Eucalyptus and sweet orange

1. The charge nurse observes an inexperienced staff nurse caring for a client who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires intervention by the charge nurse? -The nurse assesses neurological status every hour. -The nurse elevates the head of the bed to 30 degrees. -The nurse administers an analgesic before turning the client. -The nurse has client performing deep-breathing and coughing.

The nurse has client performing deep-breathing and coughing.

15. A client is admitted with Guillain-Barré syndrome (GBS). There was weakness in the feet and ankles that has now progressed to weakness with numbness and tingling in both legs. During the acute phase of the illness, the nurse understands which aspect of the condition? -Voluntary motor neurons are damaged by inflammation, while the autonomic nervous system is unaffected. -The priority of care requires monitoring the respiratory rate and depth, and vital capacity. -Early corticosteroid treatment suppresses the immune response and prevents ascending paralysis. -The most serious complication is ascending demyelination of the peripheral nerves of the lower brainstem.

The priority of care requires monitoring the respiratory rate and depth, and vital capacity.

88. True of false: Hypertension is the most common cause of intracerebral hemorrhage.

True

5. After teaching a patient about advance directives, a nurse assesses the patient's understanding. Which statement indicates that the patient correctly understands the teaching? -"An advance directive will allow me to keep my money out of the reach of my family." -"An advance directive will be completed as soon as I'm incapacitated and can't think for myself." -"An advance directive will specify what I want done when I can no longer make decisions about health care." -"An advance directive will keep my children from selling my home when I'm old."

"An advance directive will specify what I want done when I can no longer make decisions about health care."

80. A nurse discusses inpatient hospice with a patient and the patient's family. A family member expresses concern that her loved one will receive only custodial care. How will the nurse respond? -"Your relative is unaware of her surroundings and will not notice the difference between her home and a long term care facility." -"The goal of hospice care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left." -"A long term care facility is like a nursing home and costs less than a hospital because only pain medications are given." -"Hospice care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop."

-"The goal of hospice care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left."

69. The emergency room nurse is triaging four clients involved in a multiple vehicle accident. Which client should receive PRIORITY treatment? -A 5-year old with superficial facial lacerations. -A 36-year old with blunt abdominal trauma -A 42-year old with dyspnea and chest asymmetry. -A 16-year old with a closed humerus fracture.

-A 42-year old with dyspnea and chest asymmetry.

45. For which of these clients will it be MOST important for the nurse to monitor continuous pulse oximetry? -A client with acute pulmonary edema who is newly admitted to the unit. -A client who has just received morphine sulfate for postoperative pain. -A client with emphysema and a respiratory rate of 16 breaths/min. -A morbidly obese pre-operative client who is refusing to get out of bed.

-A client with acute pulmonary edema who is newly admitted to the unit.

9. A client has developed cardiogenic shock from a severe myocardial infarction resulting in acute kidney injury (AKI). The client's family is wondering why the client has developed renal failure. On what etiology of AKI should the nurse should base the response to the family? -An obstruction of urine flow from the kidneys. Formation of a thrombus in the kidneys. -A decrease in blood flow to the kidneys. -Direct kidney damage resulting in acute tubular necrosis (ATN). -A decrease in blood flow to the kidneys.

-A decrease in blood flow to the kidneys.

22. A patient present to the Emergency Room with a blood pressure of 220/110, a tearing pain in his abdomen with acute onset, and complaining of a headache. The patient has a history of coronary artery disease, smoking, atherosclerosis, and Marfan syndrome. The triage nurses sends the patient back as emergent due to what suspicion of cause of symptoms? -Hypertensive crisis. -Thrombotic stroke. -Abdominal aortic aneurysm. -Acute myocardial infarction.

-Abdominal aortic aneurysm.

84. Which of the following interventions has been demonstrated to decrease the incidence of ventilator-associated pneumonia? -Deflate endotracheal tube cuff before suctioning. -Maintain head of bed 20 degrees or higher. -Provide sedation to keep RASS score -3. -Adhere to an oral care protocol.

-Adhere to an oral care protocol.

25. A patient with persistent atrial flutter is scheduled for elective cardioversion. What intervention should the nurse anticipate performing first? -Administer a sedative before the procedure is begun. -Check the incision for bleeding after the procedure. -Set the energy level to 300 joules to convert the rhythm. -Turn the synchronizer switch to the off position.

-Administer a sedative before the procedure is begun.

59. When opening the airway of an unresponsive trauma patient in the emergency department, which of the following considerations is correct? -Flexion of the neck protects the patient from further injury. -Hyperextension of the neck is the only acceptable technique. -Airway assessment incorporates cervical spine immobilization. -Airway patency takes priority over cervical spine immobilization.

-Airway assessment incorporates cervical spine immobilization.

26. An adult client is diagnosed with disseminated intravascular coagulation (DIC). In planning for care, the nurse identifies that the client is a risk for which of the following nursing diagnoses? -Alteration in tissue perfusion related to bleeding and diminished blood flow. -Disturbed sensory perception related to interstitial bleeding. -Risk for increased cardiac output related to fluid volume excess. -Risk for aspiration related to constriction of the respiratory musculature.

-Alteration in tissue perfusion related to bleeding and diminished blood flow.

81. Which client is at GREATEST risk for multiple organ dysfunction syndrome (MODS)? -An adolescent with an autoimmune disease. -An adult male with a myocardial infarction and pericarditis. -An elderly client with intestinal obstruction and septic shock. -A near-drowning victim with a history of respiratory arrest.

-An elderly client with intestinal obstruction and septic shock.

75. An emergency room nurse assesses a patient who was rescued from a home fire. The patient suddenly develops a loud, brassy cough. What action would the nurse take first? -Provide small quantities of ice chips and sips of water. -Ask the respiratory therapist to provide humidified air. -Request a prescription for an antitussive medication. -Apply oxygen and continuous pulse oximetry.

-Apply oxygen and continuous pulse oximetry.

42. A nurse is caring for a terminally ill patient who has just died in a hospital setting with family members at the bedside. Which action will the nurse take first? -Call for emergency assistance so that resuscitation procedures can begin. -Ask family members if they would like to spend time alone with the patient. -Ensure that a death certificate has been completed by the physician. -Request family members to prepare the patient's body for the funeral home.

-Ask family members if they would like to spend time alone with the patient.

36. The nurse is admitting a client and notes 2+ pitting edema in both ankles. The echocardiogram report reveals left ventricular enlargement with an ejection fraction of 35%. Based on these findings, what should the nurse do first? -Weigh the client. -Insert an indwelling urinary catheter. -Assess respiratory status. -Review laboratory results.

-Assess respiratory status.

57. A nurse cares for a patient who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. What action would the nurse take first? -Assess the patient for airway patency. -Sedate the patient to prevent tube dislodgement. -Irrigate the gastric lumen with normal saline. -Maintain balloon pressure at 15 and 20 mm Hg.

-Assess the patient for airway patency.

55. During which period of time is the measurement of hemodynamic data most accurate? -After repositioning the patient to a side-lying position. -After leveling, from the digital readout on the monitor. -During the T wave of the electrocardiogram (ECG). -At the end of the respiratory cycle at end-expiration

-At the end of the respiratory cycle at end-expiration

49. The nurse working in the emergency department knows that which factors are commonly related to abdominal aortic aneurysm formation? -Down syndrome. -Frequent heartburn. -Thrombocytopenia. -Atherosclerosis.

-Atherosclerosis.

39. The nurse is watching the cardiac monitor, and a newly admitted patient's rhythm suddenly changes to the following: (no p waves, Fine wavy lines between QRS complexes). What is the correct interpretation of the rhythm displayed? -Atrial Fibrillation. -Supraventricular tachycardia. -Atrial Flutter. -Sinus tachycardia

-Atrial Fibrillation.

6. An adult suffered a diving accident and is being transported via ambulance intubated and strapped to a backboard with a cervical collar. What is the FIRST action the nurse would take on arrival to the Emergency Department? -Insert a large bore intravenous (IV) line. -Perform neurologic check using Glasgow scale. -Take the client's vital signs.- Assess first?? Alice? -Auscultate lungs for equal, bilateral breath sounds.

-Auscultate lungs for equal, bilateral breath sounds.

76. A client is admitted with severe dyspnea and has a history of heart failure and chronic obstructive lung disease. Which diagnostic study would the nurse expect to be elevated if the cause of dyspnea was cardiac-related heart failure? -Troponin. -Serum potassium. -B-type natriuretic peptide (BNP). -High-density lipoprotein (HDL).

-B-type natriuretic peptide (BNP).

7. The clinical features of late acute respiratory distress syndrome (ARDS) includes which of the following? (Select all that apply). -Bilateral chest infiltrates on chest x-ray. -Refractory hypoxemia. -Pulmonary capillary wedge pressure (PCWP) 18 mmHg. -Tachycardia. -Bradycardia.

-Bilateral chest infiltrates on chest x-ray. -Refractory hypoxemia. -Tachycardia.

31. In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? -Initiation of pulse oximetry. -A complete set of vital signs. -Palpation and auscultation of abdomen. -Brief neurological assessment.

-Brief neurological assessment.

78. Which of the following is most indicative of shock secondary to maldistribution of blood flow? -Systemic vascular resistance (SVR) 490 dynes-sec/cm5 -Central venous pressure (CVP) 2 mmHg -Pulmonary capillary wedge pressure (PCWP) 7 mmHg -Heart rate 130 beats per minute

-Central venous pressure (CVP) 2 mmHg

14. The nurse is caring for a patient with an acute burn injury. What action would the nurse take to prevent infection by autocontamination? -Use a disposable blood pressure cuff to avoid sharing with other patients. -Advocate for proper and consistent handwashing by all members of the staff. -Use the closed method of burn wound management for all wound care. -Change gloves between wound care on different parts of the patient's body.

-Change gloves between wound care on different parts of the patient's body.

67. A patient presents to the emergency department with a thoracic aortic aneurysm. Which finding is most concerning? -Change in mental status. -Heart burn. -Abdominal tenderness. -Changes in bowel habits.

-Change in mental status.

23. The nurse is changing the dressing over a triple-lumen central venous access device and assesses the exit site. Which observation would be cause for concern and should be reported to the physician? -Clamps are crossed on each of the triple lumens -Client febrile with redness and tenderness at exit site. -Absence of exudate and swelling at insertion site. -Dried dark red blood noted on previous dressing.

-Client febrile with redness and tenderness at exit site.

56. Laboratory values for disseminated intravascular coagulation (DIC) show abnormalities in which of the following tests? -D-dimer concentrations. -Blood glucose levels. -Renal function tests. -Liver function tests.

-D-dimer concentrations.

70. Which of the following is an appropriate treatment modality for the management of cardiogenic shock? -Corticosteroids to stabilize the cell walls of infarcted myocardium. -Vasopressors to increase systemic vascular resistance (SVR). -Colloid solutions such as albumin to decrease elevated preload. -DOBUTamine infusion to increase myocardial contractility.

-DOBUTamine infusion to increase myocardial contractility.

28. Which assessment finding indicates that administration of mannitol (Osmitrol) for increased cerebral edema is effective in a client with increased intracranial pressure (ICP)? -Increased urine output. -Decreased ICP. -Decreased pulse rate. -Increased blood pressure.

-Decreased ICP.

60. Which of the following adverse hemodynamic effects has been associated with the use of positive pressure mechanical ventilation and high levels (greater than 8 cmH2O) of positive end-expiratory pressure (PEEP)? (Select all that apply). -Decreased intrathoracic and pleural pressure. -Reduced cardiac output. -Increased systemic blood pressure. -Decreased stroke volume. -Decreased venous return.

-Decreased intrathoracic and pleural pressure. -Reduced cardiac output. -Decreased venous return

17. The nurse initiates neuro checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neurological function? -Progressive nuchal rigidity. -Deterioration in level of consciousness. -Changes in pupil size bilaterally. -Increasing muscular weakness.

-Deterioration in level of consciousness.

87. Which of the following are true regarding dialysis? (Select all that apply) -The only type of dialysis available at this time is hemodialysis -Dialysis is started by the primary care physician -Dialysis corrects fluid & electrolyte imbalances -Dialysis removes waste products

-Dialysis corrects fluid & electrolyte imbalances -Dialysis removes waste products

2. The nurse has client performing deep-breathing and coughing. Drug therapy for heart failure may include which of the following types of medications? -Diuretics, beta blockers, angiotensin receptor blockers (ARBs). -Diuretics, angiotensin-converting enzyme (ACE) inhibitors, vasopressin. -Platelet inhibitors, nitrates, calcium channel blockers -Beta blockers, calcium channel blockers, antidiuretic hormone.

-Diuretics, beta blockers, angiotensin receptor blockers (ARBs).

51. An electrocardiogram (ECG) is ordered for a client who reports chest pain. What finding does the nurse expect to find in the leads that represent the area of myocardial infarction (MI)? -Depressed ST segments. -Absence of P waves. -Elevated ST segments. -Flattened T waves

-Elevated ST segments.

29. In caring for a client with disseminated intravascular coagulation (DIC), which of the following might the nurse anticipate observing and/or implementing? (Select all that apply). -Elevated prothrombin time (PT). -Platelet count increase. -Restriction of intravascular fluids. -Administration of select blood products. -Increased fibrinogen degradation products. -Administration of unfractionated heparin.

-Elevated prothrombin time (PT). -Administration of select blood products. -Increased fibrinogen degradation products. -Administration of unfractionated heparin.

16. A client admitted to the intensive unit is experiencing the following rhythm:(v-tach) There is no pulse and the patient is unresponsive. Following initiation of compressions and defibrillation, which medications would the nurse anticipate administering in order to convert the rhythm and successfully resuscitate the client? (Select all that apply). -Epinephrine (Adrenalin). -Diltiazem (Cardizem). -Atropine sulfate. -Amiodarone (Cordarone). -Adenosine (Adenocard)

-Epinephrine (Adrenalin). -Amiodarone (Cordarone).

30. A nurse is taking pulmonary artery catheter measurements of a client with acute respiratory distress syndrome (ARDS). The pulmonary capillary wedge pressure reading is 12 mm Hg. Which of the following would the nurse interpret as correct for this measurement? -Unexpected. -Low. -High. -Expected.

-Expected.

19. Which finding indicates to the nurse that a client has oliguria due to a prerenal condition? -Urinalysis reveals a high urine sodium level. -Malignant hypertension is the causative etiology. -Urinalysis reveals a low specific gravity. -Fluid replacement that reverses the oliguria.

-Fluid replacement that reverses the oliguria.

11. A client who has just been admitted with septic shock has a blood pressure of 80/46 mmHg, pulse 136 bpm, respirations 32 breaths/min, temperature 104oF (40oC), lactate level 4.5 mmol/L, and blood glucose 246 mg/dL. Which of the following prescribed orders will the nurse complete FIRST? -Start insulin drip to maintain blood glucose less than 150 mg/dL. -Titrate NOREPInephrine (Levophed) to keep mean arterial pressure (MAP) greater than 65 mmHg. -Administer the ordered broad spectrum antibiotic -Give normal saline bolus intravenously based on weight.

-Give normal saline bolus intravenously based on weight.

74. In a client experiencing the rhythm demonstrated below, what is the preferred first line treatment? (the patient is flat lined) -High quality CPR. -Atropine 0.5 mg IV push. -Defibrillation at 200 joules biphasic. -Amiodarone (Cordarone) 150 mg IV push.

-High quality CPR.

66. A client with acute kidney injury (AKI) starts to void 4 Liters per day two weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time? -Uremia. -Hypertension. -Hyponatremia. -Hypotension.

-Hypotension.

26. A client was admitted to the ICU after sustaining traumatic cervical and thoracic spine injuries from a motor vehicle accident. During the first 24 hours the client developed an increased heart rate and decreased BP. The level of consciousness started to decrease. The client is intubated and on mechanical ventilation. The settings are: Assist/Control 18, tidal volume 380 mL, PEEP +8 cmH2O, FiO2 .40. A pulmonary artery (PA) catheter was placed for evaluation of fluid status and the following hemodynamic parameters were obtained: HR 120 bpm Pulmonary Artery BP (PAS/PAD) 12/5 mm Hg BP 90/40 mm Hg Pulmonary Artery Wedge Pressure (PAWP) 3 mm Hg Cardiac Output (CO) 2.06 L/min Central Venous Pressure (CVP) 2 mm Hg Cardiac Index (CI) 1.14 L/min/m2 Systemic Vascular resistance (SVR) 1540 DS/cm5 Pulmonary Vascular Resistance (PVR) 249 DS/cm5 These hemodynamic values are most likely indicative of which of the follo

-Hypovolemia from blood loss

86. Match the type of burn with its appropriate description: Superficial partial thickness/1st degree Deep partial thickness/2nd degree Full thickness/3rd degree Erythema, blanching on pr Fluid-lled vesicles, red, sh Visible thrombosed vessel Superficial partial thickness/1st degree= Erythema, blanching on pr Deep partial thickness/2nd degree=Fluid filled vesicles, red, sh Full thickness/3rd degree=Visible thrombosed vessel Which of the following is the BIGGEST concern of burns during the emergent/resuscitative phase? -Diuresis -Hemoconcentration -RBC hemolysis -Hypovolemic shock

-Hypovolemic shock

53. Which of the following treatment strategies has been effective in managing a client with delirium? -Use of short-acting benzodiazepines for sedation. -Identification and treatment of underlying causes. -Use of restraints to protect the client from self-injury. -Administering high doses of the anti-psychotic haloperidol (Haldol).

-Identification and treatment of underlying causes.

24. A patient weighing 65 kg is receiving mechanical ventilation. The arterial blood gases (ABGs) taken at the beginning of the shift are listed below. The patient would benefit from which of the following interventions? (Select all that apply). pH 7.29 paCO2 68 mmHg HCO3 24 mEq/L paO2 88 mmHg -Increase respiratory rate from 14 to 16 breaths per minute. -Increase the tidal volume from 360 mL to 400 mL. -Increase the fraction of inspired oxygen (FiO2) from 0.45 to 0.60. -Decrease the minute volume from 6 liters to 5 liters. -Decrease the positive end-expiratory pressure (PEEP) level.

-Increase respiratory rate from 14 to 16 breaths per minute. -Increase the tidal volume from 360 mL to 400 mL.

8. The nurse is reviewing laboratory results of a client with suspected disseminated intravascular coagulopathy (DIC). The nurse looks to the results of which laboratory test as the MORE SPECIFIC biomarker for DIC? -Decreased Partial thromboplastin time (PTT). -Decreased Prothrombin time (PT). -Increased platelet count -Increased fibrin degradation products (FDP)

-Increased fibrin degradation products (FDP)

44. In the COMPENSATORY STAGE, hypovolemic shock may exhibit normal blood pressure due to which of the following compensatory mechanisms? -Increased contractility and stroke work index. -Decreased pulmonary vascular resistance (PVR). -Decreased heart rate (HR). -Increased systemic vascular resistance (SVR).

-Increased systemic vascular resistance (SVR).

40. A client has been feeling weak for 4 days with a the following rapid heart rate and rhythm. Upon presentation to the emergency department, the monitor shows the following rhythm: (atrial fibrillation) What should the nurse anticipate as the next priority nursing intervention? -Initiate an intravenous drip of diltiazem (Cardizem). -Prepare for elective synchronized cardioversion. -Perform massage over the carotid artery. -Administer adenosine (Adenocard) by rapid intravenous push.

-Initiate an intravenous drip of diltiazem (Cardizem).

32. The lowest occurrence of heparin-induced thrombocytopenia (HIT) occurs with which type of heparin product? -Low-molecular-weight heparin [LMWH] (Lovenox). -Bivalirudin (Angiomax). -Warfarin sodium (Coumadin). -Unfractionated heparin.

-Low-molecular-weight heparin [LMWH] (Lovenox).

41. A patient is admitted with traumatic brain injury to the intensive care unit. Which nursing measure will optimize cerebral perfusion pressure? -Perform neurological assessment with noxious stimuli every hour. -Reposition patient from side-to-side every hour. -Maintain patient's head in a neutral position. -Decrease mean arterial pressure (MAP) if greater than 65 mmHg.

-Maintain patient's head in a neutral position.

71. While waiting for cardiac transplantation, a patient with severe heart failure has a ventricular assist device (VAD) implanted. When developing the plan of care, which nursing actions should be included? -Preparing the client to have the VAD in place permanently. -Administration of immunosuppressive medications. -Monitoring the surgical incision for signs of infection. -Teaching the client the reason for continuous bed rest.

-Monitoring the surgical incision for signs of infection.

79. Following a T2 spinal cord injury, the client develops a paralytic ileus. While this condition is present, the nurse anticipates that the client will need which of the following interventions? -Intravenous fluids. -Parenteral nutrition. -Nasogastric suctioning -Enteral feedings

-Nasogastric suctioning

85. A client is being evaluated in the emergency department for complaints of severe chest pain. The 12-Lead ECG confirms an ST-segment elevation myocardial infarction (STEMI). Which drug would the nurse anticipate administering to aid in reducing the intensity of the chest pain? -Nitroglycerin sublingual. -Metoprolol (Lopressor) intravenously. -Chewable aspirin PO. -Morphine intravenously.

-Nitroglycerin sublingual.

72. A client is admitted with a gastrointestinal bleed and hypovolemic shock. After insertion of a pulmonary artery (PA) catheter the following values were obtained during the initial assessment: HR 110 bpm Pulmonary Artery BP (PAS/PAD) 38/12 mm Hg BP 82/48 mm Hg Pulmonary Artery Wedge Pressure (PAWP) 8 mm Hg Cardiac Output (CO) 4 L/min Central Venous Pressure (CVP) 6 mm Hg Cardiac Index (CI) 3.14 L/min/m2 Systemic Vascular resistance (SVR) 700 DS/cm5 -Nitroglycerin (Tridil) intravenous infusion at 10 mcg/kg/min. -Norepinephrine (Levophed) intravenous infusion at 4 mcg/min. -Furosemide (Lasix) intravenous infusion at 20 mg/hr. -Nipride (Nitropress) intravenous infusion 0.3 mcg/kg/min.

-Norepinephrine (Levophed) intravenous infusion at 4 mcg/min.

38. A patient with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the patient's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (SATA) -Administer pain medication. -Have the patient sign a surgical consent. -Notify the Rapid Response Team. -Assess distal pulses every 10 minutes. -Take vital signs every 10 minutes

-Notify the Rapid Response Team. -Assess distal pulses every 10 minutes. -Take vital signs every 10 minutes

48. Which statement is correct when the nurse is explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a client being mechanically ventilated? -PEEP will push more air into the lungs during inhalation. -PEEP will prevent scarring and fibrosis of the lung from occurring. -PEEP prevents collapse of lung alveoli during exhalation. -PEEP allows the ventilator to deliver 100% oxygen to the lungs

-PEEP prevents collapse of lung alveoli during exhalation.

58. A client with thrombocytopenia presents to the emergency room because of the presence of petechiae throughout the upper body and lower torso. The nurse understands that which of the following laboratory results best supports the presence of a hemostasis disorder? -Red blood cell (RBC) count 4.0 million/microL. -Platelet count 145,000/microL. -Lymphocyte count 55%. -Hemoglobin (Hgb) value 18 g/dL.

-Platelet count 145,000/microL.

27. A client with acute kidney injury (AKI) has a serum potassium of 6.7 mEq/L and the following arterial blood gas result: pH 7.28, paCO2 30 mmHg, paO2 76 mmHg, Bicarb 18 mEq/L. The nurse recognizes that the treatment of the acid-base imbalance with sodium bicarbonate would cause a decrease in which value? -pH level. -Bicarbonate level. -Carbon dioxide level. -Potassium level.

-Potassium level.

54. When taking readings from a pulmonary artery (PA) catheter, which of these statements is TRUE regarding the relationship between the client and the transducer? -Pressure readings are accurate as long as there is no air or blood in the line regardless of the relationship between client position and transducer. -Pressure readings are accurate if the transducer is leveled to the client's phlebostatic axis with each reading. -Pressure readings are accurate only if the transducer is kept in the same location as when zeroing occurred regardless of client position. -Pressure readings are accurate regardless of transducer position relative to the client.

-Pressure readings are accurate if the transducer is leveled to the client's phlebostatic axis with each reading.

62. A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation using the assist/control (A/C) mode. The nurse notices that the patient's peak inspiratory pressures and assisted respiratory rates have been trending upwards while the oxygen saturation is not improving. The nurse will call the healthcare provider to request initiation of which of the following interventions? -Increasing the respiratory rate of the ventilator. -Propofol (Diprivan) continuous intravenous infusion. -Morphine intravenous push (IVP) prn. -High-protein enteral feedings

-Propofol (Diprivan) continuous intravenous infusion.

43. Which of the following laboratory data suggests glomerular (intrarenal) damage? (Select all that apply) -Proteinuria. -Enuresis. -Hematuria. -Azotemia. -Hypokalemia

-Proteinuria. -Hematuria. -Azotemia.

52. Two nurses are repositioning a client receiving mechanical ventilation when suddenly the low pressure alarm sounds. The alarm also indicates low tidal volume. The client is becoming short of breath and displays agitation. The pulse oximetry reading has dropped to 82%. The endotracheal tube (ETT) appears to be in place and there is no obvious disconnection from the ventilator circuit. One nurse leaves to call Respiratory Therapy. What is the MOST APPROPRIATE action of the second nurse? -Ask the second nurse to return with a dose of lorazepam (Ativan). -Increase FiO2 setting on the ventilator instructing client to remain calm. -Provide manual ventilation with a bag-valve resuscitator. -Increase the tidal volume setting on the ventilator.

-Provide manual ventilation with a bag-valve resuscitator.

65. A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions should the nurse plan to promote the client's safety? -Weigh client daily, and monitor trends. -Provide the client with a soft toothbrush. -Monitor serum potassium levels. -Monitor for symptoms of fluid retention.

-Provide the client with a soft toothbrush.

4. The nurse is assessing a client 12 hours after a spinal cord injury at the C6 level. Which finding is MOST important for the nurse to report to the healthcare provider? -Systolic blood pressure 88 mmHg after one fluid bolus. -Flaccid paralysis below the level of the injury. -Pulse oximetry (SpO2) 88% with slow, shallow respirations. -Sinus bradycardia at 56 beats per minute.

-Pulse oximetry (SpO2) 88% with slow, shallow respirations.

50. The key to treatment of septic shock is finding the source of the infection. Which of the following labs should the nurse obtain before antibiotic therapy is initiated? (Select all that apply). -Complete blood count (CBC) with differential. -Sputum culture. -Lactate level. -Urine culture. -Blood cultures x 2 sites.

-Sputum culture. -Urine culture. -Blood cultures x 2 sites.

64. The nurse is preparing to suction a client receiving mechanical ventilation with history of increased intracranial pressure (ICP) due to head injury. Which of the following interventions is contraindicated? -Limit suctioning to 1 or 2 passes. -Pre-oxygenate with 100% FiO2. -Stimulate coughing. -Provide sedation.

-Stimulate coughing.

33. A client sustains a back injury after falling 20 feet (6 m). In which position should the nurse place the client? -Lateral position with a pillow between the knees. -Sitting position with a pillow placed in the small of the back. -Supine position while not allowing the spine to flex . -Any position that reduces pain and is comfortable.

-Supine position while not allowing the spine to flex .

3. A client in the emergency room is complaining of severe dyspnea and has a heart rate of 110 beats/min and blood pressure (BP) of 90/50 mm Hg. The client was prescribed an antibiotic the previous day for sinusitis. Capillary filling time is 5 seconds, the skin is cool, neck veins are flattened, and the client is exhibiting a rash over the upper thorax with angioedema. What is the most likely cause of the symptoms? -The client is in neurogenic shock. -The client is in septic shock. -The client is in anaphylactic shock. -The client is in hypovolemic shock.

-The client is in anaphylactic shock.

13. The nurse is providing education to a 65-year old, male client with the risk factors for coronary artery disease (CAD) listed below. Which of the factors should the nurse focus on during implementation of the teaching plan? -Prevalence of cardiovascular disease in the elderly. -Presence of positive family history of CAD. -The elevated low-density lipoprotein (LDL) level. -The gender of the client.

-The elevated low-density lipoprotein (LDL) level.

12. The client is receiving Continuous Positive Airway Pressure (CPAP) mode for weaning from a mechanical ventilator. The nursing assessment reveals a respiratory rate of 32 breaths/minute, oxygen saturation of 88 percent, and use of accessory muscles with increased work of breathing. What should the nurse anticipate will occur next? -Ventilator weaning will continue. -The FiO2 will be increased. -The mode will be changed to assist/control. -The patient will be extubated.

-The mode will be changed to assist/control.

61. The admission data for a patient in respiratory failure with a history of kyphoscoliosis and heart failure (HF) are listed below. Which data is MOST concerning to the nurse? Laboratory ABG: pH 7.20 PaCO2 59 mmHg HCO3 26 mEq/L PaO2 62 mmHg Diagnostics Chest X-Ray: Bibasilar atelectasis. ECG: Sinus tachycardia with occasional PACs; HR 104 bpm Physical Assessment Dyspneic and pale. Increasing lethargy. Difficulty in arousing to voice. -The chest X-Ray results. -The physical assessment. -The oxygenation (PaO2). -The bicarb (HCO3) level.

-The physical assessment.

21. What happens to patients that meet criteria for imminent death? -They are referred to a practitioner to make the decision if they are candidates for organ donation. -They are placed on life support and referred to the organ procurement organizations in the next 48 hours. -They are referred to the organ procurement organizations at the time of their death. -They are referred to the organ procurement organizations in a timely manner.

-They are referred to the organ procurement organizations in a timely manner.

10. When discussing risk factor modification for a patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus teaching on which patient risk factor? -Male gender. -Abdominal trauma history. -Uncontrolled hypertension. -Turner syndrome.

-Uncontrolled hypertension.

73. When caring for an 80 kg client who has just been admitted with septic shock, which of these assessment data will be of GREATEST concern to the nurse? -Pulse 122 beats/min. -Arterial oxygen saturation 90%. -Blood Pressure 92/56 mmHg. -Urine output 15 mL in 2 hours.

-Urine output 15 mL in 2 hours.

82. Which of the following nursing interventions is most appropriate when communicating with a patient who is experiencing aphasia post-stroke? -Use simple, short sentences accompanied by visual cues to enhance comprehension. -Present several thoughts at once so that the patient can connect the ideas. -Finish the patient's sentences so as to minimize frustration associated with slow speech. -Ask open-ended questions to provide the patient the opportunity to speak

-Use simple, short sentences accompanied by visual cues to enhance comprehension.

77. All of the following medications are ordered for a mechanically ventilated client with pneumonia and acute kidney injury (AKI). Which medication should the nurse clarify with the healthcare provider before administration? -MethylPREDNISolone (Solu-Medrol) 125 mg IV BID. -Vancomycin (Vancocin) 750 mg IVPB daily. -Omeprazole (Prilosec) 20 mg PO or NG daily. -Lovenox (enoxaparin sodium) 40 units subcutaneously daily.

-Vancomycin (Vancocin) 750 mg IVPB daily.

37. The nurse is assisting a patient with a stroke who has homonymous hemianopsia. What will the nurse understand about the patient with this condition? -Will not be able to swallow thin liquids. -Preference for foods high in sodium. -Forgets the names of foods. -Will eat food on only half the plate.

-Will eat food on only half the plate.

68. The nurse is providing a community educational session to a group of women at risk for the development of cardiovascular disease. Which statement, made by the nurse, indicates accurate understanding of women and heart disease? -Heart disease is the second leading cause of death in women, after cancer. -Women have better survival rates than men after a myocardial infarction. -Women commonly present with different symptoms of heart disease than do men. -Hormone replacement therapy (HRT) significantly reduces the risk of heart disease in post-menopausal women.

-Women commonly present with different symptoms of heart disease than do men.

20. A 23-year old male is brought into the field emergency tent after sustaining a motor vehicle accident in a multi-car pile-up. The patient is awake, alert and has a right tibial closed fracture. Vital signs are: BP 100/72 mmHg, HR 110 bpm, RR 28 bpm and non-labored. He also presents with several small lacerations to the face. How would the field nurse tag this patient? -Blue tag. -Yellow tag. -Green tag. -Red tag.

-Yellow tag.

47. Which of the following injuries experienced by a patient should a triage nurse determine is a priority in a disaster? -closed fractures of humorous bone -lacerations with open fractures of lower extremity bones -severe traumatic brain injury with loss of consciousness -partial thickness burns over 10% of the body

-lacerations with open fractures of lower extremity bones

18. Following a procedure that involved fentanyl (Sublimaze) and midazolam (Versed) for sedation, the elderly client with chronic obstructive pulmonary disease (COPD) has the following vital signs: BP 102/56 mmHg, pulse 98 beats/min, and respirations 8 breaths/min. Which arterial blood gas (ABG) result would represent this client after 15 minutes of this status? -pH 7.22 PCO2 69 mmHg PaO2 50 mmHg HCO3 23 mEq/L -pH 7.49 PCO2 30 mmHg PaO2 75 mmHg HCO3 26 Meq/L -pH 7.40 PCO2 37 mmHg PaO2 84 mmHg HCO3 25 mEq/L -pH 7.25 PCO2 44 mmHg PaO2 81 mmHg HCO3 16 mEq/L

-pH 7.22 PCO2 69 mmHg PaO2 50 mmHg HCO3 23 mEq/L

34. A healthcare provider prescribes 500 mg of an antibiotic to be given via intravenous piggyback (IVPB) every 12 hours. The pharmacy dispenses a vial of antibiotic that contains 1 gram of the medication. The reconstitution instructions indicate that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters (mL) of the antibiotic should be added to a 100 mL IVPB bag? Enter the correct numeric response only. Round the answer to the first decimal place.

1.5

46. The healthcare provider prescribes mannitol (Osmitrol) to promote diuresis in an adult oliguric client at a dose of 300 mg/kg via IV bolus. The client weighs 185 pounds. The Mannitol label states that the concentration is 20 Grams per 100 milliliters. How many milliliters (mL) of Mannitol will the nurse administer? Enter the correct numeric response only. Round your answer to the nearest whole number.

126

63. The nurse receives an order to begin a nitroglycerin (Tridil) intravenous infusion at 15 micrograms/minute. The drug is supplied as 50 mg nitroglycerin in 500 mL D5W. What rate on the infusion pump will deliver the correct dose in mL/hour? Enter the correct numeric response only. Round your answer to nearest whole number.

9

83. The healthcare provider prescribes DOPamine (Intropin) intravenous (IV) infusion to manage symptomatic bradycardia unresponsive to atropine. The orders state to start the infusion at 3 mcg/kg/min. The patient weighs 189 pounds. The Pharmacy sends 400 mg of DOPamine mixed in a 250 mL bag of normal saline solution. What rate, in mL/hour, will need to be programmed on the infusion pump to deliver the ordered dose? Insert the correct numeric response only in the answer box. Do not include units of measurement. Round answer to the first decimal place.

9.7

35. An 80-year old client is admitted with a diagnosis of hypotension of unknown origin. The nurse's assessment demonstrates the client has an altered mental status. Vital signs are: BP 86/58 mmHg, HR 112 bpm, RR 24 breaths/min. The pulse oximetry is 92% on a 100% non-rebreather mask. The lactate level is 5.5 mmol/L. Sepsis is presumed and after blood and urine cultures are collected broad spectrum antibiotics are initiated. An initial fluid bolus of normal saline is administered in the amount of 30 mL/kg. If tissue oxygenation improved in this client, which parameter would the nurse MOST LIKELY see change? -Increase in pulse oximetry oxygen saturation. -Increase in mean arterial pressure (MAP). -Decrease in the lactate level. -Decrease in fraction of inspired oxygen (Fi02) required.

Decrease in the lactate level