455 Exam III

A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Inspect the mouth for signs of inhalation injuries.

A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspect which of the following types of anemia?

Iron-deficiency anemia

A nurse is planning care for a client who is postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

Prevent hip flexion of the affected extremity

A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests?

Schilling test

How much fluid to give a burn patient in 1st 8 hours?

2 mL lactate ringers x kg x % total body surface area that was burned

A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of the burn injury. What percentage of body surface area should the nurse estimate the client has burned?

54 %

A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer?

Vitamin K

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

"I will limit my alcohol intake."

The nurse teaches assistive personnel (AP) about care of an older adult diagnosed with osteoporosis. What teaching would the nurse include?

"Osteoporosis places the client is at risk for fractures."

A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse understanding of the procedure?

"They are going to examine my gallbladder and ducts."

A nurse is preparing to administer a dose of lactulose to a client who has cirrhosis. The client states, "I don't need this medication. I am not constipated." The nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstream?

Ammonia

A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

Aplastic anemia results from decreased bone marrow production of RBCs.

A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia?

Chronic blood loss

The nurse is caring for several clients with osteoporosis. For which client would bisphosphonates not be a good option?

Client with a spinal cord injury who cannot tolerate sitting up.

A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?

Erythrocyte sedimentation rate (ESR)

A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's Jackson-Pratt (JP) drain?

Expel the air from the JP bulb after emptying to re-establish suction.

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

Fatty stools

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?

Gallstones

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

Heart rate

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury?

Lactated Ringer's

A nurse is caring for a client who had a left hip arthroplasty. Which of the following interventions should the nurse use to prevent dislocation?

Maintain foam wedge between legs.

A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

Monitor the pulmonary artery pressure

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

Perform a neurovascular assessment.

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

Withhold oral fluids and food.

What do you monitor for, for a patient taking cholchicine?

muscle spams

What type of drug is cholchicine?

to treat gout

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

Increased serum amylase

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

The client develops a life-threatening situation.

A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory values should the nurse NOT expect?

​Increased hemoglobin count