Passpoint exam 3

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of their body. The client is in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

a urine output consistently above 40 ml/hour (40 mL/hour

A client is diagnosed with pancreatitis. Which assessment would be of most concern to the nurse?

bluish discoloration in periumbilical area

A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included temperature 99°F (37°C), pulse 100 bpm, respirations 18 breaths/min, and blood pressure 130/70 mm Hg. The nurse should report which changes, if they occur, to the health care provider (HCP)? Select all that apply.

bradycardia widening pulse pressure

Vital signs associated with ICP

bradycardia, bradypnea, and systolic hypertension

When a client with thrombocytopenia has a severe headache, what does the nurse interpret that this may indicate?

cerebral bleeding

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. The client is incontinent and has a tarry stool. Their blood pressure is 90/50 mm Hg, and hemoglobin is 10 g. Which nursing intervention is a priority for this client?

elevating the head of the bed to 30 degrees

Contraindications for tPA

3 hours or longer since onset, internal bleeding, severe hypertension

A nurse on a neurologic trauma unit must assess the corneal reflex of an unconscious client. Which method would be most appropriate for the nurse to use to perform this assessment?

Apply a drop of sterile saline solution to the cornea.

A client with cirrhosis is receiving lactulose. The nurse notes the client is more confused and has asterixis. What should the nurse do next?

Assess for gastrointestinal (GI) bleeding.

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply.

Elevate the head of the bed 15 to 20 degrees. Contact the health care provider (HCP) if ICP is greater than 28 mm Hg. Monitor neurologic status using the Glasgow Coma Scale.

A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?

Elevate the head of the bed 15 to 30 degrees.

The nurse is caring for a client with a subdural hematoma. Which is the priority outcome?

Ensure airway patency and optimal oxygen levels and protect from injury

The family of a client with a cerebrovascular accident (CVA) asks the nurse why the client is not able to speak. What is the best response by the nurse?

"Paralysis of the muscles responsible for producing speech is causing difficulty with speaking."

A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time that client is admitted to the intensive care unit (ICU) for aggressive treatment. The nurse meets with the team to develop a change strategy based on indicators. Which statement by a team member shows a need for further teaching regarding performance management?

"We can discipline the ED staff for not getting the clients to the ICU fast enough."

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

30-degree head elevation

A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number.

36

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36%

A client is stabilized in the emergency department and moved to the neurologic intensive care unit with a diagnosis of spinal cord injury at level C4-C5. The nurse is working with an experienced unlicensed assistive personnel (UAP). Which items can the nurse delegate to the UAP? Select all that apply.

Ensure that oxygen is flowing at 5 liters per minute by nasal cannula. Check the client's pulse oximetry reading every 1 hour.

What assessment is preformed on a patient receiving tPA therapy?

Neurological signs frequently throughout the course of therapy

A nurse is caring for a client with a spinal cord injury who has a urinary catheter. The nurse finds the client in a recumbent position and notices that the client's blood pressure is rapidly increasing. The client reports having a pounding headache and is damp from sweating. Place the nursing actions in the order in which the nurse should perform them to properly respond to this client's situation. All options must be used.

Notify the health care provider. Sit the client up. Loosen the client's clothing. Check the urinary catheter for kinks

A client has been admitted to the medical-surgical unit from the emergency department with a diagnosis of left-sided cerebrovascular accident (brain attack). The nurse has observed that breathing is of a snoring quality. Order the items in nursing care priority for this client. All options must be used.

Position the client on the side with the head of the bed slightly elevated. Initiate oxygen therapy via nasal cannula as ordered. Assess the client's ability to communicate needs to the health care team. Place all items that the client may need to the left side of the bed. Arrange for the discharge planner to meet with the family.

A client with a hemorrhagic stroke is slightly agitated, heart rate is 118 bpm, respirations are 22 breaths/min, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88 mm Hg, and oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? All options must be used.

Provide sedation. Hyperoxygenate. Suction the airway. Suction the mouth.

The nurse is caring for a client with a head injury and notes a loss in level of consciousness. Which nursing intervention is important to manage the care of the client? Select all that apply.

Provide supplemental oxygen. Maintain antiembolism stockings. Notify the healthcare provider of the change.

A nursing student has been assigned care of a patient with the diagnosis of autonomic dysreflexia and is unfamiliar with this diagnosis. What would be appropriate actions by the nursing student? Select all that apply.

Search the Internet for evidence-based practice in a peer-reviewed journal. Review the condition in a textbook and review the chart and nursing care plan.

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may

dislodge the autografts.

Which nursing assessments would indicate a decline in the condition of a client 2 hours after admission for a subdural hematoma?

disorientation, increasing blood pressure, bradycardia, and bradypne

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates

dysfunction in the brain stem.

While caring for the client with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the client for:

gastrointestinal ulceration

Which outcomes indicate effective management of a conscious client who is being treated with recombinant tissue plasminogen therapy during the initial phase of an ischemic cerebral vascular accident (CVA)? Select all that apply.

headache reduced responds to comfort measures no signs or symptoms of bleeding

A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which indicator of early shock?

heart rate above 100 beats/minute

A client with a diagnosis of cirrhosis and hepatic encephalopathy is receiving lactulose. Which assessment finding indicates a therapeutic effect of lactulose?

improved cognition

Three hours ago, an adult was thrown from a car into a ditch. The client is now in the emergency department in a stable condition. Vital signs are within normal limits. The client has an open fracture of the right tibia. For which sign should the nurse be especially alert?

infection

The nurse is caring for a client with a T 5-12 spinal fracture. Which nursing interventions are priorities for care? Select all that apply.

inserting a urinary catheter to manage an atonic bladder assessing level of numbness and tingling

Following a transsphenoidal hypophysectomy, a client has a cerebrospinal fluid leak. The nurse should prepare the client for which treatment of the leak?

maintaining bed rest with the head of the bed elevated to 30 degrees

A client has been injured in a snowmobile accident and is airlifted to the trauma center with a neck injury. The nurse needs to implement which interventions if the injury is at the C4 level? Select all that apply.

mechanical ventilation to prevent hypoxemia and hypercapnia assessment of level and extent of paralysis

A client had a thrombotic cerebrovascular accident and now has flaccid hemiplegia of the right side. When can the health care team begin rehabilitation for this hospitalized client?

on admission the hospital

A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the I.V. route. The nurse should assess the client for which adverse reaction?

ototoxicity

After striking their head on a tree while falling from a ladder, a client is admitted to the emergency department. The client is unconscious and their pupils are nonreactive. Which intervention should the nurse question?

performing a lumbar puncture

The client with cirrhosis who has ascites receives 100 mL of 25% serum albumin I.V. Which finding would best indicate that the albumin is having its desired effect?

reduced ascites

The nurse is assessing a client for a possible brainstem herniation. Which findings assist in confirming this diagnosis? Select all that apply.

respiratory rate decreased from 14 to 10 breaths per minute and irregular blood pressure increased from 118/70 to 140/82 mmHg

When a nurse is assessing a client for pain, what finding is most significant? The client:

tells the nurse about experiencing pain.

The client with a spinal cord injury asks the nurse why the dietitian has recommended to decrease the total daily intake of calcium. Which response by the nurse would provide the most accurate information?

"Lack of weight bearing causes demineralization of the long bones."

A client is admitted with a spinal cord injury at level C3. The nurse notes a heart rate of 50 beat/minute and a blood pressure of 90/60 mmHg. What is the nurse's priority action?

Administer rapid infusion of intravenous fluids.

The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. What should the nurse do?

Chart the client's level of consciousness as coma.

The nurse working on a neurological unit is assigned a client with spinal cord injury. Which nursing actions can the nurse delegate to the nursing student on the unit? Select all that apply.

Provide pin care. Administer oral medication to decrease muscle spasticity.

The client with a head injury receives mannitol during surgery to help decrease intracranial pressure. Which finding indicates that the drug is having the desired effect?

Urine output increases.

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

absence of reflexes along with flaccid extremities

The emergency department protocol provides for administration of alteplase (tPA) for clients with confirmed acute coronary syndrome (ACS). The nurse contacts the healthcare provider to clarify the order for the client with which health history?

atrial fibrillation and a mild stroke one month ago

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates

cranial nerves IX and X

A client with pancreatitis returns from an endoscopic retrograde cholangiopancreatography (ERCP). Which assessment would be of most concern to the nurse?

poor gag reflex

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

positioning the client on the side with the knees flexed

Which respiratory pattern indicates increasing intracranial pressure in the brain stem?

slow, irregular respirations

A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the client's score has changed from 11 to 15. Which responses did the nurse assess in this client? Select all that apply.

spontaneous eye opening orientation to person, place, and time