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The client is seen in the emergency department with pustules to the left arm. Wound cultures reveal methicillin-resistant Staphylococcus aureus (MRSA). Which action would the nurse take? 1. Place client in a private room. 2. Ask client to stay in hospital room. 3. Have visitors wash hands before entering and after leaving client's room. 4. Wear an N95 mask when entering client's room. 5. Implement airborne precautions.

1., 2., & 3. Correct: patients with MRSA will have a single room or will share a room only with someone else who also has MRSA. Patients are asked to stay in their hospital rooms as much as possible. They should not go to common areas, such as the gift shop or cafeteria. They may go to other areas of the hospital for treatments and tests. The number one way to prevent the spread of infection is through proper hand hygiene. 4. Incorrect: Contact isolation should be instituted, so an N95 mask is not needed. 5. Incorrect: The client is placed on contact precautions not airborne precautions.

A client was admitted 48 hours ago in septic shock. Treatment included oxygen at 40% per ventimask, IV therapy of Lactated Ringer's (LR) at 150 mL/hr, vancomycin 1 gram IV every 8 hours, and methylprednisolone 40 mg IVP twice a day. Which clinical data indicates that treatment has been successful? You answered this questionIncorrectly 1. pH- 7.35; pCO2- 44; pO2 -92; HCO3- 22 2. Skin cool, mottled 3. Urinary output of 300 mL/8 hr 4. Vital signs: Blood pressure 90/52; HR 110; RR 22 5. WBC 10,500/mm3 (10.5 x 10^9)/L

1., 3., & 5. Correct: This ABG result shows not acid/base imbalance. The results are normal. Urinary output should be adequate if treatment is successful. The urinary output should be at least 30 mL/hr for an adult. 300 mL over 8 hours is adequate at an average of 37.5 mL/hr. The white blood cell count is within normal limits. 2. Incorrect: Incorrect: Mottled, cyanotic skin is not good. This client would not be getting better with mottled skin. 4. Incorrect: The systolic BP is 90 which generally means that the client is perfusing vital organs. However, look at the heart rate. Tachycardia. The client is compensating to perfuse vital organs. This client is still sick.

A nurse is caring for a client who was admitted with severe dehydration due to excessive vomiting. Which data noted by the nurse validates this diagnosis? 1. Atrial fibrillation 2. Capillary refill 2 seconds 3. Eyes appear sunken 4. Hematocrit 55% 5. Several small furrows on tongue

1., 3., 4., & 5. Correct: These are signs and symptoms indicating that a client is dehydrated (fluid volume deficit). 2. Incorrect: This is a normal capillary refill.

Based on the results of the arterial blood gases (ABGs), what imbalance does the nurse understand the client to be exhibiting? pH - 7.36 PaCO2 - 55 HCO3 - 32 O2 - 93% 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

2., & 7. Correct: The pH is 7.36 normal (normal 7.35-7.45). But the paCO2 of 55 (normal 35-45) indicates a acidosis. The HCO3 is also abnormal at 32 (normal 22-26), indicating alkalosis. Since both chemicals are abnormal, but the pH is normal, compensation must have occurred. A perfect pH is 7.4. A pH of 7.36 is on the acid side of normal. So the original problem was acidosis. Which chemical abnormality matches acidosis? The CO2 is acid. This means that the client is in fully compensated respiratory acidosis.

An elderly, bed-bound client receiving G-tube feedings at home is admitted to the unit after onset of behavioral changes and hallucinations. Which nursing actions should the nurse initiate? 1. Administer furosemide 20 mg IVP 2. Frequent mouth care 3. Provide 250 mL water via G-tube every 6 hours 4. Seizure precautions 5. Start IV of 0.9% Normal Saline

2., 3., & 4. Correct: Oral mucous membranes become dry and sticky due to loss of fluid in the interstitial spaces so mouth care should be provided frequently. The client is dehydrated with a high sodium level because of the high solute tube feeding. The client needs water and a sodium free IV fluid. high sodium levels in the blood leads to dehydration of brain cells resulting in changes in mental status, ranging from drowsinness, restlessness, confusion, and lethargy to seizures and coma. Seizure precautions is necessary. 1. Incorrect: The client is dehydrated. A diuretic would make it worse. 5. Incorrect: This is an isotonic sodium fluid. The client does not need more sodium.

What should the nurse monitor for when caring for a client receiving an IV infusion of 5% Normal Saline? 1. Hypotension 2. Fluid volume deficit 3. Hyponatremia 4. Phlebitis

4. Correct: 5% NS is a hypertonic solution. Hypertonic fluids contain a higher concentration of solute compared to plasma and interstitial fluid. This creates an osmotic gradient and drives fluid from the interstitial space into the intravascular space. which causes fluid to stay in the vascular space. Hypertonic solutions are irritating to veins and can cause phlebitis. 1. Incorrect: Hypertension can occur with isotonic and hypertonic IV solutions. Hypotension can occur with hypotonic IV solutions such as 1/2 Normal Saline. 2. Incorrect: Fluid volume excess can occur with isotonic and hypertonic solutions. 3. Incorrect: Hypernatremia can occur with isotonic and hypertonic sodium solutions.

A intubated client has been admitted to the emergency department via ambulance with sustained burns to the upper torso, face, and neck as a result of a steam injury when a pressure cooker exploded at home. Which intervention is the nurse's priority? 1. Obtain blood for arterial blood gases. 2. Connect client's endotrachial tube to a ventilator. 3. Administer 1000mL of lactate ringers (LR). 4. Assess for head and neck injuries.

4. Correct: Once the client's airway is protected with an endotracheal tube, then the nurse can perform an assessment. In addition to the burns, the client may have a neck injury. So, the client should be evaluated for any head and neck injuries. 1. Incorrect: Arterial blood gases can be ordered but assess the client first. 2. Incorrect: The client can be connected to a ventilator if needed, but at present the airway is being protected by the ET tube. Nothing was said to indicate that ventilation assistance is needed at present. 3. Incorrect: Fluid resuscitation is needed, however, assess the client for injuries first.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? pH - 7.48 PaCO2 - 30 HCO3 - 23 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

4., & 5. Correct: The blood gases confirm respiratory alkalosis. Why? The pH is 7.48 (normal 7.35-7.45). This pH indicates alkalosis since it is high. Which other chemical says alkalosis? The PaCO2 of 30 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that the client is in uncompensated respiratory alkalosis.

An intravenous infusion of 5% dextrose in water is prescribed at a rate of 1000 mL in 8 hours. The tubing has a drop factor of 15. How many drops per minute (gtts/min) are delivered? Round your answer to the nearest whole number.

The formula used to calculate drop rates is the total number of milliliters divided by the total number of minutes multiplied by the drop factor. In this circumstance, the minutes portion must be figured first, that is, 8 hours equals 480 minutes. Then, dividing 1000 by 480 equals 2.08333333. This is multiplied by the drop factor, which is 15. Multiplying 15 by 2.08333333 equals 31.25, which rounds to 31.

pH - 7.32 PaO2 - 93% PaCO2 - 33 HCO3 - 19

metabolic acidosis partially compensated 1., & 6. Correct: This set of ABGs reflects partially compensated metabolic acidosis. The pH, bicarb, and carbon dioxide are all abnormal, so compensation is beginning. Since the pH is not normal yet, total compensation has not occurred. There is only partial compensation.

Which clinical manifestations would validate to the nurse that a client has developed an electrolyte imbalance due to malabsorption from celiac disease? 1. Anorexia 2. Arrhythmia 3. Doll's eyes 4. Paralysis 5. Seizure

1., 2., & 5. Correct: Low magnesium is typically due to decreased absorption of magnesium in the gut or increased excretion of magnesium in the urine. Conditions that increase the risk of magnesium deficiency include gastrointestinal (GI) diseases, such as Celiac disease, advanced age, type 2 diabetes, use of loop diuretics, and alcohol dependence. Early signs of low magnesium include nausea, vomiting, weakness, and decreased appetite. As magnesium deficiency worsens, symptoms may include numbness, tingling, muscle cramps, seizures, muscle spasticity, personality changes, dysrhythmias, tremors, hyperactive deep-tendon reflexes, hyperreactivity to sensory stimuli, positive Chvostek and Trousseau signs, tetany, and nystagmus. 3. Incorrect: Typically the doll's eyes reflex is elicited by turning the head of the unconscious patient while observing the eyes. The eyes will normally move as if the patient is fixating on a stationary object. If there is a negative doll's eyes reflex then the eyes remain stationary with respect to the head. 4. Incorrect: A low magnesium level goes muscle to become hyperactive.

The Emergency department nurse is caring for a client who has sustained a high-voltage electrical injury. Which intervention should the nurse initiate? 1. Initiate continuous cardiac monitoring. 2. Identify entrance and exit wounds. 3. Give analgesic by mouth as needed. 4. Keep burned limbs below the level of the heart. 5. Cover burned areas with clean sheets.

1., 2., & 5. Correct: These are correct interventions for the nurse to initiate when caring for a client who has sustained a high-voltage electrical injury. Remember, electricity kills vessels, nerves, and organs. Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. Electrical burns have two wounds: an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. In the emergent phase of care, the nurse needs to protect the wound from contaminants. Cover burned areas with dry dressings or a clean sheet. 3. Incorrect: Analgesics by mouth will not be as effective as IV analgesics during the emergent phase. 4. Incorrect: The burned limb should be elevated above the level of the heart to decrease peripheral edema.

What is the nurse's priority when treating a client admitted with a full thickness thermal burn over 30% of the body? 1. Insert a urinary catheter 2. Establish IV access of Normal Saline 3. Administer fentanyl (1 mcg/kg) IV 4. Apply antibiotic ointment and dressing to burns

2. Correct: The priority action for this client is fluid resuscitation. 1. Incorrect: The kidneys need to be monitored, but fluid resuscitation should begin first. 3. Incorrect: IV pain medication can be given after the IV is started. 4. Incorrect: The other three options take priority.

A nurse is caring for a client who had a cholecystectomy 4 hours ago. What interpretation should the nurse make based on the results of the client's arterial blood gases (ABGs)? pH - 7.31 PaCO2 - 49 HCO3 - 22 O2 - 92% 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

2., & 5. Correct: The pH is 7.31 (normal 7.35-7.45) which means acidosis. The paCO2 of 49 (normal 35-45) indicates a respiratory problem. The arterial blood gas results indicate that the client is in respiratory acidosis. The HCO3 is normal. This means that the client is in uncompensated respiratory acidosis.

A client arrives in the emergency department in a postictal state after having a seizure for the first time. The nurse notes peripheral edema to the lower extremities. BP 100/68, Resp 18, HR 86. Family reports client has taken "a lot of antacids for indigestion over the past 48 hours. Current health history includes chronic renal failure. What acid/base imbalance does the nurse anticipate for this client? You answered this questionCorrectly 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4. Correct: This client's condition indicates metabolic alkalosis. Antacid use won't normally lead to metabolic alkalosis. But if you have weak or failing kidneys and use a nonabsorbable antacid, it can bring on alkalosis. Nonabsorbable antacids contain aluminum hydroxide or magnesium hydroxide. The client has had a seizure for the first time, which is a sign of metabolic alkalosis when combined with the rest of the client's history. 1. Incorrect: This client has no respiratory symptoms. This is not respiratory acidosis. 2. Incorrect: This client has no respiratory symptoms. This is not respiratory alkalosis. 3. Incorrect: This client's condition is related to chronic renal failure.

A client is admitted for treatment of fluid volume deficit. The nurse reviews the admitting lab work and the primary healthcare provider's prescriptions. Which prescription would be of concern to the nurse? 1. Diet 2. Furosemide 3. IV infusion 4. Potassium Chloride (KCL)

furosemide 2. Correct: The client is in a fluid volume deficit. Furosemide is a loop diuretic which can be prescribed to get rid of excess fluid in the vascular space. Giving this medication will worsen the fluid volume deficit. 1. Incorrect: This client needs sodium so can be on a regular diet. Sodium will help retain fluid. 3. Incorrect: The IV prescription is for normal saline, which is an isotonic solution. What will this fluid do? Stay in the vascular space, thus helping to correct the fluid volume deficit. 4. Incorrect: A potassium supplement is needed because the client's potassium is low.

A client arrives at the emergency department after being removed from a burning building. The nurse suspects carbon monoxide poisoning when the client exhibits which signs and symptoms? You answered this questionCorrectly 1. Dizziness 2. Epigastric pain 3. Excess salivation 4. Premature ventricular contractions 5. Sweet aromatic odor to breath

1. & 4. Correct: Not enough oxygen is getting to the vital organs, such as the brain and heart, so dizziness, blurred vision, a dull headache, cardiac arrhythmias and respiratory depression can occur. 2. Incorrect: Epigastric pain is not a manifestation of carbon monoxide poisoning. The client will typically report nausea and might vomit. 3. Incorrect: Excessive salivation can be seen with ingestion of acids or alkalis. 5. Incorrect: The client will not have a sweet aromatic odor to breath to the breath with carbon monoxide poisioning. This odor occurs with ethylene glycol poisoning.

The community health nurse has been educating a group of college students living in a dormitory about receiving an immune globulin (IG) injection for hepatitis A virus (HAV). Which statement made by the students would indicate to the nurse that further teaching is necessary? You answered this questionCorrectly 1. Immune globulin contains antibiotics that destroy the HAV, preventing infection. 2. Immune globulin protection is temporary. 3. Common side effects of Immune globulin include soreness and swelling around the injection site. 4. It is important to take IG within four weeks of any exposure to hepatitis A. 5. Crowded living environments such as dormitories place people at risk for HAV.

1., & 4. Correct: Immune globulin contains antibodies that destroy the HAV, preventing infection. It's very important to take IG within two weeks of any exposure to hepatitis A. 2. Correct:This is a correct statement about immune globulin for Hepatitis A, indicating that teaching has been effective. 3. Correct:This is a correct statement about immune globulin for Hepatitis A, indicating that teaching has been effective. 5. Correct: This is a correct statement about immune globulin for Hepatitis A, indicating that teaching has been effective

A nurse is caring for a client who is on bed rest following admission to the hospital two days ago with a diagnosis of new onset heart failure. While evaluating the client's progress, what assessment findings would indicate to the nurse that treatment has been effective? 1. CVP 6 mmHg 2. 3.8 kg weight loss in 24 hours 3. Pink, frothy sputum 4. S3 heart sound 5. Urinary output 320 mL/8 hrs 6. Dyspnea on exertion

1., 2., & 5. Correct: These are all signs that the client is getting better. This is a normal CVP value, which would indicate the client is improving. A weight loss of 3.8 kg in 24 hours is a good thing. Excess fluid is being removed from the body. A urinary output of 320 mL in 8 hours is good. That averages out to 40 mL/hr. 3. Incorrect: Pink, frothy sputum means that there is fluid in the lungs. This is not a sign of improvement. 4. Incorrect: A S3 heart sound is often an indication of heart failure. 6. Incorrect: Dyspnea on exertion is not a sign of improvement.

The nurse is caring for a client admitted to the unit with heart failure. Opon entering the room, the nurse notes that the client is agitated, gasping for air, and attempting to sit up. The client states "I can't get my breath". What actions should the nurse take? You answered this questionCorrectly 1. Elevate the head of the bed to sitting position 2. Elevate client's legs on two pillows 3. Initiate oxygen at 2 liters per nasal cannula 4. Initiate IV of lactated ringers 5. Administer morphine 2 mg IV

1., 3., & 5. Correct: What are you worried about? The client has heart failure and is now agitated, gasping for air and trying to sit up. The client is in acute distress, likely from pulmonary edema. The first thing the nurse should do is to sit the client up. This allows for better chest expansion, thereby improving pulmonary capacity. Oxygen increases available oxygen for myocardial uptake to combat effects of hypoxia. Morphine decreases vascular resistance and venous return, reducing myocardial workload, especially when pulmonary congestion is present. Allays anxiety and breaks the feedback cycle of anxiety to catecholamine release to anxiety. 2. Incorrect: Do not elevate the legs when the client is in an acute stage of respiratory difficulty. By dangling the legs, blood is pooling in the periphery. This decreases the circulating blood volume so that the heart does not have to work as hard and blood will then go in a forward direction rather than going backward to the lungs. 4. Incorrect: Lactated Ringers is an isotonic solution, which stays in the vascular space. This will make the problem worse.

A client's arterial blood gas report has arrived at the nurses' station. Based on the results what interventions are required by the nurse? pH - 7.47 PaCO2 - 29 HCO3 -23 PO2 95%. 1. Start oxygen at 2 liters/min 2. Instruct client on taking slow deep breaths 3. Monitor serium sodium level 4. Initiate safety precautions 5. Administer sodium bicarbonate 1 ampule IVP

2., & 4. Correct: This client is in respiratory alkalosis and it's acute because the kidneys have not kicked in. Fix the problem by slowing the respirations and rebreathing the CO2. The hyperventilating client is either in a panic or hysterical so calm them and give an anxiolytic if necessary. Safety precautions are needed because dizziness and faintness can occur with respiratory alkalosis. 1. Incorrect: The client does not have an oxygen problem; they have a CO2 problem. Their O2 is normal. 3. Incorrect: Potassium, rather than socium needs to be monitored. Hypokalemia may occur as potassium is lost (urine) or shifted into the cell in exchange for hydrogen in an attempt to correct alkalosis. 5. Incorrect: The bicarb is normal. A benzodiazepine or anxiolytic medication can be given to slow the client's respiratory rate.

An elderly, confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the unlicensed assistive personnel? You answered this questionCorrectly 1. Perform a physical assessment. 2. Start an IV of NS with KCL 20 mEq at 50 mL/hr. 3. Insert a urinary catheter. 4. Weigh the client.

4. Correct: The UAP can weigh clients. 1. Incorrect: This is a new client admit. The RN should perform the physical assessment. 2. Incorrect: The RN should start an initial IV with a potassium supplement. The LPN can hang maintenance bags with premixed potassium supplements after that. 3. Incorrect: The LPN or RN can insert an indwelling urinary catheter.

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education was successful when a nurse selects which set of ABGs as compensated respiratory alkalosis? 1. pH - 7.46, PaCO2 - 30, HCO3 - 26 2. pH - 7.45, PaCO2 - 35, HCO3 - 25 3. pH - 7.36, PaCO2 - 43, HCO3 - 24 4. pH - 7.43, PaCO2 - 31, HCO3 - 20

4. Correct: This set of ABGs indicate compensated respiratory alkalosis. The pH is normal, but on the alkalotic side of normal (normal 7.35-7.45; perfect is 7.4). The PaCO2 is low, indicating alkalosis, so it matches the alkalotic pH. The bicarb are low at 20 which indicates acidosis. The bicarb is low to get rid of base. Compensation has occurred. 1. Incorrect: pH - 7.46, PaCO2 - 30, HCO3 - 26. The pH is high. The PaCOs is low. The bicarb is normal. This is uncompensated respiratory alkalsosis. 2. Incorrect: pH - 7.45, PaCO2 - 35, HCO3 - 25. All of these values are normal. No acid base problem here. 3. Incorrect: pH - 7.36, PaCO2 - 43, HCO3 - 24. The pH is normal. The PaCO2 is normal. The bicarb is normal.

A nurse is caring for a client that is lethargic and has the following ABGs: pH = 7.32, PaCO2 = 48, HCO3 = 28, O2 = 93%. What medication could contribute to these blood gases? 1. Famotidine 2. Hydrochlorothiazide 3. Hydrocortisone 4. Promethazine 5. Midazolam 6. Oxymorphone

4., 5., & 6. Correct: Yes. These medications typically decrease the respiratory rate, causing respiratory acidosis. 1. Incorrect: Famotidine is a Histamine 2 blocker. It does not affect breathing patterns. 2. Incorrect: Diuretics do not affect breathing patterns. 3. Incorrect: Steroids do not affect breathing patterns.

The nurse is assigned to care for 5 adult clients. In what order should the nurse care for these clients? The client with full thickness burns to the posterior chest who has a temperature of 102°F (38.8°C) and a blood pressure of 88/52 The client admitted with electrical burns 8 hours ago and has a serum potassium level of 5.2 mEq/L. the client with partial thickness arm burns who has a temperature of 99°F (37.2°C) and a blood pressure of 92/66. The client with facial burns 3 days ago who has been crying since recent visitors left. The client who is to receive an analgesic 30 minutes prior to wound debridement in 2 hours.

The client admitted with electrical burns 8 hours ago and has a serum potassium level of 5.2 mEq/L. The client with full thickness burns to the posterior chest who has a temperature of 102°F (38.8°C) and a blood pressure of 88/52 he client with partial thickness arm burns who has a temperature of 99°F (37.2°C) and a blood pressure of 92/66. The client who is to receive an analgesic 30 minutes prior to wound debridement in 2 hours. The client with facial burns 3 days ago who has been crying since recent visitors left. The nurse should first see is the client with full thickness burns to the posterior chest who has a temperature of 102°F (38.8°C) and a blood pressure of 88/52. This client's vital organs are not going to be perfused properly with this BP and shock is a major concern. The client's temperature is also too high - worry about infection. The nurse should see the client admitted with electrical burns 10 hours ago and has a serum potassium level of 5.2 mEq/L next. The potassium is high normal, placing the client at risk for heart problems (dysrhythmias). The nurse should see the client with the partial thickness arm burns who has a temperature of 99°F (37.2°C) and a blood pressure of 92/66 third. This client has a a low grade fever and a low normal BP. The client needs to be monitored closely for risk of shock. But at present this client is more stable than the client with a high potassium. The fourth client the nurse should see is the client who has been crying. Don't let facial burns throw you. This burn is 3 days old and swelling would be decreasing at this point. Physical problems take priority over psychological problems. This client is the more stable than the first two that should be seen. However, the client scheduled for wound debridement does not need pain medication for 1 1/2 hours and can be the last client seen.