia tachycardia moist, clammy skin
blurred vision tachycardia moist, clammy skin
A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (select all that apply) bounding pulse pitting edema swelling at IV site urine specific gravity greater than 1.030 crackles upon auscultation
bounding pulse pitting edema crackles upon auscultation
A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first? a. auscultate b. percuss c. inspect d. palpate
c
A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first? a. Determine the time the client last received pain medication. b. Measure the client's vital signs, including temperature. c. Ask the client to rate her pain on a scale from 0 to 10. d. Reposition the client and offer her a back rub
c
A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete priority assessment? A) blood pressure B) apical heart rate C) respiratory rate D) temperature
c
A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment? A. BP c. Apical HR c. RR D. Temperature
c
A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? A-Reposition the client. B- Administer the medication. C-Determine the location of the pain. D-Review the effects of the pain medication
c
A nursing is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? A. BP 102/66mmHg B. Straw-colored urine from an indwelling urinary catheter c. Yellow-green drainage on surgical incision d. Respiratory rate 18/min
c
a nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. which of the following assessments should the nurse use to determine whether the treatment is effective a. inspecting the site for reduced swelling b. monitoring the client's pulse rate c. asking the client to rate the pain d. having the client perform range-of-motion of the affected arm
c
a nurse is caring for a client who has uncontrolled type 1 diabetes. which of the following findings should the nurse expect? a. HTN b. hematuria c. weight loss d. bradycardia
c
a nurse is instructing a group of clients regarding calcium rich foods. which of the following foods should the nurse include in the teaching as the best source of calcium?a a. 1/2 cup ice cream b. 1 oz swiss cheese c. 1 cup milk d. 1 cup cottage cheese
c
a nurse is teaching about self-monitoring to a client who has type 1 diabetes. which of the following statements by the client indicates an understanding of the teaching a. i will check my urine once a day for ketones b. i will notify my provider if pre-meal glucose is 120 c. i will check my blood glucose every 4 hrs when im sick d. i will check blood glucose every 5min when lightheaded
c
a nurse is caring for a client who has hypernatremia and requires fluid therapy due to his NPO status which of the following solutions should the nurse prepare to infuse for this client a. lactated ringers b. dextrose 5% in 0.9% sodium chloride c. 0.45% sodium chloride d. dextrose 10% in water
c (a client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride)
a nurse is teaching a client who has diabetes and receives 25 units of NPH insulin every morning if her blood glucose level is above 200 mg/dL. which of the following info should the nurse include? a. discard the NPH solution if it appears cloudy b. shake the insulin vigorously before loading the syringe c. expect NPH insulin to peak in 6-14hr d. freeze unopened insulin vials
c (intermediate acting, onset 1-2hr, peaking 6-14, duration 24hr)
a nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. the nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes? a. HbA1c 5.5% b. 2hr BG 170 mg/dL c. fasting BG 155mg/dL d. casual BG 180 mg/dL
c (meets criteria above 126 mg/dL, HbA1c must be 6.5%<, 2hr must be greater than 200, casual must be greater than 200)
a client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. which of the following actions should the nurse take? a. perform suctioning for up to four passes b. apply suction to the catheter when advancing the trachea c. preoxygenate the client with 100% O2 for up to 3 min d. limit each suction pass to 25sec
c (to prevent hypoxemia, do this for 30sec to 3 min prior to suctioning)
an 80 year old client with a history of type 2 diabetes presents to the emergency department with altered mental status. the nurse reassesses the client at 15:00. which findings indicate the treatment plan has been effective? SATA frequent PVC's capillary glucose respirations BP mental status
capillary glucose, BP, mental status
a nurse is caring for a client who is postoperative following a subtotal thyroidectomy - highlight
client reports tingling around the mouth (manifestation of hypocalcemia) client has a slight tremor noted in both hands client's temp has increased client appears restless
the nurse cares for a 26 year old female on a post surgical unit on the second day after a laparoscopic appendectomy. a nurse is developing a teaching plan for a client with atelectasis. which of the following should the nurse include in the teaching?
coughing and huffing techniques; incentive spirometry; deep breathing exercises; avoiding smoking and secondhand smoke
A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take? a. insert a NG tube b. administer an antiemetic c. encourage use of the incentive spirometer d. auscultate bowel sounds
d
A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse recommend the family members to omit? a. boiled rice b. flat bread c. broiled fish fillet d. pickled vegetables
d
A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make? a. next time you think he needs more medication, call me and I'll push the button b. it's a good idea to help make sure your husband can sleep comfortably c. why do you think your husband needs more medication when he is asleep? d. your husband should decide when more medication is needed
d
a hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. the client reports that he had to increase the dose of morphine this week to obtain pain relief. which of the following scenarios should the nurse document as the explanation for this situation? a. client hasn't been taking the medication properly b. the client is experiencing episodes of confusion c. the client has become addicted to the medication d. the client has developed a tolerance to the medication
d
a nurse is administering morphine 2mg IV every 2-4hr to a client who has an abdominal incision. the nurse should monitor the client for which of the following adverse effects? a. diarrhea b. heart burn c. hiccups d. orthostatic hypotension
d
a nurse is assessing a client who has COPD. the nurse should expect the client's chest to be which of the following shapes? a. pigeon b. funnel c. kyphotic d. barrel
d
a nurse is caring for a client who has diabetes and a new prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. what is the total number of units of insulin that the nurse should prepare in the insulin syringe? a. 14 units b. 28 units c. 32 units d. 42 units
d
a nurse is developing a plan of care for a client who has COPD. the nurse should include which of the following interventions in the plan? a. restrict client's fluid intake to less than 2L/day b. provide the client with a low-protein diet c. have the client use the early-morning hours for exercise and activity d. instruct the client to use pursed-lip breathing
d
a nurse is preparing to administer morphine 4 mg IV bolus to a client who reports pain. Available is morphine 10mg/mL. which of the following actions should the nurse take? a. discard the extra medication in a sharps container b. save the extra medication for a later dosing c. send the waste amount to the pharmacy d. have another nurse witness the disposal of the extra medication
d
a nurse is caring for a client who has a long history if diabetes mellitus and is being admitted to the ED confused, flushed, and with an acetone odor on the breath. diabetic ketoacidosis is suspected. the nurse should anticipate using which of the following types of insulin to treat this client? a. NPH insulin b. insulin glargine c. insulin detemir d. regular insulin
d - Regular Insulin - short acting insulin with an onset action of less than 30 mins. Used in emergency situations of severe hyperglycemia or diabetic ketoacidosis - Insulin detemir is intermediate-acting, with an onset of 1 hr. - Insulin glargine is a long acting, with onset of 2 to 4 hr - NPH insulin is intermediate- acting, with a 1 to 3 hr onset
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being a risk for fluid volume deficit a. NPO since midnight for endoscopy b. left sided heart failure and has brain natriuretic peptide BNP level of 600 pg/mL c. client who has end stage renal failure and is scheduled for dialysis today d. client who has gastroenteritis and is febrile
d (client has two risk factors for the development of fluid volume deficit, or dehydration. gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a signifiant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. consequently, this client is at greatest risk for fluid volume deficit)
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions a. maintaining a semi-fowler's position as often as possible b. admin O2 via nasal cannula at 2L/min c. helping client select a low-salt diet d. encouraging the client to drink 2-3 L of water daily
d (help liquefy thick secretions and facilitate expectoration)
a 74 year old female is admitted to the ED with increasing dyspnea, productive cough and fatigue. the albuterol tx has been given. what med should the nurse administer next? a. acetaminophen b. amoxicillin/clavulanate c. albuterol d. methylprednisolone sodium succinate
d (it's ordered to be given now and will help decrease inflammation)
a nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to tx heart failure. the nurse should explain that which of the following medications puts the client at risk for both hyperkalemia and hyponatremia? a. furosemide b. hydrochlorothiazide c. metolazone d. spironolactone
d (potassium sparing diuretic and adverse rxns include hyperkalemia and hyponatremia)
client presents to the ED reporting that he dropped his pill box 3 days ago and when he put the medications back in the box he thinks he replaced the incorrectly. laboratory results indicate electrolyte imbalances. s/s consistent with hypokalemia, hypomagnesemia, or both
hypokalemia: skeletal muscle weakness, respiratory arrest hypomagnesemia: seizure, hyperactive reflexes both: dysrhythmias
the nurse cares for a 26 year old female on a post surgical unit on the second day after a laparoscopic appendectomy. the nurse assesses the client at 15:00. for each potential finding, click to specify if the finding indicates that the client's status has improved, declined, or unchanged
improved: pain level, O2, lung sounds declined: temp unchanged: cough
a 70 year old client with a history of COPD is admitted to the ED with increasing dyspnea. at 10:45 the nurse assess the client's vital signs after administering the ordered nebulizer treatment. for each finding, indicate if the client's status has improved, declined, or is unchanged after admin of nebulizer treatment
improved: temperature, wheezing declined: BP, pulse ox, RR, HR, breath sounds unchanged: cough
a 74 year old female is admitted to the ED with increasing dyspnea, productive cough and fatigue. the nurse administers the ordered meds and reassesses the client at 10:45. for each client finding indicate if the status has improved, declined, or unchanged
improved: wheezing declined: RR, breath sounds, BP, pulse ox unchanged: temperature
a nurse is assessing a client who has fluid overload. which of the following findings should the nurse expect? SATA increased HR increased BP increased RR increase hematocrit increased temp
increased HR increased BP increased RR
an 80 year old client with a history of type 2 diabetes presents to the emergency department with altered mental status. the client is diagnosed with HHS and the nurse begins to plan care. for each intervention click whether the intervention is indicated or contraindicated insert indwelling foley catheter monitor intake and output administer IV potassium initiate telemetry monitoring place client in tripod position
indicated: monitor I&O, admin IV potassium, initiate telemetry monitoring contraindicated: insert indwelling foley catheter, place client in tripod position
the nurse cares for a 26 year old female on a post surgical unit on the second day after a laparoscopic appendectomy. the client is diagnosed with mild atelectasis. for each intervention indicate indicated or contraindicated
initiate bed rest - contra ambulate in hall - indicated supine position - contra cough and deep breath - indicated incentive spirometer - indicated
an 80 year old client with a history of type 2 diabetes presents to the emergency department with altered mental status. for each finding specify if it is consistent with ketoacidosis or HHS older age hyperglycemia kussmaul respirations dehydration fruity breath tachycardia ketones present in urine
ketoacidosis: hyperglycemia, kussmaul resps. dehydration, fruity breath, tachycardia, ketones present HHS: older age, hyperglycemia, dehydration, tachycardia
an 80 year old client with a history of type 2 diabetes presents to the emergency department with altered mental status. which of the 4 findings are most significant? mental status home medications respiratory status circulation lung sounds history of type 2 diabetes
mental status respiratory status circulation history of type 2 diabetes
a nurse is caring for a 78 year old who was recently admitted from the ED and is reporting weakness. the client is at risk for ? and ?
metabolic acidosis and hypernatremia
an 80 year old client with a history of type 2 diabetes presents to the emergency department with altered mental status. which actions should the nurse take when caring for a client with HHS? SATA admin a bolus of dextrose to quickly raise BG levels monitor BG levels frequently encourage client to consume high-carb diet restrict fluid intake to prevent further electrolyte imbalances encourage client to drink plenty of fluids administer regular insulin as prescribed
monitor BG levels frequently encourage client to drink plenty of fluids administer regular insulin as prescribed
a nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. which of the following sets of values should the nurse expect?
pH 7.25, HCO3 - 19, PaCo2 30 (metabolic acidosis characterized by low HCO3-, low pH, and low/normal CO2)
a 74 year old female is admitted to the ED with increasing dyspnea, productive cough and fatigue. select an order the nurse should include in the plan of care at this time the nurse anticipated the provider's orders and considers possible nursing interventions. select an order the nurse should include in the plan of care at this time: Nursing order ?. Medication order?
place pt in tripod position and administer methylprednisolone (which will decrease inflammation)
for each client finding indicate if the finding is consistent with pneumonia, post-operative atelectasis, pulmonary embolism, or fluid overload. each finding may have more than one type of condition.
pneumonia: diminished breath sounds, low grade fever, decrease O2, cough w/ mucus atelectasis: diminished breath sounds, decreased O2 pulmonary embolus: diminished breath sounds, decreased O2 pulmonary edema: diminished breath sounds, wt gain, decreased O2
a nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. which of the following factors should the nurse include in the teachings? SATA poor nutritional state altered mental status obesity pain medication administration wound infection
poor nutritional state obesity wound infection
the nurse cares for a 26 year old female on a post surgical unit on the second day after a laparoscopic appendectomy. the nurse recognizes that the client is likely experiencing
post operative atelectasis
the nurse cares for a 26 year old female on a post surgical unit on the second day after a laparoscopic appendectomy. the nurse considers that can cause post-operative respiratory distress. for each finding indicate the finding that it's consistent with
post operative atelectasis: crackles, decreased pulse oximeter, tachypnea pulmonary embolism: tachypnea, crackles, decreased pulse oximeter fluid overload: crackles, wt gain, decreased pulse oximeter, tachypnea
a nurse is caring for a client who has severe right wrist pain. the client is at risk for developing ? and ?
respiratory acidosis and hypervolemia
an 80 year old client with a history of type 2 diabetes presents to the emergency department with altered mental status. complete the sentence: the problem the nurse should address first is ? (for a patient with HHS) - correcting pH - restoring fluid volume - lowering glucose
restoring fluid volume
the nurse cares for a 26 year old female on a post surgical unit on the second day after a laparoscopic appendectomy. which assessment findings are most concerning to the nurse?
temperature of 100.0; feeling short of breath; pulse rate
a home health nurse is visiting a client. for each statement click to specify if the statement indicates an understanding of the teaching or a need for further teaching: i should try to vary the times I eat from day to day I am able to eat as many vegetables as i want since they are not carbohydrates my family member bought nonnutritive sweetener to use in my coffee i only need to take the metformin if i eat foods with carbohydrates instead of using white bread, i should use whole wheat bread i should no longer eat ice cream i should keep my sodium intake to less than 2300mg/day
understanding: my family member bought nonnutritive sweetener to use in my coffee instead of using white bread, i should use whole wheat bread i should keep my sodium intake to less than 2300mg/day further teaching: i should try to vary the times I eat from day to day I am able to eat as many vegetables as i want since they are not carbohydrates i only need to take the metformin if i eat foods with carbohydrates i should no longer eat ice cream
a 74 year old female is admitted to the ED with increasing dyspnea, productive cough and fatigue - highlight the findings that require immediate follow up
worsening SOB, cough, sputum, fatigue are important s/s to report. use of inhaler with no relief and abnormal respiratory assessment are priority to report + has course crackles in bilateral lower lung fields with a barrel chest appearance, using accessory muscles, expiratory wheezes on auscultation
a nurse is caring for a client who had abdominal surgery 3 days ago. the client is at risk for developing ? and ?
wound infection + dehiscence
