MED SERG

The nurse is initiating a blood transfusion. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's lung fields. 2. Have the client sign a consent form. 3. Start an IV with a 22-gauge IV catheter. 4. Hang 250 mL of D5W at a keep-open rate. 5. Check the chart for the HCP's order.

1,2,5 (The nurse must make a decision on the amount of blood to infuse per hour. If the client is showing any sign of heart or lung compromise, the nurse would infuse the blood at the slowest possible rate Blood products require the client to give specific consent to receive blood. The IV should be started with an18-gauge catheter if possible; the smallest possible catheter is a 20-gauge. Smaller gauge catheters break down the blood cells. Blood is not compatible with D5W; the nurse should hang 0.9% normal saline (NS) to keep open. The nurse should verify the HCP's order before having the client sign the consent form.)

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? 1.U waves 2.Absent P waves 3.Inverted T waves 4.Depressed ST segment 5.Widened QRS complex

1,3, 4 (Low and slow)

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. 1. U waves 2.Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Widened QRS complex

1,3,4 (The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.)

A woman who is 14 weeks pregnant presents to the ED after falling down a flight of stairs. What should be the nurse's first intervention? 1. Administer oxygen 2. Attempt to locate fetal heart tones 3. Start an IV with a large-bore catheter 4. Position the patient on her right side

1. Administer oxygen (Oxygen consumption is increased in pregnancy. The pregnant trauma patient should always receive supplemental oxygen. This should be the first action according to the ABCs of assessment.)

The client comes to the clinic complaining of itching on the left wrist near a wristwatch. The nurse notes an erythematous area along with pruritic vesicles around the left wrist. Which condition should the nurse suspect?1. Contact dermatitis. 1. Contact dermatitis. 2. Herpes simplex 1. 3. Impetigo. 4. Seborrheic dermatitis.

1. Contact dermatitis (Contact dermatitis is a type of dermatitis caused by a hypersensitivity response. In this case, it is a hyper- sensitivity reaction to metal salts in the watch the client is wearing. Any- time the nurse assesses redness or irritation in areas where jewelry (such as rings, watches, necklaces) or clothing (such as socks, shoes, or gloves) are worn, the nurse should suspect contact dermatitis.)

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level.

1. The client diagnosed with myocardial infarction who has an audible S3 heart sound (An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation. The nurse would expect a client with CHF to have sacral edema of 4+; the client with an S3 would be in a more life-threatening situation. A general guideline for this type of question is for the test taker to ask "Is this within normal limits?" or "Is this expected for the disease process?" If the answer is yes to either question, then the test taker can eliminate these options and look for abnormal data that would make that client a priority.)

Which question should the nurse ask the client who is being admitted to rule out infective endocarditis? 1. "Do you have a history of a heart attack?" 2. "Have you had a cardiac valve replacement?" 3. "Is there a family history of rheumatic heart disease?" 4. "Do you take non steroidal anti-inflammatory medications?"

2. "Have you had a cardiac valve replacement?" (Cardiac valve replacement and valve disorders are risk factors for develop- ing infective endocarditis. This is why clients must receive prophylactic antibiotic treatment before dental work and invasive procedures.A personal history of rheumatic fever, not a family history, increases the risk of developing infective endocarditis. NSAIDs have no effect on the development of infective endocarditis.)

The client with venous insufficiency tells the nurse, "The doctor just told me about my disease and walked out of the room. What am I supposed to do?" Which statement is the nurse's best response? 1. "I will have your HCP come back and discuss this with you." 2. "One thing you can do elevate your legs above your heart while watching TV." 3. "You will probably need to have surgery within a few months." 4. "This will go away after you lose about 20 pounds and start walking.

2. "One thing you can do elevate your legs above your heart while watching TV." (It is the nurses duty to teach about the disease process)

The 33-year-old client had a traumatic amputation of the right forearm as a result of a work-related injury. Which referral by the rehabilitation nurse is most appropriate? 1. Physical therapist. 2. Occupational therapist. 3. Worker's compensation. 4. State rehabilitation commission.

2. Occupational therapist. (Focus on ADL's to increase independence. You need to ADL's to be able to live on your own)

The nurse observes the unlicensed assistive personnel (UAP) taking vital signs on an unconscious client. Which action by the UAP warrants intervention by the nurse? 1. The UAP uses a vital sign machine to check the BP. 2. The UAP takes the client's temperature orally. 3. The UAP verifies the blood pressure manually. 4. The UAP counts the respirations for 30 seconds.

2. The UAP takes the client's temperature orally. (Temp should never be take orally when the patient is unconscious!)

The client diagnosed with a brain tumor who had radiation treatment and developed alopecia asks, "When will my hair grow back?" Which statement is the nurse's best response? 1. "Your hair should start growing back within three (3) weeks." 2. "Are you concerned your hair will not grow back?" 3. "It may take months, if your hair grows back at all." 4. "It may take a couple of years for the hair to grow back."

3. "It may take months, if your hair grows back at all." Radiation therapy can cause permanent damage to the hair follicles and the hair may not grow back at all; the nurse should answer the client's question honestly.

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? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP)

3. An increase in blood pressure and increased respirations (think fluid volume over load. High BP and increased repatriations are s/s of this)

A patient recovering from surgery in the postoperative area suddenly becomes confused, pulse ox reading shows a drop from 98% to 90% on room air. What is the most appropriate intervention 1. Apply a non re-breather mask 2. Apply a simple face mask 3. Apply nasal cannula 4. Raise the head of the bed

3. Apply nasal cannula ( The patient is recovering from surgery. Key term: post op. This is a short term problem---a short term solution such as the nasal canal should be selected. Raising the HOB is not appropriate without the knowledge of surgery Depending on the surgery this could lead to more damage)

The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily.2. Walk for 15 minutes three (3) times a week. 3. Do not walk outside if it is less than 40 ̊F. 4. Wear open-toed shoes when ambulating.

3. Do not walk outside if it is less than 40 ̊F. (When it is cold outside, vasoconstriction occurs, and this will decrease oxygen to the heart muscle. Therefore, the client should not exercise when it is cold outside. Isometric exercises are weight lifting-type exercises. A client with CAD should per- form isotonic exercises, which increase muscle tone, not isometric exercises)

The client is diagnosed with aortic stenosis. Which assessment data indicate a complication is occurring? 1. Barrel chest and clubbing of the fingers. 2. Intermittent claudication and rest pain. 3. Pink, frothy sputum and dyspnea on exertion. 4. Bilateral wheezing and friction rub.

3. Pink, frothy sputum and dyspnea on exertion. (Pink, frothy sputum and dyspnea on exertion are signs of congestive heart failure, which occurs when the heart can no longer compensate for the strain of an incompetent valve.)

The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement 1. Instruct the UAP to stop encouraging the leg movements. 2. Report this behavior to the charge nurse as soon as possible. 3. Praise the UAP for encouraging the client to move legs. 4. Take no action concerning the UAP's behavior.

3. Praise the UAP for encouraging the client to move legs . (The nurse should praise and encourage UAPs to participate in the client's care. Clients on bedrest are at risk for deep vein thrombosis, and moving the legs will help prevent this from occurring. The nurse should praise subordinates for appropriate behavior, especially when it is helping to prevent life-threatening complications.)

Assessment of a patient postarthroplasty reveals tachypnea, air hunger, hypoxia, O2 sat of 86%, declining mental status, and petechiae. What is the nurse's priority action? 1. Apply oxygen at 3 to 4 liters /minute.2. Call a code for potential cardiac arrest. 3. Prepare the patient for immediate intubation and mechanical ventilation with PEEP. 4. Raise the head of the bed (HOB) and encourage coughing every hour.

3. Prepare the patient for immediate intubation and mechanical ventilation with PEEP (The symptoms are related to severely compromised pulmonary status, probably acute respiratory distress syndrome (ARDS), which is related to a fat embolus blocking the pulmonary vessel and inactivating surfactant. Intubation and mechanical ventilation with PEEP (positive end- expiratory pressure) are needed to maximize air)

Which client should the nurse consider at risk for developing acute renal failure? 1. The client diagnosed with essential hypertension. 2. The client diagnosed with type 2 diabetes. 3. The client who had an anaphylactic reaction. 4. The client who had an autologous blood transfusion.

3. The client who had an anaphylactic reaction. (Anaphylaxis lead to circulatory collapse, which decreases perfusion to your kidneys and can lead to acute renal failure)

The primary nurse is applying anti-embolism hose to the client who had a total hip replacement. Which situation warrants immediate intervention by the charge nurse? 1. Two fingers can be placed under the top of the band. 2. The peripheral capillary refill time is 3 seconds. 3. There are wrinkles in the hose behind the knees. 4. The nurse does not place a hose on the foot with a venous ulcer.

3. There are wrinkles in the hose behind the knees. ( The wrinkles would cause constriction of the blood vessels and could lead to a clot. Wrinkles are a no-no in anti-embolism stockings)

A patient is admitted with an ulcer on the right great toe. The nurse determines that the blood pressure in the patient's right arm is 138 systolic, the left arm is 136 systolic, the right ankle is 65 systolic, and the left ankle is 66 systolic. How does the nurse evaluate these readings? 1. The wound will require debridement. 2. The patient is getting adequate circulation to the feet. 3. This ulcer is not likely to heal. 4. The patient needs intravenous fluids to support intravascular volume.

3. This ulcer is not likely to heal (Rationale 3: An ankle-brachial index (ABI) of less than 0.5 indicates poor prognosis for healing. The patient's right ABI is 0.47)

The client diagnosed with atherosclerosis has coronary artery disease. The client experiences sudden chest pain when walking to the nurse's station. Which intervention should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Apply oxygen via nasal cannula. 3. Obtain a STAT electrocardiogram. 4. Have the client sit in a chair.

4. Have the client sit in a chair. (Stopping the client from whatever activity the client is doing is the first intervention because this decreases the oxygen demands of the heart muscle and may decrease or eliminate the chest pain.)

The nurse writes the goal "the client will list three (3) food sources of vitamin B12" for the client diagnosed with pernicious anemia. Which foods listed by the client indicate the goal has been met? 1. Brown rice, dried fruits, and oatmeal. 2. Beef, chicken, and pork. 3. Broccoli, asparagus, and kidney beans. 4. Liver, cheese, and eggs.

4. Liver, cheese, and eggs. (Brown rice, dried fruit, and oatmeal are sources of nonheme iron. Nonheme iron comes from vegetable sources.Beef, chicken, and pork are sources of heme iron or animal sources of iron. Broccoli, asparagus, and kidney beans are sources of folic acid. Liver, cheese, and eggs are sources of vitamin B12.)

The unlicensed assistive personnel (UAP) notifies the nurse the client diagnosed with chronic obstructive pulmonary disease is complaining of shortness of breath and would like his oxygen level increased. Which intervention should the nurse implement? 1. Notify the respiratory therapist (RT). 2. Ask the UAP to increase the oxygen. 3. Obtain a STAT pulse oximeter reading. 4. Tell the UAP to leave the oxygen alone.

4. Tell the UAP to leave the oxygen alone. ( The patient with COPD should not receive more than 3L of 02 because it can stop their stimulus for breathing.)

Which client should the charge nurse on the substance abuse unit assign to the licensed practical nurse (LPN)? 1. The client with chronic alcoholism who has been on the unit three (3) days. 2. The client who is complaining of palpitations and has a history of cocaine abuse. 3. The client diagnosed with amphetamine abuse who tried to commit suicide. 4. The client diagnosed with cannabinoid abuse who is threatening to leave AMA.

4. The client diagnosed with cannabinoid abuse who is threatening to leave AMA (The client has a right to leave against medical advice (AMA), and marijuana abuse is not life threatening to him or to others. Therefore, the LPN could be assigned to this client. Option 3-client is at high risk for injury to self and should be assigned to a registered nurse and be on one-to-one precautions.)

A hospital patient is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test? A) Arrange for a portable x-ray machine to be used. B) Have the patient wear a mask to the x-ray department. C) Ensure that the radiology department has been disinfected prior to the test. D) Send the patient to the x-ray department, and have the staff in the department wear masks.

A) Arrange for a portable x-ray machine to be used. (A patient who is immunocompromised is at an increased risk of contracting nosocomial infections due to suppressed immunity. The safest way the test can be facilitated is to have a portable x-ray machine in the patients room. This confers more protection than disinfecting the radiology department or using masks.-think what they do for you when malnourished)

A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite that he has not recently performed any physical activity. What assessment question should the nurse ask the patient while preparing to perform a physical assessment? A) On a scale from 1 to 10, how bad would rate your shortness of breath? B) When was the last time you ate or drank anything? C) Are you feeling any nausea along with your shortness of breath? D) Do you think that some medication might help you catch your breath?

A) On a scale from 1 to 10, how bad would rate your shortness of breath? (Gauging the severity of the patients dyspnea is an important part of the nursing process. Oral intake and nausea are much less important considerations. The nurse must perform assessment prior to interventions such as providing medication.)

A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patient's gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis? A) Acute Abdominal Pain B) Diarrhea C) Bowel Incontinence D) Constipation

B) Diarrhea (Diarrhea is a problem in 50% to 60% of all AIDS patients. As such, this nursing diagnosis is more likely than abdominal pain, incontinence, or constipation, though none of these diagnoses is guaranteed not to apply.)

The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patients blood? A) A capillary blood sample B) Pulse oximetry C) An arterial blood gas (ABG) study D) A complete blood count (CBC)

C) An arterial blood gas (ABG) study (Capillary blood samples are venous blood, not arterial blood, so they are not as accurate as an ABG. Pulse oximetry is a useful clinical tool but does not replace ABG measurement, because it is not as accurate.)

A patient with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath? A) Total lung capacity B) Forced vital capacity C) Tidal volume D)Residual volume

C) Tidal volume (Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.)

A patients primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patients immune response. This physiologic state is known as which of the following? A) Static stage B) Latent stage C) Viral set point D) Window period

C) Viral set point (The remaining amount of virus in the body after primary infection is referred to as the viral set point, which results in a steady state of infection that lasts for years. This is not known as the static or latent stage. The window period is the time a person infected with HIV tests negative even though he or she is infected)

During a life threatening emergency a nurse hurriedly gives the patient a medication by IV push there is an extravasation of medication. Later, necrosis and tissue sloughing takes place. the nurses behavior may be the Basis for which action? A. Felony Charge B. Misdemeanor Charge C. Tort suit D. Defamation suit

C. Tort suit (And unintentional tort is a wrong occurring to an injuryEven though it was not intended)

In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patients arterial oxygen saturation (SaO2). What procedure will best accomplish this? A) Incentive spirometry B) Arterial blood gas (ABG) measurement C) Peak flow measurement D) Pulse oximetry

D) Pulse oximetry (ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. In this question they are just trying to get regular vitals)

The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what? A) Nitrogen narcosis B) Infection C) Impaired diffusion D) Shunting

D) Shunting (Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Impairment of normal diffusion is a less common cause. Infection would not likely be present at this early stage of recovery and nitrogen narcosis only occurs from breathing compressed air.)

True or False: Sleep apnea has genetic risk factors?

False

What type of law? Willful acts that violate another person's rights or property usually physical acts that may result in crime. Including Assault, Battery, False imprisonment, intentional infliction of emotional distress, conversion of property (destroying a patients property)

Intentional Torts

An unintentional wrong doing to a patient that causes harm is an example of a

Unintentional tort