Quiz 1

A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? a. Administer furosemide (Lasix) 40 mg IV b. Increase normal saline infusion to 250 mL/hr c. Give hydrocortisone (Solu-Cortef) 100 mg IV d. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg

a. Administer furosemide (Lasix) 40 mg IV Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. Patients in septic shock require large amounts of fluid replacement. If the patient remains hypotensive after initial volume resuscitation with minimally 30 mL/kg, vasopressors such as norepinephrine may be added. IV corticosteroids may be considered for patients in septic shock who cannot maintain an adequate BP with vasopressor therapy despite fluid resuscitation.

After insertion of a central venous catheter through the left subclavian vein, a client reports chest pain and dyspnea and has decreased breath sounds on the left side. Which action would the nurse take first? a. Administer oxygen as prescribed b. Activate the Rapid Response Team c. Give the prescribed as needed morphine sulfate d. Assist the client to cough and deep breathe

a. Administer oxygen as prescribed The client's history of a subclavian vein central line insertion and sudden onset of pain, dyspnea, and decreased breath sounds suggest tension pneumothorax. The nurse will initially administer oxygen. The next action would be to activate the Rapid Response Team, because chest tube placement is likely to be needed to allow lung re expansion. Morphine sulfate may be needed for pain control, but would not be the initial action. Coughing and deep breathing will not help with dyspnea caused by tension pneumothorax, although the client would be encouraged to cough and deep breathe once the chest tube is in place.

A client is diagnosed with hyperglycemic hyperosmolar nonketotic coma (HHNK) after being admitted with a blood glucose level of 720 mg/dL. The admitting orders include: normal saline infusion, insulin infusion, Tylenol PRN and glucagon PRN. When should the nurse prepare to give the glucagon? a. For precipitous drop in blood glucose leading to unresponsiveness b. When the blood sugar reaches 150 mg/dL c. For urine output less than 60 mL/hr d. For symptomatic BP less than 100/60 mmHg

a. For precipitous drop in blood glucose leading to unresponsiveness Glucagon is given IM or SC for low blood glucose associated with unconsciousness; usually the blood glucose is less than 20 mg/dL. Hypoglycemia associated with a change in level of consciousness or seizure requires immediate interventions. Glucagon will not help urine output or blood pressure, and is not administered routinely when glucose levels fall to 150 mg/dL.

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 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 to keep systolic blood pressure above 90 mm Hg

a. Give normal saline IV at 500 mL/hr Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.

The nurse is caring for a client who underwent surgical resection of an oral cancerous tumor. Which client problem is of highest priority to guide care? a. Maintain airway b. Monitor vital signs c. Administer intravenous (IV) fluids d. Empty surgical drains

a. Maintain airway The highest priority in planning care for a client who underwent a surgical resection for oral cancer is to maintain the airway and promote gas exchange. Other interventions include monitoring vital signs, administering IV fluids, and empty surgical drains, but these are of lower priority.

A client is brought to the emergency department with moderate substernal chest pain radiating to the inner aspect of the left arm, unrelieved by rest and nitroglycerin. The pain is associated with slight nausea and anxiety. Which is the priority nursing intervention for this client? a. Provide pain medication b. Transfer to the coronary care unit c. Obtain a single electrocardiogram (ECG) d. Have a blood specimen drawn for enzyme studies

a. Provide pain medication Providing for comfort reduces anxiety and subsequently decreases catecholamine release, indirectly decreasing myocardial oxygen requirements. The client's condition should be stabilized before transfer; relief of pain facilitates stabilization. Obtaining an electrocardiogram is important, but the client should be placed on continuous monitoring, not just receive a reading; therefore pain relief is the priority. The ECG is significant to examine for progressive myocardial changes. Securing blood for enzyme studies is not an emergency intervention, although a blood sample for cardiac enzymes is important for a definitive diagnosis.

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? a. "I will wash my hands often during the day." b. "I will remove my contact lenses at bedtime." c. "I will not share towels with my friends or family." d. "I will monitor my family for eye redness or drainage."

b. "I will remove my contact lenses at bedtime." Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva. Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact.

The registered nurse (RN) is planning client assignments and cannot take a client assignment today. Two unlicensed assistive personnel (UAP) and a licensed practical nurse (LPN) also are assigned to the unit. Which client should the RN most appropriately assign to the LPN? a. A client requiring frequent ambulation b. A client scheduled for a cardiac catheterization c. A client requiring range-of-motion (ROM) exercises d. A client with a 24-hour urine collection who is on strict bed rest

b. A client scheduled for a cardiac catheterization The RN is legally responsible for client assignments and must assign tasks according to the guidelines of Nurse Practice Acts and the job description of the employing agency. A client scheduled for a cardiac catheterization requires physiological needs and frequent nursing assessments; this is the most appropriate assignment for the LPN. The RN can work with the LPN and supervise care. The UAP has been trained to care for a client on bed rest and on urine collection, provide assistance with ambulation, and perform ROM exercises. The RN would provide instructions to the UAP regarding the tasks, but the tasks required for these clients are within the role description of a UAP.

A patient admitted with DKA, what is the priority nursing action? a. Correcting the client's glucose levels b. Correcting the client's fluid deficit c. Restarting the client's home SQ insulin schedule d. Ensuring the client has the evening meal

b. Correcting the client's fluid deficit Because fluid imbalance in a patient with DKA is potentially life threatening, the initial goal of therapy is to establish IV access and begin fluid and electrolyte replacement.

The nurse is obtaining the health history of a client scheduled for magnetic resonance imaging (MRI). Which condition requires the nurse to cancel the MRI? a. Amputated leg b. Internal insulin pump c. Intrauterine device (IUD) d. Atrioventricular (AV) graft

b. Internal insulin pump Metal devices such as pacemakers and prostheses interfere with the accuracy of the image and can become displaced by the magnetic force generated by an MRI procedure. An intrauterine device and an AV graft do not contain any metal.

Which condition in a client with a brain injury is contraindicated for magnetic resonance imaging (MRI) with contrast? a. Renal failure b. Metal aneurysm clip c. Claustrophobia d. Soft tissue imaging needs

b. Metal aneurysm clip Patient preparation for an MRI consists of removing all metal-containing objects prior to the examination.

A client who is having a tunneled central venous catheter inserted begins to report chest pain and difficulty breathing. What action does the nurse take first? a. Administer the PRN pain medication b. Prepare to assist with chest tube insertion c. Place a sterile dressing over the IV site d. Place the client in the Trendelenburg position

b. Prepare to assist with chest tube insertion An insertion-related complication of central venous catheters is a pneumothorax. Signs and symptoms of a pneumothorax include chest pain and dyspnea. Treatment includes removing the catheter, administering oxygen, and placing a chest tube. Pain is caused by the pneumothorax, which must be taken care of with a chest tube insertion. Use of a sterile dressing and placement of the client in a Trendelenburg position are not indicated for the primary problem of a pneumothorax.

Which assessment finding the nurse expects in a patient with hyperosmolar hyperglycemic syndrome, blood sugar is 700 g/dL? a. Moist skin and mucous membranes b. Profound dehydration c. Blood ketone level of 2.0 mmol/L d. Very high urine ketone level

b. Profound dehydration High blood sugar can reduce fluid levels in your body, which can lead to dehydration.

A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions? a. Withholding stimulants 24 to 48 hours prior to exam b. Removing all metal-containing objects c. Instructing the patient to void prior to the MRI d. Initiating an IV line for administration of contrast

b. Removing all metal-containing objects Patient preparation for an MRI consists of removing all metal-containing objects prior to the examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the patient to void is patient preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done if the patient was having a CT scan with contrast.

A nurse received orders for a patient with esophageal varices. Which order the nurse will question? a. Check for hemoglobin and hematocrit values b. Maintain head of bed greater than 60 degrees c. Insertion of a nasogastric tube into the stomach d. Administration of octreotide acetate via IV infusion

c. Insertion of a nasogastric tube into the stomach Esophageal varices are similar to varicose veins within the esophagus. A nurse would never insert an NG tube if this diagnosis is suspected because it might rupture the varices and cause an acute hemorrhage.

The nurse is admitting a client diagnosed with diabetic ketoacidosis (DKA). What is the nurse's priority intervention? a. Glucocorticoid administration b. Transfusion of whole blood c. Intravenous insulin d. Subcutaneous glucagon administration

c. Intravenous insulin A client with DKA should receive IV insulin to lower glucose and IV fluids to correct hypotension. Glucagon is given to treat hypoglycemia and is not appropriate for DKA. Blood products aren't needed to correct DKA. Glucocorticoids are not used to treat DKA, and may aggravate the hyperglycemia.

Which prescribed action has the highest priority when a client comes to the emergency department with moderate substernal chest pain that is unrelieved by rest and nitroglycerin? a. Administer morphine sulfate b. Transfer to the coronary care unit c. Obtain a 12-lead electrocardiogram (ECG) d. Have a blood specimen drawn for troponin studies

c. Obtain a 12-lead electrocardiogram (ECG) Current guidelines state that an ECG should be done and reviewed by the health care provider within 10 minutes of the arrival of a client with possible acute coronary syndrome. The other actions are also essential. Administration of morphine sulfate will be done to relieve pain, but the ECG has priority because the presence or absence of ECG changes will determine whether the client needs immediate interventions such as percutaneous coronary intervention or thrombolysis. The client will be transferred as quickly as possible to the coronary care unit, but the ECG would be done in the emergency department. Obtaining blood for troponin should be done as quickly as possible, but the presence or absence of elevated troponin will not affect decision-making about the client's immediate care.

An adolescent client is diagnosed with conjunctivitis, and the nurse provides information to the client about the use of contact lenses. Which client statement indicates the need for further information? a. "I should obtain new contact lenses." b. "I should not wear my contact lenses." c. "My old contact lenses should be discarded." d. "My contact lenses can be worn if they are cleaned as directed."

d. "My contact lenses can be worn if they are cleaned as directed." If the adolescent wears contact lenses, he or she should be instructed to discontinue wearing the until the infection has cleared completely. Securing new contact lenses will eliminate the chance of reinfection from contaminated contact lenses and will also lessen the risk of a corneal ulceration.

A patient with Addison's disease gets admitted for pneumonia. What intervention helps to prevent Addison's crisis? a. Ensure client is given adequate fluids b. Administer omeprazole to prevent gastric ulcers c. Ensure that antibiotic therapy is started d. Administer IV hydrocortisone as ordered

d. Administer IV hydrocortisone as ordered

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? a. Correct the acidosis b. Administer 5% dextrose intravenously c. Apply a monitor for an electrocardiogram d. Administer short-duration insulin intravenously

d. Administer short-duration insulin intravenously Lack (absolute or relative) of insulin is the primary cause of DKA. Treatment consists of insulin administration (short or rapid-acting), intravenous fluid administration (normal saline initially), and potassium replacement, followed by correcting acidosis. Applying an electrocardiogram monitor is not the priority action.

Which findings help the nurse recognize disequilibrium syndrome in a patient who is just back after dialysis? a. Elevated blood pressure b. Muscle cramps c. Night sweats and insomnia d. Agitation and dizziness

d. Agitation and dizziness Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.

After admitting a patient with diabetic ketoacidosis (DKA) to the emergency department, which nursing intervention is a priority? a. Administer IV insulin b. Administer oxygen c. Insert a Foley catheter d. Establish IV access

d. Establish IV access Because fluid imbalance in a patient with DKA is potentially life threatening, the initial goal of therapy is to establish IV access and begin fluid and electrolyte replacement. Insulin is administered IV only after a potassium level is determined, because insulin administration may cause hypokalemia. Administration of oxygen and insertion of a Foley catheter may be necessary in the initial emergency management of DKA, but obtaining IV access is a priority.

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? a. Hypertension, tachycardia, and fever b. Hypotension, bradycardia, and hypothermia c. Restlessness, irritability, and generalized weakness d. Headache, deteriorating level of consciousness, and twitching

d. Headache, deteriorating level of consciousness, and twitching Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing increased intracranial pressure and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.

A nurse in the emergency department is caring for a client with Addison's disease, reports nausea and vomiting, diarrhea and abdominal pain. To prevent an Addisonian crisis , the nurse should administer which of the following medications? a. Calcium b. Potassium c. Iodine d. Hydrocortisone

d. Hydrocortisone

The client is admitted with anemia, suspected to be caused by slowly bleeding esophageal varices. Which physician order should the nurse question? a. Send three stool samples for occult blood b. Obtain complete blood count (CBC) c. Administer ranitidine (Zantac) 150 mg tab twice a day by mouth d. Insert nasogastric (NG) tube to gravity

d. Insert nasogastric (NG) tube to gravity Esophageal varices are similar to varicose veins within the esophagus. A nurse would never insert an NG tube if this diagnosis is suspected because it might rupture the varices and cause an acute hemorrhage. The other orders make sense during a GI work-up for anemia. Checking CBC will provide hemoglobin and hematocrit values to quantify the degree of anemia. Ranitidine decreases stomach acid and may decrease loss of blood through a possible ulcer. Getting stool samples for occult blood can identify the presence of small amounts of blood in the stool that are not visible to the naked eye.

In developing a teaching plan for the patient with Addison's disease, what is the nurse's highest priority? a. Avoiding infection b. Following a low-salt diet c. Practicing stress management techniques d. Managing lifelong corticosteroid replacement

d. Managing lifelong corticosteroid replacement The patient with Addison's disease experiences hypo functioning of the adrenal cortex, resulting in decreased production of glucocorticoids, mineral corticoids, and androgens. Patients with Addison's disease require lifelong glucocorticoid and mineral corticoid replacement therapy to avoid Addisonian crisis. Addisonian crisis is characterized by profound hypotension, dehydration, fever, tachycardia, hyponatremia, and hyperkalemia. Circulatory collapse may occur if the patient is treated inadequately. Although Addisonian crisis often is triggered by illness-related physiologic stress, and although avoiding infection is important, avoiding infection is of lower priority than managing lifelong corticosteroid replacement. Corticosteroid replacement must be increased during times of stress to prevent Addisonian crisis. Patients taking a mineralocorticoid should increase their salt intake. Emotional stress may contribute to the need for increased corticosteroid replacement. Stress management techniques are important. Practicing stress management techniques, however, is of lower priority than managing lifelong corticosteroid replacement.

A nurse should question a prescription for which medication in the client concurrently receiving tramadol (Ultram)? a. Beta blockers b. Calcium channel blockers c. Histamine H2 antagonists d. Monoamine oxidase inhibitors (MAOIs)

d. Monoamine oxidase inhibitors (MAOIs) Do not take medicines called monoamine oxidase inhibitors or MAOIs (which are used to treat depression) with tramadol. The combination can cause significant side effects such as anxiety, confusion and hallucinations.

The nurse is caring for a client who just returned from an esophagogastroduodenoscopy (EGD) and directs the unlicensed assistive personnel (UAP) to get the client settled in the room. Which action made by the UAP is incorrect? a. Raising the head of bed b. Straightening bed linens c. Obtaining vital signs d. Offering client water

d. Offering client water After an EGD, the client should not have any food or drink until the gag reflex has returned. Therefore, the nurse would correct the UAP to not offer the client water. Raising the head of bed, straightening bed linens and obtaining vital signs are acceptable tasks to perform.

When assessing clients scheduled for imaging with contrast media, which client is contraindicated to receive contrast media? a. The client with asthma b. The client who is nothing-by-mouth (NPO) since midnight with an intravenous (IV) infusion of 0.9% normal saline (NS) c. The client with a recent creatinine level of 0.9 d. The client administered a dose of metformin this morning with a sip of water

d. The client administered a dose of metformin this morning with a sip of water Metformin should be discontinued 24 hours before and 48 hours after contrast media to prevent the risk of lactic acidosis. Clients with asthma should be monitored closely for reaction to the contrast, and reaction could be severe but does not preclude receiving contrast. A creatinine level of 0.9 is normal reflecting good kidney function to handle the contrast. NPO status with IV hydration is not a contraindication to receive contrast.