Exam 2 review
The nurse is caring for a client with metabolic alkalosis. The nurse plans care knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems? Select all that apply
Cardiac, Nervous, neuromuscular
Which clients are most likely to be at risk for the development of third spacing? Select all that apply.
Cirrhosis, liver failure, CKD
The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
Twicthing
The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?
Wearing gloves and a gown only when giving direct care to the client
The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?
Weight loss and poor skin turgor
Which electrolyte plays the largest role in maintaining blood osmolarity?
sodium
The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times?
at least 30 mins before the sun
A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound?
autograph
The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator?
daily weight
A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred?
hyperventilation
The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level?
malnutrition
Which acid-base imbalance will the nurse expect in a client who has chronic kidney disease?
metabolic acidosis
In a patient undergoing surgery, it was vital to aspirate the contents of the upper gastrointestinal tract. After the operation, the following values were acquired from an arteria blood sample: pH 7.55, PCO2 52 mm Hg and HC03- 40 mmol/I. What is the underlying disorder?
metabolic alkalosis
The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?
metabolic alkalosis
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?
metabolic alkalosis
Development of expiratory wheezes The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site?
mitral area
The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication?
muffled or distant heart sounds
A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present?
muscle weakness
The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition?
myocardial infraction
The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?
pH 7.25, Paco2 50 mm Hg
Which client ABG results would the nurse interpret as metabolic alkalosis?
pH 7.50, PaCO2 45, bicarbonate, 36, Pa02 95
which client results would the nurse interpret as metabolic alkalosis?
pH 7.50, PaCO2 45, bicarbonate, 36, Pa02 95
The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of prominent U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value?
potassium 3.0
The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value should the nurse expect to note?
potassium of 5.2
The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level?
prolonged bed rest
Which of the following symptoms is the most likely origin of pain the client described as knifelike chest pain that increases in intensity with inspiration?
pulmonary
Anne, who is drinking beer at a party, falls and hits her head on the ground. Her friend Liza dials "911" because Anne is unconscious, depressed ventilation (shallow and slow respirations), rapid heart rate, and is profusely bleeding from both ears. Which primary acid-base imbalance is Anne at risk for if medical attention is not provided? A. Metabolic Acidosis B. Metabolic Alkalosis C. Respiratory Acidosis D. Respiratory Alkalosis
respiratory acidosis
The nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31 (7.31), Paco2 is 50 mm Hg (50 mm Hg), and the bicarbonate (HCO3) level is 26 mEq/L (26 mmol/L). The nurse concludes that which acid-base disturbance is present in this client?
respiratory acidosis
The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mm Hg, PaO2 of 80 mm Hg, and HCO3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance?
respiratory acidosis
A client is scheduled for a cardiac catheterization using an iodine agent. Which assessment is most critical before the procedure?
allergy
The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item?
antacids
The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission workup on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention?
apply a warm compress
The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and HCO3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance?
respiratory acidosis
The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client?
respiratory depression
The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20?
this is a normal finding
Which of the following blood tests is most indicative of cardiac damage?
troponin I
A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about this procedure
wear loose clothing with a shirt that buttons in front
The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?
A client with an ileostomy
On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?
The client with kidney disease and a 12-year history of diabetes mellitus
The nurse is monitoring a client who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication?
The development of audible expiratory wheezes
The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction?
"I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."
The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided?
"I will eat enough daily fiber to prevent straining at stool.
A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and is receiving education about the procedure from the nurse. Which statement by the client indicates that the teaching has been effective?
"It involves injecting an agent into the vein to damage the vein wall and close it off.
A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching?
"My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."
The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube?
0.9% sodium chloride
The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period?
18-24 hours after
The registered nurse (RN) is orienting a new RN assigned to the care of a client with a cardiac disorder and is told that the client has an alteration in cardiac output. After educating the new RN about cardiac output, which statement made by the new RN indicates the need for further instruction?
2L/MIN is norm
A patient who is hospitalized due to vomiting and a decreased level of consciousness displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation The doctor diagnosed him of having dehydration. Measurement of arterial blood gas shows pH 7.0, Pa02 90 mm Hg, PaCO2 22 mm Hg, and HC03 14 mmol/L; other results are Na+ 120mmol/L, K+ 2.5 mmol/L, and CI-95 mmol/L. As a knowledgeable nurse, you know that the normal value for PacO2 is:
36 mm Hg
An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?
36%
With which client does the nurse remain most alert for an electrolyte imbalance?
49-year-old with diabetes mellitus who also takes a diuretic daily
The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority?
Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver
A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer?
An arterial ulcer
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?
An increase in blood pressure and increased respirations
The nurse would perform which action to assess for a pulse deficit?The nurse would perform which action to assess for a pulse deficit?
Auscultate the apical heartbeat while palpating the radial artery.
The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.
Tall peaked T waves, widened QRS complexes
The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?
Integumentary output
An ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which statement indicates that the client needs additional education?
It is important that I limit protein intake.
The cardiologist has written a prescription for a client to have an echocardiogram. Which action should the nurse take to prepare the client for the procedure?
Tells the client that the procedure is painless and takes 30 to 60 minutes
The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings should be anticipated in this client? Select all that apply.
Tetany, hypotension, prolonged QT interval, positive chvosteks
Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?
The client who has sustained a traumatic burn
A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse monitoring this client should expect to note which signs/symptoms?
Decreased respiratory rate and depth
A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply
Dehydration, stress, decreased blood volume
The nurse is providing care to a client with the following arterial blood gas results: pH of 7.50 (7.50), Pao2 of 90 mm Hg (90 mm Hg), Paco2 of 40 mm Hg (40 mm Hg), and bicarbonate of 35 mEq/L (35 mmol/L). When the nurse notifies the primary health care provider about these levels, the nurse should anticipate receiving from the PHCP which prescription for this client?
Discontinue nasogastric suctioning
The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan?
Elevate and immobilize the grafted extremity
A preceptor is observing a nursing student provide care to a patient with major burns to the face and head. What nursing intervention does the student perform correctly?
Elevate the head of the bed at 30*
The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burninjury?
Elevated Hematocrit levels
The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply
Ensure adequate O2, provide assistance to prevent falls, monitor med admin of diuretics, prevent complications during potassium adminin
A client is diagnosed with a full-thickness burn. The nurse plans care, knowing that which structural areas of the skin are involved?
Epidermis, entire dermis, and epithelial portion of subcutaneous fat
The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see? Select all that apply.
Tetany, tingling, numbness, restlessness
Which laboratory value indicates to the nurse that a client has acidosis as a result of a metabolic problem?
HC03 = 17mEq/L(mmol/L)
A hypertensive client has been prescribed clonidine hydrochloride, a transdermal patch. The nurse provides written instructions to the client on the use of the patch. Which statement by the client indicates the need for further instruction?
I need to change the patch every 24 hours."
A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions?
I probably will feel tired after the test from lying on a hard x-ray table for a few hours.
The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client?
Immobilization of affected leg
What response does the nurse expect to see in the blood volume and blood osmolarity if a client whose secretion of antidiuretic hormone (ADH) is extremely low?
Increased blood volume; decreased blood osmolarity
Which signs and symptoms would the nurse expect to find in a client with severe metabolic acidosis? Select all that apply?
Kussmaul respirations Decreased bicarbonate Warm flushed skin
The nurse is listening to a cardiologist explain the results of a cardiac catheterization to a client and family. The cardiologist tells the client that a blockage is present in the large blood vessel that supplies the anterior wall of the left ventricle. The nurse determines that the blockage is located in which area?
Left anterior descending coronary artery (LAD)
The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest?
Over the fifth intercostal space in the left midclavicular line
A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe?
PINK/RED
As a nursing working on a burn unit, which of your patients are at high risk for internal tissue damage?
Patient with an electrical burn to the torso
The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase?
Period from time of burn to time pt is physiologically stable
Which is the best technique to use for assessing the skin turgor for an 80-year-old client?
Pinching the skin over the sternum and observe for tenting and resumption of skin to its position after release.
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?
Potassium level of 3.0
The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate?
Pour the aspirate into the NG tube through a syringe with the plunger removed
The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply
Raisins, potatos, cantaloupe, strawberries
A client has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action?
Remove the nasal cannula for 15 minutes; then have the ABG samples drawn.
The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation?
Requires nasogastric suction
The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented?
Requires nasogastric suction
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply
Respirations that are increased in rate, Respirations that are abnormally deep
A nursing instructor asks a nursing student to describe the structure and function of the coronary arteries. Which response by the student indicates a need for further teaching on the anatomy and physiology of the heart?
"The left coronary artery supplies the right atrium and right ventricle with blood
Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?
"The medication is likely to cause stinging every time it is applied."
The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia?
A client admitted 6 hours ago with a 40% burn injury
A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply
Blood transfusions, bleeding/hemorrhage, ingestion of potassium in meds, failure to restrict dietary potassium.
The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply.
Bounding pulse, diff w/ breathing, dependant edema, neck vein distension upright
The client who is beginning an exercise program asks the nurse why his heart "feels like it's pounding" when he is exercising vigorously. The nurse provides education to the client about increased cardiac response based on which physiological concept?
Cardiac output is the body's attempt to meet metabolic demands
The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid?
Client with an ischemic stroke
A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply
Lethargy, headache, weakness, confusion
A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing?
Liquefaction necrosis
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?
Metformin
The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply
Nausea, confusion, tachycardia, lightheadedness
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply.
Respirations that are increased in rate; Respirations that are abnormally deep
The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe, the client will be at risk for which acid-base imbalance?
Respiratory acidosis
The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?
Respiratory acidosis from inadequate ventilation
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mmol/L), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?
Respiratory acidosis without compensation
The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?
Respiratory alkalosis, compensated
Which effect on respiratory effort does the nurse expect to find in a client with severe hypokalemia?
Shallow respirations and low oxygen saturation
AN registered nurse (RN) has instructed an assistive personnel (AP) to administer soap suds enemas until clear to a client. The AP reports that 3 enemas have been administered and the client is still passing brown, liquid stool. What should the RN instruct the AP to do?
Stop administering the enemas until the primary health care provider (PHCP) is notified
Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?
The client who is taking diuretic
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status?
The neurovascular status is normal because of increased blood flow through the leg
The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply
U waves, Absent P waves. Inverted T waves
The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply
Uwaves, INVERTED T WAVES, depressed QRS complex
Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse?
White blood cell count of 3000 mm3 (3.0 × 109/L)
While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?
a blowing of swooshing noise
The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?
active ROM
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?
acute kidney injury
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?
an increase in pH and increased HCO3-
The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited?
areflexia
The nurse is assessing a client newly diagnosed with mild hypertension. Which assessment finding should the nurse expect?
asymptomatic
A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound?
best type of bandage for this wound? Semipermeable film dressing
The nurse is performing a cardiovascular assessment on a client. Which parameter would the nurse assess to gain the best information about the client's left-sided heart function?
breathe sounds
The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note?
changes in mental status
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to:
check the clients status and lead placement
A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure?
chest pain
The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm (72 mmol/L), and HCO3− = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?
client is probably hyperventilating
The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction?
client should be maintained in a standing position
Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)
client who is taking a diuretic
The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit?
client with diabetes insipidus
The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first?
contact the primary HCP
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take?
continue to monitor for any rhythm change
The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit who is receiving nasal oxygen and notes a pH of 7.38 (7.38), Paco2 of 38 mm Hg (38 mm Hg), Pao2 of 86 mm Hg (86 mm Hg), and HCO3 of 23 mEq/L (23 mmol/L). What action should the nurse take in response to these results?
continue to monitor the client
The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action?
cooling the injury with water
During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/min, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition?
dehydration
The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse expect to observe based on the client's magnesium level?
depressed ST segment
The nurse is monitoring a client with hypertension who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication?
development of expiratory wheezes
The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention?
elevate the legs higher than the heart
A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate. The client returns to the primary health care provider's (PHCP's) office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment?
follow-up data base
A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type?
full thickness
The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the primary health care provider's prescriptions and should plan to question which prescription?
gastric lavage
A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?
headache, restlessness, confusion
The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation?
heart rate of 95
the nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report?
hematocrit 60%
The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed?
heparin
The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body. Which finding suggests that an escharotomy may be necessary
high pressure alarms
The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?
hyperactive bowel sounds
A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder should the nurse monitor for that could accompany the acid-base imbalance?
hypokalemia
The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note?
hypotension
The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding?
hypotension
A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate?
keep PT NPO
A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse plans care knowing that what reaction is the most powerful regulator of acid-base balance?
kidney
The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"?
leave dressing intact 3-4 days
A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms?
left ventricle
The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function?
listening to lung sounds
The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level?
loss of deep tendon reflexes
The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse would include which intervention in the plan?
maintain activity level as prescribed
A client with diabetes mellitus has a blood glucose level of 644 mg/dL (35.7 mmol/L). The nurse plans care knowing that the client is at risk for the development of which type of acid-base imbalance?
metabolic acidosis
A client with diabetes mellitus is most likely to experience which type of acid-base imbalance as a complication of the disorder?
metabolic acidosis
the nurse is caring for a client with hyperglycemia and diabetic ketoacidosis (DKA) who now has developed Kussmaul's respirations. The nurse knows that the purpose of this type of breathing is to correct what imbalance?
metabolic acidosis
A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which priority problem?
metabolic alkalosis
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action should the nurse take?
monitor for rhythm change
A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis?
potassium
Which laboratory test results may be associated with peaked or tall, tented T waves on a client's electrocardiogram (ECG)?
potassium
The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30 (7.30), a Paco2 of 58 mm Hg (58 mm Hg), a Pao2 of 80 mm Hg (80 mm Hg), and an HCO3 of 26 mEq/L (26 mmol/L). The nurse should interpret this to mean that the client has which acid-base disturbance?
respiratory acidosis
Arterial blood gas analysis yields the following results: pH 7.48 (7.48), Paco2 32 mm Hg (32 mm Hg), Pao2 94 mm Hg (94 mm Hg), HCO3 level 24 mEq/L (24 mmol/L) for a client seen in the health care clinic. The nurse interprets that the client has which acid-base disturbance?
respiratory alkalosis
A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action?
resume full acitivity
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?
return of distal pulses
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective?
rise in blood pressure
The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse should intervene if the student planned to implement which action to apply the medication?
saline soaked dressing
The nurse is caring for a client who is experiencing metabolic alkalosis. Knowing the risks of this imbalance, the nurse plans to protect the client's safety by carefully implementing which prescribed precaution?
seizure precautions
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats per minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse interpret this rhythm?
sinus tachycardia
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm?
sinus tachycardia
The nurse is caring for a 34-year-old male patient who sustained a deep partial thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn?
skin is shiny, red with clear fluid blisters
The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food?
smoked salami
The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation?
sodium chloride
A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?
summer squash
The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action should the nurse take?
take no action
The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mm Hg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?
the client is probably hyperventilating
.The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?
urine output
The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?
urine specific gravity of 1.032
