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65. A patient diagnosed with diabetic ketoacidosis presents with Kussmaul respirations at a rate of 28. A newly licensed nurse asks the patient to try to slow his breathing. What instruction will the preceptor provide?
"Let the patient set his respiratory rate as rapid breathing helps to compensate for his acidosis
A nurse assesses a patient who has mitral valve regurgitation. For which cardiac dysrhythmia will the nurse assess?
Atrial fibrillation
The nurse is reading the cardiac monitor and notes a patient's heart rhythm is irregular and there are no discernible P waves. The ventricular rate is 90 beats per minute, and the patient is hemodynamically stable. How will the nurse document this rhythm correctly
Atrial fibrillation
The nurse is advised that a patient diagnosed with hyperthyroid crisis will be admitted from the emergency department. The nurse prepares to care for a patient with which possible conditions? (Select all that apply.)
Atrial fibrillation High fever Heart failure Agitation
A client arrives in the emergency department with facial and chest burns caused by a house fire. Which action will the nurse take first?
Auscultate the patient's lung sounds.
A client is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HHS? (Select all that apply.)
B) Glycosuria C) Dehydration E) Hyperglycemia Hypernatremia
The nurse is caring for a client who has been intubated and on a mechanical ventilator and has been restrained with soft wrist restraints. The client no longer requires the restraints, so the nurse removes them. What type of ethical decision making does this nurse display?
Beneficence
Clinical manifestations of neurogenic shock include which of the following? (Sata)
Bradycardia Warm skin Venous pooling in the extremities
. A nurse assesses several patients who have a history of asthma. Which patient would the nurse assess first?
. A 27-year-old patient with a heart rate of 130 beats per minute
The nurse received a client from the postanesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report front the PACU nurse included drainage in the chest tube at 80 mLs of bloody fluid. 15 minutes after transfer from the PACU, the chest tube indicates and additional 120 mLs of bloody fluid. The client is reporting pain at 8 on a scale of 0-10. The first action of the nurse is to:
. Assess pulse and blood pressure
A diabetic patient becomes septic after a bowel resection and is having problems with respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50. PaCO2 30, HCO3 24, and PaO2 68. What does the nurse recognize as the primary factor causing this acid-base imbalance?
. Hyperventilation due to poor oxygenation
The client was admitted to the emergency department after being injured in a drive-by shooting. Despite very serious injuries, the patient is awake and alert and cries continuously that "someone tried to kill me." The nurse tries to calm the client because
. Increased heart rate . Increased blood pressure Increase in blood glucose
A patient's arterial blood gases (ABGs) are as follows: pH 7.30, PaCO2 30 mm HG, HCO3 14 mEq/L, and PaO2 50. The nurse evaluates these ABGs as representing which acid- base imbalances?
. Partially compensated metabolic acidosis and moderate hypoxemia
A patient is diagnosed with Prinzmetal angina. Which assessment findings will the nurse attribute to this diagnosis?
. The patient has chest pain that is not related to physical activity . The patient is awakened from sleep by chest pain
The nurse working in the emergency department places a client in cardiac arrest on a cardiac monitor and sees the cardiac rhythm below. What dysrhythmia will the nurse document?
. Ventricular tachycardia
A nurse cares for a patient who is on a cardiac monitor. The monitor displayed the rhythm shown below, what action should the nurse take first?
.Assess airway, breathing, and circulation
The nurse has identified that a client who has hyperthyroidism has decreased cardiac output. Which interventions are indicated to address this diagnosis? (Select all that apply.)
1. Monitor for development of peripheral edema. 3. Provide medications to manage pain. 4. Frequently reassure and calm the patient. 5. Monitor activity tolerance.
A patient has been tentatively diagnosed with adrenal insufficiency. Which findings will the nurse evaluates as supporting this diagnosis? (Select all that apply.)
1. The patient's low blood pressure is not responding to fluid infusion. 3. The patient has had a fever for a week. 4. Arterial blood gas results reveal acidosis. 5. The patient reports abdominal pain.
A patient is diagnosed with septic shock and has a decrease in afterload. The nurse would expect which initial changes in the patient's cardiac statu
Decrease in blood pressure Increase in cardiac output
A nurse assesses a client who experienced a spinal cord injury at the T% level 12 hours ago. Which manifestations would the nurse correlate with neurogenic shock? (Select all that apply)
Decreased level of consciousness Urine output less than 30 mL/hr Heart rate of 34 beats/min
A nurse is evaluating a patient who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?
Decreased orthostatic light-headedness and dizziness
A client infected with HIV is being monitored for the development of AIDS. Which characteristics will the nurse monitor? (Select all that apply.)
2. CD4+ T-cell count 4. Presence of Pneumocystis jiroveci (PJP) infection 5. Presence of cytomegalovirus (CMV)
A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations will the nurse monitor the patient? (Select all that apply.)
Deep and fast respirations Tachycardia Orthostatic hypotension
A nurse is caring for a client who has expressive aphasia following a cerebral vascular accident (CVA). Which of the following parameters will the nurse use first in order to assess the client's pain level?
A self-report pain rating scale
A client receiving a blood transfusion reports nausea and back pain 10 minutes into the transfusion. The nurse realizes the patient is experiencing which type of hypersensitivity response?
4. Type II
The patient is diagnosed with abrupt onset of supraventricular tachycardia (SVT). The nurse prepares which medication that has a short half life and is recommended to treat symptomatic SVT?
Adenosine
A client who fell and broke his hip while being assisted to the bathroom by the nurse states he plans to sue the nurse. The nurse will know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?
Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation
The nurse is present and talking with the client when the client's monitor alarms and shows this rhythm (lead II 6 second strip). The nurse will:
Assess the patient and the electrical leads
A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions will the nurse take?
Call the emergency response team
Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness?
Contusion
A client with severe, deep partial-thickness burns experiences procedural, background, and breakthrough pain. What is the nurse's most important plan for controlling this patient's pain?
Designate one pain assessment technique for use by all providers.
The nurse is caring for a patient with a chest tube and a 3-chamber disposable drainage system. The physician orders an anteroposterior (AP) chest X-ray to be done in the x-ray department. How will the nurse transport the patient?
Disconnect the drainage system from the wall suction and transport
A patient has been ruled out for MI (myocardial infarction). What diagnostic findings would support this finding?
EKG and cardiac markers remain unchanged for 12-24 hours
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar fracture. Which of the following correctly describes Battle's sign?
Ecchymosis over the mastoid
A patient is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this patient's care?
Electrolyte and fluid imbalance
The nurse is caring for a client with complex needs. When applying critical thinking skills to the client's care, the nurse will do which of the following action?
Examine and analyze all available information
. A patient who will require long-term mechanical ventilation has had a tracheostomy for two weeks. The nurse is concerned that stoma erosion is occurring. Which nursing assessment will support the nurse's concern?
Excessive amount of secretions are present at the stoma opening
An older adult client with type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 623 mg/dL. The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority?
Fluid and electrolyte replacement
A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS) and who is unresponsive. Which clinical manifestation indicates to the nurse that the therapy is ineffective?
Glasgow Coma Scale score is unchanged.
A student with diabetes tells the school nurse that he is feeling nervous and hungry. The nurse assesses the child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What will the school nurse administer?
Half of a cup of juice, followed by cheese and crackers
The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic value is the nurse most likely to assess?
High cardiac output and low systemic vascular resistance
A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)
Hypokalemia - Flaccid paralysis with respiratory depression Hyponatremia - Decreased level of consciousness
A nurse educator is teaching a group of recent nursing graduates about their occupational risk for contracting Hepatitis B. What preventative measures will the educator promote? SATA
Immunizations . Proper disposal of sharps Use of standard precautions
The nurse is caring for a patient on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below:
Initiate cardiopulmonary resuscitation (CPR)
The nurse is caring for a client with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death due to life threatening dysrhythmias. What medical intervention can be performed that may extend the survival of the client?
Insertion of an implantable cardioverter defibrillator (ICD)
. A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions will the nurse anticipate the neurosurgeon taking?
Invoking implied consent
. A patient has been admitted to the intensive care unit with the diagnosis of liver failure. Which assessment findings will the nurse anticipate in this patient? (SATA)
Jaundice INR greater than 1.5 Serum glucose greater than 145 Mental status changes
The nurse is performing an assessment on a patient with a central venous pressure (CVP) of 12mmHg. Which findings will the nurse anticipate?
Jugular vein distention Hepatomegaly
A patient has had a large ischemic stroke and is hospitalized in the hospital neurologic intensive care unit. What interventions will be provided for this patient to decrease intracranial pressure (ICP)? (Select all that apply.)
Maintain the partial pressure of carbon dioxide (PaCO2) within a range of 30 to 35 mmHg Administering mannitol Administering supplemental oxygen if the oxygen saturation is below 90% Elevating the head of the bed 30 degrees
A postoperative patient's nasogastric drainage has been 500 mL in the last 8 hours. The nurse will assess this patient for findings associated with which acid-base imbalance?
Metabolic alkalosis
An elderly client was admitted to the Medical-Surgical unit after a fall. What vital signs indicate Cushing's triad? (Select all that apply.)
Morning vital signs include blood pressure of 110/70 Afternoon vital signs include blood pressure of 130/50 Morning vital signs include heart rate of 62 Afternoon vital signs include heart rate of 52
The nurse is assessing a patient with a diagnosis of prerenal acute kidney injury (AKI). Which condition will the nurse expect to find in the patient's recent history?
Myocardial infarction
A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles will the nurse use to support the decision not to administer the medication?
Nonmaleficence
A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The client's symptoms have now resolved and the client asks, "When can I stop taking these medications?" How will the nurse respond?
Once you start corticosteroids, you have to be weaned off them.
A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding will the nurse attend to immediately?
Oxygen saturation of 90%
A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following is the priority action?
Place the client in a sitting position
After reading electrolyte lab values, which nurse assessment completes first The health care provider writes orders for a patient who is admitted with a serum potassium (K) level of 6.9 mEq/L. What does the nurse implement first?
Place the patient on a cardiac monitor
What are the cognitive deficits as a result of a neurologic event? (Select all that apply.)
Poor abstract reasoning Short- and long-term memory loss Decreased attention span
Which of the following is a clinical manifestation of pupillary changes that indicate increasing ICP?
Pupils are showing progressive dilation
A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members will the nurse include in this interdisciplinary team meeting? (Select all that apply.)
Registered dietitian Clinical pharmacist Health care provider
. A patient with type 2 diabetes mellitus, lethargy, and a blood glucose level of 650 mg/dL has been diagnosed with hyperglycemic hyperosmolar syndrome (HHS). The nurse monitors this patient for the development of which complication?
Seizures
A nurse assesses a patient who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse?
Serum potassium of 2.9 mEq/L (2.9mmol/L) Expanding groin hematoma Rhythm changes on the cardiac monitor
An emergency room nurse assesses a patient with potential liver trauma. Which clinical manifestations will alert the nurse to internal bleeding and hypovolemic shock? (SATA)
Tachycardia Confusion Tachypnea
A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock will be reported with the healthcare provider?
Tachycardia and tachypnea
The nurse is discussing macrovascular complications of diabetes with a client. The nurse address what topic during this dialogue?
The fact that patients with diabetes have an elevated risk of myocardial infarction
The nurse is discussing macrovascular complications of diabetes with a client. The nurse will address what topic during this dialogue?
The fact that patients with diabetes have an elevated risk of myocardial infarction
A nurse working in the emergency department (ED) reviews arterial blood gases (ABG) values for a patient diagnosed with heatstroke. Blood gas values are pH 7.48, pCO2 32, pO2 85, HCO2 22 and SO2 90%. Which of the following nursing interventions demonstrate the nurse's understanding of the patient's ABGs and knowledge of Maslow's hierarchy of needs when providing care for this patient?
The nurse prepares for endotracheal intubation and mechanical ventilation for the patient
. A patient has been tentatively diagnosed with adrenal insufficiency. Which findings will the nurse evaluates as supporting this diagnosis? (Select all that apply.)
The patient's low blood pressure is not responding to fluid infusion. . The patient has had a fever for a week. Arterial blood gas results reveal acidosis. The patient reports abdominal pain.
A client tells the nurse that he had a tuberculin test several months ago and the site of the injection became very red and inflamed. How will the nurse interpret this information?
This type IV hypersensitivity response indicates the tuberculin test was positive.
A critically ill patient's plasma cortisol level is 2.6 mcg/dL. Which intervention does the nurse expect?
Treatment for adrenal insufficiency
The nurse executive is planning education for new nurse managers regarding the AACN standards for a Healthy Work Environment. Which information will be included?
True collaboration must be promoted to ensure a healthy work environment
The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.)
Type I - Examples include hay fever and anaphylaxis . Type III - Immune complex deposits in blood vessel walls (arthrus reaction) Type 11-Blood tranfusions d. Type IV - Examples are poison ivy and transplant rejection
The nurse working in the emergency department puts a client in anaphylactic shock on a cardiac monitor and sees the cardiac rhythm below. What dysrhythmia will the nurse document?
Ventricular fibrillation
A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the physician or return to the ED if the client demonstrates reports which complications? (Select all that apply
Vomiting Irritability - slurred speech Weakness on one side of the body
A client in the intensive care unit is surprised to learn that he has an elevated blood glucose level since he has not been diagnosed with diabetes. How will the nurse explain this elevation?
When stressed, the body releases more glucose into the blood, raising the blood glucose level."
A nurse has been assigned to provide care for a 58-year-old man with a diagnosis of AIDS-related pneumonia. The nurse tells the charge nurse that she is unwilling to care for this client. What key component of critical thinking is most likely missing from this nurse's practice?
Withholding judgement
. A client is chronically short of breath and yet has normal lung ventilation, clear lung, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:
a. A possible hematologic problem
The nurse caring for mechanically ventilated patients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (SATA)
a. Adherence to proper hand hygiene b. suctioning the patient only when needed c. elevating the head of the bed e. Providing Oral care per protocol
A patient is diagnosed with rupture of an aortic aneurysm and surgery is imminent. What interventions will the nurse anticipate prior to surgery?
a. Administration of blood c. Administration of IV narcotic for pain d. Starting intravenous lines for fluid resuscitation e. Prepare for endotracheal intubation
A patient who is being mechanically ventilated is demonstrating respiratory acidosis. The nurse suspects that which metabolic process is malfunctioning?
a. Aerobic metabolism
A nurse performs an admission assessment on a 75 year old patient with multiple chronic diseases. The patient's blood pressure is 135/75 mmHg and oxygen saturation is 94% on 2L per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown below:
a. Ask the patient what medications he or she takes
The nurse is concerned that an older adult patient is at risk for developing acute renal failure. Which information in the patient's history supports the nurse's concern? (Select all that apply.)
a. Diagnosed with hypotension b. Recent aortic valve replacement surgery c. Prescribed high doses of intravenous antibiotics
. An emergency room nurse assesses a female patient. Which assessment findings will alert the nurse to request a prescription for an electrocardiogram?
a. Fatigue despite adequate rest b. Indigestion c. Shortness of breath d. Abdominal fullness
A patient admitted in hypertensive crisis is being cared for by a newly licensed nurse and his preceptor. The preceptor will consider which information when explaining the potential etiology of this crisis?
a. How well has the patient's hypertension been controlled in the past c. Has the patient been following the prescribed therapy? d. What therapy was the patient prescribed?
The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states?
a. Hypermetabolism b. Activation of the inflammatory response c. Hypoperfusion of tissues d. Must produce energy through anaerobic metabolism
A nurse assesses a client with untreated hypothyroidism who is admitted with acute appendicitis. The nurse notes that the patient's level of consciousness has decreased. What actions does the nurse perform? (Select all that apply.)
a. Infuse intravenous fluids. b. Cover the client with warm blankets. e. Administer oral glucose as prescribed.
A nurse cares for a patient who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action will the nurse take? (SATA)
a. Instruct the patient to take deep breaths b. Administer pain medication and encourage the patient to take deep breaths e. Instruct the patient on proper incentive spirometer (IS) use
The causes of acquired seizures include what? (Select all that apply.)
a. Metabolic and toxic conditions b. Cerebral vascular disease c. Brain tumor d. Hypoxemia e. Drug and alcohol withdrawal
The nurse is assessing a patient recovering from surgery for abdominal compartment syndrome. Which findings will indicate a life-threatening condition may be developing in this patient? (SATA)
a. Temperature 101.7 degrees F b. Complaint of dyspnea e. Complaint of chest pain
A client has sought care stating that she developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed?
a. Type I
The nurse caring for hospitalized patients includes which actions on their care plan to help prevent the possibility of the patients developing shock?
a. Using aseptic technique during procedures c. Removing invasive lines as soon as possible d. Assessing and identifying patients at risk e. Performing proper hand hygiene
A patient is hospitalized with recurrent gastric ulcers. Which education will the nurse provide? SATA
a. You may need to consider treating you chronic with some therapy besides NSAIDs b. You should monitor for symptoms such as bloating, nausea, and vomiting c. It is time for you to seriously consider smoking cessation
The nurse is caring for a patient in neurogenic shock due to a spinal cord injury. Vital signs include blood pressure 80/40 mmHg, heart rate 40 beats/ minute, respirations 24 breaths/ minute, oxygen saturation 88% on room air, and an oral temperature 96.8F. What interventions will the nurse include in the patient's care?
b. Begin an IV infusion for volume c. Stabilization of C-spine d. Application of 100% oxygen via facemask e. Give the patient a medication to increase the heart rate
A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential for herniation also increases. If the brain herniates, which of the following are potential consequences? (Select all that apply.)
b. Death c. Impaired cellular activity d. Temporary or permanent neurologic dysfunction
The nurse is caring for a patient with multiple organ dysfunction syndrome. Which interventions will help optimize tissue perfusion for this patient?
b. Maintain patency of the airway c. Administer pain medications as scheduled e. Keep the environment calm and quiet
What are the indications for chest drainage systems? SATA
b. Spontaneous pneumothorax c. Chest trauma resulting in pneumothorax d. Post-thoracotomy e. Pleural effusion
A client has suddenly developed this rhythm associated with a decrease in level of consciousness and a Bp of 82/48. The nurse knows to prepare for which priority treatment/ medication?
b. Synchronized cardioversion
The nurse is preparing to suction a client with a tracheostomy. What will be the nurse's first step in the suctioning process?
c. Assess the client's lung sounds and SaO2 via pulse oximeter
A patient is scheduled for an echocardiogram with measurement of ejection fraction. The nurse explains to the patient that this test will provide the most information about which cardiac characteristic?
c.The strength of the heartbeat
A patient who will require long-term mechanical ventilation has had a tracheostomy for two weeks. The nurse is concerned that stoma erosion is occurring. Which nursing assessment will support the nurse's concern?
d. Excessive amount of secretions are present at the stoma opening
A nurse assesses a patient's electrocardiogram (ECG) and observes the reading shown below, how will the nurse document the patient's ECG strip?
d. Sinus rhythm with premature ventricular contractions (PVCs)