2220 exam 2
Which statement demonstrates understanding of a computer-based client information system?
"Client information is immediately available when this system is used."
What factor increases an older adult's risk for distributive (septic) shock? A. Reduced skin integrity B. Diuretic therapy C. Cardiomyopathy D. Musculoskeletal weakness
A. Reduced skin integrity
Which was the underlying purpose of the national health information technology infrastructure that originated from the executive order Incentives for the Use of Health Information Technology issued by President George W. Bush in 2004?
Improves the quality, safety, and efficiency of health care
Which terminology system would the nurse use to enter nursing diagnoses, interventions, and outcomes in electronic health records?
Perioperative Nursing Data Set (PNDS)
The nursing student has enrolled in a Public Health Informatics (PHI) fellowship program. Which would the student expect to learn in this program? Select all that apply 1. Developing insurance policies 2. Providing culturally competent care 3. Designing new tools for biosurveillance 4. Developing online analytic processing tools 5. Methodologies for determining outbreak response
answer: 3, 4, 5
The nurse is caring for a client in the refractory stage shock. Which intervention does the nurse consider? a. Enrollment in a cardiac transplantation program b. Admission to rehabilitation hospital for ambulatory retraining c. Collaboration with home care agency for return to home d. Discussion with family and provider regarding palliative care
d. Discussion with family and provider regarding palliative care
A young woman comes to the emergency department (ED) with lightheadedness and "a feeling of impending doom". Pulse is 110 beats/min; respirations are 30/min; and blood pressure is 140/90 mm Hg. Which factors does the nurse ask about that could contribute to shock? SATA A. Recent accident or trauma B. Prolonged diarrhea or vomiting C. History of depression or anxiety D. Possibility of pregnancy E. Use of over-the-counter medications F. Recent hospitalization
A. Recent accident or trauma B. Prolonged diarrhea or vomiting D. Possibility of pregnancy E. Use of over-the-counter medications
The nurse is caring for a patient in septic shock. The nurse notes that the rate and depth of respirations are markedly increased. The nurse interprets this as a possible manifestation of the respiratory system compensating for which condition? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
A. Metabolic acidosis
When the nurse is preparing to assist with endotracheal intubation of Ms. D, in which order will these actions be accomplished? 1. Use capnography to check for exhaled carbon dioxide 2. Secure the endotracheal tube in place 3. Preoxygenate with bag-valve mask device at 100% oxygen 4. Inflate the endotracheal tube cuff 5. Obtain all needed equipment and supplies 6. Insert the endotracheal tube orally through the vocal cords
5, 3, 6, 4, 1, 2
The home health nurse is visiting a frail older adult patient at risk for sepsis because of failure to thrive and immunosuppression. What does the nurse assess this patient for? SATA A. Signs of skin breakdown and presence of redness or swelling B. Cough or any other symptoms of a cold or the flu C. Appearance and odor of urine, and pain or burning during urination D. Patient's and family's understanding of isolation precautions E. Availability and type of facilities for handwashing F. General cleanliness of the patient's home
A. Signs of skin breakdown and presence of redness or swelling B. Cough or any other symptoms of a cold or the flu C. Appearance and odor of urine, and pain or burning during urination E. Availability and type of facilities for handwashing F. General cleanliness of the patient's home
Which statement about assessment of skin during shock is accurate? A. For a patient with dark skin, pallor or cyanosis is best assessed in the oral mucous membranes B. For all patients in shock, the skin is expected to feel warm and dry to the touch C. For a lighter skinned patient, skin is usually a whitish blue color D. For a patient with dark skin, color will be bluish gray
A. For a patient with dark skin, pallor or cyanosis is best assessed in the oral mucous membranes
A nurse admits an 81-year-old man to the hospital with aspiration pneumonia. Which of the following risk factors should the nurse predict that the client has in his history? A) Cigarette smoking B) Lung cancer C) Dysphagia D) Sleep apnea
Ans: C Dysphagia creates a serious risk for aspiration pneumonia. Smoking, cancer, and sleep apnea do not have a direct correlation with aspiration pneumonia
A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? A. An irreversible phenomenon B. A failure of the circulatory pump C. Usually a fleeting reaction to tissue injury D. Generally caused by decreased blood volume
B. A failure of the circulatory pump
The nurse is caring for a postoperative patient who had major abdominal surgery. Which assessment finding is consistent with hypovolemic shock? A. Pulse pressure of 40 mm Hg B. A rapid, weak, thready pulse C. Warm, flushed skin D. Increased urinary output
B. A rapid, weak, thready pulse
Which method of oxygen administration will be best to increase Ms. D's oxygen saturation? A. Nasal cannula B. Nonrebreather C. Venturi mask D. Simple face mask
B. Nonrebreather
A 70-year-old man is admitted to the hospital with an infected finger for several days' duration. He is lethargic and confused and has a temperature of 101.3. Other assessment findings include blood pressure of 94/50 mm Hg, pulse 105 beats/min, respirations of 40/min, and shallow breathing. These assessment findings indicate which type of shock? A. Hypovolemic B. Cardiogenic C. Anaphylactic D. Septic
D. Septic
Which database can be used to find studies related to allied health sciences?
Medline
A client is exhibiting signs and symptoms of early shock. Which nursing actions support the psychosocial integrity of the client? (Select all that apply.) a. ask family members to stay with the client b. increase IV and oxygen rates c. call the health care provider c. remain with the client d. reassure the client that everything is being done for him or her
a. ask family members to stay with the client c. remain with the client d. reassure the client that everything is being done for him or her
Which nurse would be assigned to care for a client who is intubated with septic shock due to a methicillin-resistant Staphylococcus aureus (MRSA) infection? a. The RN who will also be caring for a client who had coronary artery bypass graft (CABG) surgery 12 hours ago. b. The RN with 2 years of experience in intensive care unit (ICU). c. The LPN/LVN who has 20 years of experience. d. The new RN who recently finished orienting and is working independently with moderately complex clients.
b. The RN with 2 years of experience in intensive care unit (ICU).
A postoperative client is admitted to the intensive care unit (ICU) with hypovolemic shock. Which nursing action will the nurse delegate to an experienced assistive personnel (AP)? a. assess level of alertness b. obtain vital signs every 15 minutes c. measure hourly urine output d. check oxygen saturation
c. Measure hourly urine output.
Which client demonstrates the highest risk for hypovolemic shock? a. client receiving a blood transfusion b. Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion c. client with myocardial infarction d. client with severe ascites
d. client with severe ascites
Which condition results in blood vessels that are normally partially constricted? A. Hypoxia B. Vasodilation C. Sympathetic tone D. Decreased mean arterial pressure
C. Sympathetic tone
The nurse quickly reviews Ms. D's latest laboratory test results, which have just arrived on the unit: Hematocrit: 32% (0.32) Hemoglobin: 10.9 Platelet count: 96,000 WBC: 26,000 BUN: 56 Creatinine: 2.9 Glucose: 330 Potassium: 5.2 Sodium: 140 Which laboratory value requires the most immediate action by the nurse? A. Creatinine level B. Glucose level C. Potassium level D. Hemoglobin level
B. Glucose level
While being prepared for surgery for a ruptured spleen, a client complains of feeling light-headed. The client's color is pale and the pulse is rapid. What should the nurse conclude about the client's condition? A. Hyperventilating B. Going into shock C. Experiencing anxiety D. Developing an infection
B. Going into shock
The nurse identifies signs and symptoms of internal hemorrhage in a postoperative patient. What is included in the care of this patient for hypovolemic shock? SATA A. Elevate the feet with the head of flat or elevated at 30 degrees B. Monitor vital signs every 5 minutes until they are stable C. Administer clotting factors or plasma D. Provide oxygen therapy E. Ensure IV access F. Leave the patient and notify the Rapid Response Team
A. Elevate the feet with the head of flat or elevated at 30 degrees B. Monitor vital signs every 5 minutes until they are stable D. Provide oxygen therapy E. Ensure IV access
After the successful intubation, the nurse performs a rapid assessment of Ms. D and documents the findings: "Apical pulse irregularly irregular. Face flushed and warm. Extremities cool and mottled. Breath sounds audible bilaterally with crackles present in lung bases. Reports pain with suprapubic palpation. Urine is amber and cloudy, with red streaks. 100 mL urine output when Foley catheter inserted." The patient's current vital sign values and capillary blood glucose are as follows: BP: 86/40 HR: 102 bpm O2 Sat: 93% RR: 32 breaths/min Temp: 103F Blood Glucose: 167 Which data collected about this patient are most important in alerting the nurse to a diagnosis of sepsis and systemic inflammatory response syndrome (SIRS)? SATA A. Hematuria B. Atrial fibrillation C. Temperature D. Apical pulse rate E. Blood glucose level F. Respiratory rate
A. Hematuria C. Temperature D. Apical pulse rate F. Respiratory rate
A 65-year-old client with a long-standing history of chronic obstructive pulmonary disease (COPD) was placed recently on Coumadin after experiencing atrial fibrillation. Upon discharge from the hospital, which of the following statements by the client indicates a need for further teaching? A) "I will continue to use smokeless tobacco since it's a lot better than smoking." B)"I will avoid using over-the-counter antihistamines since they can dry my mucosal secretions." C)"I will watch my intake of dark green leafy vegetables since they may impact the effects of Coumadin." D)"I will not take any herbal preparations without my health care provider's knowledge."
Ans: A Smokeless tobacco is associated with mouth cancer, gingivitis, and tooth loss and may be carcinogenic to the pancreas. The other noted actions are appropriate to the maintenance of health.
A 70-year-old client smoked for 30 years and has a history of COPD. The spouse assists with cooking, cleaning, and transportation. The spouse has become ill, and they now receive assistance from a home health nurse. Which of the following interventions should be the priority? A) Assisting the clients to perform instrumental activities of daily living (IADLs) B) Determining a plan for providing meals C) Setting up medications for the clients D) Smoking cessation plan
Ans: B The nurse's role is not to perform the IADLs, but to plan for the IADLs including meals, cleaning, and transportation. There is no indication that the clients need their medications set up, smoking cession is important, but basic needs come first
A nurse plans interventions in a skilled nursing facility to prevent lower respiratory infections. Which of the following nursing interventions should be included in the plan? (Select all that apply.) A) Encourage annual pneumonia vaccinations. B) Encourage annual influenza vaccinations. C) Encourage annual chest radiographs to detect tuberculosis. D) Encourage influenza vaccinations every 5 years. E) Encourage hand hygiene for residents and staff.
Ans: B, E Influenza vaccinations should be given yearly to older adults. The Centers for Disease Control and Prevention (CDC) recommends a one-time booster dose of the pneumonia vaccination for all people 65 years of age or older if they received an initial pneumonia vaccination 5 or more years earlier or were younger than 65 years of age when they first received the pneumonia vaccine. Chest radiographs will not prevent lower respiratory infections. Hand hygiene is essential in prevention of infections
A patient is showing early clinical manifestations of hypovolemic shock. The healthcare provider orders an arterial blood gas (ABG). Which ABG values does the nurse expect to see in hypovolemic shock? A. Increased pH with decreased PaO2 and increased PaCO2 B. Decreased pH with decreased PaO2 and increased PaCO2 C. Normal pH with decreased PaO2 and normal PaCO2 D. Normal pH with decreased PaO2 and decreased PaCO2
B. Decreased pH with decreased PaO2 and increased PaCO2
Which information would the nurse provide to clients regarding benefits of electronic health records (EHRs)? Select all that apply. One, some, or all responses may be correct.
1. Obtains Medicare and Medicaid payments 2.Shares personal health information with selected family members 3. Provides more accurate diagnoses and treatment in emergency conditions
The nurse is preparing to transfer Ms. D to the intensive care unit (ICU). Using SBAR (situation, background, assessment, recommendation) format, in what order will the nurse communicate pertinent information about Ms. D to the ICU nurse? 1. "Current blood pressure is 92/42, pulse rate 112, and respirations 32. Capillary blood glucose is 167 mg/dL, and lactate level is 36.04. Blood and urine culture pending" 2. "The patient has diabetes and chronic atrial fibrillation. She has been experiencing nausea, abdominal pain, and back pain. Today she was noted to be increasingly lethargic" 3. "Ms. D will need a central line insertion for fluid and vasopressor management, along with titration of norepinephrine and normal saline to maintain mean arterial pressure at 65 mm Hg" 4. "Ms. D is ready to transfer to intensive care. She has septic shock and is receiving mechanical ventilation, norepinephrine drip, and normal saline infusion through a peripheral line"
4, 2, 1, 3
The cardiac monitor shows this rhythm (Afib). Routine treatment orders for dysrhythmias are in the emergency department protocols. Which action should the nurse take next? A. Continue to monitor cardiac rhythm B. Administer metoprolol 5 mg IV push C. Prepare to perform cardioversion at 50 J D. Administer amiodarone 150 mg IV push
A. Continue to monitor cardiac rhythm
Ms. D is transferred to the ICU, and a two-port central IV line is started at the subclavian site to infuse fluids and norepinephrine. The intensive care nurse is working with an experienced LPN/LVN in caring for Ms. D. Which nursing activities included in the care plan should be assigned to the LPN/LVN? SATA A. Documenting the hourly urinary output B. Monitoring the central line site for signs of infection C. Checking capillary blood glucose levels every 2 hours D. Completing a head-to-toe assessment every 4 hours E. Administering sliding-scale insulin lispro per protocol F. Infusing normal saline at 400 mL/hr
A. Documenting the hourly urinary output C. Checking capillary blood glucose levels every 2 hours E. Administering sliding-scale insulin lispro per protocol
For which indications would the nurse be prepared to administer a colloid product? SATA A. Hemorrhagic shock B. Dehydration C. Peripheral tissue hypoxia D. Fluid replacement E. Restore osmotic pressure F. Increase hematocrit and hemoglobin levels
A. Hemorrhagic shock C. Peripheral tissue hypoxia E. Restore osmotic pressure F. Increase hematocrit and hemoglobin levels
Which questions can help guide the nurse when evaluating the mental status of a patient at risk for shock? SATA A. Is it necessary to repeat questions to obtain a response? B. Can the patient answer "yes" or "no" questions? C. Does the response answer the question asked? D. Does the patient have difficulty making word choices? E. Is the patient irritated or upset by the questions? F. How long is the patient's attention span?
A. Is it necessary to repeat questions to obtain a response? C. Does the response answer the question asked? D. Does the patient have difficulty making word choices? E. Is the patient irritated or upset by the questions? F. How long is the patient's attention span?
Available staffing in the emergency department includes an experienced unlicensed assistive personnel (UAP). Which actions should the nurse delegate to the UAP? SATA A. Measuring vital signs every 15 minutes B. Attaching the patient to a cardiac monitor C. Documenting a head-to-toe assessment D. Checking orientation and alertness E. Inserting an IV line F. Monitoring urine output hourly
A. Measuring vital signs every 15 minutes B. Attaching the patient to a cardiac monitor F. Monitoring urine output hourly
Assessment findings of a patient with trauma injuries reveal cool and pale skin, reported thirst, urine output 100mL/8 hr, blood pressure 122/78 mm Hg, pulse 102 beats/min, and respirations 24/min with decreased breath sounds. The nurse recognizes that the patient is in which phase of shock? A. Nonprogressive B. Progressive C. Refractory D. Multiple organ dysfunction
A. Nonprogressive
The unlicensed assistive personnel (UAP) working under supervision of an RN is checking vital signs on the patient at risk for hypovolemic shock. Which instructions must the nurse give the UAP? A. Report any increase in heart rate because it is an early sign of shock B. Report any increased systolic pressure, which is an early sign of shock C. Report any changes in body temperature, which may indicate sepsis D. Report any increase in respiratory rate because of acid-base changes
A. Report any increase in heart rate because it is an early sign of shock
The nursing student takes the morning blood pressure of a postoperative patient, and the reading is 90/50 mm Hg. What does the student do next? SATA A. Report the reading to the primary nurse as a possible sign of hypovolemia B. Assess the patient for subjective feelings of dizziness or shortness of breath C. Check the patient's chart for trends in morning vital sign readings D. Notify the instructor to verify the significance of the finding E. Call a "code blue" F. Place the patient in reverse Trendelenburg position
A. Report the reading to the primary nurse as a possible sign of hypovolemia B. Assess the patient for subjective feelings of dizziness or shortness of breath C. Check the patient's chart for trends in morning vital sign readings D. Notify the instructor to verify the significance of the finding
Based on the assessment data and vital signs, which collaborative actions should the nurse anticipate at this time? SATA A. Send specimens for blood and urine culture B. Start norepinephrine infusion at 8 mcg/min C. Give normal saline bolus of 30 mL/kg D. Draw blood for serum lactate level E. Administer vancomycin 1 g IV
A. Send specimens for blood and urine culture C. Give normal saline bolus of 30 mL/kg D. Draw blood for serum lactate level E. Administer vancomycin 1 g IV
Which statements about shock are true? SATA A. Shock is a whole-body response to tissues not receiving enough oxygen B. Shock is widespread abnormal cellular metabolism C. Shock occurs only in the acute care setting D. Shock may occur in older adults in response to urinary tract infections E. Shock is mostly classified as a disease F. Shock affects all body organs
A. Shock is a whole-body response to tissues not receiving enough oxygen B. Shock is widespread abnormal cellular metabolism D. Shock may occur in older adults in response to urinary tract infections F. Shock affects all body organs
After infusion of the normal saline bolus, Ms. D's blood pressure is 92/42. Lactate level is elevated at 36. Norepinephrine infusion is prescribed at 8 mcg/min and infusion is started through a peripheral IV line. When assessing the norepinephrine infusion site, the nurse notes that the skin around the IV insertion site is cool and pale. Which action should be taken first? A. Shut off the infusion pump B. Assess for pain at the site C. Notify the HCP about the possible norepinephrine extravasation D. Inject the pale area with phentolamine solution per hospital protocol
A. Shut off the infusion pump
A patient with hypovolemic shock is receiving an infusion of dopamine. Which nursing interventions are essential when a patient is receiving this drug? SATA A. Take the blood pressure at least every 15 minutes B. Monitor urine output every hour C. Cover the infusion bag to protect it from light D. Assess the patient for chest pain E. Check the infusion site every 30 minutes for extravasation F. Ask a patient receiving this drug about headaches
A. Take the blood pressure at least every 15 minutes B. Monitor urine output every hour D. Assess the patient for chest pain E. Check the infusion site every 30 minutes for extravasation F. Ask a patient receiving this drug about headaches
At the end of the shift, the supervisor consults with the nurse about which of these oncoming staff members should be assigned to care for Ms. D. Which RN will be best to assign to care for this patient? A. Travel RN with 20 years of ICU experience who has been working in this ICU for 4 months B. Newly graduated RN who has worked in the ICU as a nursing assistant and has finished the precepted orientation C. Experienced ICU RN who has been called in on a day off to work for the first 4 hours of the shift D. RN who has been floated from the postanesthesia care unit (PACU) to the ICU for the shift
A. Travel RN with 20 years of ICU experience who has been working in this ICU for 4 months
The nurse is preparing for a teaching session for a patient at risk for septic shock. Which topic does the nurse include in this teaching? SATA A. Wash hands frequently using antimicrobial soap B. Avoid aspirin and aspirin-containing products C. Avoid large crowds or gatherings where people might be ill D. Do not share eating utensils E. Wash toothbrushes in a dishwasher F. Take temperature once a week
A. Wash hands frequently using antimicrobial soap C. Avoid large crowds or gatherings where people might be ill D. Do not share eating utensils E. Wash toothbrushes in a dishwasher
A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowler's position. d. Administer prescribed albuterol.
ANS: A Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse should document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client's position because the finding is normal.
A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Encourage deep breathing and coughing. b. Implement an air mattress overlay. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins. e. Administer acetaminophen (Tylenol) twice daily.
ANS: A, C, D Regular pulmonary hygiene and activities to maintain health and fitness help to maximize functioning of the respiratory system and prevent infection. A client at high risk for a pulmonary infection may need a specialty bed to help with postural drainage or percussion; this would not include an air mattress overlay, which is used to prevent pressure ulcers. Tylenol would not decrease the risk of a pulmonary infection.
A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. "I held the client's morning bronchodilator medication." b. "The client is ready to go down to radiology for this examination." c. "Physical therapy states the client can run on a treadmill." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands."
ANS: A, D, E To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside. A treadmill is not used for this test.
A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first? a. Encourage the client to increase fluid intake. b. Assess the client's level of consciousness. c. Raise the head of the bed to at least 45 degrees. d. Provide the client with humidified oxygen.
ANS: B Assessing the client's level of consciousness will be most important because it will show how the client is responding to the presence of the infection. Although it will be important for the nurse to encourage the client to turn, cough, and frequently breathe deeply; raise the head of the bed; increase oral fluid intake; and humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is present.
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the client's peripheral pulses. d. Obtain blood and sputum cultures.
ANS: B Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care. An albuterol treatment would not address the client's oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat this client.
A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding? a. "Are you taking any medications or herbal supplements?" b. "Do you have any chronic breathing problems?" c. "How often do you perform aerobic exercise?" d. "What is your occupation and what are your hobbies?"
ANS: B The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked but is not as indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and should be asked first.
A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next? a. Call the physician and request a prescription for food and water. b. Provide the client with ice chips instead of a drink of water. c. Assess the client's gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.
ANS: C The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.
A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention? a. Hollow sounds are heard over the trachea. - The nurse increases the oxygen flowrate. b. Crackles are heard in bases. - The nurse encourages the client to cough forcefully. c. Wheezes are heard in central areas. - The nurse administers an inhaledbronchodilator. d. Vesicular sounds are heard over the periphery. - The nurse has the client breathe deeply
ANS: C Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no intervention.
A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain? a. Average daily fluid intake b. Neck circumference c. Height and weight d. Occupation and hobbies
ANS: D Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the client's neck circumference will not be an important part of a respiratory assessment.
A nurse plans care for a frail older adult in long-term care. Which of the following interventions should be included in the plan of care to reduce the risk of respiratory infections? A) Oral care B) Oxygen administration C) Pulmonary function testing D) Tracheal suctioning
Ans: A Poor oral care in long-term care residents increases the risk for pneumonia. Tracheal suctioning should be limited to those who are intubated. Neither testing nor oxygen would decrease risk of pneumonia
A nurse in a long-term care facility is aware of the effects of age-related changes to the respiratory system. Which of the following functional consequences most likely results from age-related changes? A) Snoring and mouth breathing B) A persistent, dry cough C) Increased sensitivity to environmental allergens D) Hemoptysis on exertion
Ans: A Snoring and mouth breathing often become more prevalent with age. Hemoptysis and a persistent cough are considered pathologic at any age, and allergies do not typically worsen with age.
A nurse discusses common illnesses at the local health fair. The older adult asks, "Why do all my friends seem to get pneumonia?We never did when we were younger." Which of the following interventions should the nurse include in the teaching? A) Examinations by health care provider B) Hand hygiene C) Jogging/running D) Yearly pneumovax
Ans: B Age-related alterations of the immune functions are a major contributing factor in the prevalence of lung diseases among older adults. Examinations are helpful in early identification of some lung diseases but not preventative regarding communicable diseases such as pneumonia. Pneumovax is not required yearly
A nurse admits an older adult from a longterm care facility into the hospital for respiratory infection. Which diagnostic testing should the nurse anticipate? A) Electrocardiogram B) Lung cancer screening C) Mantoux testing D) Pulmonary function testing
Ans: C Residents of long-term care are at risk for tuberculosis. While cancer and cardiac and lung function testing may occur, testing for tuberculosis should be done to screen for this contagious disease to protect others
Based on analysis of ABG values (PaCO2 62 mm Hg, PaO2 50 mm Hg, HCO3 22 mEq/L, O2 82%, pH 7.23), which collaborative intervention will the nurse anticipate next? A. Sodium bicarbonate bolus IV B. Endotracheal intubation and mechanical ventilation C. Continuous monitoring of Ms. D's respiratory status D. Nebulized albuterol therapy
B. Endotracheal intubation and mechanical ventilation
A patient is in hypovolemic shock related to hemorrhage from a large gunshot wound. Which order must the nurse question? A. Establish a large-bore peripheral IV and give crystalloid bolus B. Give furosemide (Lasix) 20 mg slow IVP C. Insert a Foley catheter and monitor intake and output D. Give high-flow oxygen via mask at 10 L/min
B. Give furosemide (Lasix) 20 mg slow IVP
A patient is brought to the emergency department (ED) with a gunshot wound. What are the early signs of hypovolemic shock the nurse should monitor? SATA A. Elevated serum potassium level B. Increase in heart rate C. Decrease in oxygen saturations D. Marked decrease in blood pressure E. Increase in respiratory rate F. Decreased MAP of 10-15 mm Hg
B. Increase in heart rate E. Increase in respiratory rate F. Decreased MAP of 10-15 mm Hg
A patient has a systemic infection with a fever, increased respiratory rate, and change in mental status. Which laboratory values does the nurse seek out that are considered "hallmarks" of sepsis? A. Increased white blood cell count and increased glucose level B. Increased serum lactate level and rising band neutrophils C. Increased oxygen saturation and decreased clotting times D. Decreased white blood count with increased hematocrit
B. Increased serum lactate level and rising band neutrophils
Ms. D, a 54-year-old patient, is brought to the emergency department by her daughter because of weakness and a decreasing level of consciousness. The daughter says that Ms. D has been reporting nausea, with associated abdominal and back pain. Although usually Ms. D is very alert and oriented, today she has been increasingly lethargic. Her medical history includes hypertension, atrial fibrillation, and diabetes mellitus type 2. The initial vital signs are as follows: BP: 102/38 HR: 102 bpm O2 Sat: 76% RR: 30 breaths/min Temp: 102.4F Based on the initial history and assessment, which action prescribed by the healthcare provider (HCP) will the nurse implement first? A. Insert a foley catheter and monitor urine output hourly B. Start oxygen and maintain oxygen saturation at 90% or higher C. Place the patient on a cardiac monitor D. Check the blood glucose level
B. Start oxygen and maintain oxygen saturation at 90% or higher
A patient comes to the emergency department (ED) with severe injury and significant blood loss. The nurse anticipates that resuscitation will begin with which fluid? A. Whole blood B. 0.5% dextrose in water C. 0.9% sodium chloride D. Plasma protein fractions
C. 0.9% sodium chloride
A patient at risk for hypovolemic shock has a central venous pressure (CVP) catheter in place. Which finding is a priority concern for the nurse? A. Heart rate is decreased from 120 to 110 per minute B. Central venous pressure is increased from 1 to 6 mm Hg C. Central venous pressure is decreased from 6 to 1 mm Hg D. Heart rate is increased from 100 to 110 per minute
C. Central venous pressure is decreased from 6 to 1 mm Hg
A patient receives dopamine 20 mcg/kg/min IV for the treatment of shock. What does the nurse assess for while administering this drug? A. Decreased urine output and decreased blood pressure B. Increased respiratory rate and increased urine output C. Chest pain and hypertension D. Bradycardia and headache
C. Chest pain and hypertension
The nurse is reviewing the laboratory results of a patient with a systemic infection. What is the significance of a "left shift" in the differential leukocyte count? A. Expected finding because the patient has a serious infection B. Indication that the infection is progressing toward resolution C. Indication that the infection is outpacing the white cell production D. Important to watch for trends but otherwise not urgently significant
C. Indication that the infection is outpacing the white cell production
When the nurse is infusing the normal saline, which action is most important in evaluating for an adverse reaction to the rapid fluid infusion? A. Palpating for any peripheral edema B. Monitoring urinary output C. Listening to lung sounds D. Checking for jugular venous distention
C. Listening to lung sounds
After 2 hours, the values for vital signs are as follows: BP: 104/56 HR: 104 bpm O2 Sat: 92% Central Venous Pressure: 3 mm Hg RR: 26 breaths/min Temp: 101.6F Which information about Ms. D is most important for the nurse to communicate to the healthcare provider? A. Decreased blood pressure B. Ongoing atrial fibrillation C. Low central venous pressure D. Continued temperature elevation
C. Low central venous pressure
Which patient is at risk for obstructive shock? A. Patient with a history of angina B. Patient with chronic atrial fibrillation C. Patient with pulmonary embolism D. Patient with a history of heart failure
C. Patient with pulmonary embolism
The nurse is caring for a patient at risk for sepsis. Why does the nurse closely monitor the patient for early signs of shock? A. The patient is unable to self-identify or report these early signs B. Distributive shock usually begins as a bacterial or fungal infection C. Prevention of septic shock is easier to achieve in the early phase D. There is widespread vasodilation and pooling of blood in some tissues
C. Prevention of septic shock is easier to achieve in the early phase
The nurse is caring for a patient in septic shock with a serum glucose level of 280 mg/dL. What is the nurse's best interpretation of this finding? A. The patient is developing type 2 diabetes B. The patient is developing type 1 diabetes C. This finding is associated with a poor outcome D. This finding is unexpected in septic shock
C. This finding is associated with a poor outcome
The nurse is caring for a patient with sepsis. At the beginning of the shift, the patient is in a hyperdynamic state. Several hours later, the patient has a rapid respiratory rate, decreased urine output, and altered level of consciousness. How does the nurse interpret this change? A. A positive response and a signal of recovery B. Temporary situation that is likely to normalize C. Worsening of the condition rather than improvement D. Expected response to standard therapies
C. Worsening of the condition rather than improvement
Which organization assists in establishing policies related to Medicare and Medicaid payment for meaningful use of electronic health records (EHRs)?
Center for Medicare and Medicaid Services (CMS)
The student nurse is assessing a patient's mental status because of the patient's risk for decreased tissue perfusion. The supervising nurse intervene when the student nurse asks the patient which question? A. "What is today's date?" B. "Who is the president of this country?" C. "Where are we right now?" D. "Is your name Mr. John Smith?"
D. "Is your name Mr. John Smith?"
Which of these actions prescribed by the HCP will be most important for the nurse to question? A. Increase oxygen flow rate B. Raise normal saline rate to 450 mL/hr C. Administer acetaminophen 650 mg rectally D. Increase norepinephrine infusion rate to 12 mcg/kg
D. Increase norepinephrine infusion rate to 12 mcg/kg
The nurse is evaluating the care and treatment for a patient in shock. Which finding indicates that the patient is having an appropriate response to the treatment? A. Blood pH of 7.28 B. Arterial PO2 of 65 mm Hg C. Distended neck veins D. Increased urinary output
D. Increased urinary output
A patient with head trauma was treated for a cerebral hematoma. After surgery, this patient is at risk for what type of shock? A. Obstructive B. Cardiogenic C. Chemical-induced distributive D. Neural-induced distributive
D. Neural-induced distributive
Which statement about the systematic effects of shock is correct? A. The liver is essentially unaffected, but liver enzymes may be lower than normal B. The current heart rate and blood pressure indicate the cardiac system is at baseline C. The brain and neurologic system can withstand 10-15 minutes of severe hypoperfusion D. The kidneys can tolerate hypoxia and anoxia up to 1 hour without permanent damage
D. The kidneys can tolerate hypoxia and anoxia up to 1 hour without permanent damage
A client with diabetes mellitus experiences a sudden fall in blood glucose levels while traveling by air. The client is not carrying any medications or a copy of a personal medical record. Which type of health information technology would be beneficial for this client?
Personal health record (PHR)
Which is the role of cognitive science in health informatics?
Provides a structure for analysis of complex human performance in technology-based settings
A group of nursing students can use which websites to find codes for nursing diagnoses, interventions, and outcomes of endocrine diseases as a part of an assignment? Select all that apply. One, some, or all responses may be correct. 1.www.nanda.org 2.www.sabacare.com 3.www.icn.ch/icnp.htm 4.www.nursing.uiowa.edu/cncce/nic 5.www.nursing.uiowa.edu/cncce/noc
answer: 1,2,3
During a newborn assessment the nurse identifies that the temperature, pulse, respirations, and other physical characteristics are within the expected range. The nurse records these findings on the electronic health record. How would the nurse's action be interpreted?
The nurse performed her or his role correctly.
The research nurse is conducting genomic analyses of clients with acquired immune deficiency syndrome (AIDS) to identify new biomarkers for AIDS. Which computational method would the nurse use for these analyses?
Translational bioinformatics
Which action would the nurse take to minimize ambiguity and confusion when entering a client's data in the electronic health record?
Use consistent, codified terminology.
Based on the assessment data, which client will the nurse identify as having a higher risk for development of sepsis and septic shock? (Select all that apply.) a. A 40-year-old female with a history of a double lung transplant 4 years ago. b. A 41-year-old male client with a closed fracture of the femur. c. A 44-year-old female client with a history of anxiety and infertility. d. A 38-year-old male with HIV who has a low viral load. e. A 54-year-old female with breast cancer who is receiving chemotherapy. f. A 44-year-old male client who has a history of alcoholism and diabetes mellitus. g. An 86-year-old male with acute onset confusion.
a. A 40-year-old female with a history of a double lung transplant 4 years ago. d. A 38-year-old male with HIV who has a low viral load. e. A 54-year-old female with breast cancer who is receiving chemotherapy. f. A 44-year-old male client who has a history of alcoholism and diabetes mellitus. g. An 86-year-old male with acute onset confusion.
Which client has a risk for hypovolemic shock? a. A client with esophageal varices b. a client with kidney failure c. a client with arthritis taking daily acetaminophen d. a client with pain from a kidney stone
a. A client with esophageal varices
The assistive personnel (AP) is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. What is the appropriate nursing action? a. Compare these vital signs with the last several readings. b. Increase the rate of intravenous fluids. c. Request that the surgeon see the client. d. Reassess vital signs using different equipment.
a. Compare these vital signs with the last several readings.
How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? a. lactate 81 mg/dL (9.0 mmol/L) b. Partial thromboplastin time 64 seconds c. Potassium 2.8 mEq/L (2.8 mmol/L) d. PaCO2 58 mm Hg
a. lactate 81 mg/dL (9.0 mmol/L)
The nurse is reviewing a newly admitted client's medication administration record (MAR). Which element, if missing, makes the record incomplete?
allergies
The nurse is reviewing the website www.nursing.uiowa.edu/cnc to gather information about standardized terminology. The website would provide the nurse with which standardized nursing terminologies? Select all that apply. One, some, or all responses may be correct. 1.Clinical Care Classification 2.Perioperative 3.Nursing Outcomes 4.Nursing Interventions Classification 5.International Classification of Nursing Practice
answer: 3, 4
The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action will the nurse take first? a. take the client's vital signs b. ensure that blood cultures were drawn c. insert an intravenous line d. administer the antibiotic
b. ensure that blood cultures were drawn
Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? a. reduces urinary output and increased respiratory rate b. low-grade fever and mild hypotension c. low oxygen saturation rate and decreased cognition d. localized erythema and edema
b. low-grade fever and mild hypotension
The nurse is teaching a class on the management of sepsis. What teaching will the nurse include regarding the Hour-1 sepsis management bundle? (Select all that apply.) a. measure fibrinogen levels b. measure lactate levels c. Initiate insulin therapy according to blood glucose levels. d. Administer broad spectrum antibiotics. e. Begin rapid administration of crystalloids for hypotension. f. A bundle is a group of two or more interventions that has been shown to be effective when applied in a sequence.
b. measure lactate levels d. Administer broad spectrum antibiotics. e. Begin rapid administration of crystalloids for hypotension. f. A bundle is a group of two or more interventions that has been shown to be effective when applied in a sequence.
Which problem places a client at highest risk for sepsis? a. client owns an iguana b. pericarditis c. post kidney transplant d. pernicious anemia
c. post kidney transplant
When caring for a client who is obtunded and admitted with shock of unknown origin, which action will the nurse take first? a. obtain IV access and hang prescribed fluid infusions b. assess level of consciousness and pupil reaction to light c. apply the automatic blood pressure cuff d. check the airway and respiratory status
d. check the airway and respiratory status
The nurse is caring for a postoperative client at risk for hypovolemic shock. Which assessment indicates an early sign of shock? a. first-degree heart block b. blood pressure of 100/48 mmHg c. respiratory rate 12 breaths/min d. heart rate 120 beats/min
d. heart rate 120 beats/min
The nurse working in a cardiac center is preparing to enter client data using health information technology. The nurse needs to refer to these data during subsequent follow-up client visits. Which type of record would the nurse use to enter the client's data?
electronic medical record (EMR)
A registered nurse notices that the insertion site of a client receiving intravenous medication is swollen. The nurse takes appropriate measures to treat the area and takes a photo of the insertion site and saves it in the client's electronic health record. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse following?
informatics