Questions R/T to the kahoot

nursing delegation

*E-A-T (do not delegate what nurse can: evaluate, assess, teach)* UAP- vitals, feeding, responsibility and authority of tasks are transferred from 1 to another who accepts responsibility o Responsibility: obligation to accomplish task, Accountability: accepting ownership, Authority: right to act or empower o UAP: no scope of practice, noninvasive, skin care, range-of-motion, ambulation, grooming, and hygiene measures o LPN: UAP and dressings, suctioning, urinary catheterization, administering meds (PO, SQ, IM, some piggyback) o RN: responsible for assessment, planning care, analyzing client data, implementing and evaluating care, supervising care, initiating teaching, and administering medications intravenously. o RN can only delegate tasks RN is responsible for, remains accountable, delegation is a contractual agreement o Steps: 5 Rights of Delegation • Right task: define task and determine safety • Right circumstances: pt condition, resources, equipment • Right person: staff w/ necessary knowledge, skills, abilities (KSA), pt stable • Right direction/communication: clear, specific, expectations, documentation • Right supervision/evaluation: monitoring, evaluation, feedback

HIV Standard Precautions

- Always put on gloves before leaving the ambulance - Take care in handling and properly disposing of needles and other sharp objects in a sharps container so that you and others are not inadvertently exposed to them - Cover any open wounds that you have whenever you are on the job

TPA Parameters

- stroke must be witnessed - must be administered within 3 hours of onset of clinical signs of ischemic stroke

CABG pre-op care

-Baseline labs, studies, assessments -Teaching -Bath/shower -Type/cross/order blood products -Allow time with family -Sleep med as ordered -Prophylactic ABX

chest tube

-Continuous bubbling in the water seal champers indicates an air leak or pneumothorax. (tidaling normal) If this is observed, the nurse should attempt to locate the source of the air leak and intervene accordingly (tighten the connections, replace drainage system) Gentle bubbling in suction chamber is normal. Tube dislodges= cover with sterile dressing and tape 3 sides, Call MD System breaks- put tubing in NS

ICP management and care

-HOB to facilitate outflow but promote CPP -Prevent neck flexion -airway Keep MAP 70-90 -Skin care -Prevent infection, hemorrhage (BP >160= edema) tx- labatolol/nifedipine No lumbar puncture, Nitro -Pain management -Psychosocial issues -Decrease environmental stimuli -Decrease causes that raise ICP- causes herniation (metabolic demand, stress, suction, ab distension) -Freq. neuro assessment -Seizure precautions -Hydrated, normotensive, hydrated, and nutritionally adequate -Maintain ICP, CBF, and CPP -Watch for secondary brain injury

CVP (central venous pressure)

-Provides important info about right sided heart preload; ventricular function/venous blood return to right side of heart. 0-8

CVP (central venous pressure)

-Provides important info about right sided heart preload; ventricular function/venous blood return to right side of heart. 1-8; 1 indicates dehydration, 8 indicates hypervolemia

Tracheostomy care procedure

-don sterile gloves -clean, rinse, dry INSIDE of inner cannula & reinsert (DO NOT DRY THE OUTSIDE OF THE INNER CANNULA) -once the inner cannula has been cleaned & replaced, the sterile portion of the procedure is complete -assess & clean the trach site & face plate: use N/S & wipe clean, then dry the skin and face plate -apply trach dressing & replace ties (NEVER REMOVE THE OLD TIES WITHOUT SECURING THE NEW TIES); ensure 2 finger width bw pt and ties If falls out insert new cannula right away

dysrhythmia intervention and prevention

-treat cause -give o2 -adjust UFR -review pt H&P labs

pacemaker nursing care

1. monitor EKG 2. rest 3. monitor pulse; rate should never be lower than what pacemaker is set at Time, should be within 5 4. whatever arm pacemaker is near should be in sling and immobilized

Vent Respiratory Rate

> 30= bad

Toxicity from which of the following medications may cause a client to see a green halo around lights? A. Digoxin B. Furosemide C. Metoprolol D. Enalapril

A One of the most common signs of digoxin toxicity is the visual disturbance known as the green halo sign. The other medications aren't associated with such an effect. RELATED TO Q41

respiratory acidosis

A drop in blood pH (low) due to hypoventilation (too little breathing) and a resulting accumulation of Co2 (high). Norm for COPD- S/S confusion restlessness (hypoxia early sign). Tx- bronchodilators.

Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block

ANS C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI). Immediate therapy with percutaneous coronary intervention (PCI) or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy, but not as rapid RELATED TO Q38

Following surgery for an abdominal aortic aneurysm, a patients central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take? a. Administer IV diuretic medications. b. Increase the IV fluid infusion per protocol. c. Document the CVP and continue to monitor. d. Elevate the head of the patients bed to 45 degree

ANS: B A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP

A patient complains of leg cramps during hemodialysis. The nurse should first a. massage the patients legs. b. reposition the patient supine. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline

ANS: D Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the crampS RELATED TO Q7

First degree Heart Block EKG

AV block Prolonged PR Interval >0.20 seconds miscommunication between SA & AV node (takes too long). Large PR interval. -Associated w/ MI, CAD, rheumatic fever, hyperthyroidism, hypokalemia, drugs (digoxin, BB, CCB) -Usually asymptomatic -No treatment. Correct underlying cause.

Hyperreflexia

Abnormally increased reflexes resulting from nervous system damage Increased HR, diaphoresis d/t stimulants

Modes of Ventilation

Assist-control ventilation (AC) Synchronized intermittent mandatory ventilation (SIMV) Bi-level positive airway pressure (BiPAP)

Dialysis education can

Change positions slowly Low phosphorus, protein, K+

Increased amonia

Cirrhosis

dysequilibrium syndrome

Complication of hemodialysis Rapid ↓BUN > cerebral edema and ↑ICP. S/s: N/V, altered LOC, agitation, seizures Interventions: Slow rate and give anticonvulsants if needed

Art line indications

Continuous BP/ drawing ABG's only No fluids

CABG (Coronary Artery Bypass Graft)

Creation of a new blood supply to an area of the heart with a clotted/blocked artery.

Crohn's vs. Ulcerative Colitis

Crohn's - most commonly affects distal small intestine and proximal colon, skip lesions, cobblestone/granulomas, Transmural inflammation Ulcerative colitis - continuous involvement, confined to colon and rectum, Crypt abscesses, mucosal inflammation

Infection prevention in burn patient

Hand hygiene aseptic technique Monitor s/s of infection

metabolic alkalosis

High PH and HCO3- usually caused by an excessive loss of metabolic acids- vomiting. Tx underlying cause, fluids & electrolytes

HHNS treatment

Hyperglycemia in Type 2 which is really just dehydration. Increased BUN/Cr/ Na, Decreased K+ Days to weeks of polyuria Treat with fluids/ insulin

Hemodialysis Complications

Hypotension Muscle cramps Loss of blood Hepatitis Sepsis Disequilibrium syndrome Hold meds- dont abosorb. Lasts > 3 hours

Pre-renal AKI

Hypotension, hypovolemia, shock, HF

Tx of DKA

IV bolus NS or 1/2 NS for dehydration then regular insulin IV bc insulin cause water, K, gluc into cell which can exacerbate dehydration

ARDS

In prone, decreased Paco2 tachycardia hypotension= flip to fowlers

Chronic Kidney Disease (CKD)

Inability of kidneys to excrete wastes; staged from 1 (mild damage to kidney) to 5 (complete kidney failure requiring either dialysis or a renal transplant). Stage 5 is also called end stage renal disease Decreased protein, potassium, and phosphates

Dialysis

Increased (not high) protein intake, Increased CA, Decreased Phosphorus, Na, and K+

1st sign of hypovolemia

Increased HR

DOPAMINE - THERAPEUTIC EFFECTS

Increased cardiac output, increased BP, and improved renal blood flow.

Cushing's triad indicates

Increased intracranial pressure (brain herniation) Change in LOC= early sign S/S- increased syst. BP, widening pulse pressure, bradycardia Tx- diuretics (decrease cerebral vol) Manitol- osmotic, dont give to renal pt's Loop diuretics- lasix= remove Na/ water. Can cause rebound ICPP Strict I&O

Stop weaning from ventilator if

Low O2 Anxiety Fighting vent

risk factors of cardiovascular disease

Non-modifiable: Age, Heredity, Gender Modifiable: Smoking, High BP, high blood fats, overweight and obesity, lack of physical exercise.

INR lab values

Norm- 1-2 2-3, critical value if off, potential for patient to bleed. Use default order for order ?'s (hold all coumadin, assess for bleeding, prepare Vit K (antidote for Coumadin), Call or notify On anticoagulant= 1.5 times normal limit

SVC syndrome

Occurs due to a tumor usually obstructing the SVC, commonly LUNG CANCER followed by lymphoma. S/Sx include: Periorbital edema- 1st sign Causes "facial plethora", facial edema, neck (Jugular venous distension) and upper extremities (edema). Medical emergency, can raise ICP, cause headache, dizziness, risk of aneurysm/rupture in brain. *dilated collateral veins in the upper trunk* !!!

TZDs

Pioglitazone (Actos) Rosiglitazone (Avandia) AFFECT LIVER, risk of MI/stroke. No CHF patients

total parenteral nutrition (TPN)

Providing 100% of a patient's nutrition intravenously. Used when a patient is unable to eat. Change tubing q12hrs Give D10 if run out to prevent hypoglycemia

chronic kidney disease

Pulmonary edema- reduce chance by monitoring I & O's Progressive, irreversible deterioration in renal function d/t HTN, DM, glomerulopathy, mephritis, polycystic disease, congenital. s/s: pulm edema, HTN, hyperkalemia, lethargy, hyperlipidemia, glucose intolerance, water retention, metabolic acidosis, hyperkalemia, hypocalcemia, hypermagnesemia, hypophosphatemia, anorexia, n/v, gastric ulcerations, hemorrhage, anemia,hyperpigmentation, ecchymosis) Labs: elevated BUN, Cr Phosphorus. Rx: meds for hypertension, statins, epoetin, diuretics, calcium, LOW protein, low salt, restrict K, phosphorus (no chicken, milk, legumes, carbonated drinks), dialysis. Nursing: assess fistula for thrill and bruit, edema

Oxygen Delivery Systems

RA- 20% Low-flow oxygen delivery system: nasal cannula - 24-28% (1L= 24%- NC) Simple face mask Partial rebreather Nonrebreather mask High flow oxygen delivery system: Venturie mask- COPD Aerosol mask, face tent, tracheostomy collar (24-100%)

Early signs of hypoxia

Restlessness, irritability, apprehension, tachycardia, anxiety. Can lead to ARDS

Crohn's disease symptoms

Right lower quadrant pain with NON-BLOODY diarrhea, fistula, cobblestone/ granulomas, high pitched bs Take dicyclomine 30 min before meals to decrease pain

Hypovolemia S/S

S&S Include: increased temp, rapid/weak pulse, increase respirations, hypotension, anxiety, w/ a urine specific gravity > 1.030

Diabetes type 1 with BS of 600+

S/S= tachycardia decreased BP

STEMI vs NSTEMI

STEMI = ST elevation, V-tach, >troponin NSTEMI = ST depression, T-wave inversions

Post-renal AKI

Secondary to obstruction of urinary outflow Usually no kidney damage Reversible once obstruction resolved

flacid paralysis

Seen in spinal shock Weakness or loss of muscle due to injury or disease of the motor neurons

cardiogenic shock

Shock caused by inadequate function of the heart, or pump failure.

thorectomy

Shoulder exercises need to be completed

CAD risk factors

Smoking age obesity

Heart palpitations and PAC's resolve spontaneously

Stop caffine

vent weaning parameters

TV >5ml/kg, minute volume <12, spontaneous RR < 35, vital capacity > 10, negative inspiratory force, rapid shallow breathing index assessed by RT

Prolonged QRS interval

Taking too long for the electrical impulse to travel down the bundle branches to the purkinje fibers (Bundle branch block) Check K+

expressive aphasia

The inability to produce language ( despite being able to understand language)

Burn patient compression garment

Wear to decrease scar tissue/ protect skin from infection

global aphasia

When both production and understanding of language is damaged

tumor lysis syndrome treatment

With this, monitor urine pH to prevent ARF. You want a pH below 6.57. - Also, hydration is important. Have patients drink the day before, of, and 3 days after treatment at scheduled times. - do an EKG - Medication - Alopurinol to decrease uric acid.

Ambubag

a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately Self exebates/

Burn patients

a typically wont go into shock as a result of the burn, its from an underlying injury, don`t develop tunnel vision continue with your assessment. Increased urine o/p= tx working

Ifosfamide

alkylating agent Used to prevent hemmorrhagic cystis in chemo for testicular cancer in conjunction with mesna

Tidal Volume (TV)

amount of air inhaled or exhaled with each breath under resting conditions Norm 450-500

Atrial Fibrillation (A-Fib)

an irregular and often very fast heart rate originating from abnormal conduction in the atria <48 hrs= Cardiovert >48 hrs= Anticoagulants

Heparin

anticoagulant found in blood and tissue cells, does not dissolve clots

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

b. Assess vital signs and level of consciousness. In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture. RELATED TOT Q42

Cardioversion vs Defibrillation

cardioversion - in sync defibrillation - no rhythm, shock whenever *Ensure machine not turned on before* Cardioversion: in sync with QRS, used in AFib, atrial flutter, VT w/ a pulse, SVT Defibrillation: not in sync with QRS, used in VFib and VT without a pulse

CPP

cerebral perfusion pressure Normal is 80-100 <70 is bad= no good perfusion Could indicate clot etc. (see with PE) <30 = ischemia/ brain death (herniation)

A client has a long history of hypertension. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)? a. Antibiotic b. Histamine blocker c. Bronchodilator d. Angiotensin-converting enzyme (ACE) inhibitor

d. Angiotensin-converting enzyme (ACE) inhibitor RELATED TO Q8

acute pancreatitis

inflammation of the pancreas secondary to the leakage of pancreatic enzymes from the acinar cells into the parenchyma of the organ Increased amylase/lipase Decreased Ca (9-11)/ Mag (1.5-2)

nephrotic syndrome treatment

loss of large amounts of plasma protein, usually albumin, through urine due to an increased permeability of the glomerular membrane Tx- reduce proteinuria with steroids: -can cause bone demineralization and increase blood glucose! control edema: -diuretics -albumin followed by lasix, NAS diet prevent infection: ascites can cause peritonitis, serious complication

pacing spike

mark on an ECG tracing that represents the stimulation of electrical current from the pacemaker generator Assess LOC and vitals

Decrease VAP

oral care, turn patient q 2 hours

COPD ABGs

pH ↓ PaCO2⬆ HCO3 ⬆ PaO2 ↓

Increased risk factors of shock

poor nutrition, mobility, decreased fluid intake

peep

positive end-expiratory pressure - common mechanical ventilator setting in which airway pressure is maintained above atmospheric pressure

Mean Arterial Pressure (MAP)

pressure forcing blood into tissues, averaged over cardiac cycle Norm 70-100

intracranial pressure

the amount of pressure inside the skull 0-10 normal If at 20 > 5 min call MD

Cushing's triad

three classic signs—bradycardia, syst. hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation with increased ICP

afib risk of

Stroke

high pressure alarm

Excess secretions, client biting tube, kinks, cough, edema, pneumothorax, bronchospasm

V fib

*SHOCK* on R wave chaotic rapid rhythm fatal if not treated in 3-5 mins CPR, defib, Epi, O2, antidysrhythmics- Rx amioderone

Low pressure alarm

Disconnection, cuff leak, displacement

CPP=

MAP-ICP

ACE inhibitors

"PRIL" Captopril, Enalapril, Afosiopril Antihypertensive. Blocks ACE in lungs from converting angiotensin I to angiotensin II (powerful vasoconstrictor). Decreases BP, Decreased Aldosterone secretions, Sodium and fluid loss. Check BP before giving (hypotension) *Orthostatic Hypotension Cough- s.e

Autonomic Dysreflexia

(Potentially life-threatening emergency!) HOB elevate 90 degrees- high fowlers, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) Spinal shock= RX- vasodilators

chest tube

-Decrease air -Re-Expand lung

cause of sepsis

Bacterial- chemicals released into the bloodstream to fight an infection trigger an inflammatory response throughout the body

Advanced COPD symptoms

Barrel chest Low Oxygen Club fingers

Adenosine Indications

1. SVT or PSVT unresponsive to Valsalva (vagal) maneuvers Stops heart and restarts it

Sepsis bundle: 3 hours

- Measure lactate level - Administer fluids 30 mL/kg if pt. is hypotensive or lactate of 4 - Culture before antibiotics - Start antibiotic *within 1 hour*

Epinephrine

Last resort, Increase BP/P First drup in pulseless situation

atrial fibrillation

Monitor for clots

PTT/APTT

60-70 seconds/20-35 seconds

Adenosine

Antiarrhythmic, used to stop and restart heart.

diabetic medications effective if

BS decreasing, can decrease meds= good control

Spinal shock occurs

immediately after spinal injury of T6 Sudden increase in BP, hypertensive crisis that can result in stroke or seizures= Autonomic dysreflexia Tx- HOB elevated high, Rx- hydralozine or appresoline Caused by bowel obstruction bladder distention wrinkles in bed (body) ingrown toenail- anything. S/S- HA, HTN, bradycardia, diaphoresis, nausea- label in chart

receptive aphasia

inability to understand spoken or written words

WBC shift to the left

increase in immature neutrophils ANC increased Notify MD, start antibiotics

CABG post op care

1) ICU + *telemetry* 2) watch for MI / stroke (elderly) 3) monitor *EF* (*0.55-0.6*) - *PCWP* (Swan Ganz - should be 8-12) = *Left Atrial P* - most serious long term effect = *CHF / PULM HTN* No lifting >15lb, raising arms above head

Intra-Renal Failure

Damage has occurred inside the kidney -Glomerulonephritis -Nephrotic Syndrome -Dye used in tests such as heart cath and CT scan because the dye is excreted by the kidney -Drugs (Aminoglycosides, Mycins) are nephrotoxic -malignant hypertension -also DM causes severe kidney vascular damage Lupus, antibiotics, NSAIDS, Dye

DKA ABG

Decreased pH Decreased PaCO2,

subcutaneous emphysema (crepitus)

Air escapes into the tissues, dissects fascial planes under the skin and accumulates making areas appear puffy. Slight finger pressure produces a crackling sound and feel. Lightly dot the area

SARS (severe acute respiratory syndrome)

Airborne and Contact precautions (same as varicella)

ABGs

Arterial Blood Gases pH 7.35- 7.45 HCO3 (Bicarbonate) normal values 22-26 mEq/L PaCO2 ( CO2 or carbon dioxide content) 35-45 mm Hg PaO2 (oxygen saturation in arteria blood)- 80-100 mm Hg

Resp. Acidosis

COPD- Decreased PH, Increased Co2,

AM insulin, and increase in PM blood sugar

Call MD for orders

pacemaker placement precautions

Dont lift arm

fluid overload s/s

Elevated CVP, increased resp. Enlarged neck veins. Increased Blood pressure. Dyspnea.

pursed lip breathing

Emphysema- Deep inspiration followed by prolonged expiration through pursed lips. Exp. Lung capacity

SIADH treatment

Fluid restriction, IV hypertonic saline, conivaptan/tolvaptan, demeclocycline

HHNS

Give fluids Insulin K+

Non-STEMI treatment

Give heparin to prevent blood clots in coronary arteries

Chest contusion

Green tag if did not affect airway Red if so

Hypovolemia

Low K+ , CVP, low grade temp

3 hour sepsis bundle includes:

Measure lactate level Draw blood cultures Administer 30mL/kg crystalloid fluid bolus Administer broad spectrum ABX

DKA s/s

Metabolic Acidosis: Abd. pain, weakness, fatigue, headaches, dysrhythmia, Kusmals resp., hyperglycemia, dehydration, acetone breath, mental status changes, N/V Low PH (acidotic) and Bicarb. (22-26)(lower end).

CD4 count

The lab value that counts a certain type of erythrocyte. It is used to assess the magnitude of injury to the immune system and to determine the effectiveness of treatment in HIV and AIDS patients. < 500= HIV <200= aids

Leading cause of sepsis

UTI

Nitroglycerin (Nitrostat)

Vasodilator Take up to 3 tabs during single episode place under tongue x 3 every 5 min until chest pain subsides, call 911 store in original container dark cool place discard on expiration date (6 months)

ARDS positioning

high fowlers prone (pt with severe ARDS, helps alveoli expand) Prone to increase O2, if 30 min has not increased back to high fowlers Increase PEEP is decreased O2 when weening from vent If PaCO2 decreased (35-45)- tachycardia/ decreased BP

tumor lysis syndrome

hyperkalemia may occur =requires insulin to reduce serum potassium = monitor serium potassium and blood glucose levels

ICP

intracranial pressure (normal pressure is 5 to 15 mm Hg) >15 or decreased BP= notify MD

A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question? a. Give PRN furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Administer hydrocortisone (Solu-Cortef) 100 mg IV. d. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm H

ANS: A Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate RELATED TO Q24

A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first? a. Place the patient on a cardiac monitor. b. Administer IV potassium supplements. c. Obtain urine glucose and ketone levels. d. Start an insulin infusion at 0.1 units/kg/h

ANS: A Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Urine glucose and ketone levels are not urgently needed to manage the patients care RELATED TO Q1

A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first? a. Infuse 1 liter of normal saline per hour. b. Give sodium bicarbonate 50 mEq IV push. c. Administer regular insulin 10 U by IV push. d. Start a regular insulin infusion at 0.1 units/kg/h

ANS: A The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. The other actions can be done after the infusion of normal saline is initiatE RELATED TO Q1

A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone positioning is used, which information obtained by the nurse indicates that the positioning is effective? a. The patients PaO2 is 89 mm Hg, and the SaO2 is 91%. b. Endotracheal suctioning results in clear mucous return. c. Sputum and blood cultures show no growth after 48 hours. d. The skin on the patients back is intact and without redness

ANS: A The purpose of prone positioning is to improve the patients oxygenation as indicated by the PaO2 and SaO2 RELATED TO Q44

A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first? a. Assess the airway. b. Administer prescribed bronchodilators. c. Provide oxygen. d. Administer prescribed mucolytics

ANS: A All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be HELPFUL RELATED T0 Q39

A nurse contacts the health care provider after reviewing a clients laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity

ANS: A Normal BUN is 10 to 20 mg/dL. Normal creatinine is 0.6 to 1.2 mg/dL (males) or 0.5 to 1.1 mg/dL (females). Creatinine is more specific for kidney function than BUN, because BUN can be affected by several factors (dehydration, high-protein diet, and catabolism). This clients creatinine is normal, which suggests a non-renal cause for the elevated BUN. A common cause of increased BUN is dehydration, so the nurse should anticipate giving the client more fluids, not placing the client on fluid restrictions. Hemodialysis is not an appropriate treatment for dehydration. The lab results do not indicate an infection; therefore, a urine culture and sensitivity is not appropriate. RELATED TO Q7

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the clients nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

ANS: A The client has experienced a combination of metabolic and acute respiratory acidosis through heavy skeletal muscle contractions and no gas exchange. When the seizures have stopped and the client can breathe again, the fastest way to return acid-base balance is to administer oxygen. Applying a paper bag over the clients nose and mouth would worsen the acidosis. Sodium bicarbonate should not be administered because the clients arterial bicarbonate level is normal. Glucose and insulin are administered together to decrease serum potassium levels. This action is not appropriate based on the information provided. RELATED TO Q39

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the clients oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

ANS: A This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client. RELATED TO Q22

A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best? a. Check the clients digoxin (Lanoxin) level. b. Administer an anti-nausea medication. c. Ask if the client is able to eat crackers. d. Get a referral to a gastrointestinal provider.

ANS: A These signs and symptoms are indications of digoxin (Lanoxin) toxicity. The nurse should check the level of this medication. Administering antiemetics, asking if the client can eat, and obtaining a referral to a specialist all address the clients symptoms but do not lead to the cause of the symptoms. RELATED TO Q41

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.) a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis d. Firefighter with severe burns e. Young woman with lupus

ANS: A, B, C Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes post-renal AKI. Severe burns would be a pre-renal cause. Lupus would be an intrarenal cause for AKI. RELATED TO Q11

The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory findings would the nurse expect for this client? (Select all that apply.) a. Elevated amylase b. Elevated lipase c. Elevated glucose d. Decreased calcium e. Elevated bilirubin f. Elevated leukocyte count

ANS: A, B, C, D, E, F All of these choices are correct. Amylase and lipase are pancreatic enzymes that are released during pancreatic inflammation and injury. Leukocytes also increased due to his inflammatory response. Pancreatic injury affects the ability of insulin to be released causing increased glucose levels. Bilirubin is also typically increased due to hepatobiliary obstruction. Calcium and magnesium levels decrease because fatty acids bind free calcium and magnesium causing a lowered serum level; these changes occur in the presence of fat necrosis. RELATED TO Q29

A client is undergoing hemodialysis. The client's blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions would the nurse perform to maintain blood pressure? (Select all that apply.) a. Adjust the rate of extracorporeal blood flow. b. Place the patient in the Trendelenburg position. c. Stop the hemodialysis treatment. d. Administer a 250-mL bolus of normal saline. e. Contact the primary health care provider

ANS: A, B, D Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the primary health care provider contacted. RELATED TO Q7

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging(MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

ANS: A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker RELATED TO Q45

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.

ANS: A, B, E Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours.

A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension

ANS: A, C, E DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur. RELATED TO Q6

A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which assessment findings would the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary craterm-1ckles e. Orthostatic hypotension

ANS: A, C, E DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually, patients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur. RELATED TO Q1

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

ANS: B Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for RELATED TO Q17

Following surgery for an abdominal aortic aneurysm, a patients central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take? a. Administer IV diuretic medications. b. Increase the IV fluid infusion per protocol. c. Document the CVP and continue to monitor. d. Elevate the head of the patients bed to 45 degree

ANS: B A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP RELATED TO Q14

The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The patients central venous pressure (CVP) is decreased. c. The patient has a level 7 (0 to 10 point scale) incisional pain. d. The blood urea nitrogen (BUN) and creatinine levels are elevate

ANS: B The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant

After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. 56-year-old with frequent explosive diarrhea b. 33-year-old with a fever of 100.8 F (38.2 C) c. 66-year-old who has white pharyngeal lesions d. 23-year old who is complaining of severe fatiguE

ANS: B Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problem RELATED TO Q24

An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to a. give a bolus of 50% dextrose. b. insert a large-bore IV catheter. c. initiate oxygen by nasal cannula. d. administer glargine (Lantus) insuliN

ANS: B HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patients blood glucose and would be contraindicated RELATED TO Q5

When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias

ANS: B The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and blood pressure (BP) and observe for dysrhythmias, but these parameters will not indicate whether the medication is effectivE RELATED TO Q38

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

ANS: B The patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified immediately so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur. RELATED TO Q25

Meglitinides

- repaglinide (Prandin) and nateglinide (Starlix) increase insulin production by the pancreas. - less likely to cause hypoglycemia because of rapid absorption - When they are taken just before meals, pancreatic insulin production increases during and after the meal, mimicking the normal response to eating. Instruct patients to take meglitinides any time from 30 minutes before each meal right up to the time of the meal. These drugs should not be taken if a meal is skipped.

During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Check patients blood pressure (BP). c. Review the hematocrit (Hct) level. d. Give prescribed PRN antiemetic drugs.

ANS: B The patients complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions may also be appropriate based on the blood pressure obtaineD RELATED TO Q7

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a. The patients PaO2 is 50 mm Hg and the SaO2 is 88%. b.The patient has subcutaneous emphysema on the upper thorax. c.The patient has bronchial breath sounds in both the lung fields. d.The patient has a first-degree atrioventricular heart block with a rate of 5

ANS: B The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications that PEEP should be reduced. RELATED TO Q22

Which assessment finding in a woman who recently started taking hormone therapy (HT) is most important for the nurse to report to the health care provider? a. Breast tenderness b. Left calf swelling c. Weight gain of 3 lb d. Intermittent spotting

ANS: B Unilateral calf swelling may indicate deep vein thrombosis caused by the changes in coagulation associated with HT and would indicate that the HT should be discontinued. Breast tenderness, weight gain, and intermittent spotting are common side effects of HT and do not indicate a need for a change in therapy RELATED TO Q43

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mmHg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. nitroglycerine (Tridil). b. norepinephrine (Levophed). c. sodium nitroprusside (Nipride). d. methylprednisolone (Solu-Medrol

ANS: B When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and blood pressure, and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Methylprednisolone (Solu-Medrol) is considered if blood pressure does not respond first to fluids and vasopressors. Nitroprusside is an arterial vasodilator and would further decrease SVR RELATED TO Q24

A nurse cares for a client who is prescribed pioglitazone (Actos). After 6 months of therapy, the client reports that his urine has become darker since starting the medication. Which action should the nurse take? a. Assess for pain or burning with urination. b. Review the clients liver function study results. c. Instruct the client to increase water intake. d. Test a sample of urine for occult blood.

ANS: B Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator of liver impairment because bilirubin is increased in the blood and is excreted in the urine. The nurse should check the clients most recent liver function studies. The nurse does not need to assess for pain or burning with urination and does not need to check the urine for occult blood. The client does not need to be told to increase water intake. RELATED TO Q3

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO3 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.32, HCO3 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

ANS: B When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels. RELATED TO Q39

A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: Vital Signs and Assessment Laboratory Results Medications Blood pressure: 90/62 mm Hg Pulse: 120 beats/min Respiratory rate: 28 breaths/min Urine output: 20 mL/hr via catheter Serum potassium: 2.6 mEq/L Potassium chloride 40 mEq IV bolus STAT Increase IV fluid to 100 mL/hr Which action should the nurse take? a. Administer the potassium and then consult with the provider about the fluid order. b. Increase the intravenous rate and then consult with the provider about the potassium prescription. c. Administer the potassium first before increasing the infusion flow rate. d. Increase the intravenous flow rate before administering the potassium

ANS: B The client is acutely ill and is severely dehydrated and hypokalemic. The client requires more IV fluids and potassium. However, potassium should not be infused unless the urine output is at least 30 mL/hr. The nurse should first increase the IV rate and then consult with the provider about the potassium. RELATED TO Q1

A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care? a. Do you take any over-the-counter medications? b. You appear anxious. What is causing your distress? c. Do you have a history of anxiety attacks? d. You are breathing fast. Is this causing you to feel light-headed?

ANS: B The nurse should assist the client who is experiencing anxiety-induced respiratory alkalosis to identify causes of the anxiety. The other questions will not identify the cause of the acid-base imbalance RELATED TO Q39

A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.) a. Metabolic alkalosis Young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis Older adult who is following a carbohydrate-free diet c. Respiratory alkalosis Client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis Postoperative client who received 6 units of packed red blood cells e. Metabolic alkalosis Older client prescribed antacids for gastroesophageal reflux disease

ANS: B, C, E Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis. One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis. Citrate is a substance used as a preservative in blood products. It is not only a base, it is also a precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis. RELATED TO Q39

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? a. I will check my pulse rate before I take any nitroglycerin tablets. b. I will put the nitroglycerin patch on as soon as I get any chest pain. c. I will stop what I am doing and sit down before I put the nitroglycerin under my tongue. d. I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin

ANS: C The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitratES RELATED TO Q17

A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the clients breath has a fruity odor. Which action should the nurse take? a. Encourage the client to use an incentive spirometer. b. Increase the clients intravenous fluid flow rate. c. Consult the provider to test for ketoacidosis. d. Perform meticulous pulmonary hygiene care.

ANS: C The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a fruity odor to the breath. Documentation should occur after all assessments have been completed. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this clients problem. RELATED TO Q6

The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8 F (37.6 C). What is the most appropriate action by the nurse? a. Administer fluid to increase blood pressure. b. Check the white blood cell count. c. Monitor the clients temperature. d. Connect the client to an electrocardiographic (ECG) monitor.

ANS: C During hemodialysis, the dialysate is warmed to increase diffusion and prevent hypothermia. The clients temperature could reflect the temperature of the dialysate. There is no indication to check the white blood cell count or connect the client to an ECG monitor. The other vital signs are within normal limits. RELATED TO Q7

A nurse reviews the laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L (135 mmol/L) Potassium 5 mEq/L (5 mmol/L) Blood urea nitrogen (BUN) 44 mg/dL (15.7 mmol/L) Serum creatinine 2.5 mg/dL (221 mcmol/L) What initial intervention would the nurse anticipate? a. Start hemodialysis immediately. b. Discuss the need for peritoneal dialysis. c. Increase the dose of immunosuppression. d. Return the client to surgery for exploration.

ANS: C The client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point RELATED TO Q10

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis? a.Calcium b.Bilirubin c.Amylase d.Potassium

ANS: C Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effectivE RELATED TO Q29

Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider? a. The patients urine output is 18 mL/hr. b. The patients heart rate is 110 beats/minute. c. The patient is complaining of chest pain. d. The patients peripheral pulses are weaK

ANS: C Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patients diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy. RELATED TO Q24

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be a. myoglobin b. low-density lipoprotein (LDL) cholesterol. c. troponins T and I. d. creatine kinase-MB (CK-MB

ANS: C Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction. Myoglobin rises in response to myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body, thus limiting its use in the diagnosis of myocardial infarction. LDL cholesterol is useful in assessing cardiovascular risk but is not helpful in determining whether a patient is having an acute myocardial infarction. Creatine kinase (CK-MB) is specific to myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often trended with troponin levels RELATED TO Q38

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction- control chamber of the collection device. Which action by the nurse is most appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Take no further action with the collection device. d. Adjust the dial on the wall regulator to decrease suction

ANS: C Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system RELATED TO Q20

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b .Approach the patient from the right side. c. Place objects needed on the patients left side. d. Teach the patient that the left visual deficit will resolve

ANS: C During the acute period, the nurse should place objects on the patients unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect RELATED TO Q33

A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most appropriate? a. Taking two blood thinners reduces the risk for another clot to form. b. Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from forming. c. Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots. d. Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner.

ANS: C Low molecular weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE. Furthermore, anticoagulants should not be described as blood thinner RELATED TO Q18

A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. Unlimited fluids are allowed because retained fluid is removed during dialysis. c. More protein is allowed because urea and creatinine are removed by dialysis. d. Dietary potassium is not restricted because the level is normalized by dialysIS

ANS: C Once the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes RELATED TO Q7

When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patients right hand. Which action should the nurse take next? a.Ask the patient about any arm pain. b.Retake the patients blood pressure. c.Check the calcium level in the chart. d.Notify the health care provider immediatelY

ANS: C The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseaus sign. The health care provider should be notified after the nurse checks the patients calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pAIN RELATED TO Q29

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

ANS: C Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.

The nurse is caring for a newly admitted client who is diagnosed with hyperglycemic-hyperosmolar state (HHS). What is the nurse's priority action at this time? a. Assess the client's blood glucose level. b. Monitor the client's urinary output every hour. c. Establish intravenous access to provide fluids. d. Give regular insulin per agency policy.

ANS: C The first priority in caring for a client with HHS is to increase blood volume to prevent shock or severe hypotension from dehydration. The nurse would monitor vital signs, urinary output, and blood glucose to determine if interventions were effective. Regular insulin is also indicated but not as the first priority action. RELATED TO Q5

The charge nurse is orienting a new nurse about care for an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm

ANS: C The nurse would not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula would be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment. RELATED TO Q7

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next? a. Initiate oxygen via a nasal cannula. b. Recheck the client's blood pressure. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury such as s stroke. The other actions are not appropriate for this complication. RELATED TO Q36

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3 (3.8 109 /L), blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2° F (35.6° C). What action by the nurse takes priority? a. Document the findings in the client's chart. b. Give the client warmed blankets for comfort. c. Notify the primary health care provider immediately. d. Prepare to administer insulin per sliding scale.

ANS: C This client has several indicators of sepsis with systemic inflammatory response. The nurse would notify the primary health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may need insulin if blood glucose is being regulated tightly. RELATED TO Q24

A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema? a. Maintaining oxygen saturation of 89% b. Minimal crackles and wheezes in lung sounds c. Maintaining a balanced intake and output d. Limited shortness of breath upon exertion

ANS: C With an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Other ideal goals are oxygen saturations greater than 92%, no auscultated crackles or wheezes, and no demonstrated shortness of breath. RELATED TO Q9

A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse? a. Use the catheter for the next laboratory blood draw b. Monitor the central venous pressure through this line. c. Access the line for the next intravenous medication. d. Place a heparin or heparin/saline dwell after hemodialysis.

ANS: D The central line should have a heparin or heparin/saline dwell after hemodialysis treatment. The central line catheter used for dialysis should not be used for blood sampling, monitoring central venous pressures, or giving drugs or fluids RELATED TO Q7

A nurse receives a hand-off report on a female client who had a left-sided stroke with homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder and bowel retention and/or incontinence. b. Listen to the client's lungs after eating or drinking for diminished breath sounds. c. Support the client's left side when sitting in a chair or in bed. d. Remind the client to move her head from side to side to increase her visual field.

ANS: D Homonymous hemianopsia is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control. RELATED TO Q33

The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL (16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect? a. Diabetic ketoacidosis (DKA) b. Severe hypoglycemia c. Chronic kidney disease (CKD) d. Hyperglycemic-hyperosmolar state (HHS)

ANS: D The client most likely has diabetes mellitus type 2 and has a high blood glucose causing increased blood osmolarity and dehydration, as evidenced by an insufficient urinary output and increased BUN. Older adults are at the greatest risk for dehydration due to age-related physiologic changes. RELATED TO Q5

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? A.Nausea and vomiting b.Hypotonic bowel sounds c.Abdominal tenderness and guarding d.Muscle twitching and finger numbness

ANS: D Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings should also be reported to the health care provider, they do not indicate complications that require rapid actioN RELATED TO Q29

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L d. Patient who has just returned from having hemodialysis and has a heart rate of 124/m

ANS: D The patient who is tachycardic after hemodialysis may be bleeding or excessively hypovolemic and should be assessed immediately for these complications. The other patients also need assessments or interventions but are not at risk for life-threatening complication RELATED TO Q7

A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best? a. Administer cefazolin since the level of the antibiotic must be maintained. b. Hold the vitamins but administer the cefazolin. c. Hold the cefazolin but administer the vitamins. d. Hold all medications since both cefazolin and vitamins are dialyzable

ANS: D Both the cefazolin and the vitamins should be held until after the hemodialysis is completed because they would otherwise be removed by the dialysis process. RELATED TO Q7

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide (Lasix) intravenously. c. Encourage the client to take deep breaths. d. Teach the client fall prevention measures

ANS: D The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis. RELATED TO Q39

After teaching a patient with type 2 diabetes mellitus who is prescribed nateglinide, the nurse assesses the client's understanding. Which statement made by the patient indicates a correct understanding of the prescribed therapy? a. "I'll take this medicine during each of my meals." b. "I must take this medicine in the morning when I wake." c. "I will take this medicine before I go to bed." d. "I will take this medicine immediately before I eat."

ANS: D Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken immediately before each meal. The medication should not be taken without eating as it will decrease the client's blood glucose levels causing hypoglycemia. The medication should be taken before meals instead of during meals RELATED TO Q4

A client is admitted with possible sepsis. Which action will the nurse perform first? a. Administer antibiotics. b. Give an antipyretic. c. Place the client in isolation. d. Obtain specified cultures.

ANS: D Prior to administering antibiotics, the nurse obtains the prescribed cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known. Antipyretics are given if the client is uncomfortable; fever is a defense mechanism. Giving antipyretics does not occur before obtaining cultures. The client may or may not need isolation. RELATED TO Q24

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? a. Administration of oxygen via face mask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

ANS: D The rapid, deep respiratory efforts of Kussmaul respirations are the bodys attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The client who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the client glucose would be contraindicated. The client does not require seizure precautions. RELATED TO Q1

The patient with a pacemaker shows pacemaker spikes that are not followed by a QRS. The nurse interprets this as: 1. failure to capture 2. failure to pace. 3. failure to sense. 4. demand mode

1. failure to capture. rationale: When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as failure to capture. Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Failure to sense manifests as pacer spikes that fall too closely to the patient's own rhythm, earlier than the programmed rate. The demand mode paces the heart when no intrinsic or native beat is sensed. RELATED TO Q42

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar state (HHS) is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription 1.Endotracheal intubation 2.100 units of NPH insulin 3.Intravenous infusion of normal saline 4.Intravenous infusion of sodium bicarbonate

3 The primary goal of treatment in hyperglycemic hyperosmolar state (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS. RELATED TO Q2

A client with type 1 diabetes presents with a decreased level of consciousness and a fingerstick glucose level of 39 mg/dl. His family reports that he has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate? A. Administering 1 ampule of 50% dextrose solution, per physician's order B. Administering a 500-ml bolus of normal saline solution C. Inserting a feeding tube and providing tube feedings D. Observing the client for 1 hour, then rechecking the fingerstick glucose level

A The nurse should administer 50% dextrose solution to restore the client's physiological integrity. Feeding through a feeding tube isn't appropriate for this client. A bolus of normal saline solution doesn't provide the client with the much-needed glucose. Observing the client for 1 hour delays treatment. The client's blood glucose level could drop further during this time, placing him at risk for irreversible brain damage. RELATED TO Q2

A patient is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse caring for this patient is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine. What guidelines will the nurse follow when administering atropine? A)Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. B)Administer atropine as a continuous infusion until symptoms resolve. C)Administer atropine as a continuous infusion to a maximum of 30 mg in 24 hours. D)Administer atropine 1.0 mg sublingually

ANS A Atropine 0.5 mg given rapidly as an intravenous (IV) bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic sinus bradycardia. By this guideline, the other listed options are inappropriate RELATED TO Q16

The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate? A) Possible hypovolemia B) Possible myocardial infarction (MI) C) Left-sided heart failure D) Aortic valve regurgitation

ANS A Hypovolemia may cause a decreased CVP. MI, valve regurgitation and heart failure are less likely causes of decreased CVP RELATED TO Q14

The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurses assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurses analysis of these data should lead to what preliminary conclusion? A) The patient is in the compensatory stage of shock. B)The patient is in the progressive stage of shock. C)The patient will stabilize and be released by tomorrow. D)The patient is in the irreversible stage of shocK

ANS A In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Patients display the often-described fight or flight response. The body shunts blood from organs such as the skin, kidneys, and GI tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the patients chance of survival is low and he will certainly not be released within 24 hours. If the patient were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing RELATED TO Q24

The critical care nurse is caring for a patient with a central venous pressure (CVP) monitoring system. The nurse notes that the patients CVP is increasing. Of what may this indicate? A) Psychosocial stress B) Hypervolemia C) Dislodgment of the catheter D) HypomagnesemiA

ANS B CVP is a useful hemodynamic parameter to observe when managing an unstable patients fluid volume status. An increasing pressure may be caused by hypervolemia or by a condition, such as heart failure, that results in decreased myocardial contractility. Stress, dislodgement of the catheter, and low magnesium levels would not typically result in increased CVP RELATED TO Q14

A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patients initial phase of treatment? A) Monitoring the patient for dysrhythmias B) Maintaining and monitoring the patients fluid balance C) Assessing the patients level of consciousness D) Assessing the patient for signs and symptoms of venous thromboembolis

ANS B In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. The nurse should monitor the patient for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the highest prioritY RELATED TO Q1

You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly? A)Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly. B)Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. C)Malnourished patients who receive fluids too rapidly are at risk for hypernatremia. D)Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate

ANS B The nurse identifies patients who are at risk for hypophosphatemia and monitors them. Because malnourished patients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Patients receiving TPN are not at risk for hypercalcemia or hypernatremia if calories or fluids are started to rapidly. Digestive enzymes are not a relevant consideration RELATED TO Q13

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include a. limit dietary sources of potassium. b. take the hydrochlorothiazide before bedtime. c. notify the health care provider if nausea develops. d. skip the digoxin if the pulse is below 60 beats/minute

ANS C Adherence to the therapeutic regimen increases when patients actively participate in self-care, including self-monitoring of BP and diet. Dire warnings may motivate some patients, but for many patients this is not an appropriate or effective strategy. Screening for vision changes and promoting healthy lifestyle are appropriate nursing actions, but do not necessarily promote adherence to a therapeutic regimen RELATED TO Q 41

The nurse is caring for a patient who has central venous pressure (CVP) monitoring in place. The nurses most recent assessment reveals that CVP is 7 mm Hg. What is the nurses most appropriate action? A)Arrange for continuous cardiac monitoring and reposition the patient. B)Remove the CVP catheter and apply an occlusive dressing. C)Assess the patient for fluid overload and inform the physician. D)Raise the head of the patients bed and have the patient perform deep breathing exercise, if possible

ANS C The normal CVP is 2 to 6 mm Hg. Many problems can cause an elevated CVP, but the most common is due to hypervolemia. Assessing the patient and informing the physician are the most prudent actions. Repositioning the patient is ineffective and removing the device is inappropriate RELATED TO Q14

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude? A) The system is functioning normally. B) The patient has a pneumothorax. C) The system has an air leak. D) The chest tube is obstructed

ANS C Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber RELATED TO Q20

After change-of-shift report, which patient will the nurse assess first? a.19-year-old with type 1 diabetes who was admitted with possible dawn phenomenon b.35-year-old with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL c.60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa d.68-year-old with type 2 diabetes who has severe peripheral neuropathy and complains of burning foot pain

ANS C The patients diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed. The other patients also need assessment and intervention but do not have life-threatening complications RELATED TO Q5

A medical nurse is aware of the need to screen specific patients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what patient population does hyperosmolar nonketotic syndrome most often occur? A) Patients who are obese and who have no known history of diabetes B) Patients with type 1 diabetes and poor dietary control C) Adolescents with type 2 diabetes and sporadic use of antihyperglycemics D) Middle-aged or older people with either type 2 diabetes or no known history of diabeteS

ANS D HHS occurs most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes RELATED TO Q5

A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care? A) Ensure that the patient moves the extremity with the vascular access site as little as possible. B) Change the dressing over the vascular access site at least every 12 hours. C) Utilize the vascular access site for infusion of IV fluids. D) Assess for a thrill or bruit over the vascular access site each shif

ANS D The bruit, or thrill, over the venous access site must be evaluated at least every shift. Frequent dressing changes are unnecessary and the patient does not normally need to immobilize the site. The site must not be used for purposes other than dialysiS RELATED TO Q7

A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via nasal cannula. The following clinical data are available: Arterial Blood Gases Vital Signs pH = 7.28 Pulse rate = 96 beats/min PaO2 = 85 mm Hg Blood pressure = 135/45 PaCO2 = 55 mm Hg Respiratory rate = 6 breaths/min HCO3 = 26 mEq/L O2 saturation = 88% Which action should the nurse take first? a. Notify the Rapid Response Team and provide ventilation support. b. Change the nasal cannula to a mask and reassess in 10 minutes. c. Place the client in Fowlers position if he or she is able to tolerate it. d. Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess

ANS: A The primary trigger for respiration in a client with chronic respiratory acidosis is a decreased arterial oxygen level (hypoxic drive). Oxygen therapy can inhibit respiratory efforts in this case, eventually causing respiratory arrest and death. The nurse could decrease the oxygen flow rate; eventually, this might improve the clients respiratory rate, but the priority action would be to call the Rapid Response Team whenever a client with chronic carbon dioxide retention has a respiratory rate less than 10 breaths/min. Changing the cannula to a mask does nothing to improve the clients hypoxic drive, nor would it address the clients most pressing need. Positioning will not help the client breathe at a normal rate or maintain client safety. REATED TO Q39

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism? a. Increased rate and depth of respirations b. Increased urinary output c. Increased thirst and hunger d. Increased release of acids from the kidneys

ANS: A This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are manifestations of hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids. RELATED TO Q39

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer's solution.

ANS: A A patient with facial and chest burns is at risk for inhalation injury and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured. RELATED TO Q25

A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft? a. A fistula is much less likely to clot. b. A fistula increases patient mobility. c. A fistula can accommodate larger needles. d. A fistula can be used sooner after surgerY

ANS: A Arteriovenous (AV) fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility RELATED TO Q7

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? a. Increase in the patients heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contraction

ANS: A Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contraction RELATED TO Q16

A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104 F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm H

ANS: A Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as wELL RELATED TO Q24

respiratory alkalosis

Arise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2. Tx- breath in paper bag. S/S- numbness in fingers and toes, dizziness

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a. Assessing that the ventilator settings are correct b. Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room

B Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival. RELATED TO Q21

A hospitalized client is found to be comatose and hypoglycemic with a blood sugar of 50 mg/dL. Which of the following would the nurse do first? A. Check the client's urine for the presence of sugar and acetone. B. Administer 50% glucose intravenously. C. Encourage the client to drink orange juice with added sugar. D. Infuse 1000 mL D5W over a 12-hour period.

B The unconscious, hypoglycemic client needs immediate treatment with IV glucose. If the client does not respond quickly and the blood glucose level continues to be low, glucagon, a hormone that stimulates the liver to release glycogen, or 20 to 50 mL of 50% glucose is prescribed for IV administration. A dose of 1,000 mL D5W over a 12-hour period indicates a lower strength of glucose and a slow administration rate. Checking the client's urine for the presence of sugar and acetone is incorrect because a blood sample is easier to collect and the blood test is more specific and reliable. An unconscious client cannot be given a drink. In such a case glucose gel may be applied in the buccal cavity of the mouth. RELATED TO Q2

The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a.The troponin level is elevated. b.The patient denies ever having a heart attack. c.Bilateral crackles are auscultated in the mid-lower lobes. d.The patient has occasional premature atrial contractions (PACs).

C RELATED TO Q38

A home health care patient has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control of heart failure. The patient data that will require the most immediate action by the nurse is if the patient's a. weight increases from 120 pounds to 122 pounds over 3 days. b. liver is palpable 2 cm below the ribs on the right side. c. serum potassium level is 3.0 mEq/L after 1 week of therapy. d. has 1 to 2+ edema in the feet and ankles in the morning.

C Rationale: Hypokalemia potentiates the actions of digoxin and increases the risk for digoxin toxicity, which can cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level. RELATED TO Q41

A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. Do you have any allergies? b. Do you take aspirin on a daily basis? c. What time did your chest pain begin? d. Can you rate your chest pain using a 0 to 10 scale

C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about thrombolytic theraPY RELATED TO Q38

The patient has type 1 diabetes mellitus and is found unresponsive with cool and clammy skin. What action is a priority? A. Obtain a serum glucose level. B. Give hard candy under the tongue. C. Administer glucagon per standing order. D. Notify the health care provider.

C. Administer glucagon per standing order. The patient has signs and symptoms of hypoglycemia for which treatment should be the priority. Glucagon stimulates a strong hepatic response to convert glycogen to glucose and therefore makes glucose rapidly available. Waiting for a serum result (up to an hour) is improper because brain cells continue to die from a lack of glucose. Nothing solid should be placed in the mouth when the patient has an altered level of consciousness and can aspirate. With obvious symptoms, emergent treatment takes priority over notifying the health care provider. RELATED TO Q2