Oxygenation, perfusion, fluid and electrolytes, sensation, and pain

True or False: Capnography measures the partial pressure of oxygen in the blood.

False

What does the acronym OLD CARTS stand for?

Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing, Severity

A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity? a. yellow halos, around lights and objects b. ototoxicity c. jaundice d. ataxia

a

A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO 0.25 mg/tablet. How many tablets should the nurse administer per dose?

0.5 tablet

A nurse is preparing to administer amoxicillin 30 mg/kg/day divided equally every 12 hours to a toddler who weighs 33 lbs. Available is amoxicillin 200 mg/ 5 mL suspension. How many mL should the nurse administer?

11.3 mL

The nurse is planning care for an elderly client diagnosed with end stage heart failure and a nursing diagnosis of decreased cardiac output secondary to ineffective left ventricular function. What outcome would the nurse plan for this client to measure improvement in cardiac output? a. Brisk capillary refill in feet bilaterally b. heart rate of 110, S1, S2 noted with audible murmur at Erb's point c. lungs are clear to auscultation in all fields and a respiratory rate is within 12-20 d. radial pulse is +2/3

a

The nurse is providing care for a young adult client with an intracranial hemorrhage secondary to a closed head injury. During the assessment, the nurse notices that the client's respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern? a. Cheyne-Stokes respirations b. kussmauls respirations c. sleep apnea d. eupnea

a

Which is the priority nursing diagnosis for a patient with visual impairment? a. risk for falls b. self neglect c. social isolation d. risk for imbalanced nutrition: less than body requirements

a

Which structure within the brain is responsible for consciousness and alertness? a. reticular activating system b. cerebellum c. thalamus d. hypothalamus

a

A patient is experiencing 5-7 watery stools every 2-3 hours. The nurse realizes that the patient is at risk for which problem? a. respiratory acidosis b. metabolic acidosis c. respiratory alkalosis d. metabolic alkalosis

b

Which nursing diagnosis has the highest priority for a patient with impaired tactile perception? a. self care deficit: dressing and grooming b. impaired adjustment c. risk for injury d. activity intolerance

c

Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? select all that apply a. increased alveolar capillary gas exchange b. lower lobe respiratory tract infections c. sleep apnea d. HTN e. artherosclerosis

d, e

The nurse auscultates bronchovesicular inspiratory and expiatory wheezes on a patient. The nurse knows that this is a problem of which aspect of ventilation? a. rate b. depth c. lung compliance d. lung elasticity e. airway resistance

e

The nurse is caring for patient who's pulse oximeter reasoning is 82%. The nurse check the chart and finds and order to apply supplemental O2 to titrate. What is the BEST way for the nurse to intervene for this patient? a. Place the patient on 2 liters per nasal cannula b. set the HOB above 45 degrees c. encourage the patient to deep breathe through the NC d. Do nothing. This is a normal O2 sat. e. a, b, c

e

Match the following descriptions to the correct place in the ECG. 1. Depolarization of the ventricles. Leading to ventricular contraction 2. Ventricular repolarization. Returning the ventricles to an electrical resting state 3. Represents the firing of the SA node and conduction of the impulse through the atria. Leading to atrial contraction. a. P-wave b. QRS complex c. T-wave

1=b 2=c 3=a

A nurse is documenting the intake for a client who is scheduled for an abdominal computed axial tomography (CT) scan. The client has an IV of D5A1/2 NS running at 75mL/hr from 0700 until 1200. the IV runs at 30 mL/hr from 1200 to 1500. At 1500 the client has 6 oz juice. How many mL should the nurse document as the client's intake for the shift?

645 mL

A patient is experiencing ascites. The nurse knows that the fluid that has entered the peritoneal space is now physiologically unavailable and presents a risk to the patient. This type of fluid buildup is called: a. third spacing b. left shift c. edema d. transcellular

a

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? a. weak, thready pulse b. increased blood pressure c. dyspnea d. decreased heart rate

a

A nurse is preparing to administer digoxin and carvedilol to a patient. The nurse knows that they will need to collect what following assessment data in order to safely administer these drugs? a. take an apical pulse for 60 seconds. Hold the medication if pulse is less than 60 b. assess all peripheral pulses for 30 seconds and multiply by 2. Hold the medicine if pulse is +2/3 and within normal limits at all sites c. Take a blood pressure. Hold the medication if BP is within normal limits. d. take an O2 sat. Hold if sat is less than 95%.

a

A patient has been experiencing a respiratory pattern of 50 respirations per minute and an O2 sat of 86% for the last 2 hours. The nurse identifies which actual and potential NDx as a priority? a. breathing pattern impairment with risk for spontaneous ventilation impairment b. airway clearance impairment with risk for gas exchange impairment c. spontaneous ventilation impairment with the risk for breathing pattern impairment d. airway clearance impairment with risk for ventilator weaning response impairment

a

A patient suddenly develops right lower quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient's pain? a. acute b. chronic c. intractable d. neuropathic

a

A patient weighing 100 kilograms has lost 12 kilos in 2 days. there is no visible bleeding. The patient reports several black, tarry stools, and coffee grounds emesis. After notifying the physician, what is the priority nursing intervention? a. start 2 16 gauge IVs in each arm and prepare to administer high volumes of isotonic fluid b. start 2 16 gauge IVs in each arm and prepare to administer high volumes of hypotonic fluid c. start 2 18 gauge IVs in each arm and prepare to administer moderate volumes of hypertonic fluid d. elevate the HOB and prepare to administer D51/ 2NS at a casual rate

a

A patient with GERD is complaining of pain that starts in the abdomen and involves the entire sternum, and upper thorax. The nurse classifies this type of pain as: a. deep somatic b. visceral c. radiating d. referred

a

The nurse is caring for a client diagnosed with pneumonia, teaching him or her how to cough and deep breathe. The client asks, "Why is drinking fluids so important?"What is the nurse's best response? a. fluids will thin the secretions in your lungs and make them easy to cough up b. the doctor ordered increased fluid intake c. fluids prevent pathogens form growing in your lungs d. fluids pull salt into the airway

a

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? Select all that apply a. Increased heart rate b. increased blood pressure c. increase hematocrit d. increased temperature e. increased respiratory rate

a, b

A nurse observing the UAP communicate with a patient who has dementia. The nurse identifies which strategies to enhance communication with dementia patients? Select all that apply. a. The UAP reorients the patient to person, place, and time as needed b. The UAP uses a clear, loud lower register when communicating with the patient c. The UAP faces the patient and uses short sentences to communicate care d. The UAP describes everything they are doing in detail e. The UAP asks the patient. "Would you like your bath now or in the afternoon?"

a, c, e

A nurse in an outpatient clinic is assessing a middle adult client as part of a routine physical examination. The client's BP is 142/88 mmHg, his body mass index is 31, and he is a current smoker. The nurse should identify that this client has multiple risk factors for which of the following disorders? a. testicular cancer b. cardiovascular disease c. depression d. thyroid disease

b

A nurse is administering a Mucolytic to a patient. The nurse knows that in order for a mucolytic to be MOST effective they have to provide which interventions? a. encourage the patient to rinse their mouth after use b. encourage the patient to drink plenty of fluids and deep breathe and cough every 1-2 hours after use c. encourage the patient to avoid OTC oral anticholinergics because it can put them at risk for anti-ACH toxicity d. have the patient use their SABA inh before taking the mucolytic

b

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? a. increase the client's oral fluid intake b. obtain a pair of slipper socks for the client c. rub the client's feet briskly for several minutes d. place a moist heating pad under the client's feet.

b

A nurse is scheduling oral care for ventilated patients in the ICU. The nurse knows that the MOST important benefit of providing this care is? a. prevents infection of the oral cavity and associated structures b. prevents incidence of ventilator associated pneumonia (VAP) c. promotes the patient's sense of well being d. promotes increased activity and self care

b

A patient who underwent left above the knee amputation reports pain in the left foot. The nurse should document this finding as what type of pain? a. psychogenic b. phantom c. referred d. radiating

b

Provider order for cough syrup with codeine. 10 mL Q 8 hours for cough a. Hand: 10 mg Codeine/ 5 ml. How many mg of codeine will the patient ingest in three doses (pay attention to the question) b. 30 mg c. 40 mg d. 50 mg e. 60 mg

b

The nurse checks a patient's pupils using a penlight. Which receptors is the nurse stimulating? a. chemoreceptors b. photoreceptors c. proprioceptors d. mechanoreceptors

b

The nurse is caring for a patient in the post op unit following thoracic surgery. After the patient is awakened from anesthesia the nurse encourages the patient to use incentive spirometry (IS). Incentive spirometry is used to mitigate which risk in post op patients? a. deep vein thrombosis (DVT) b. atelectasis c. pulmonary HTN d. pulmonary embolus

b

The nurse is educating UAP on the use of incentive spirometry (IS). The nurse identifies this as the appropriate reps and timing for this exercise: a. 2-4 times every hour b. 12-20 times every 4 hours c. 5-10 times every 2 hours d. 50-75 times every 10 minutes

b

The nurse is caring for a client who had experienced an acute asthma event. What classification of medications would the nurse anticipate administering to this client? Select all that apply. a. expectorant b. inhaled corticosteroid c. short acting beta agonist d. cough suppressant e. antibiotic

b, c

A nurse is teaching her client how to obtain a sputum specimen. In order to provide safe and effective care, the nurse instructs the patient that the following action will facilitate obtaining the specimen. Select all that apply. a. limiting fluid intake b. having the client take deep breaths c. asking the client to spit into a collection container d. rinse their mouth e. cough into the container

b, d, e

The nurse is preparing to educate a patient on smoking cessation. The nurse knows that teaching will be most effective if they: Select all that apply a. Tell the patient that all of the evidence supports the fact that smoking will kill them b. work with the patient to identify what benefits are most important to the patient c. Show the patient pictures of cadavers with black lung d. include the family in the decision making e. advises the patient that smoking cessation helps prevent cognitive decline and improves family well being

b, d, e

A nurse is caring for a client who reports an area of redness, warmth, tenderness, swelling, and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding? a. massage the area b. ambulate the patient c. check homan's sign d. apply cold therapy to the area

c

A nurse is preparing to administer verapamil, a calcium channel blocker, by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication? a. muscle pain b. hyperthermia c. hypotension d. ototoxicity

c

A patient syncopates and becomes unresponsive. Their HR is 20, respiratory rate cannot be detected and their QRS complex is revealing ventricular fibrillation. What is the nurses' priority intervention? a. attempt to rouse the patient using painful stimuli b. call a code and begin breathing for the patient through an ambu bag with o2 sat at 15 liters. c. Call a code and grab the defibrillator, unlock the atropine, and start compressions d. scream help i need a nurse

c

Normal circulation of blood relies on fluid moving from the high pressure arterial system to the low pressure venous system. The forces created by the fluid within this system is known as: a. osmosis b. diffusion c. hydrostatic pressure d. active transport

c

The patient reports pain after surgery, ranking it 6 on scale of 1 to 10. The patient tells the nurse, "I don't want to be all doped up. My family is coming to visit and I want to be alert enough to visit with them." Which medication would most likely be effective for postoperative pain relief without excessive sedation? a. Fentanyl IV b. Morphine IV c. Ibuprofen PO d. Hydrocodone PO

c

Which condition increases a patient's risk for digoxin toxicity? a. hypernatremia b. hypocalcemia c. hypokalemia d. hyperkalemia

c

Which instruction would the nurse include when providing discharge teaching for a patient who has a serious visual deficit? a. wear properly fitting shoes and socks b. install blinking lights to alert the patient about an incoming phone call. c. avoid using throw rugs on the floors d. have gas appliances inspected regularly to detect gas leaks.

c

A diabetes patient has failed a 2 point discrimination test. The nurse knows that this test indicates that the patient has which sensory deficit? a. auditory b. kinesthetic c. gustatory d. tactile

d

A nurse administers fentanyl 5 mg PO as prescribed to a patient who complains of pain 10/10. The patient has previously been treated for intractable pain with morphine 23 mg IV. What is the priority nursing intervention for this patient? a. Assess respiratory rate and depth 30-45 minutes after administration of medication b. assess patient's pain level 1 hour after administration c. assess patient's O2 sat 1 hour after administration d. assess respiratory rate and depth 10 minutes after administration of medication.

d

A nurse is caring for a client who has a serum potassium level of 7.4 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG? a. Restoration of QRS complex amplitude b. Widening of the QRS complex c. shortening of P wave duration d. reduction of T wave amplitude

d

A nurse is caring for a client who is taking Lisinopril, an ACE inhibitor. Which of the following outcomes indicates a therapeutic effect of the medication? a. Increase of HDL cholesterol b. prevention of bipolar manic episodes c. INR is within a range of 2-3 d. decreased blood pressure

d

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make? a. "They protect your legs and heels from skin breakdown" b. "They help keep you warm after your surgery." c. "They make it easier for you to do leg exercises after your surgery" d. "they improve your circulation to keep blood from pooling in your legs"

d

A nurse receives a call from paramedics. They are inbound with an 18 YO patient in DKA. The nurse anticipates which breathing pattern? a. alternating shallow breaths, then apnea, then tachypnea b. gradual increase in depth, then decrease, then apnea c. stop/ start, or periodic breathing d. a deep, fast regular breathing pattern

d

How should the nurse classify pain that a patient with bowel cancer is experiencing? a. cutaneous b. deep somatic c. neuropathic d. visceral

d

Interpret the following ABG. Identify whether it is respiratory or metabolic acidosis/ alkalosis and whether is compensated or uncompensated. pH: 7.19 CO2: 58 HCO3: 23 a. uncompensated metabolic acidosis b. compensated respiratory alkalosis c. compensated respiratory acidosis d. uncompensated respiratory acidosis

d

The nurse is preparing to administer medication to the client with an exacerbation of asthma. Which of the following medications would improve the respiratory function of the client? a. opioid b. vasodilator c. tylenol d. bronchodilator

d

Which intervention is MOST helpful when caring for a hospitalized patient with impaired vision? a. suggest that the patient use bright overhead lighting b. advise the patient to avoid wearing sunglasses when outdoors. c. do not offer large print books because this may embarrass the patient d. place the patient's eyeglasses within easy reach.

d