NUR2048 Exam 2 Study Set

Losartan

ARB

Olmesartan

ARB

Clinical Significance of Sodium

Evaluates fluid-electrolyte imbalance and acid-base balance related to neuromuscular, renal, and adrenal functions

Clinical Significance of BUN

Evaluates kidney function and aids in the diagnosis of renal failure or liver disease; aids in assessment of hydration; assesses effectiveness of dialysis

A client with third-degree burn asks a nurse, "Why do I need a temporary pigskin graft?" What is the nurse's best response? 1. "It promotes rapid healing of the wound" 2. "Topical lotions can be used concurrently with the graft" 3. "When sutured in place, it provides better adherence" 4. "It helps debride necrotic tissue"

1. "It promotes rapid healing of the wound"

A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs? 1. Increased restlessness 2. No secretions when client is suctioned 3. PaO2 of 93 4. Skin warm and dry

1. Increased restlessness

The nurse is teaching a health awareness class. Which situation would the nurse teach as being the *highest* risk factor for the development of a deep vein thrombosis (DVT)? 1. Pregnancy 2. Inactivity 3. Aerobic exercise 4. Tight clothing

2. Inactivity

A client develops bacterial pneumonia and is admitted to the emergency department. The client's initial PaO2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is 65 mm Hg. Which action would the nurse take *first*? 1. Ensure that intubation equipment is available. 2. Increase the oxygen flow rate per facility protocol. 3. Notify the health care provider to request a chest x-ray 4. Recheck the arterial blood gases to verify accuracy

2. Increase the oxygen flow rate per facility protocol

When palpating the chest during a respiratory assessment, which finding would the nurse expect in a client with pneumonia? 1. Bilateral decreased chest expansion 2. Increased fremitus over the affected area 3. Tracheal deviation away from the affected side 4. Decreased chest expansion on the affected side

2. Increased fremitus over the affected area

When a client is diagnosed with pneumonia, which findings would the nurse expect when assessing the chest? 1. Hyperresonance to percussion 2. Increased tactile (vocal) fremitus 3. Cheyne-Stokes respiratory pattern 4. Vesicular sounds over all lung fields

2. Increased tactile (Vocal) fremitus

A client is admitted for treatment of partial and full-thickness burns of the entire right lower extremity and the anterior portion of the right upper extremity. The nurse performs an immediate appraisal, using the rule of nines. Which percentage of body surface area burned will the nurse record? 1. 36.5% 2. 27% 3. 22.5% 4. 18%

3. 22.5%

Normal Albumin Level

3.4-5.4

Normal Potassium Level

3.5-5

Normal CO2

35-45

The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? 1. PO2 value is 80 mmHg 2. HCO3 value is 50 mEq/L 3. Serum potassium value is 4 mEq/L 4. PCO2 value is 60 mmHg

2. HCO3 value is 50 mEq/L

The nurse is caring for a client who has been admitted with partial and full-thickness burns over 25% of the total body surface area. Lactated Ringer solution and 5% dextrose have been prescribed. What is the purpose of these fluids? 1. Prevent fluid shifts 2. Maintain blood volume 3. Replace electrolytes lost 4. Expand the plasma

2. Maintain blood volume

Which action would the nurse take to prevent aspiration recurrence in a client with aspiration pneumonia who is NPO status with a nasogastric tube and a prescription for antibiotics? *Select all that apply. One, some, or all responses may be correct* 1. Obtaining vital signs after feedings 2. Administering intravenous antibiotics 3. Elevating the head of the bed to 30 degrees 4. Determining residual every 4 hours 5. Assessing for the gag reflex before feeding

3. Elevating the head of the bed to 30 degrees

Which clinical manifestations would the nurse expect to identify when performing an admission history and physical for a client with chronic peripheral arterial disease? 1. Edema of the feet and ankles 2. Reddened and painful areas on the calves 3. Pain when exercising and thickening of the toenails 4. Ulcers around the ankles and reports of a dull ache in the legs

3. Pain when exercising and thickening of the toenails

Following a fire, the disaster management team assesses burn injuries of the survivors. The team finds that most survivors have pink to cherry red skin with blisters. Which type of burns does the nurse identify on the survivors? 1. Fourth degree burns 2. First degree burns 3. Second degree burns 4. Third degree burns

3. Second degree burns

Which action should be the nurse's *first* priority for a client with major burns? 1. Administering oxygen as needed 2. Elevating the extremities if no fractures are noticed 3. Assessing airway patency 4. Checking the client from head to toe

3. Assessing airway patency

Normal pH

7.35-7.45

Normal PaO2

80-100

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? 1. Decreased blood pressure 2. Cyanosis 3. Crackles in the lungs 4. Decreased heart rate

3. Crackles in the lungs

Which action would he nurse include in the postprocedure plan of care for a client with peripheral arterial disease who is scheduled for a femoral angiogram? 1. Elevate the foot of the bed 2. Place in the high-Fowler position 3. Perform urinary catheter care every 12 hours 4. Check pedal pulses every 15 minutes postprocedure

4. Check pedal pulses every 15 minutes postprocedure

What would be the *priority* nursing intervention in a client with electric burns? 1. Cooling the burns for no more than 10 min 2. Gently removing the burned cloth 3. Wrapping the client in a dry clean sheet 4. Checking the airway, breathing, and circulation

4. Checking the airway, breathing, and circulation

What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism? *Select all that apply* 1. Clients are instructed to lie still on a hard table. 2. A client's serum creatinine level is evaluated after the test. 3. The test involves the administration of a contrast medium. 4. Clients are served shellfish before the test. 5. Clients should have their hydration levels assessed.

1. Clients are instructed to lie still on a hard table. 3. The test involves the administration of a contrast medium. 5. Clients should have their hydration levels assessed.

When caring for a client with pneumonia, which nursing intervention is the *highest priority*? 1. Increase fluid intake 2. Employ breathing exercises and controlled coughing 3. Ambulate as much as possible 4. Maintain a nothing-by-mouth (NPO) status

2. Employ breathing exercises and controlled coughing

Which action by a client with peripheral arterial disease indicates that more teaching about how to manage the disease is needed? 1. Applying a hot water bottle to the abdomen 2. Using a heating pad to warm the extremities 3. Drinking a warm cup of tea when feeling chilly 4. Turning the room thermostat above 72 degrees

2. Using a heating pad to warm the extremities

Which mechanism would the nurse attempt to increase to prevent postoperative deep vein thrombosis? 1. Coagulability of the blood 2. Velocity of the venous return 3. Effectiveness of internal respiration 4. Oxygen-carrying capacity of the blood

2. Velocity of the venous return

Normal HCO3

22-26

Normal Creatinine Level

0.5-1

Which complication may be caused by sepsis in burns? 1. Paralytic ileus 2. Curling's ulcer 3. Constipation 4. Diarrhea

1. Paralytic ileus

Normal BUN Level

10-20

Normal Hgb Count

12-18

Normal Sodium Level

135-145

Normal Platelet Count

150-400

To determine the presence of respiratory alkalosis in the laboring client, what should the nurse evaluate her for? 1. A pulse oximetry reading of less than 98% 2. A tingling sensation in the hands 3. A change in the respiratory rate 4. Periodic changes in the fetal heart rate

2. A tingling sensation in the hands

Normal WBC Count

5-10

What are some causes of PAD?

Artherosclerosis

Clinical Significance of Creatinine

Assesses glomerular filtration; screens for renal damage

What discharge teaching instructions should a nurse provide to a patient with a DVT?

Avoid prolonged sitting or standing, elevate the legs for 10-20 minutes every few hours, avoid smoking

Clinical Significance of Albumin

Determine whether the patient has liver disease or kidney disease; determine whether the body is absorbing enough protein; assess overall health; assess nutritional status

A client is brought to the emergency department with deep partial-thickness burns on the face and full-thickness burns on the neck, entire anterior chest, and one arm. To assess for heat inhalation, the nurse should observe for which finding? 1. Changes in the chest x-ray findings 2. Changes in the arterial blood gases consistent with acidosis 3. Nasal discharge containing carbon particles 4. Sputum that contains particles of blood

3. Nasal discharge containing carbon particles

Lisinopril

ACE inhibitor

A nurse is caring for a client who has had a hysterectomy is concerned about the client's risk for postoperative thrombosis. The nurse remembers that the majority of pulmonary emboli begin as deep vein thromboses in what area? 1. Calf 2. Extremities and abdomen 3. Thoracic cavity 4. Pelvis and thighs

4. Pelvis and thighs

Clinical Significance of Platelets

Evaluates platelet production; assesses effects of chemotherapy or radiation; diagnoses or monitors thrombocytosis or thrombocytopenia

A client is receiving warfarin for a pulmonary embolism. Which drug is often contraindicated when taking Warfarin? 1. Acetylsalicylic acid 2. Chlorpromazine 3. Atenolol 4. Ferrous sulfate

1. Acetylsalicylic acid

A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? 1. An elevated pH, decreased PCO2 2. A decreased pH, decreased PCO2 3. An elevated pH, elevated PCO2 4. A decreased pH, elevated PCO2

1. An elevated pH, decreased PCO2

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the *highest* risk for developing a pulmonary embolism? 1. An obese client with leg trauma 2. A client with diabetes who has cholecystitis 3. A client with pneumonia who is immunocompromised 4. A pregnant client with acute asthma

1. An obese client with leg trauma

A client is a 36 hours' postpartum is being treated with subcutaneous enoxaparin for deep vein thrombosis of the left calf. Which client adaptation is of most concern to the nurse? 1. Dyspnea 2. Pulse rate of 62 beats/min 3. Blood pressure of 136/88 mmHg 4. Positive Homan sign in the left leg

1. Dyspnea

What is a clinical manifestation of hypernatremia in burns? 1. Seizures 2. Fatigue 3. Cardiac dysrhythmias 4. Paresthesias

1. Seizures

After an infant undergoes surgery for the repair of myelomeningocele, diarrhea and metabolic acidosis develop, accompanied by decreased urine output. In light of the infant's status, what prescription does the nurse anticipate? 1. Sodium lactate 2. Isotonic saline 3. Serum albumin 4. Potassium chloride

1. Sodium lactate

After the nurse completes teaching for a client with foot pain who has peripheral arterial disease, which client statement indicates that further teaching is needed? 1. "I will wear socks" 2. "I will elevate my foot" 3. "I will increase fluid intake" 4. "I will drink a moderate amount of alcohol"

2. "I will elevate my foot"

After the nurse has taught a client with peripheral arterial disease about a heart-healthy diet, which client statement *best* indicates that the teaching has been effective? 1. "I have a weight loss goal of 20 pounds." 2. "I will need to eat more vegetables and less steak." 3. "Thank you for taking the time to teach me about diet." 4. "My spouse will need to buy more healthy foods to cook."

2. "I will need to eat more vegetables and less steak."

Which nursing action is *most* important to promote the nutritional status of a client during the acute phase of treatment after extensive burns? 1. Provide a diet high in sodium 2. Limit caloric intake to decrease the work of the body 3. Administer the prescribed intravenous fluid with the added vitamin C 4. Reduce protein intake to avoid overtaxing the kidneys

3. Administer the prescribed intravenous fluid with the added vitamin C

A nurse is admitting a 2-year-old toddler who ingested half of a bottle of aspirin tablets to the emergency department. What is the origin of the metabolic acidosis caused by aspirin toxicity? 1. Deep rapid breathing 2. Increased renal excretion of bicarbonate 3. Rapid absorption of salicylate 4. Higher pH of gastric contents

3. Rapid absorption of salicylate

Which inpatient admission orders for a child with viral pneumonia would the nurse question? 1. Encourage oral fluids 2. Chest physiotherapy twice a day 3. Start IV fluids D5NS at 80mL/h 4. Aspirin 325mg every 4 hours PRN for fever higher than 101.4

4. Aspirin 325mg every 4 hours PRN for fever higher than 101.4

Clinical Significance of Neutrophils

Presence of increased bands indicates infection; increased bands with decreased WBC indicated bone marrow depression; Decreased neutrophils indicates neutropenia

A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs or respiratory acidosis? * Select all that apply* 1. Restlessness 2. Lightheadedness 3. Hypertension 4. Irritability 5. Headache

1. Restlessness 4. Irritability 5. Headache

Ingestion of which chemicals may cause chemical pneumonia? 1. Bleach 2. Lighter fluid 3. Toilet cleaner 4. Mildew remover

2. Lighter fluid

A client with burns is hospitalized in the emergency department and advised to get an electrocardiogram (ECG) done. Which type of burn injury has the client *most* likely sustained? 1. Chemical burn 2. Flame burn 3. Radiation burn 4. Electrical burn

4. Electrical burn

While performing a respiratory assessment of a client with pneumonia, the nurse hears these sounds. Which assessment finding would the nurse document in the client's medical record? 1. Ronchi 2. Fine Crackles 3. Coarse Crackles 4. Pleural friction rubs

4. Pleural friction rubs

A nurse evaluates the condition of a client with burns of teh upper body. Which assessment findings indicate potential respiratory obstruction? *Select all that apply.* 1. Brassy cough 2. Deep breathing 3. Soot on legs 4. Dark mucous membranes 5. Singed nasal hair

1. Brassy cough 4. Dark mucous membranes 5. Singed nasal hair

DVT= Blood is going to the _____ extremity, just not returning to the ____ side of the heart.

Lower; Right

Clinical Significance of Hgb

Measures the severity of anemia; obtain baseline before procedures and treatments; assesses the body's ability to distribute oxygen to organs and tissues

What intervention should a nurse do for patients with PAD?

Monitor for pain, assess BP, assess for ulcer formation, instruct patient to walk to the point of claudication pain, stop, rest, and walk a little further

Enalapril

ACE inhibitor

Valsartan

ARB

Clinical Significance of Potassium

Evaluates signs and symptoms of hyperkalemia or hypokalemia; Monitors renal function, acid-base balance, and glucose metabolism; evaluates neuromuscular and endocrine disorders; detects origin of dysrhythmias

What are some causes of DVT?

PAD, vein inflammation, lack of movement

What S/S should a nurse look for with DVT?

Redness, pain, swelling, warmth

What S/S should a nurse look for with PAD?

Resting pain in the lower extremities, numbness, lower back discomfort, loss of hair or scaly skin on lower extremities, thickened toenails

ARBs

*Functional Class:* Antihypertensive *Mechanism of Action:* Blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II; selectively blocks the binding of angiotensin II to the AT1 receptor found in tissues *Uses:* Hypertension, alone or in combination; nephropathy in T2DM; proteinuria; stroke prophylaxis for hypertensive patient with left ventricular hypertrophy *Common Side Effects:* Dizziness, insomnia, hypotension, diarrhea, dyspepsia, cough, upper respiratory infection *Life Threatening Side Effects:* CVA, MI, dysrhythmias, renal failure, thrombocytopenia, angioedema, diabetic vascular disease *Nursing Considerations:* Assess for angioedema (facial swelling, dyspnea, wheezing; may occur rapidly); Blood dyscrasias (Thrombocytopenia, anemia); *Pregnancy/breastfeeding* (Assess for pregnancy before starting treatment; do not use in pregnancy; do not breastfeeding)

Warfarin Sodium

*Functioning Class:* Anticoagulant *Chemical Class:* Coumarin derivative *Mechanism of Action:* Interferes with Blood clotting by indirect means; depresses hepatic synthesis of vitamin k dependent coagulation factors (II, VII, IX, X) *Uses:* Antiphospholipid antibody syndrome, arterial thromboembolism prophylaxis, DVT, MI prophylaxis, after MI, stroke prophylaxis, thrombosis prophylaxis, pulmonary embolism *Common Side Effects:* Rash *Life Threatening Side Effects:* Hematuria, hemorrhage, agranulocytosis, leukopenia, eosinophilia, anaphylaxis, exfoliative dermatitis, purple toe syndrome *Nursing Considerations:* Blood studies (Hct, PT, platelets, occult blood in stools); Bleeding (Bleeding gums, petechiae, ecchymosis, black tarry stools, hematuria, occult bleeding (Cerebral, intraabdominal; fatal hemorrhage can occur; do not use in uncontrolled bleeding); Pregnancy/Breastfeeding (Do not use in pregnancy; use effective contraception during and for one month after final dose; cautious use in breastfeeding) *Treatment of Overdose:* Administer vitamin K, fresh frozen plasma, prothrombin complex concentrate

Dabigatran Etexilate Mesylate

*Functioning Class:* Anticoagulant *Chemical Class:* Thrombin inhibitor *Mechanism of Action:* Direct thrombin inhibitor that inhibits both free and clot-bound thrombin; prevents thrombin-induced platelet aggregation and thrombus formation by preventing conversion of fibrinogen to fibrin *Uses:* Stroke/systemic embolism prophylaxis with nonvalvular atrial fibrillation, DVT, pulmonary embolism in hip replacements Life Threatening Side Effects: Bleeding, anaphylaxis, angioedema *Nursing Considerations:* Assess Bleeding (blood in urine or emesis, dark tarry stools, lower back pain; caution with arterial/venous punctures, catheters, NG tubes; monitor vital signs frequently; elderly patients more prone to serious bleeding, monitor aPTT, ecarin clotting time baseline and during treatment), *Premature discontinuation: Risk of thrombosis/MI/emboli* (Swelling, pain, redness, difficulty breathing, chest pain, tachypnea, cough, coughing up blood, cyanosis); Prothrombotic syndrome (Pain, heaviness, itching/tingling, swelling, varicose veins, brownish/reddish skin, discoloration, ulcers; use of ambulation, compression stockings, adequate anticoagulation can prevent this syndrome); Surgery (Discontinue 24-96 hours before surgery); *Epidural/spinal anesthesia, lumbar puncture* (Risk of hematoma that may cause permanent paralysis; indwelling epidural catheters and products that cause coagulation changes (NSAIDs, anticoagulants), may increase risk of paralysis); Do not discontinue abruptly; Pregnancy/breastfeeding (No well controlled studies; bleeding may occur if used during pregnancy; discontinue breastfeeding or product, unknown if excreted in breast milk); *Neurological changes* (To notify prescriber immediately of bowel or bladder changes, numbness in lower extremities, midline back pain)

ACE inhibitors

*Functioning Class:* Antihypertensive *Mechanism of action:* Selectively suppresses renin-angiotensin-aldosterone system; inhibits ACE; prevents conversion of angiotensin I to angiotensin II *Uses:* Hypertension, HF, left ventricular dysfunction after MI, diabetic nephropathy, proteinuria *Common Side Effects:* Hypotension, tachycardia, dyspnea, cough *Life Threatening Side Effects:* Nephrotic syndrome, acute reversible renal failure, neutropenia, agranulocytosis, pancytopenia, thrombocytopenia, angioedema, bronchospasm *Nursing Considerations:* Assess for blood dyscrasias (Blood studies: decreased platelets; CBC with differential at baseline); *Pregnancy/breastfeeding* (Discontinue when pregnancy is detected; monitor fetal development regularly; do not breastfeed)

Argatroban

*High Alert Drug* *Functioning Class:* Anticoagulant *Chemical Class:* Direct thrombin inhibitor *Mechanism of Action:* Direct inhibitor of thrombin; it reversibly binds to thrombin active site *Uses:* Anticoagulation prevention/treatment of thrombosis in heparin-induced thrombocytopenia; adjunct to percutaneous coronary intervention (PCI) in those with history of HIT, DVT, PE *Common Side Effects:* Fever, chest pain, hypotension, nausea, vomiting, abdominal pain, diarrhea *Life Threatening Side Effects:* Intracranial bleeding, atrial fibrillation, coronary thrombosis, MI, myocardial ischemia, coronary occlusion, VTach, Bradycardia, GI bleeding, Bleeding, Anaphylaxis *Nursing Considerations:* Bleeding (Gums; petechiae; ecchymosis; black, tarry stools; hematuria/epistaxis; decreased BP, Hct; vaginal bleeding, possible hemorrhage); Anaphylaxis (Dyspnea, rash during treatment); Pregnancy/breastfeeding (if pregnancy is planned or suspected; if pregnancy, use only if benefits outweigh fetal risk; do not breastfeed, excretion unknown)

Rivaroxaban

*High Alert Drug* *Functioning Class:* Anticoagulant *Chemical Class:* Factor Xa Inhibitor *Mechanism of Action:* A novel oral anticoagulant that selectively and potently inhibits coagulation factor Xa *Uses:* For DVT prophylaxis/treatment, PE, in patients undergoing knee or hip replacement surgery; for stroke prophylaxis and systemic embolism prophylaxis in patient with nonvalvular atrial fibrillation *Life Threatening Side Effects:* Cytolytic hepatitis, bleeding, intracranial bleeding, epidural hematoma, GI bleeding, retinal hemorrhage, adrenal bleeding, retroperitoneal hemorrhage, cerebral hemorrhage, subdural hematoma, epidural hematoma, hemiparesis, thrombocytopenia, anaphylactic reaction, anaphylactic shock, Stevens-Johnson syndrome *Nursing Considerations:* *Bleeding* (Monitor for bleeding, including bleeding during dental procedures (easy bruising, blood in urine, stools, emesis, sputum, epistaxis); there is no specific antidote); *Abrupt discontinuation* (Avoid abrupt discontinuation unless an alternative anticoagulant in those with atrial fibrillation; discontinuing puts patients at an increased risk of thrombotic events; if product must be discontinued for reasons other than pathological bleeding, consider administering another anticoagulant); *Epidural/spinal anesthesia* (Epidural or spinal hematomas that result in long-term or permanent paralysis may occur in patients who have received anticoagulants and are receiving neuraxial anesthesia or undergoing spinal puncture ; epidural catheter should not be removed <18hr after the last dose of rivaroxaban; do not administer the next dose <6hr after the catheter removal; delay rivaroxaban administration for 24hr if traumatic puncture occurs; monitor for neuro changes); Hepatic/renal disease (Increase in effect of product in hepatic disease, hepatic disease with coagulopathy; renal failure/severe renal impairment (creatinine clearance <30 mL/min in DVT prophylaxis and <15 mL/min for stroke or systemic embolism prophylaxis in nonvalvular atrial fibrillation); product should be discontinued in acute renal failure; reduce dose in those with atrial fibrillation and CrCl 15-50 mL/min; monitor renal function periodically (Creatinine clearance, BUN)); Pregnancy/breastfeeding (Use only if benefits outweigh fetal risk; do not breastfeed, excretion unknown; pregnancy-related hemorrhage may occur)

Enoxaparin

*High Alert Drug* *Functioning Class:* Anticoagulant *Chemical Class:* Low-molecular-weight-heparin (LMWH) *Mechanism of Action:* Binds to antithrombin III inactivating factors Xa/IIa, thereby resulting in a higher ratio of anti-factor Xa to IIa *Uses:* Prevention of DVT, PE in hip and knee replacement, abdominal surgery at risk for thrombosis; unstable angina, acute MI, coronary artery thrombosis *Life Threatening Side Effects:* Hemorrhage from any site, hypochromic anemia, thrombocytopenia, bleeding, angioedema, anaphylaxis *Nursing Considerations:* Monitor anti-factor Xa activity in chronic therapy; Bleeding (Gums, petechiae, ecchymosis, black tarry stools, hematuria; notify prescriber); Anaphylaxis/angioedema (Monitor for rash, swelling of face, lips, tongue, dyspnea; stop product, initiate emergency procedures); *Neurologic symptoms* (In patients who have received spinal anesthesia, may develop spinal hematoma; those who have had trauma, spinal surgery are at a greater risk); Pregnancy/breastfeeding (Do not use in multidose vials, benzyl alcohol is present; do not breastfeed)

Heparin Sodium

*High Alert Drug* *Functioning Class:* Anticoagulant, antithrombotic *Mechanism of Action:* Prevents conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing inhibitory effects of antithrombin III *Uses:* Prevention treatment of DVT, PE, MI, open heart surgery, disseminated intravascular clotting syndrome, atrial fibrillation with embolization, as an anticoagulant in transfusion and dialysis procedures, to maintain patency of indwelling venipuncture devices; diagnosis, treatment of DIC *Common Side Effects:* Fever, rash *Life Threatening Side Effects:* Hematuria, hemorrhage, thrombocytopenia, heparin-induced-thrombocytopenia, anaphylaxis *Nursing Considerations:* Bleeding/hemorrhage (Gums, petechiae, ecchymosis, black tarry stools, hematuria, epistaxis, decrease in Hct, BP, HIT may occur after product discontinuation; check periodically for sign of decreasing clots); Thrombosis (Monitor for increased thrombosis daily); Heparin-Induced Thrombocytopenia

A client requiring long-term ventilator management is discharged from the health care facility. Which health care setting should this client be referred to? 1. Intermediate care 2. Assisted living 3. Rehabilitation 4. Home care

1. Intermediate care

The nurse is caring for a client with deep partial-thickness burns who is receiving an opioid for pain management. What is the preferred mode of medication administration for this client? 1. Intravenous 2. Rectal 3. Intramuscular 4. Oral

1. Intravenous

A client is admitted to the hospital due to electrical burns. Which assessment findings does the nurse anticipate? *Select all that apply.* 1. Leathery skin 2. Coughing 3. Cardiac arrest 4. Burn odor 5. Smoky breath

1. Leathery skin 3. Cardiac arrest 4. Burn odor

Which question would the nurse ask a client who has developed pneumonia when assessing risk factors? 1. "Are you diabetic? 2. "Have you traveled recently?" 3. "What do you use for contraception?" 4. "Do you have a history of intravenous (IV) drug abuse?"

1. "Are you diabetic?"

A nurse is changing the dressing of a sixth-grader with severe burns. What basic principles of surgical asepsis must the nurse consider? *Select all that apply* 1. A 1-inch border around a sterile field is considered contaminated 2. A fenestrated drape is not considered sterile 3. Sterile objects in contact with clean objects are considered contaminated 4. Sterile items held below the waist are considered sterile 5. A paper field must remain dry to be considered sterile

1. A 1-inch border around a sterile field is considered contaminated 3. Sterile objects in contact with clean objects are considered contaminated 5. A paper field must remain dry to be considered sterile

When caring for a client with peripheral arterial disease, which assessment findings will the nurse expect? *Select all that apply. One, some, or all responses may be correct.* 1. Absence of hair on the toes 2. Pink and moist ankle ulcers 3. Pitting edema of the lower legs 4. Reports of pain associated with exercising 5. Increased pigmentation of the medial malleolus area

1. Absence of hair on the toes 4. Reports of pain associated with exercising

The nurse is caring for a client with burns and reviews the client's laboratory results: BUN: 30 mg/dL, creatinine 2.4 mg/dL, serum potassium 6.3 mEq/L, pH 7.1, PaO2 90 mmHg, Hemoglobin 7.4 g/dL. Which condition does the nurse suspect the client based upon these findings? 1. Azotemia 2. Hypokalemia 3. Metabolic alkalosis 4. Respiratory alkalosis

1. Azotemia

When assessing a client with a diagnosis of peripheral arterial disease before a scheduled arteriogram, the nurse is unable to palpate the pedal pulses. Which action would the nurse take *next*? 1. Check the pulses with a Doppler device. 2. Notify the primary health care provider. 3. Notify the staff in the catheterization laboratory. 4. Document the findings in the client's medical record.

1. Check the pulse with a Doppler device.

A client who sustained serious burns now has a stress ulcer. Which clinical indicators should the nurse immediately report to the primary healthcare provider? *Select all that apply.* 1. Diaphoresis 2. Cold extremities 3. Tachycardia 4. Weakness 5. Flushed skin tone

1. Diaphoresis 2. Cold extremities 3. Tachycardia 4. Weakness

On the second day after sustaining extensive severe burns a 6-year-old child exhibits edema and decreased urine output. For which additional adverse response should the nurse assess the child in this early stage of injury? 1. Disorientation 2. Bradycardia 3. Subnormal temperature 4. Systolic blood pressure of 100 mmHg

1. Disorientation

A toddler in the pediatric intensive care unit is on a ventilator. One of the nurses asks what should be done when condensation collects in the ventilator tubing. How should the nurse manager respond? 1. Empty the fluid and reconnect the tubing to the ventilator 2. Notify the physician assistant 3. Measure the fluid and mark it on the intake and output record 4. Decrease the amount of humidity

1. Empty the fluid and reconnect the tubing to the ventilator

A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? 1. Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate 2. Impaired glomerular filtration, causing retention of sodium and metabolic waste products 3. Inability of the renal tubules to reabsorb water to dilute the acid contents of blood 4. Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention

1. Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate

Which dietary choices would the nurse teach for the client with peripheral arterial disease? *Select all that apply. One, some, or all responses may be correct.* 1. Limit salt intake 2. Choose foods high in calcium 3. Eat whole-grain breads 4. Use liquid vegetable oils 5. Reduce fresh fruits and vegetables 6. Avoid processed meats

1. Limit salt intake 3. Eat whole-grain breads 4. Use liquid vegetable oils 6. Avoid processed meats

While the nurse was caring for a client with a client with chemical burns after a factory explosion, there was increased edema in the surrounding tissues. What might have led to increased edema? 1. Lowering burned limbs below the heart 2. Brushing dry chemical from skin before irrigation 3. Flushing chemical from wound with saline solution 4. Stabilizing the cervical spine

1. Lowering burned limbs below the heart

An older client with shortness of breath is admitted to the hospital. The medical history reveals and a diagnosis of pneumonia 3 days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? 1. Oxygen saturation: 89% 2. Body temperature: 101 3. Blood pressure: 130/80 4. Respiratory rate: 26 BPM

1. Oxygen saturation: 89%

Which findings would the nurse expect when assessing a client with peripheral arterial disease? *Select all that apply. One, some, or all responses may be correct.* 1. Pallor of feet 2. Warm extremities 3. Ulcers on the toes 4. Thick, hardened skin 5. Delayed capillary refill

1. Pallor of feet 3. Ulcers on the toes 5. Delayed capillary refill

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? 1. Plasma proteins moving out of the intravascular compartment 2. Decreased rate of glomerular filtration 3. Excessive blood loss through the burned tissues 4. Sodium retention occurring as a result of the aldosterone mechanism

1. Plasma proteins moving out of the intravascular compartment

A client is admitted to the hospital with a tentative diagnosis of pneumonia. The client has a high fever and is short of breath. Education related to prevention of pneumonia, oxygen via nasal cannula, an intravenous antibiotic, and blood and sputum specimens for culture and sensitivity (C&S) are prescribed. In which order should these intervention be implemented?

1. Provide oxygen via nasal cannula 2. Obtain blood specimens for C&S 3. Administer prescribed antibiotic 4. Provide education about prevention of pneumonia

Which observations by the nurse indicate a client with pneumonia is able to use an incentive spirometer correctly? *Select all that apply. One, some, or all responses may be correct.* 1. Records the volume of the air inspired 2. Performs 10 breaths per session every hour 3. Inhales air fully before inserting the mouthpiece 4. Takes a long, slow, deep breath keeping the mouthpiece in place 5. Exhales deep breaths with the mouthpiece in their mouth

1. Records the volume of the air inspired 2. Performs 10 breaths per session every hour 4. Takes a long, slow, deep breath keeping the mouthpiece in place

A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the *priority* during this phase? 1. Restoring fluid volume 2. Preventing infection 3. Alleviating pain 4. Replacing blood loss

1. Restoring fluid volume

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? *Select all that apply.* 1. Severe dyspnea 2. Increased pulmonary wedge pressure 3. Crackles 4. Atelectasis 5. Hypoxemia

1. Severe dyspnea 3. Crackles 4. Atelectasis 5. Hypoxemia

A client is admitted to the burn unit with partial-thickness burns over 30% of the body surface area. Twenty-four hours later, the client, who has an intravenous (IV) line of 5% dextrose in saline running, has tremors, twitching, and signs of disorientation. During the past hour the urinary output was 110 mL. What should the nurse do next? 1. Slow the IV rate and notify the healthcare provider 2. Increase the IV rate and request a prescription for calcium gluconate 3. Slow the IV rate and check the last chest x-ray film 4. Increase the IV rate and assess the arterial blood gases

1. Slow the IV rate and notify the healthcare provider

A nurse is teaching a safety class about burns. Which examples will the nurse use to describe occupational hazards for burn injuries? *Select all that apply* 1. Tar 2. Power lines 3. Outdoor grills 4. Radiators 5. Fertilizers

1. Tar 2. Power lines 5. Fertilizers

Which action would the home health nurse suggest to decrease risk for injury for an older adult with peripheral arterial disease? 1. Move into an assisted living community. 2. Lower the thermostat setting on the hot water tank. 3. Reduce fluid intake to less than 2500 mL/day. 4. Limit physical activity to a short walk daily.

2. Lower the thermostat setting on the hot water tank.

What is a nursing *priority* to prevent complications in client with respiratory acidosis? 1. Assessing the nail beds 2. Monitoring breathing status 3. Checking muscle contractions 4. Listening to breath sounds

2. Monitoring breathing status

When a client with pneumonia is experiencing dyspnea because of difficulty expectorating thick respiratory secretions, which action by the nurse will be *most* helpful? 1. Administer continuous oxygen 2. Offer fluids at frequent intervals. 3. Place the client in a high-Fowler position 4. Administer prescribed steroid inhaler

2. Offer fluids at frequent intervals

A client is on a ventilator. A nurse asks another nurse, "What should be done when condensation resulting from humidity collects in the ventilator tubing?" What is the nurse's *best* response? 1. "Notify the respiratory therapist" 2. "Empty the fluid from the tubing" 3. "Decrease the amount of humidity" 4. "Document the output on the record"

2. "Empty the fluid from the tubing"

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client? 1. Tenacious sputum 2. Altered mental status 3. Slowed rate of breathing 4. Hypertension

2. Altered mental status

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? 1. Deflate the cuff on the endotracheal tube for a few minutes every one to two hours 2. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated 3. Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations. 4. Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered.

2. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated

Which preferred medication will the nurse administer to a client hospitalized with pneumococcal pneumonia? 1. Penicillin G 2. Ceftriaxone 3. Vancomycin 4. Meropenem

2. Ceftriaxone

A client with known peripheral arterial disease calls the clinic and tells the nurse about experiencing several symptoms. Which symptom requires the *most* rapid action by the nurse? 1. Anxiety 2. Chest pain 3. Weak pulse quality 4. Cool and pale lower legs

2. Chest pain

On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse *most* likely to identify? 1. Muscle twitching 2. Deep and rapid respirations 3. Mental instability 4. Tachycardia and cardiac dysrhythmias

2. Deep and rapid respirations

Which would the nurse assess using the PASS acronym to prevent aspiration pneumonia in a client with stomatitis? *Select all that apply. One, some, or all responses may be correct.* 1. Is the client's airway open? 2. Does the client have any difficulty swallowing? 3. Does the client have a history of trouble swallowing? 4. Has a speech language-pathologist been consulted? 5. Does the client have any signs or symptoms of dysphagia? 6. What have been the client's dietary intake patterns

2. Does the client have any difficulty swallowing? 3. Does the client have a history of trouble swallowing? 4. Has a speech language-pathologist been consulted? 5. Does the client have any signs or symptoms of dysphagia?

A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the *primary* nursing concern? 1. Risk for injury 2. Electrolyte imbalance 3. Chronic pain 4. Inadequate gas exchange

2. Electrolyte imbalance

A client is admitted to the emergency department with dyspnea, a productive cough, and fever. The health care provider suspects pneumonia and writes prescriptions. In which order would the nursing actions be preformed? 1. Obtain a sputum culture 2. Elevate the head of the bed 3. Review the results of the sensitivity test 4. Encourage cough and deep-breathing exercises on an ongoing basis 5. Administer the prescribed intravenous piggyback antibiotic

2. Elevate the head of the bed 1. Obtain a sputum culture 5. Administer the prescribed intravenous piggyback antibiotic 3. Review the results of the sensitivity test 4. Encourage cough and deep-breathing exercises on an ongoing basis

When caring for a client hospitalized with deep vein thrombosis, which topic would the nurse include when doing discharge teaching about ways to avoid another venous thrombosis? 1. Daily aspirin use 2. Frequent ambulation 3. Warm soaks to legs 4. Avoidance of cold

2. Frequent ambulation

A postpartum client receiving a continuous heparin infusion for a deep vein thrombosis has an activated partial thromboplastin time (aPTT) of 98 seconds. Which action would the nurse take in response to this solution? 1. Increase the IV rate of heparin 2. Interrupt the infusion and notify the primary health care provider of the aPPT result 3. Document the result on the medical record and recheck the aPTT in 4 hours 4. Call the primary health care provider to obtain a prescription for a low-molecular-weight heparin

2. Interrupt the infusion and notify the primary health care provider of the aPPT result

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by doing what? 1. Opening collapsed bronchioles, which allows more oxygen to reach lung tissue 2. Opening collapsed alveoli and keeping them open 3. Adding pressure to lung tissue, which improves gas exchange 4. Providing more oxygen to lung tissue

2. Opening collapsed alveoli and keeping them open

A client on diuretic therapy developed metabolic alkalosis. What does the nurse consider to be the *priority* nursing care while correcting alkalosis? 1. Monitoring electrolytes 2. Preventing falls 3. Administering antiemetics 4. Adjusting the diuretic therapy

2. Preventing falls

In which order will the emergency department nurse take the prescribed actions for a client with hypoxemia and possible pneumonia? 1. Administer levofloxacin 750mg intravenously 2. Start oxygen to keep oxygen saturation higher than 93% 3. Admit client to the inpatient medical unit 4. Obtain blood cultures from 3 sites

2. Start oxygen to keep oxygen saturation higher than 93% 4. Obtain blood cultures from 3 sites 3. Administer levofloxacin 750 mg intravenously 1. Admit client to the inpatient medical unit

When teaching a client with peripheral arterial disease about the prescribed walking program, which action will the nurse tell the client to take if leg cramps occur with walking? 1. Chew 1 aspirin to relieve pain. 2. Stop to rest until the pain resolves. 3. Walk more slowly while pain is present. 4. Notify the health care provider about the pain.

2. Stop to rest until the pain resolves.

The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations that indicate a pulmonary embolism? *Select all that apply.* 1. Flushing of the face 2. Sudden chest pain 3. Pain rating increase from 2 to 8 in the hip 4. Abrupt onset of shortness of breath 5. Elevation of temperature

2. Sudden chest pain 4. Abrupt onset of shortness of breath

A client has a diagnosis of superficial partial-thickness burns. The client asks what layers of skin are involved with this type of burn. Which response by the nurse is *most* appropriate? 1. Both the epidermis and the dermis are destroyed 2. The epidermis is damaged 3. The structures beneath the skin are destroyed 4. The dermis is damaged partially

2. The epidermis is damaged

A client's extensive burns are being treated with silver nitrate 0.5% dressings. A week after treatment is begun, the nurse identifies that the client's sodium level is 135 mEq/L and the potassium level is 3.0 mEq/L. The nurse notifies the primary healthcare provider. Which prescription should the nurse be prepared to administer? 1. Add sodium chloride (NaCl) to the existing IV lactated Ringer solution 2. Discontinue the IV 5% D5W with 40 mEq KCl solution and replace with IV 5% D5W solution 3. Add potassium chloride (KCl) to the existing intravenous (IV) lactated Ringer solution 4. Discontinue the IV NaCl with 20 mEq KCl solution and replace with IV 5% D5W solution

3. Add potassium chloride (KCl) to the existing intravenous (IV) lactated Ringer solution

A client rescued from a burning building has partial and full-thickness burns over 40% of the body. Which initial physiologic change will the nurse expect? 1. A decrease in urinary specific gravity 2. An increase in blood volume 3. An increase in serum potassium 4. A decrease in capillary permeability

3. An increase in serum potassium

A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome (ARDS)? 1. Experiencing an anaphylactic reaction 2. Receiving multiple blood transfusions 3. Aspirating gastric contents 4. Getting an opioid overdose

3. Aspirating gastric contents

A client with a suspected pulmonary embolism is scheduled for a spiral computed tomography scan. Which intervention should the nurse perform when preparing the client for the test? 1. Instruct the client to remove his or her dentures. 2. Obtain informed consent from the client. 3. Assess if the client is allergic to shellfish 4. Check the client's blood glucose levels.

3. Assess if the client is allergic to shellfish

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? 1. Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered. 2. Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. 3. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. 4. Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations.

3. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.

A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? 1. Change the method of oxygen delivery. 2. Question the client about the confusion. 3. Discontinue or decrease the oxygen flow rate. 4. Percuss and vibrate the client's chest wall.

3. Discontinue or decrease the oxygen flow rate.

Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities? 1. Thermography 2. Plethysmography 3. Duplex venous Doppler 4. Somatosensory evoked potential

3. Duplex venous Doppler

A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). Which phase characterized by signs of pulmonary edema and atelectasis should the nurse consider when planning care? 1. Reparative 2. Fibrotic 3. Exudative 4. Proliferative

3. Exudative

When a client with peripheral arterial disease tells the nurse about having leg pain and weakness after walking a short distance, how will the nurse document this information? 1. Rest pain 2. Raynaud phenomenon 3. Intermittent claudication 4. Phantom limb sensation

3. Intermittent claudication

A client is admitted to the emergency department with burns to the anterior trunk, entire right arm, and anterior right leg. The practitioner prescribes morphine sulfate for pain. What route of administration should the nurse expect to administer this medication? 1. Orally 2. Intramuscularly 3. Intravenously 4. Subcutaneously

3. Intravenously

Which collaborative action would the nurse anticipate when caring for a client with pneumonia whos arterial blood gases are pH 7.24, PaCO2 60 mm Hg, HCO3 20 mEq/L, PaO2 54 mm Hg, and O2 saturation 88%? 1. Oxygen at 6 L/min by nasal cannula 2. Nebulized albuterol treatment 3. Intubation and mechanical ventilation 4. Sodium bicarbonate

3. Intubation and mechanical ventilation

Which action by a client who requires an above-the-knee amputation for peripheral arterial disease *best* indicates emotional readiness for the surgery? 1. Explains the goals of the procedure 2. Displays few signs of anticipatory grief 3. Participates in learning perioperative care 4. Verbalizes acceptance of permanent dependency needs

3. Participates in learning perioperative care

A hospital management team has conducted a randomized controlled trial to decrease the occurrence of ventilator-associated pneumonia. The trial was successful and had positive outcomes. The nurse manager, in collaboration with other hospital management staff, conducted the same trial in another hospital, but the results were different. Which research strategy implementation would the nurse manager consider to be beneficial in preventing dramatic differences in trial results? 1. Client-centered outcomes research 2. Comparative effectiveness research (CER) 3. Practice-based evidence (PBE) 4. Evidence-based practice (EBP)

3. Practice-based evidence (PBE)

The disaster management team is caring for workers of a factory who survived a thermal blast. Which findings in the workers would the nurse consider as confirmation of second degree burns? 1. Presence of leathery bleb and skin appears dark brown 2. Presence of dry eschar and skin appears waxy white 3. Presence of moist blebs and skin appears mottled white or pink 4. Presence of pain and redness with moderate to severe tenderness

3. Presence of moist blebs and skin appears mottled white or pink

A client with burns caused by flames is hospitalized. Which specific emergency burn management would be appropriate for this client? 1. Initiating CPR 2. Administering tetanus toxoid for prophylaxis 3. Removing all metal objects 4. Helping the client bathe or shower

3. Removing all metal objects

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? 1. Circulatory and urinary 2. Muscular and endocrine 3. Respiratory and urinary 4. Skeletal and nervous

3. Respiratory and urinary

A client is admitted to the hospital with severe burns. Which client response should the nurse anticipate during the acute phase of burn recovery? 1. High serum potassium levels 2. Decreased urinary output 3. Stable vital signs 4. Reduced intravascular fluid volume

3. Stable vital signs

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? 1. Turn the client every four hours 2. Increased ventilator settings as needed 3. Suction as needed 4. Administer sedatives around the clock

3. Suction as needed

A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? 1. Bradycardia 2. Flushed face 3. Unilateral chest pain 4. Decreased blood pressure

3. Unilateral chest pain

A nurse is caring for a client who has a tracheostomy tube and is on a ventilator. What must the nurse ensure about the tracheostomy tube? 1. Is cleansed once a day 2. Is changed every week 3. Has an inner cannula 4. Has a low-pressure cuff

4. Has a low-pressure cuff

A nurse is evaluating a client's fluid loss resulting from extensive burns. Which laboratory result will the nurse check? 1. Blood urea nitrogen (BUN) 2. Blood pH 3. Sedimentation rate 4. Hematocrit (Hct)

4. Hematocrit (Hct)

When a client who has peripheral arterial disease of the lower extremities tells the nurse, "I walk so slowly that no one wants to walk with me," which response by the nurse is *best*? 1. "Many people enjoy walking alone." 2. "You will be able to walk faster eventually." 3. "It is important that you keep walking to improve circulation." 4. "Perhaps you might consider a supervised exercise training program."

4. "Perhaps you might consider a supervised exercise training program."

A nurse is caring for a variety of clients. In which client is it *most* essential for the nurse to implement measures to prevent pulmonary embolism? 1. A 68-year-old who had emergency dental surgery 2. A 76-year-old who has a history of thrombocytopenia 3. A 60-year-old who has bacterial pneumonia 4. A 59-year-old who had a knee replacement

4. A 59-year-old who had a knee replacement

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, what does the nurse expect to identify? 1. Hypertension 2. Tenacious sputum 3. Slow rate of breathing 4. Altered mental status

4. Altered mental status

When a client with peripheral arterial disease returns to the nursing unit after a femoral angiogram, which action will the nurse take *first*? 1. Check the oral temperature. 2. Encourage the client to void. 3. Place the head of the bed flat. 4. Assess the client's affected leg.

4. Assess the client's affected leg.

The nurse finds that some clients have full-thickness body burns and severe head trauma after an apartment building fire. The nurse also finds that these clients require mechanical ventilator for survival. Which disaster triage tag does the nurse apply to this group of clients? 1. Yellow 2. Red 3. Green 4. Black

4. Black

A client with a history of pulmonary emboli is taking warfarin daily. The nurse teaches the client about foods that are appropriate to consume when taking this medication. The nurse evaluated that the client needs further teaching when the client makes which statement? 1. "Yellow vegetables are high in vitamin A and should be included in the diet." 2. "Milk and other high-calcium dairy products are necessary to counteract bone density loss." 3. "Eggs provide a good source of iron, which is needed to prevent anemia." 4. Dark green leafy vegetables are high in vitamin K so I should eat them more often."

4. Dark green leafy vegetables are high in vitamin K so I should eat them more often."

A client is on mechanical ventilation. When condensation collects in the ventilator tubing, what should the nurse do? 1. Decrease the amount of humidity 2. Record the amount of fluid removed from the tubing 3. Notify a respiratory therapist 4. Drain the fluid from the tubing

4. Drain the fluid from the tubing

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take *first?* 1. Remove the client's clothing 2. Determine the extent of the burns, using the rule of nines 3. Insert a venous access device is an unaffected arm 4. Evaluate whether the client has inhaled smoke

4. Evaluate whether the client has inhaled smoke

A 68-year-old client has multiple risk factors for peripheral arterial disease, including client age, siblings with diabetes, a sedentary lifestyle, and family history of heart disease. Which risk factor is the highest *priority* for client teaching? 1. Older age 2. Low activity level 3. Blood glucose control 4. Family history of cardiac disease

4. Family history of cardiac disease

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute pneumonia. The client is in moderate respiratory distress. The nurse would place the client in which position to enhance comfort? 1. Side-lying with head elevated 45 degrees 2. Sims with head elevated 90 degrees 3. Semi-Fowler with legs elevated 4. high Fowler using bedside table to rest the arms

4. High Fowler using bedside table to rest the arms

A client is admitted to the hospital with partial and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's *priority* concern? 1. Decreased fluid volume because of the depth of the burns 2. Loss of skin integrity caused by the burns 3. Potential infection as a result of the burn injury 4. Inadequate gas exchange caused by smoke inhalation

4. Inadequate gas exchange caused by smoke inhalation

The primary healthcare provider instructs the nurse to place a client with burns in the supine position with the affected arm over the head to reduce the risk on contractures. Which part of the client is affected due to burns? 1. Posterior shoulder 2. Anterior shoulder 3. Wrist 4. Lateral trunk

4. Lateral trunk

A nurse is caring for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head. Which nursing goal is the *priority* during the emergent phase of a burn injury? 1. Preventing infection 2. Preventing pain 3. Managing leukopenia 4.Managing fluid loss

4. Managing fluid loss

When changing the dressing on deep partial-thickness burns on a client's hand, the nurse should use which type of gauze and which technique? 1. Non-cotton-backed; extending fingers fully with gauze between each finger 2. Cotton-backed; a hand roll, with fingers completely flexed and thumb in opposition 3. Cotton-backed; fully extending the fingers with thumb in opposition 4. Non-cotton-backed; placing a hand roll with fingers slightly flexed

4. Non-cotton-backed; placing a hand roll with fingers slightly flexed

A client is admitted to the hospital with a diagnosis of pneumonia. In which order should the following nursing actions be accomplished? 1. Review chest x-ray results on an ongoing basis 2. Administer prescribed antibiotic intravenous piggyback 3. Check peak and trough levels of the antibiotic 4. Obtain assessment information 5. Collect a sputum sample for culture and sensitivity

4. Obtain assessment information 5. Collect a sputum sample for culture and sensitivity 2. Administer prescribed antibiotic intravenous piggyback 3. Check peak and trough levels of the antibiotic 1. Review chest x-ray results on an ongoing basis

When the oxygen saturation of a client with pneumonia is at 89% to 90% while using a nonrebreather mask, which collaborative action would the nurse anticipate? 1. Administration of oxygen using a simple face mask 2. Use of a Venturi mask for administration of high-flow oxygen 3. Continued oxygen administration with the nonrebreather mask 4. Oxygen administration with bi-level positive airway pressure (BiPAP)

4. Oxygen administration with bi-level positive airway pressure (BiPAP)

When the nurse is caring for a client who has had a femoropopliteal bypass for peripheral arterial disease, which finding is *most* important to communicate to the health care provider? 1. Pain at the incisional site 2. Nonpalpable popliteal pulse 3. Erythema of the incision 4. Pallor of the lower leg

4. Pallor of the lower leg

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? 1. Chest tube insertion 2. Aggressive diuretic therapy 3. Administration of beta-blockers 4. Positive end-expiratory pressure (PEEP)

4. Positive end-expiratory pressure (PEEP)

A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, which medication will the nurse be prepared to administer? 1. Vitamin K 2. Oprelvekin 3. Warfarin sodium 4. Protamine sulfate

4. Protamine sulfate

Which diagnostic test would the nurse consider to be the gold standard for diagnosis of pulmonary embolism? 1. Computed tomography pulmonary angiography (CT-PA) 2. Ventilation-perfusion (V/Q) scans 3. Helical computed tomography (CT) 4. Pulmonary angiography

4. Pulmonary angiography

The nurse is assessing a client with burns over 15% of the body. Which *priority* nursing action should be taken to ensure a complete assessment? 1. Determining the level of mobility 2. Cleaning the wounds with antiseptic solution 3. Placing the client in recumbent position 4. Removing the clothes of the client

4. Removing the clothes of the client

Which assessment finding for a client with pneumonia would be *most* important for the nurse to communicate to the health care provider? 1. Cough productive of rust-colored sputum 2. Sharp chest pain with deep inspiration 3. Oral temperature 103 4. Respiratory rate 38 breaths per minute

4. Respiratory rate 38 breaths per minute

Normal neutrophil Count

55-75% of WBC

Captopril

ACE inhibitor

What interventions should a nurse do for patient with DVT?

Bedrest, elevate the legs above the heart, do not use a pillow under the knees or massage, apply anti-embolism stockings, administer warm compresses

What is PAD?

Chronic disorder in which partial or total arterial occlusion deprives the lower extremities of O2 and nutrients

Clinical Significance of WBC

Helps determine infection or inflammation; can detect various types of leukemia

S/S of PAD are from a lack of ______ and _______ to the lower _______.

O2; Nutrients; Extremities

What is a DVT?

Thrombus in the lower extremities associated with vein inflammation that puts the patient at risk for a PE