Spring Acute Care 1
Identify the hormone responsible for the regulation of water balance. a.-Parathyroid Hormone b.-Antidiuretic Hormone c.-Renin d.-Aldosterone
b.
A nurse is assessing a client who has adrenal insufficiency. Which of the following findings should the nurse expect? a. Moon face b. Weight gain c. Serum calcium 12.8 mg/dL d. Serum sodium 150 mEq/L
c
Naegele's Rule
-subtract 3 months from the LMP then add 7 days and 1 year
When can quickening be felt?
14-20 weeks
a nurse is creating a plan of care for a client who is preoperative for a total hip arthroplasty, practices judaism, adheres to a kosher diet, which of the following interventions is the nurses priority? 1. listen and allow client to express feelings regarding surger 2. determine if clients faith conflicts w treatment plan 3. ensure the clients meal plan serves only kosher food following surgery 4. teach the client how to perform various relaxation exercises
2.
A client is receiving conscious sedation with a benzodiazepine. Resp rate and o2 begin to decline. what medication will you administer? 1. atropine 2. acetylcysteine 3. flumazenil 4. protamine sulfate
3. flumazenil this is antidote for benzo's diazepam, lorazepam, and midazolam
a circulating nurse is monitoring the temp in a surgical suite. cool temperatures reduce a client's risk for what possible complication of surgery? 1. malignant hyperthermia 2. blood clots 3. infection 4. hypoxia
3. infection cool room temp w/ humidity between 30-60% along with proper filter system reduces risk for infection during surgery.
A nurse is assessing a client who is 2 hr postoperative following an appendectomy. Which of the following findings should the nurse report to the provider? A- Urine output of 20 mL/hr B- Temp of 36.5 C C- A 2 cm X 2 cm area of bloody drainage on the dressing D- WBC 9,000 MM
A
A nurse is caring for a client who is 12 hours postoperative from a gastrectomy and has an NG tube set to continuous low suction. Which of the following findings requires intervention by the nurse? A- Gastric distention B- Absent bowel sounds C- Urine output of 150 mL over the last 4 hr D- Yellow drainage in the NG tube
A
A nurse is monitoring a client who received succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops manifestations of malignant hyperthemia? A- Administer dantrolene B- Institute seizure precautions C- Remove endotracheal tube D- Give IV atropine
A
A nurse is receiving evening shift report on four clients who returned from the PACU that morning. The nurse should assess which of the following clients first? A- A client who is postoperative following a thoracotomy and and has a chest tube with 150 mL of bringht-red blood in the collection chamber from the past 1 hr B- A client who is postoperative following a small bowel resection and has a temporary colostomy along with absent bowel sounds in all four quadrants C- A client who is postoperative following a tonsillectomy and has had one episode of coffee-ground emesis D- A client who is postoperative following a total knee arthroplasty and is reporting a knee pain level of 7 on a scale from 0 to 10
A
A surgical nurse enters a surgical suite to ensure surgical asepsis is maintained. Which of the following findings requires intervention by the nurse? A- The scrub tech is wearing a watch under his scrubs B- The circulating nurse opens dressing packages before applying sterile gloves C- The surgeon has her hands folded 5 cm above her waist D- The holding area nurse is performing client education
A
A nurse is assessing a client who is preoperative. The nurse should identify that which of the following factors reported by the client increases the risk for a postoperative wound infection? A- Frequent use of echinacea B- Long term use of steriods C- History of osteoporosis D- Diet high in vit C
B
a nurse is caring for a client who has SIADH. which of the following findings should the nurse expect? a. decreased blood sodium b. increased urine osmolarity c. blood osmolarity 230mOsm d. polyuria e. increased thirst
A, C
A nurse is caring for a client who has a surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform? A- Cut a slit in a 4-inch square gauze pad to place around the drain B- Use the sterile technique when performing dressing changes C- Establish a clamping schedule prior to removal D- Apply negative pressure when emptying the drain
B
A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hr and reports a pain level of 8 on a scale on a scale from 0 to 10. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first? A- Draw the clients blood for LYTES B- Insert an NG tube C- Administer pain meds D- Initiate intake and output
B
A nurse is caring for a client who is primigravida, at term, and having contractions, but is saying that she is " not really sure if she is in labor or not". which of the following should the nurse recognize as a sign of true labor? A. Rupture of the membranes B. Changes of the Cervix C. Station of the Presenting part D. Pattern of regular contractions.
B
A nurse is providing discharge instructions for a client who is postoperative following abdominal surgery. Which of the following client statements indicates an understanding of the teaching? A- I will have an increase in yellow-colored drainage from my incision for 2 weeks B- I will eat foods that are high in protein and vitamin C during my recovery C- I should avoid taking over the counter pain medication if my pain is not severe D- I will remain on bed rest until my follow up appointment with my doc
B
A nurse is providing preoperative for a client who is about to have a below-the-knee amputation. Which of the following instructions should the nurse include? A- "You should avoid lying on your abdomen after surgery" B-"your surgeon might prescribe an antibiotic before surgery" C- "It is important for you to sit in a chair at the bedside for several hours every day to reduce the risk of pneumonia" D- "To promote wound healing, it is important for you to reduce your intake
B
A nurse is assessing a clients recovery from spinal anesthesia. Which of the following sensations should the nurse expect to return to the client first? A- Pain B- Cold C- Touch D- Warmth
C
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following nursing interventions should the nurse perform to prevent respiratory complications? A- Instruct the client to exhale into the incentive spirometer every 1-2 hr B- Minimize the amount of pain medication the client receives to prevent sedation C- Advise the client to splint the surgical incision when coughing and deep breathing D- Reposition the client every 8 hr for the first 48 hr
C
A nurse is planning care for a client who is postoperative and has a closed-wound drainage system in place. Which of the following interventions should the nurse plan to include? A- Check the patency of the drain every 12 hrs. B- Clamp the drain while the client is ambulating. C- Cleanse the drain plug with alcohol after emptying. D- Secure the drain
C
A nurse in the PACU assessing a client who is postoperative. Which of the following findings should the nurse report to the provider? A- BP 10% lower than baseline B- Pain level of 4 on 0 to 10 scale C- Presence of inspiratory stridor D- Small amount of sanguinous drainage on dressing
C manifestation of tracheal edema requires intubation
what does a variable deceleration indicate?
Cord prolapse or compression
A client had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take? A- Go to the nurses station to seek assistance B- Reinsert the organs into the abdominal cavity C- Place the client in a reverse Trendelenburg position D- Obtain vital signs to assess for shock
D
A client is transferred from the surgical suite to the PACU following oral surgery. While monitoring the client's vital signs, the nurse finds that the client's tongue has become swollen and is obstructing the airway. Which of the following actions should the nurse take first? A- Contact the anesthesiologist B- Assist the endotracheal intubation C- Increase the clients flow of oxygen D- Use the head-tilt, chin-life method to open the airway
D
A nurse is caring for a client who has bradycardia following a surgical procedure spinal anesthesia. The nurse should plan to administer which of the following medications to the client? A- Amiodarone B- Propranolol C- Methyldopa D- Epinephrine
D
a nurse is providing preoperative teaching to a client who is scheduled to have a mastectomy with reconstructive surgery. Which of the following statements by the client indicates an understanding of the teaching? A- I should wait to take my pain meds until after I have completed my range-of-motion exercises B- I should wait a week after surgery to start my hand strengthening exercises C- I will be able to lift up an object that weighs 10 pounds 2 weeks after my surgery D- I will be able to shower after the doctor removes the drain
D
What does a biophysical profile measure?
Fetal Breathing, Fetal Motion, Amniotic Fluid Volume.
A nurse is managing the care of a client who is postoperative and experiencing acute adrenal insufficiency. Which of the following actions should the nurse take? a. Administer IV hydrocortisone b. Give oral spironolactone. c. Infuse 1 unit of platelets. d. Restrict daily fluid intake.
a
A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? a. P wave falls before the QRS complex b. T wave is in the inverted position c. PR interval measures .22 seconds d. QRS duration is .20 seconds
a
A nurse is monitoring a client's status 24 hr after a total thyroidectomy. Which of the following findings should the nurse report to the provider? a. Laryngeal stridor b. Productive cough c. Pain with hyperextension of the neck d. Hoarse, weak voice
a
A nurse is performing an assessment on a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessment data should the nurse report? a. Serum sodium 110 mEq/L b. 2+ deep-tendon reflexes c. Serum potassium 3.7 mEq/L d. Urine specific gravity 1.025
a
Parasympathetic stimulation of the gastrointestinal tract will a-stimulate motility b-inhibit acidity c-decrease hydrogen chloride secretion d-decrease motility
a
The registered nurse is teaching about the pathophysiology of nonalcoholic fatty liver disease (NAFLD) to student nurses. Which statement made by the student nurses indicates effective learning? a-NAFLD is linked to metabolic syndrome b-Exposure to vinyl chloride can cause NAFLD c-Increased level of adiponectin is associated with NAFLD d-NAFLD is caused by accumulation of fat in the adipose tissue.
a
Which part of the GI tract most commonly harbors Helicobacter pylori (H. pylori)? a-Duodenum b-Pylorus c-Fundus d-Body
a
a nurse in the ED is caring for a client w manifestations of MI. which lab tests should the nurse expect the provider to prescribe? a. troponin b. creatinine kinase c. BNP d. c-reactive protein
a
client had a left hemisphere stroke. what goal should the nurse include in the rehabilitation program? a. establish the ability to communicate effectively b. compensate for loss of depth perception c. learn to control impulsive behavior d. improve L side motor function
a
client had a stroke involving right hemisphere. what should the nurse monitor? a. poor impulse control b. unable to discriminate words and letters c. deficits in right visual field d. motor retardation
a
a nurse is preparing to receive a client from the PACU who is postop following a thyroidectomy. the nurse should ensure which of the following equipment available? a. suction b. humidified o2 c. flashlight d. tracheostomy tray e. chest tube tray
a b d
a nurse is reviewing the manifestations of hyperthyroidism with a client. which of the following findings should the nurse include? a. anorexia b. heat intolerance c. constipation d. palpitations e. weight loss f. bradycardia
b d e
The Lab reports of a client with gastritis reveal Helicobacter pylori is the causation organism. Which pathophysiological changes can result from this infection? Select all that apply a.-Decreased production of HCL acid b-Increased production of prostaglandins c-Increased production of intrinsic factor d-Decreased production of pepsin e-Increased production of gastrin
a, d, e
A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings? a. Decreased heart rate b. Increased hematocrit c. High urine specific gravity d. Decreased BUN
b
A nurse is providing discharge teaching for a client who has diabetes insipidus and has a new prescription for desmopressin nasal spray. Which of the following instructions should the nurse include in the teaching? a. Breathe deeply while using the nasal spray. b. Blow nose gently prior to using the nasal spray. c. Administer the nasal spray while in a side-lying position. d. Instill the medication four times per day.
b
The nurse teaches a group of staff nurses about the diagnosis of IBS and the presence of lactose intolerance in the patient with IBS. Which intervention by the nurse indicates effective learning? a. -The nurse performs testing on a stool sample for occult blood. b.-The nurse performs teaching of the patient how to perform a hydrogen breath test. c.-The nurse performs a blood draw for culture and sensitivity. d.-The nurse performs a complete blood analysis of the client.
b
While reviewing the medical file of a patient with NASH, the nurse finds the patent has steatorrhea. Which reason does the nurse identify for this condition in this patient? a-Nitrogenous waste accumulation b-Diminished synthesis of bile c-Activation of stellate cells d-Hyperbilirubinemia
b
a nurse in a clinic is caring for a client who has frequent migraine headaches. the client asks about foods that can cause headaches. the nurse should recommend that the client avoid which of the following foods? a. baked salmon b. salted cashews c. frozen strawberries d. fresh asparagus
b
a nurse is caring for a client 2 days post op. which of the following findings indicates the client is developing an infection? a. temp of 37.8c (100 F) b. erythema at the incision site c. WBC count 9,000/mm3 d. pain reported 6/10
b
a nurse is caring for a client who has diabetes insipidus. which of the following UA lab findings should the nurse expect? a. glucose b. decreased specific gravity c. presence of ketones d. presence of RBC
b
a nurse is reviewing lab results for a client being evaluated for secondary hypothyroidism. which lab result is expected? a. elevated T4 b. decreased T3 c. elevated TSH d. decreased cholesterol
b
A nurse is caring for a client following a thyroidectomy. The nurse should assess for which of the following findings as an indication of hypocalcemia? a. Strong, bounding pulse b. Decreased bowel sounds c. Tingling and numbness of the hands and feet d. Diminished deep-tendon reflexes
c
A nurse is caring for a client who is taking propylthiouracil (PTU). The nurse should recognize that the client has met the treatment goals when she reports an increase in which of the following effects? a. Sweating b. Stools c. Weight d. Appetite
c
A nurse is teaching a client who has a new prescription for sumatriptan tablets to treat migraine headaches. Which of the following instructions should the nurse include? A: "Take daily to prevent headaches" B: "Chew tablet well before swallowing" C: "Report swelling of eyelids after dosage." D: "Repeat dose in 1 hour for unrelieved headache."
c
Aldosterone regulates fluid balance by increasing the reabsorption of: a-chloride b-calcium c-sodium d-water
c
Cholecystitis is inflammation of the gallbladder and is usually caused by: a.-Viral infection of the gallbladder b.-Accumulation of fate in the wall of the gallbladder c.-Cholelithiasis d.-Accumulation of bile in the hepatic duct
c
The most common form of gallstones are composed of: a.-uric acids salts b.-calcium c.-cholesterol d.-bile
c
The nurse is preparing for information for a patient newly diagnosed with ulcerative colitis. Which information is more likely associated with Crohn's disease than with ulcerative colitis? a-The disease affects only the mucosa and submucosa layers b-The disease predisposes the client to colon cancer c-The patient is prone to anal fistula and fissure formation d-Only large intestine is affected
c
Where does the herpes simplex virus (HSV) remain during it's dormant stage? a. -Gummas b.-Dorsal Ganglion of sensory Nerves c.-Sacral Spinal Nerves d.-Epithelium Layer
c
Your patient developing glomerulonephritis after having a throat infection two weeks ago. The patients asked why he developed swelling/ edema throughout his body. The nurse uses the knowledge that edema seen in clients with nephrotic syndrome results from: a-hyperlipidemia and failure of the RAAS system b-acidosis and osmotic diuresis c-proteinuria and decreased plasma colloidal osmotic pull d-vesicoureteral reflux and increased plasma colloidal osmotic pull.
c
client comes in with reports of onset of severe chest pain. what action will the RN take to determine if the client is experiencing an MI? a. check BP b. auscultate heart tones c. perform 12 lead ekg d. determine if pain radiates to L arm
c
what cardiac enzyme can confirm that an MI occurred 14 days ago? a. myoglobin b. CK-MB c. Troponin T d. Troponin I
c
what manifestations should the nurse expect to find for a client experiencing an acute MI? (SATA) a. orthopnea b. headache c. nausea d. tachycardia e. diaphoresis
c, d, e
A home health nurse is assessing a client who is on lifelong hormone replacement therapy for treatment of hypothyroidism. The client has not been taking his medication regularly. Which of the following findings should the nurse expect?a. Significant weight loss b. Persistent diarrhea c. Tachycardia d. Hypotension
d
A nurse is caring for a client undergoing screening for primary Cushing's disease. The nurse should expect that which of the following laboratory findings to be elevated? a. Lymphocyte count b. Serum potassium c. Serum calcium d. Blood glucose
d
A nurse is preparing a teaching plan for a client who has diabetes insipidus and is receiving intranasal desmopressin. Which of the following information should the nurse include in the teaching plan? a. Daily fluid intake should be at least 3 L. b. Obtain weight weekly while wearing similar clothing at the same time of day. c. Notify the provider if a weight loss of 0.45 kg (1 lb) or more per week is noted. d. Occurrence of nocturia
d
A nurse is preparing to give a client information about an adrenocorticotropic hormone (ACTH) stimulation test. The nurse should explain that the purpose of the test is to assess for which of the following disorders? a. cushings b. hyperthyroidism c. pheochromocytoma d. addison's
d
Chronic pancreatitis may lead to: a- Peptic ulcer disease b-Gallstones c-Crohn's disease d-Diabetes mellitus
d
Which of the following symptoms would indicate the most emergent situation in the client who has a history of bilateral renal calculi? a.-Hematuria b.-Albuminuria c.-Proteinuria d.-Anuria
d
a nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus. which of the following statements indicates an understanding of the teaching? a. i can drink up to 2 quarts of fluid daily b. i will need insulin to control my blood glucose levels c. i should expect to gain weight during this illness d. i might experience confusion or balance problems.
d
polyhydramnios
excessive amniotic fluid
what does an early deceleration indicate?
head compression
when does lighting occur in a pregnancy?
towards the end of preg
What does late deceleration indicate?
uteroplacental insufficiency
