Study guide exam 3 480

Which assessment finding will help confirm a diagnosis of neurogenic shock?

Heart rate 45 beats/min

The patient has acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit?

Left upper abdominal pain Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?

O2 saturation of 93% on room air Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient's status.

Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective?

Oxygen saturation

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department.

Prepare to administer atropine IV.b. Obtain baseline body temperature.d. Provide high-flow oxygen (100%) by non-rebreather mask.e. Prepare for emergent intubation and mechanical ventilation.

For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

Providing oral hygiene is within the scope of UAP. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and scope of practice and would be delegated to licensed practical/vocational nurses (LPNs/LVNs) or RNs.

What laboratory values, the nurse expects to find elevations in which test results to establish a diagnosis of acute liver failure?

Serum bilirubin and alkaline phosphatase levels

What nursing action is a priority for a burn injury while working on an electrical power line?

Stabilize the cervical spine.

Clients who have a history of pancreatitis should avoid foods high in fat.

TRUE

The nurse should not anticipate the provider will prescribe ferrous sulfate, as there is no indication the client is anemic.

TRUE

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) (select all 4 correct answers that apply)?

Use aseptic technique when caring for invasive lines or devices.b.Ambulate postoperative patients as soon as possible after surgery.c.Remove indwelling urinary catheters as soon as possible after surgery. e.Administer prescribed antibiotics within 1 hour for patients with possible sepsis. Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be administered within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?

Use pulse oximetry to check the oxygen saturation.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first?

Use pulse oximetry to check the oxygen saturation. Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is: Select the 2 correct answers.

applying pressure garmentsRationale: Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.

The patient has bilateral crackles throughout lung fields.

bronchitis??? pneumonia????

Why does the health care provider orders lactulose for a patient with hepatic encephalopathy?

decreases ammonia level Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy.

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns. What is the nurse's priority intervention?

dislodge the autografts.

What assessments indicate that a client with advanced cirrhosis is experiencing a serious complication?

frequent nose bleeds and bruising Complications of cirrhosis of the liver include peripheral edema, gastric varices, and hepatic encephalopathy. 1 Peripheral edema presents itself as swelling/edema of the feet, or pedal edema. 3 Hepatic encephalopathy presents as disorientation, altered mental status, sleep disturbance, and lethargy. 4 Gastric varices bleed easily. This bleeding can present as blood in vomitus or blood in the stool

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first?

Give epinephrine.

Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?

Maintain adequate nutrition.

List 3 instructions about bowel cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy.

Abdominal bloating might occur

To evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy, which action should the nurse take?

Ask the patient to extend both arms to the front.Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopat

The patient with cirrhosis who has been vomiting blood is admitted to the emergency department. Which action should the nurse take first?

Check BP, heart rate, and respirations.The nurse's first action should be to determine the patient's hemodynamic status by assessing vital signs.

A nurse is caring for a client who has a history of pancreatitis. Which of the following food choices should the client avoid?

Cheddar cheese

The nurse caring for a patient admitted with burns assesses that urine output has dramatically increased.

Continue to monitor the urine output.

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS)

Fewer episodes of bleeding varicesTIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

Which of the following areas is the most dependable for the nurse to inspect the client for jaundice?

Hard Plate According to evidence-based practice, inspecting the client's oral mucous membrane and hard palate are the most reliable methods to determine jaundice for a client who is African-American.

An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next?

Increase the rate for the sodium nitroprusside infusion.

While talking with a client with a diagnosis of end-stage liver disease, the nurse notices the client is unable to stay awake and seems to fall asleep in the middle of a sentence.

Increased blood ammonia levels

During the administration of the enema, the client is having abdominal cramps. What actions should the nurse take to relieve the client's discomfort?

LOWER HEIGHT OF CONTAINER Stop the flow and encourage the client to take deep breaths before restarting the enema. If the client reports pain, cramping, or bloating, the nurse should stop the flow of the enema for a few minutes, encourage the client to take deep breaths and relax, and then start the flow again when the pain subsides. The nurse should stop the enema and notify the health care provider if the pain continues the second time. It is not necessary to contact the health care provider at this time. The nurse should not continue administering the enema until after the client has had a few minutes of deep breathing to relieve the cramping. The client can be told that this is a common occurrence, but the nurse should stop the enema for a few minutes and instruct the client to take deep breaths.

During the emergent phase of burn care how much would the patient adequate fluid infusion?

Measure hourly urine output. When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?

Monitor breath sounds frequently.

The health care provider plans a paracentesis for a patient with ascites caused by liver cancer. To prepare the patient for the procedure, the nurse implements which of the following?

The patient should void urine immediately before paracentesis.The nurse should instruct the patient to void prior to the paracentesis to prevent accidental puncture of the bladder. During the procedure, the patient sits on the side of the bed or is placed in high Fowler's position. There is no need to keep the patient on NPO status (taking nothing by mouth) or to restrict fluid intake.

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?

The patient's serum creatinine level is elevated.

A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat-soluble vitamin supplements.

Vitamin A and Vitamin D

A nurse is caring for a client with cirrhosis who has a prothrombin time of 30 seconds. Which of the following medications does the nurse anticipate the provider will prescribe?

Vitamin K

A nurse is assessing a patient who is receiving a nitroprusside (Nitride) infusion to treat cardiogenic shock.

Warm, pink, and dry skin Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

A nurse is caring for a client with decreased liver function due to cirrhosis. When selecting a snack, which of the following selections indicates the client understands dietary requirements?

hard boiled egg decrease your sodium intake to 1-2 grams a day. - this decreases fluid retention they can not eat anything high in salt like ham

A nurse is assessing a client's abdomen who reports stomach pain. List 3 actions the nurse take first?

inspect assculate palpate

A nurse is caring for a client with cirrhosis who has a new prescription for cephalic (Lactulose)

level of consciousness (LOC). over dose= watery diarrhea

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheeze. What is the best action for the nurse to take?

notify the health care provider and prepare for endotracheal intubation