Hurst Review Elevate Quiz 1

A client has been admitted with advanced Cirrhosis. The nurse's assessment of the abdominal girth verifies an increase in 5 inches (12.7 centimeters) and an increase in 6 lbs. (2.72 kg) since yesterday's measurements. The client reports a decreased desire to eat due to gastric reflux and is having steatorrhea. Which interventions would the nurse expect to see in this client's plan of care? SATA 1. Administer pantoprazole 40 mg by mouth every morning. 2. Prepare the client for thoracentesis. 3. Infuse Albumin, human 25% 50 mL over 1 hour. 4. Provide a diet of 1500 calories per day. 5. Administer Vitamins A, D, and E in water-soluble form.

1. Administer Pantoprazole 40 mg by mouth every morning. 3. Infuse Albumin, human 25% 50 mL over 1 hour. 5. Administer Vitamins A, D, and E in water-soluble form. Pantoprazole is a proton pump inhibitor that decreases the amount of acid produced in the stomach. In acute liver failure, Albumin (Human) 25% solution helps to stabilize vascular circulation by moving fluid into the vascular space. Clients who have fatty stools (steatorrhea) are losing fat-soluble vitamins. They need to receive water-soluble forms of fat-soluble vitamins A,D, and E 1. Correct: Pantoprazole is a proton pump inhibitor that decreases the amount of acid produced in the stomach. This will help the client's ability to eat small frequent meals. Remember the client needs a diet high in calories (up to 3000 calories a day). 2. Incorrect: This client would need to be prepared for a paracentesis, not a thoracentesis. What is a thoracentesis? Thoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, from the pleural space to help the client breathe easier. But where is this client's excess fluid? In the abdominal cavity. So what is needed? A paracentesis, a procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes. 3. Correct: In acute liver failure, Albumin (Human) 25% solution may serve the triple purpose of stabilizing the circulation, correcting an oncotic deficit and binding excessive serum bilirubin. It increases blood volume if circulatory instability follows the withdrawal of ascitic fluid. 4. Incorrect: This client needs 3000 calories per day. This client is in a hypermetabolic state and needs more calories. Up to 3000 calories per day. 1500 calories is not adequate for the client's needs. However, with all the fluid in the abdominal cavity, the client may not be able to eat much at a meal. Six small, high calorie, moderate to low fat meals spread throughout the day should be provided. 5. Correct: Provide clients who have fatty stools (Steatorrhea) with water-soluble forms of fat-soluble vitamins A, D, and E, and give folic acid and iron to prevent anemia.

Which client would the nurse monitor for the development of cardiogenic shock? SATA 1. Admitted with pericardial tamponade 2. Admitted with pulmonary embolism 3. Diagnosed with Cushing's Disease 4. Diagnoses with left sided heart failure 5. Admitted with multiple wasp stings

1. Admitted with pericardial tamponade 2. Admitted with pulmonary embolism 4. Admitted with multiple wasp stings These clients are at risk for cardiogenic shock. 1: Correct: With pericardial tamponade, think cardiogenic shock. 2. Correct: A sudden blockage of a blood vessel in the lung increases the workload of the heart. If increased too much, then cardiogenic shock can occur. 3. Incorrect: I would worry about fluid volume excess with this client. With Cushing's disease, the client is retaining too much sodium and water in the vascular space which can lead to fluid volume excess. 4. Correct: Heart failure can reduce the heart's ability to deliver oxygen-rich blood to your organs, leading to cardiogenic shock. 5. Incorrect: Wasp stings, especially multiple stings can lead to anaphalactic shock.

A client was admitted 48 hours ago in septic shock. Treatment included oxygen at 40% per ventimask, IV therapy of Lactated Ringer's (LR) at 150 ml/hr, vancomycin 1 gram IV every 8 hours, and methylprednisolone 40 mg IVP twice a day. Which clinical data indicates that treatment has been successful? SATA 1. pH-7.35; pCO2-44; pO2-92, HCO3-22 2. Skin, cool, mottled 3.Urinary Output of 300 mL/8hr 4. Vital Signs: Blood Pressure-90/50; HR-110; RR-22 5. WBC 10,500/mm3 (10.5 x 10^9)/L

1. pH-7.35; pCO2-44; pO2-92, HCO3-22 3. Urinary Output of 300 mL/8hr 5. WBC 10,500/mm3 (10.5x10^9)/L This ABG result shows no acid/base imbalance. The results are normal. Urinary Output should be adequate if treatment is successful. The urinary output should be at least 30 mL/hr for an adult. 300 mL over 8 hours is adequate at an average of 37.5 mL/hr. The white blood cell count is within normal limits. You are looking for signs and symptoms of that treatment of septic shock has been successful. If treatment has been successful then the client should be better. Here is one more thing to understand. The lactate provided in LR is quickly metabolized into bircarbonate by the normal liver; thus this solution can be used to treat many forms of metabolic acidosis. 1. Correct: This is a normal ABG result. No problem here. This would indicate that the client is improving. 2. Incorrect: Mottled, cyanotic skin is not good. This client would not be getting better with mottled skin. 3. Correct: The urinary output should be at least 30 mL/hr for an adult. 300 mL over 8 hours is adequate at an average of 37.5 mL/hr. The kidneys are being perfused. 4. Incorrect: The systolic BP is 90 which generally means that the client is perfusing vital organs. However, look at the heart rate. Tachycardia. The client is compensating to perfuse vital organs. The client is still sick. 5. Correct: The WBCs is within normal limits, indicating that the client is better. Normal range is 4,500-11,000/mm3 (12 x 109)/L

A client's arterial blood gas report has arrived at the nurse's station. Based on the results what interventions are required by the nurse? (pH-7.47, PaCo2-29, HCO3-23, PO2-95%) SATA 1. Start oxygen at 2 liters/min 2. Instruct client on taking slow deep breaths 3. Monitor serum sodium level 4. Initiate safety precautions 5. Administer sodium bicarbonate 1 ampule IVP

2. Instruct client on taking slow deep breaths 4. Initiate safety precautions This client is in respiratory alkalosis and it's acute because the kidneys have not kicked in. Fix the problem by slowing the respirations and rebreathing the CO2. The hyperventilating client is either in a panic or hysterical so calm them and give them an anxiolytic if necessary. Safety precautions are needed because dizziness or faintness can occur with respiratory alkalosis. 1. Incorrect: the client does not have an oxygen problem, they have a CO2 problem. their O2 is normal. False. More CO2 is needed, not more oxygen. 3. Incorrect: Potassium, rather than sodium needs to be monitored. Hypokalemia may occur as potassium is lost (urine) or shifted into the cell in exchange for hydrogen in an attempt to correct alkalosis. Serum potassium, rather than sodium needs to be monitored. 5. Incorrect: The bicarb is normal. A benzodiazepene or anxiolytic medication can be given to slow the client's respiratory rate. Anxiolytics or sedatives will decrease respirations so that more CO2 is retained. This question requires the test taker to go through a two-step process. First, the ABGs have to be interpreted correctly in order to then look at the responses to see what fits the results. The pH of 7.47 is high so it indicates alkalosis. The PaCO2 of 29 is low which also indicates alkalosis. The HCO3 of 23 is normal. So the client is in respiratory alkalosis. How did this happen? The client was breathing too fast. Note that the PO2 is 95%. Now you must look at interventions that will fix this problem. 2. True. When breathing slows down, more CO2 is retained. 4. True. Safety precautions are needed because dizziness and faintness can occur with respiratory alkalosis.

The nurse is reviewing laboratory results for multiple clients. Which client laboratory results should the nurse immediately report to the Healthcare provider? SATA 1. Client with chronic obstructive pulmonary disease (COPD) and a PCO2 of 50 mm Hg. 2. Diabetic client with fasting blood sugar of 145 mg/dL (8.0 mmol/L). 3. Cardiac client on furosemide with potassium of 3.1 mEq/L (3.1 mmol/L). 4. Client with sepsis and total white blood cell count of 16,000 mm3 5. Client following a thyroidectomy with calcium level of 8.0 mg/dL (2mmol/L).

3. Cardiact Client on furosemide with potassium of 3.1 mEq/L (3.1 mmol/L). 5. Client following a thyroidectomy with calcium level of 8.0 mg/dL (2 mmol/L). Although all of the laboratory results are outside of standard accepted levels, two particular clients are the most concerning. The cardiac client's potassium level of 3.1 is extremely concerning, since normal potassium levels should be between 3.5-5.0 mEq/L. Hypokalemia can cause muscle weakness and heart arrythmias, such as PVC's. Secondly, after the client's thyroidectomy, their calcium level is 8.0 mg/dl (normal 9.0-10.5 mg/dl), indicating possible removal of parathyroid glands. Because hypocalcemia places the client at risk for seizures or laryngospasms as well as arrythmias, the primary healthcare provider needs to be notified immediately so that corrective therapy can be initiated. 1. Incorrect: While this client's PCO2 of 50 is elevated (normal is 35-45 mm Hg), this is neither unexpected or unusual for an individual with COPD. This client will frequently experience elevated levels of PCO2; therefore the nurse should just continue monitoring for any changes in respiratory status. The client has COPD, which means the arterial blood gas results will always be abnormal! A PCO2 of 50 mm Hg would not be unexpected in this client, even though normal levels are 35-45 mmHG. The nurse would continue to monitor the respiratory status of this client, so no need to page the primary healthcare provider. 2. Incorrect: This diabetic client has a fasting blood sugar of 145 which is elevated above normal levels of 70-110. However, it is not uncommon for diabetics to occasionally have elevated glucose levels, even early in the morning. The nurse can address this issue by referring to the sliding scale for insulin administration. This does not need to be reported immediately to the primary healthcare provider. The big issue with diabetic clients is the on-going battle to control blood glucose levels. You ae also aware that since this client is hospitalized, there must be some type of illness, and that will most likely increase blood sugar readings, there is no need for immediate primary healthcare provider intervention. 3. Correct. The information presented indicates this client has a history of cardiac problems and is taking furosemide. You remember that this particular loop diuretic causes the body to excrete potassium in urine; therefore, the potassium levels should be monitored. Also, recall that potassium has a very small normal range of 3.5-5.0 mEq/L, indicating that this client's levels are too low. Potassium can cause big problems for the body, regardless of whether it's too high or too low. In this case, low potassium levels can cause muscle cramps or twitching, leading to muscle paralysis, or worse yet, life-threatening arrythmias. This is very dangerous for this cardiac client, and the nurse should definitely report this immediately to the primary healthcare provider. 4. Incorrect: It is expected that clients diagnosed with sepsis will have extremely elevated white blood cell counts. Despite the fact that this lab result is outside of normal values (4,500-10,000 mm3), this level is not concerning enough to immediately contact the primary healthcare provider. Start with what you know and what you expect. We know this client had a thyroidectomy and so you quickly recall what you know: it is a surgical intervention in which the client will have a frontal neck incision, and you also know that initial concerns include airway and bleeding. But what else do we worry about? How about the possibility that a couple parathyroid glands might accidentally be removed? So now think about what that means: possible hypocalcemia. What do we worry about? Seizure, laryngospasms, aspiration and even arrythmias as the muscles become tight and rigid. Do you think the primary healthcare provider might worry that this client's calcium level is 8.0 mg/dl, when it should be between 9.0-10.5 mg/dl? (yes)

What signs and symptoms would concern the nurse if assessed in a client post radical neck surgery? SATA 1. Decreased deep tendon reflexes 2. Flaccid muscle tone 3. Laryngeal Stridor 4. Muscle Cramps 5. Negative Trousseau's sign.

3. Laryngeal Stridor 4. Muscle Cramps Laryngeal Stridor and muscle cramps are signs indicating that muscles are rigid and tight due to a low calcium level. Some of the parathyroids could have been removed, resulting in hypocalcemia. 1. Incorrect: Decreased deep tendon reflexes would be seen with hypermagnesemia and hypercalcemia because they act like sedatives. Calcium acts like a sedative, so if the calcium level were high, the client would exhibit decreased deep tendon reflexes. 2. Incorrect: Flaccid muscle tone is seen with hypermagnesemia and hypercalcemia because they act like sedatives. Because calcium acts like a sedative, too much calcium would cause flaccid muscle tone and numbness and tingling of the face, hands, and feet. 3. Correct: The trachea and larynx are smooth muscles affected by the calcium level. A low calcium level will cause rigid, and tight muscles. This indicates that muscles are rigid and tight due to a low calcium level. This is something that you have to worry about post radical neck surgery. Some of the parathyroids could have been removed resulting in hypocalcemia. 4. Correct: a low calcium level will cause rigid, and tight muscles. So muscles will contract to the point of causing cramps. 5. Incorrect: A negative Trousseau's sign is a good thing. It would be positive if the Calcium level is low. a negative Trousseau's sign is a good thing. It would be positive if the calcium level is low. The Trousseau's sign refers to carpal spasms induced by inflating a BP cuff on the arm. When you inflate the cuff above the systolic pressure, carpal spasms occur within 3 minutes if hypocalcemia is present.

What clinical manifestations does the nurse expect to see in a client suspected of having hypercalcemia? SATA 1. Tachycardia 2. Positive Chvostek 3. Lethargy 4. Tachypnea 5. Decreased deep tendon reflexes

3. Lethargy 5. Decreased deep tendon reflexes Hypercalcemia is a condition in which the calcium level in the blood is above normal. Too much calcium in blood can weaken bones, create kidney stones, and interfere with heart and brain function. Hypercalcemia is usually a result of overactive parathyroid glands. Other causes include cancer, some medications, and taking too much calcium and vitamin D supplements. Signs and symptoms of hypercalcemia range from nonexistent to severe. Lethargy and decreased deep tendon reflexes are two manifestations of hypercalcemia. 1. Incorrect: Bradycardia rather than tachycardia is seen with hypercalcemia. Remember, muscles are sedated. 2. Incorrect: a negative Chvostek will be seen with hypercalcemia. It will be positive in hypocalcemia. 4. Incorrect: Hypercalcemia will result in a decreased, rather than increased respiratory rate.

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

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

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

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

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

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

A nurse is assessing a client who is one day post thyroidectomy and identifies an arrythmia on auscultation. While taking the blood pressure, the nurse notices the client's hand starts to tremble. What interventions should the nurse initiate? SATA 1. Administer magnesium sulfate IV 2. Continuous cardiac monitoring 3. Draw blood for phosphorous level 4. Initiate seizure precautions 5. Prepare to send client to surgery.

2. Continuous cardiac monitoring 3. Draw blood for phosphorous level 4. Initiate seizure precautions The parathyroid glands can be accidentally removed with a thyroidectomy. Low calcium causes rigid and tight muscles. The heart can be affected and life threatening arrythmias can occur. So the client should be placed on continuous cardiac monitoring. If some of the parathyroids have been removed, then calcium will be low and phosphorous will be high. They have an inverse relationship to each other. So both values should be monitored. The client is at risk for seizures so seizures precautions are needed. The clues in this question are "post thyroidectomy", "trembling hands (Positive Trousseau's)", "arrythmia". So what is the problem? What safety precautions are needed for this client. What are you worried about? Loss of some or all 4 parathyroids, which drops calcium. A low calcium makes muscles rigid and tight, so the client can have a seizure or laryngospasm. So what the NCLEX lady is really saying here is "Hey brand new nurse, what are you going to do if your client is hypocalcemic?" Ok, calcium. We said HYPO- Not enough calcium. So are they sedated or not? NOT sedated, and not sedated=Tight, rigid muscles. Could they seize? Yes! is the airway a muscle? Yes! 1. Incorrect: Is this the problem chemical? No, calcium is the problem, Calcium gluconate should be given IV 2. Correct. The heart can be affected and life threatening arrythmias can occur. So the client should be placed on continuous cardiac monitoring. 3. Correct: If some of the parathyroids have been removed, then calcium will be low and phosphorous will be high. They have an inverse relationship to each other. So both values should be monitored. 4. Correct: The client is at risk for seizures so seizures precautions are needed. 5. Incorrect: Surgery will not fix the problem.

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

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

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

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

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

1. Atrial Fibrillation 3. Eyes appear sunken 4. Hematocrit 55% 5. Several small furrows on tongue These are signs and symptoms that a client is dehydrated (fluid volume deficit). Lack of electrolytes in the blood associated with dehydration, especially potassium, can trigger A-fib symptoms. Normal capillary refill time is 1-2 seconds. This is consistent with a normal blood volume and perfusion. A CRT longer than 2 seconds suggests poor perfusion due to peripheral vasoconstriction. The client eyes appear sunken with severe dehydration and the skin is pale. This hematocrit is high which would indicate fluid volume deficit. Dilute decreases hematocrit, sodium, and specific gravity. Concentrated volume would make these numbers go up. The tongue normally has one main furrow. With fluid volume deficit there will be several more small furrows on the tongue.

A client is being treated for fluid volume deficit with D5W, oral hydration, and management of viral symptoms. Which client data would indicate to the nurse that further treatment is needed? SATA 1. BP 120/70 lying; 98/68 standing 2. Bounding Pulses 3. One day weight gain of 5 kg 4. Urine specific gravity of 1.010 5. Serum sodium 145 mEq (145 mmol/L)

1. BP 120/70 lying; 98/68 standing 2. Bounding Pulses 3. One day weight gain of 5 kg The systolic BP has dropped more than 20 mm Hg from lying to standing. This is considered orthostatic hypotension and indicates that the client is still in a fluid volume deficit. A bounding pulse is an indication of fluid volume excess. We have given the client too much fluid. This weight gain for one day is way too much. This indicates that we have put the client into fluid volume excess, which is a problem. You can answer this question easily if there is a knowledge of the signs and symptoms of fluid volume deficit. If treatment has been successful, then these signs and symptoms would be improved or absent. If treatment has not been effective, then the client will still have signs and symptoms. 1. Correct: Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position. In this case the systolic BP has dropped more than 20 mm Hg from lying to standing. This client is still in a fluid volume deficit. 2. Correct: A bounding pulse is an indication of fluid volume excess. If you feel a bounding pulse in this client, then we now have to worry about this problem. 3. Correct: When we treat a client for fluid volume deficit we have to make certain that we don't cause other problems. It is possible to give the client too much fluid and throw the client into fluid volume excess. 4. Incorrect: With fluid volume deficit, the specific gravity can be expected to be abnormally high. This urine specific gravity is normal. That means treatment has been successful. Normal urine specific gravity is 1.000 to 1.030 so this result is normal. Remember, the urine output will be low and concentrated with dehydration. Concentrated makes numbers go up. What three numbers? Sodium, specific gravity, and hematocrit. 5. Incorrect: This is a normal sodium level. Treatment is working. A serum sodium level of 145 mEq or 145 mmol/L is high normal (normal 134-145 mEq or 134-145 mmol/L). This indicates that the client is getting better. If the client's sodium level was high, then the client would still be sick. Hypernatremia is the same thing as dehydration.

A client arrives at the emergency department after being removed from a burning building. The nurse suspects carbon monoxide poisoning when the client exhibits which signs and symptoms? SATA 1. Dizziness 2. Epigastric Pain 3. Excess Salivation 4. Premature Ventricular Contractions 5. Sweet Aromatic Odor to Breath

1. Dizziness 4. Premature Ventricular Contractions Not enough oxygen is getting to the vital organs, such as the brain and heart, so dizziness, blurred vision, a dull headache, cardiac arrythmias and respiratory depression can occur. What should you know to answer this question? A person with carbon monoxide poisoning will have signs and symptoms of hypoxia because the carbon monoxide has replaced the oxygen on the hemoglobin. Clues in this question include "client in a closed place: building". What are the signs of carbon monoxide poisoning? The brain is not getting enough oxygen, so CNS symptoms predominate with carbon monoxide toxicity including headache, muscular weakness, palpitation, dizziness, and confusion, which can progress rapidly to coma. The heart will not get enough oxygen, so arrythmias, chest pain, and palpitations can occur. You should focus on decreased oxygen getting to the vital organs. 1. Correct: The brain is not being perfused properly so the client could report dizziness. 2. Incorrect: Epigastric pain is not a manifestation of carbon monoxide poisoning. The client will typically report nausea and might vomit. 3. Incorrect: Excessive salivation can be seen with indigestion of acids or alkalis 4. Correct: The heart is not being perfused and becomes irritable. Arrythmias, such as premature ventricular contractions can occur. 5. Incorrect: The client will not have a sweet aromatic odor to the breath with carbon monoxide poisoning. This occurs with ethylene glycol poisoning.

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

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

A nurse arrives at the scene of a home fire along with local emergency medical services (EMS) to find a client lying in the front yard. Burns are noted to the face, neck and chest. In what order should the nurse care for this client at the scene? 1. Administer 100% humidified oxygen 2. Remove restricted objects 3. Establish airway patency 4. Assess breathing 5. Soak burned area with cool water

1. Establish airway patency 2. Assess breathing 3. Administer 100% humidified oxygen 4. Soak burned area with cool water 5. Remove restrictive objects This is the correct emergency procedures at the burn scene. First, establish airway patency. Second, assess breathing. Third, administer 100% humidified oxygen. Fourth, soak burned area with cool water. Fifth, remove restrictive objects. Look at the hints in this question. The burns are to the face, neck and chest. What is the first thing that should pop into your mind when burns are noted to these areas? Airway! So the first three things that should be done for the client deals with airway and breathing. Make sure the airway is patent, that the client is breathing, and provide oxygen. Why 100%? Because the burn occurred in a closed environment, so the client is at risk for carbon monoxide poisoning. What should be done next? Stop the burning process. Just because the flames are gone does not mean that the burning process has stopped. Apply lots of cool water to stop the burning process. Burns cause swelling to occur. So the nurse needs to remove anything that would restrict circulation once swelling begins.

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

1. Immune globulin contains antibiotics that destroy the HAV, preventing infection. 4. It is important to take IG within four weeks of any exposure to hepatitis A Immune globulin contains antibodies that destroy the HAV, preventing infection. It's very important to take IG within two weeks of any exposure to hepatitis A. The clues in this question include "immune globulin" and "hepatitis A" You need to know that immune globulin provides passive immunity, which is temporary protection against a disease. When immune globulin is given, the client receives antibodies immediately to fight against the disease. The body does not have to do anything for this protection. This is why it is called passive immunity. In contrast, active immunity provides the client with a small dose of the antigen. The body then has to actively produce the antibodies. It takes several weeks for the client to produce these antibodies. During this time, the client is not protected. 1. Further teaching is necessary. The client gets the antibodies, not antibiotics immediately. 2. This is a correct statement, immune globulin protection is temporary. 3. This statement is accurate. Even if the test taker did not know this, most injections cause some discomfort and swelling at the site. 4. Further teaching is needed. It is important to take IG within four weeks of any exposure to hepatitis A. 5. Further teaching is not needed with this statement. The most common method of transmission for Hepatitis A is through the fecal/oral route. People living in crowded, confined places are at a higher risk of contracting Hepatitis A.

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

1. Initiate continuous cardiac monitoring. 2. Identify entrance and exit wounds. 5. Cover burned areas with clean sheets. These ae correct interventions for the nurse to initiate when caring for a client who has sustained a high-voltage electrical injury. Remember, electricity kills vessels, nerves, and organs. Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. Electrical burns have two wounds; an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. In the emergent phase of care, the nurse needs to protect the wound from contaminants. Cover burned areas with dry dressings or a clean sheet. You need to understand that high-voltage current of electricity damages the vascular system and the nerves nearby. This alteration in the vascular system can damage vital organs, so we worry about organ failure. Remember, vessels, nerves, and organs can be damaged. the nurse needs to monitor vital signs frequently, especially those assessing the respiratory and cardiac systems, since we worry about organ damage. 1. Correct: Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. 2. Correct: Electrical burns have two wounds: an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. 3. Incorrect: Analgesics by mouth will not be as effective as IV analgesics during the emergent phase. 4. Incorrect: The burned limb should be elevated above the level of the heart to decrease peripheral edema. 5. Correct: In the emergent phase of care, the nurse needs to protect the wound from contaminants. Cover burned areas with dry dressings or a clean sheet.

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

1. Place client in a private room 2. Ask client to stay in hospital room. 3. Have visitors wash hands before entering and after leaving client's room. Patients with MRSA will have a single room or will share a room only with someone else who has MRSA. Patients are asked to stay in their hospital rooms as much as possible. They should not go to common areas, such as the gift shop or cafeteria. They may go to other areas of the hospital for treatments and tests. The number one way to prevent the spread of infection is through proper hand hygiene. 1. Correct: The goal is to prevent the spread of infection, so a private room is best for the client. 2. Correct: The chance of spreading infection to others will go up if the client moves freely around the hospital. 3. Correct: Hand hygiene is the number 1 way to prevent the spread of infection. 4. Incorrect: Contact isolation should be instituted since the drainage is what spreads the infection so an N95 mask is not needed 5. Incorrect: The client is placed on contact precautions, not airborne precautions.

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

2. Frequent mouth care 3. Provide 250 mL water via G-tube every 6 hours 4. Seizure Precautions Oral mucous membranes become sticky and dry due to loss of fluid in the interstitial spaces so mouth care should be provided frequently. The client is dehydrated with a high sodium level because of the high solute tube feeding. The client needs water and a sodium free IV fluid. High sodium levels in the blood leads to dehydration of brain cells resulting in changes in mental status, ranging from drowsiness, restlessness, confusion, and lethargy to seizures and coma. Seizures precautions are necessary. 1. Incorrect: The client is dehydrated. A diuretic would make it worse. 5. Incorrect: This is an isotonic sodium fluid. The client does not need more sodium.

A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client. (pH-7.46, PaO2-97%, PaCo2-47, HCO3-28) SATA 1. Metabolic acidosis 2. Respiratory alkalosis 3. Metabolic alkalosis 4. Respiratory acidosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

3. Metabolic alkalosis 6. Partially compensated Partially compensated metabolic alkalosis is indicated by these ABGs. The pH is 7.46 (normal 7.35-7.45) which is high, which means alkalosis. The PaCO2 is 47 (normal 35-45) which is high. Greater than 45 is acidosis from too much CO2. The HCO3 is 28 (normal 22-26) which is high. A high bicarb level equals alkalosis. The HCO3 matches the pH as both indicate alkalosis. The initial problem was a kidney problem or metabolic alkalosis. The lungs are trying to compensate by holding on to more acid. So the correct answer is partially compensated metabolic alkalosis. 1. Incorrect: A pH of greather than 7.45 indicates alkalosis rather than acidosis. So this option is incorrect. 2. Incorrect: The PaCO2 would be low rather than high if the problem was respiratory alkalosis. 4. Incorrect: A pH of greater than 7.45 indicates alkalosis rather than acidosis. So this option is incorrect. 5. Incorrect: If the ABGs indicated that compensation had not begun (uncompensated) than the CO2 would be normal. Since it is high, the lungs are attempting to compensate for the metabolic alkalosis retaining more acid (decrease breathing to hold on to acid). 7. Incorrect: Full compensation does not occur until the pH is normal. The pH is still abnormal here.