Adult Nursing II Final Exam Review

Assessment of ascites

* Record abdominal girth and weight daily * Patient may have striae, distended veins, and umbilical hernia * Assess for fluid in abdominal cavity by percussion for shifting dullness or by fluid wave * Monitor for potential fluid and electrolyte imbalances

Obstructive Sleep Apnea (OSA) Risk Factors

- Obesity - Gender (men) - Post-menopausal - Advanced age - Structural changes in upper airway

The correct procedure for obtaining a sputum study?

-Obtain early in am - Before meals _ Clear nose, throat, and rinse mouth (NO gargling) -Deep breathe -Deep cough -Launch Lugie

Delayed Complications of a Fracture

-delayed union (healing) -non-union (fracture fails to mend) -bone necrosis -avascular necrosis (no blood flow reaches bone) -reaction to external fixation device

Patients usually begin ambulatory how long after surgery using walker or crutches?

1 day

Assess swelling and neurovascular status every ___ to ____ hours for the first 24 hours.

1-2

Three distinct characteristics of Rheumatologic disorders

1. Inflammation 2. Autoimmunity 3. Degeneration

The 2 most important things when monitoring an EKG/ECG?

1. Treat rate 2. Treat the patient

No smoking/heavy lifting for up to ____ days after surgery.

10

Normal triglycerides range

100-200 mg/dL

Hypertension Stage 1

130-139/80-89

Hypertension Stage 2

140 or higher/90 or higher

Reduce blood pressure by what during the first hour of a patient with hypertensive emergency

20-25%

How much drainage is expected within the first 24 hours?

200-500 mL

To prevent infection, when do you remove a drain after hip replacement surgery?

24-48 hours

Inspect skin atleast ____x/day in a patient with skin traction.

3

Promotion of vericose veins: elevate the legs how many inches higher than heart level?

3-6 inches

Normal capacity of bladder

500 mL

What is normal EF?

55-65%

Avoid sports activities for ___ weeks following nasal surgery/nasal packing

6

With a clavicle fracture, do not elevate arm above shoulder for approximately how long?

6 weeks

Assess pressure points in skin every ___ hours in a patient with skeletal traction.

8

Bleeding can occur up to _____ days after surgery.

8

Trousseau's sign

A sign of hypocalcemia . Carpal spasm caused by inflating a blood pressure cuff above the client's systolic pressure and leaving it in place for 3 minutes.

What are post-procedure complications of a thoracentesis? SATA: a. Pulmonary edema b. Subcutaneous emphysema c. Pneumothorax d. Pyogenic infection e. Tension pneumothorax

ALL. Pneumothorax, subcutaneous emphysema, tension pneumothorax, and pyogenic infection are all complications of a thoracentesis. Pulmonary edema or cardiac distress can occur after a sudden shift in mediastinal contents when large amounts of fluid are aspirated.

S1 (Lub) is the closure of what valves

AV

Where does gas exchange take place?

Alevoli

Absent, diminished pulse

Arterial

Cool to touch, thin/dry/scaly, hairless,thick nails

Arterial

What is an example of coughing effectively?

Assume a sitting position, bend slightly forward, inhale slowly and cough twice during exhalation.

5 C's complications of HTN

CAD, Chronic RF, CHF, Cardiac arrest, CVA

Gold standard treatment of OSA

CPAP

A rigid, external immobilizing device

Cast

Arterial ulcers border

Circular (due to deadness of tissue)

A fracture that causes no break in the skin

Closed/simple

Avoid this in patients with PAD

Cold

What potential factors could make a pulse ox reading become unreliable?

Cold hands, Artificial nails, Nail polish, Rayons

Allows muscle to shorten when stimulated

Contractility

Soft tissue injury produced by blunt force (S.S = pain, swelling, discoloration, ecchymosis)

Contusion

ACE inhibitor primary side effect

Cough

What position do you use for patients with arterial disorders?

Dangle/dependent position

Articular surfaces of the joint are not in contact

Dislocation

Who are at higher risks of developing pneumonia?

Elderly patients and children

What does a fuzzy, buzzy baseline indicate?

Electrical interference

What position do you use for patients with venous disorders?

Elevate

ability of myocardial cell to contract when stimulated by an electrical impulse

Excitabilility

Signs and symptoms of tracheobronchitis

Fever/chills Nights sweats Malaise Dry cough- scanty thick secretion of purulent sputum

What stores and secretes bile?

Gallbladder

good cholesterol

HDL

Promote wound healing in a patient with an amputation by:

Handle limb gently, residual limb shaping

What do tall/tented T waves represent?

Hyperkalemia

What does ICOUGH stand for?

Incentive Spirometry, Cough and deep breathe, Oral care, Understand, Get out of bed and walk, HOB elevated

The nurse is providing pre-procedure teaching about an ultrasound. The nurse informs the client that in preparation for an ultrasound of the lower urinary tract the client will require wat?

Increased fluid intake to produce a full bladder.

Rhinosinusitis

Infection or allergy obstructs sinus drainage - Acute = <4 weeks - Subacute = 4-12 weeks - Chronic= >12 weeks

Blanching, cooling, and swelling are signs of what?

Infiltration

Pain that occurs when you exercises but subsides with rest

Intermittent Claudication

A fracture that extends into the joint surface of a bone

Intra-articular

Venous stasis ulcer border

Irregular

Prevention of infection post-op surgery

Keep dressing clean and dry, wound care, S.S of infection

Bad cholesterol

LDL

Physical assessment of a patient with Osteoporosis

Localized pain, constipation, altered body image

Pain control measures for a patient undergoing musculoskeletal surgery

Medication, elevation, intermittent ice/cold

What represents ventricular depolarization?

QRS complex

Goal of bone tumors

Relieve pain and promote quality of life

Occurs when foot is not elevated and there is not adequate blood flow

Rubor

Rhinitis

Runny nose

S2 (Dub) is the closure of what valves

Semilunar valves

Presents with a warm, painful, swollen joint with decreased ROM. Systemic chills, fever, and leukocytosis are sometimes present

Septic (Infectious) Arthritis

What is arterial pain described as?

Sharp, worst at night.. "rest pain"

Early complications of fractures

Shock, Fat embolism, Compartment syndrome, VTE/PE

Relieving pain for patients with Osteoporosis

Short periods of rest, supportive mattress, intermittent local heat and back rubs

What is the main cause of hypoxia after thoracic or abdominal surgery?

Shunting of blood

HR = 101-150

Sinus tachycardia

Manifestations of Paget Disease

Skeletal deformities, mild-moderate aching pain, tenderness/warmth over bones

OSA Signs and symptoms

Snoring/periods of apnea Leg jerking Restlessness Daytime Sleepiness HTN, dysthymias Pulmonary HTN

Pharnygitis

Sore throat.. Viral is most common cause -Fluids, rest, cool meals

Injury to ligaments and supporting muscle fiber around a joint (joint is tender, movement is painful, edema, disability and pain increases within first 2-3 hours)

Sprain

Ejection fraction is severely reduced in which type of heart failure?

Systolic

Synchronized cardioversion is synchronized to NOT fire on what?

T wave

What wave represents ventricular repolarization?

T wave

Which cardiac biomarker is most important to monitor if the patient has an MI?

Troponin "Troponin is TOP"

True or False: Phantom limb pain is perceived in the amputated limb

True

Ten minutes after the nurse begins an infusion of PRBCs the client complains of chills, chest/back pain, and nausea. His face is flushed and he is anxious. What should the nurse do FIRST? a. Reverify the packed RBCs b. Notify the physician of possible reaction c. Stop the infusion and maintain IV d. Obtain a serum specimen to send to the lab

c. Stop the infusion and maintain the IV. The patient is showing S.S of a transfusion reaction. The first thing the nurse should do is stop the infusion and maintain IV using a new line.

The nurse observes a client place one hand on the abdomen and another on the chest as the abdomen is pushed out with each inspiration. Which breathing technique did the nurse observe the client performing? a. Huff coughing b. Pursed-lip breathing c. Controlled breathing d. Diaphragmatic breathing

d. Diaphragmatic breathing

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

inappropriately increased ADH, inappropriate water retention, decreased Na+ levels, low urine output Treatment= Lasix & treat cause

Inflammation or infection of the lymphatic channels

lymphangitis

What color are cholesterol stones

peanut colored

What does pink frothy sputum indicate?

pulmonary edema

rhinitis medicamentosa

rebound nasal congestion commonly associated with overuse of over-the-counter nasal decongestants

What does RICE stand for?

rest, ice, compression, elevation Immobilize and anti-inflammatory meds

The kidneys help to regulate blood pressure by:

secreting renin

Chvostek's sign

spasm of the facial muscles produced by sharply tapping over the facial nerve in front of the parotid gland and anterior to the ear; suggestive of latent tetany in patients with hypocalcemia

Diastolic HF results from what?

stiff Left ventricle

C- reactive protein is produced in response to what?

systemic inflammation

portal hypertension

the elevation of blood pressure within the portal venous system

stress incontinence

the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing

Assess neurovascular status every ___ to ___ hours after knee replacement surgery

2-4

After a total laryngectomy, drains are removed when the patient has had less than ____ mL of drainage for 2 consecutive days

30 mL

Total recovery time of knee replacement surgery.

6 weeks Acute rehab for 1-2 weeks

What is the usual duration of TB medication?

6-12 months

normal sinus rhythm

60-100 bpm

A hospitalized client is being treated for a stroke. While giving the client water they cough and choke. Which of the following interventions should the nurse implement? SATA: a. Have suction equipment at the bedside b. Lie the client flat while feeding c. Give the client thin liquids such as juice d. Prevent stimulation of gag reflex while suctioning e. Request a swallowing study to be performed

A, D, E Suction needs to be available. When suctioning, the nurse needs to avoid stimulating the gag reflex to prevent vomiting. A swallowing study needs to be requested

A client informs the nurse the venipuncture site "hurts". The nurse should assess the site for which of the following? SATA: a. Redness b. Pain c. Coolness d. Blanching e. Firmness

ALL.

The nurse is caring for a client who has a fluid volume deficit. When evaluating the client's urinalysis results, what should the nurse anticipate?

An increased urinary specific gravity

Punched out lesions, deep in toes/feet

Arterial

Hardening of the arteries

Arteriosclerosis

Fatty plaque build up

Atherosclerosis

Chaotic, irregular, atrial activity

Atrial Fibrillation

Drug of choice for bradycardia

Atropine

Treatment for symptomatic bradycardia

Atropine.. 0.5mg every 3-5 minutes until 3mg is given

Does not have to have neuro/brain input to be stimulated

Automaticity

Death of tissue secondary to poor perfusion and hypoxemia

Avascular necrosis

If the patient has an arterial condition, lower extremities _____ heart level.

BELOW

Prevention of osteoporosis

Balanced diet high in Calcium and vitamin D Use of calcium supplements Regular weight-bearing exercises: 20-30 mins/day (increases balance and reduces incidence of falls/fx) Weight training to stimulate bone mineral density

Thromboletics dissolve?

Blood clots

Right sides heart failure backs up into the ____?

Body - Visceral/peripheral congestion, JVD!!, Edema(pitting), Swelling, fatigue, Ascites, weight gain

left ventricular assist device

Booster pump implanted in the abdomen with a tube inserted into the left ventricle. An LVAD is a "bridge to transplant" or destination therapy when heart transplantation is impossible.

Inflammation of a fluid-filled sac in the joint

Bursitis

What is the number 1 cause of Peripheral Arterial Disease?

Cigarette smoking/nicotine

Refers to ability of muscle to transmit an impulse from cell to cell

Conductivity

Signs and symptoms of a UTI in elderly patients?

Confusion/altered LOC and fatigue

Type 2 Diabetes

Diabetes of a form that develops especially in adults and most often obese individuals and that is characterized by high blood glucose resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production.

Type 1 Diabetes

Diabetes of a form that usually develops during childhood or adolescence and is characterized by a severe deficiency of insulin, leading to high blood glucose levels.

If the patient has a venous condition, ______ extremities above heart level.

ELEVATE

What are the 3 factors of Virchow's Triad?

Endothelial damage, Venous stasis, Altered coagulation

1 cm long clean wound

Grade I

Larger wound without extensive damage

Grade II

Highly contaminated, extensive soft tissue injury, may have amputation

Grade III

What is venous pain described as?

Heavy, dull, throbbing, aching

Improving bowel elimination

High fiber diet, increase fluids, stool softeners

Hypertensive crisis

Higher than 180 and/or higher than 120

The nurse is teaching an overweight 54-year old about ways to decrease symptoms of OSA. Which interventions would be most effective? SATA a. Eating a high-protein snack at bedtime b. Limiting alcohol intake c. Weight loss d. Taking a sedative at bedtime e. Taking a nap during the day

Limiting alcohol intake and losing weight

S.S of infection

Localized pain, edema, erythema, fever, drainage

Treatment of ascites

Low-sodium diet Diuretics Bed rest Paracentesis Administration of salt-poor albumin Transjugular intrahepatic portosystemic shunt (TIPS)

Left sided heart failure backs up into the _____?

Lungs -Pulmonary congestion, crackles, DOE< Low O2 sat, Dry/non productive cough, Oliguria **SIT THEM UP HIGH AS POSSIBLE!!**

Inflammation or infection of the lymph nodes

Lymphadenitis

Tissue swelling related to obstruction of lymphatic flow

Lymphedema

What do flat or inverted T waves indicate?

MI or ischemia

A fracture where the wound extends to the bone

Open or compound/complex

Infection of the bone

Osteomyelitis

Most prevalent bone disease in the world

Osteoporosis

Which wave represents atrial depolarization?

P wave

Disorder of localized bone turnover.. bone structure disorganized, weak, and highly vascular

Paget's disease

Most common symptom of rheumatic diseases

Pain

6 P's of assessing neurovascular changes

Pain Poikilothermia Pallor Pulselessness Parasthesias Paralysis

HR >150 rhythm is regularly irregular

Paroxysmal Supraventricular Tachycardia (PVST)

Most common major suppurative complication of sore throat

Peritonsillar abscess (Quinsy)

Foot with an abnormally high arch and a fixed equinus deformity of the forefoot

Pes cavus

Anti-platelet drugs prevent what?

Platelets from sticking together

Three P's of hyperglycemia

Polyuria, polydipsia, polyphagia

Prolonged hoarseness of more than 2 weeks can be a sign of what?

Possible laryngeal cancer. Prolonged hoarseness should be followed-up by a physician.

The most important electrolyte we focus on with heart problems

Potassium

How are you able to distinguish a bacterial infection from something viral?

Presence of a fever and elevated WBC count

Post-Op position for after a tonsillectomy

Prone position(laying on stomach, head to side)

Braces are used to:

Provide support, control movement, prevent additional injury

Normal conduction pathway of the heart

SA node -> Internodal pathways-> AV node -> Bundle of His -> R&L Bundle Branches -> Perkinje Fibers

Prevention of Occupational-Related Injuries

Safe patient handling training/proper use or equipment Correct use of body mechanics

Pulled muscle injury to the musculotendinous unit (pain, edema, muscle spasm, ecchymosis, loss of function.. graded by 1st, 2nd, and 3rd degree)

Strain

HR >150 regular rhythm

Supraventricular Tachycardia (SVT)

What should you avoid with a sinus infection?

Swimming, diving, air traveling(pressure) Smoking

Ejection Fraction (EF)

The percentage that the ventricles empty

What is usually the first drug prescribed for treating HTN?

Thiazide Diuretic

True or False: The nurse never adjusts the clamps on an external fixator frame

True. It is the physicians responsibility to do so

True or False: The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs

True. Removal of the weights completely defeats the purpose and may result in injury to the patient

Prevention of Sports-Related Injuries

Use of proper equipment; running shoes for runners, wrist guards for skaters, and so on Effective training and conditioning specific for the person and the sport Stretching before engaging in a sport or exercise Hydration Proper nutrition

What is the recommended dosage for nasal spray?

Use only twice a day for 3 days MAX

#1 treatment for all atria arrhythmia

Vagal Maneuvers

Normal pulse present

Venous

Warm to touch, thick/tough skin, brownish color

Venous

Edema at night

Venous disorder

Lesions on medial parts of lower legs, drainage and granulation present

Venous disorders

Systolic HF results from what?

Weakened heart muscle

Which topics will the nurse include in discharge teaching of a patient with heart failure? SATA: a. How to record and monitor daily weight b. S.S of worsening heart failure c. Purpose of chronic antibiotic therapy d. How to read food labels for sodium content e. Date and time of follow up appt

a, b, d, e Discharge teaching of a client with HF includes knowing how to weigh daily, knowing the S.S of HF, knowing how to read food labels, and the date/time of follow up appts.

The nurse is caring for a client who had a tonsillectomy. The client has an intact gag reflex. What are appropriate nursing interventions? SATA a. Apply an ice collar to the client's neck b. Encourage the client to eat ice chips c. Have the client cough frequently d. Administer pain meds as ordered e. Monitor for an increase in the pulse rate

a, b, d, e Having the client cough would cause bleeding

The nurse is gathering data on a client with obstructive sleep apnea. Which findings are consistent with this client's diagnosis? a. Excessive daytime sleepiness b. Morning headaches c. Increased incidence of falls d. Snoring during sleep e. Repeated episodes of apnea

a, b, d, e Signs and symptoms of OSA include: excessive daytime sleepiness, morning headaches, snoring while sleeping, and repeated episodes of apnea.

Which classification of medications play a pivotal role in the management of HF caused by systolic dysfunction? a. ACE inhibitors b. Beta-blockers c. Diuretics d. Digitalis

a. ACE inhibitors

A client with a nasal fracture is being discharged. Which of the following discharge instructions would be most effective for decreasing pain and edema? a. "Apply cold compresses to the area" b. "Perform mouth care often" c. "Use a bedside humidifier while sleeping" d. "Use a corticosteroid nasal spray"

a. Apply cold compresses to the area Pain and edema can be decreased by the application of cold compresses to the area.

A client is brought to the emergency department following a motor vehicle collision. The client's VS; BP 70/50, HR 123 and RR 8. The nurse anticipates the results of which diagnostic test to best evaluate the client's oxygenation and ventilation status? a. Arterial blood gas b. Chest x-ray c. Hct level d. Serum lactate level

a. Arterial blood gas An ABG is the best way to determine oxygenation and ventilation status.

A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessment should the nurse perform the first post-op day? a. Assess pulses of the affected extremity every 15 minutes b. Palpate the leg for pain during every assessment c. Assess for S.S of compartment syndrome q2h d. Perform Doppler evaluation once daily

a. Assess pulses every 15 minutes

Which of the following interventions would be important to include in the care of a client with pneumonia? SATA: a. Assist the client in using a bedside commode b. Evaluate effectiveness of incentive spirometer use c. Limit the amount of oral fluid the client intakes d. Place the client in a negative pressure room e. Teach the client to cough and deep breathe

a. Assist with a bedside commode b. Evaluate effectiveness of incentive spirometer use e. Teach to cough and deep breathe This conserves energy and assist the client in maintaining a good gas flow.

The nurse assesses a client with a fever and productive cough for the past 10 days. Which findings support the presence of pneumonia? a. Pleuritic chest pain b. Hyperresonance c. Course crackles d. Shortness of breath e. Tracheal deviation

a. Chest pain c. Crackles d. SOB

The nurse is changing the dressing, injection caps, and IV tubing of a client who is receiving TPN through a right PICC line. The nurse should implement what precautions during this procedure? SATA: a. Clamp the PICC line before removing and changing the injection caps b. Instruct the client to keep their head turned to the right during the procedure c. Perform hand hygiene before and after the procedure d. Place the client in a trendleburg position e. Put on sterile gloves and a mask before performing the procedure

a. Clamp the PICC line c. Hand hygiene e. Sterile gloves and mask

The nurse should assess a client for left-sided heart failure for which of the following? SATA: a. Decreased O2 sat b. Ascites c. Crackles d. JVD e. Oliguria

a. Decreased O2 sat c. Crackles e. Oliguria These are all symptoms of left-sided heart failure.

An adult client has tested positive for TB. While providing client teaching, what information should the nurse prioritize? a. Importance of adhering to the medication regimen b. The fact that the disease is a lifelong, chronic disease c. The fact that it is self-limiting and can take up to 2 years to resolve d. The need to work closely with the occupational and physical therapists

a. Importance of adhering to the medication regimen Successful treatment of TB is highly dependent on careful adherence to the medication regimen.

Which statements made by the patient demonstrate understanding of the pursed-lip breathing technique? a. Inhale through the nose while slowly counting to 3 b. Exhale slowly and evenly against pursed lips while tightening abdominal muscles c. Count to 7 slowly while prolonging expiration through pursed lips d. Inhale through the nose while walking 2 steps e. Exhale slowly while walking 8-10 steps

a. Inhale through nose while slowly counting to 3 b. Exhale slowly and evenly while tightening abdominal muscles c. Count to 7 slowly while prolonging expiration d. Inhale while walking 2 steps (exhale while walking 5 steps)

A client is being discharged home on oxygen. What information should the nurse give to the client regarding safe oxygen use? SATA a. Keep oxygen tank out of direct sunlight b. Secure oxygen tank when riding in a car c. Use petroleum based products on oxygen equipment d. Post "No smoking- oxygen in use" signs

a. Keep out of direct sunlight b. Secure while in car d. Post No smoking signs

A client has questioned the nurse's administration of IV normal saline, asking whether sterile water would be a more appropriate choice than "saltwater". Under what circumstances would a nurse administer electrolyte-free water instead? a. Never, because it rapidly enters RBCs causing them to rupture b. When the client is severely dehydrated resulting in neuro S.S c. When the client is in excess of calcium or magnesium ions d. When a client's fluid volume deficit is due to acute or chronic renal failure

a. Never, because it rapidly enters RBCs causing them to rupture.

The chemotherapy client has been admitted with thrombocytopenia. What blood product should the nurse anticipate giving? a. Platelets b. Fresh frozen plasma c. Whole blood d. PRBCs e. WBCs

a. Platelets Thrombocytopenia is a low platelets.

The physician orders D5N5 at 100 mL/hr for a client diagnosed with CHF. Which of the following is the nurse's BEST intervention? a. Use an infusion pump to administer the meds b. Monitor breath sounds periodically c. Monitor the client's urine output each shift d. Monitor the IV site for infiltration

a. Use an infusion pump to administer the meds This will PREVENT fluid overload. The other interventions will not.

Which statements made by a client show understanding of home management of PAD? SATA: a. "I will apply moisturizing lotion to my legs every day" b. "I will elevate my legs at night when I'm sleeping" c. "I will keep my legs below the level of my heart when sitting" d. "I will start walking outside daily" e. "I will use a heating pad to promote circulation in my legs"

a. apply lotion c. keep legs below level of heart d. walking daily

A 79 year old male is admitted to the floor with digital gangrene. Which of the following is most important for the nurse to assess in this client? a. presence of peripheral pulses b. measurement of ankle-brachial index c. presence of sensation in the client's feet d. measurement of blood glucose level

a. presence of peripheral pulses Poorly perfused toes are susceptible to gangrene.

Which of the following are significant data to gather from a client who has been diagnosed with pneumonia? SATA: a. quality of breath sounds b. presence of bowel sounds c. LOC and orientation d. amount of peripheral edema e. color of nail beds

a. quality of breath sounds c. LOC and orientation e. color of nail beds These all indicate respiratory status

Risk factors for osteoporosis

age, skinny, smoking, alcoholics, steroids, menopause, malnutrition, family hx, Asians/whites

Diabetes Insipidus

antidiuretic hormone is not secreted adequately, or the kidney is resistant to its effect - dump dilute urine, low specific gravity, dehydration Treatment is DDAVP

The nurse is caring for a client in the ED with a epistaxis (nosebleed). Which of the following interventions should the nurse implement? a. Position the client supine and turned on side b. Apply direct pressure to the nose c. Apply heat or a warm compress to the nose d. Teach the client to avoid blowing the nose e. Maintain standard body substance precautions

b. Apply direct pressure to the nose d. Avoid blowing the nose e. Maintain standard body substance precautions

A client with a PIV line that is infusing NS @80 mL/hr states the insertion site is painful. Assessment of the site reveals a vein that is warm, red, and hard. Which actions would the nurse take? SATA: a. Restart an IV distal to the affected site b. Apply warm soaks to the painful site c. Discontinue the IV at the affected site d. Slow the infusion rate while notifying the physician e. Document the action taken and the client's response

b. Apply warm soaks c. Discontinue IV e. Document IV should be restarted proximal to the IV site.

A nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication? a. ARDS b. Atelectasis c. Aspiration d. Pulmonary embolism

b. Atelectasis

A client comes to the ED with severe dyspnea and a cough. The client has a history of COPD and CHF. Which diagnostic test will be most useful to the nurse to determine if this is an exacerbation of HF? a. Arterial blood gas (ABG)\ b. B-type natriuretic peptide (BNP) c. Cardiac enzymes (CK-MB) d. X-ray of the client's chest

b. BNP The diagnostic test for an exacerbation of heart failure is BNP.

An older adult with a history of left-sided HF is admitted to the ED complaining of weakness and fatigue. On admission, which should the nurse assess first? a. serum potassium b. BP c. abdominal distention d. urine output

b. BP Left sided HF leads to a decreased cardiac output that could lead to weakness and fatigue. BP is a good indicator of cardiac output.

What is a contusion? a. A musculotendinous injury B. Blunt force injury to soft tissue C. A break in the continuity of a bone d. an injury to ligaments and other soft tissues at a joint

b. Blunt force injury to soft tissue Fracture is a break in the continuity of a bone. Sprain is an injury to ligaments and other soft tissues.

A nurse priming an IV administration set uncaps the distal end to attach a needless device. Before administration, the administration set falls and hits the countertop. Which action should be taken by the nurse? a. Attach a new needless device b. Change the administration set c. Wipe the tubing port with iodine d. Scrub the needless device with an alcohol swab

b. Change the administration set Contamination could result in systemic infection for the patient

The physician has ordered a PIV to be inserted before the clients goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter? a. Choose a hairless site if possible b. Consider potential effects on the clients mobility when selecting a site c. Have the client briefly hold his arm over his head before insertion d. Leave the tourniquet on for atleast 3 minutes

b. Consider potential effects on the clients mobility when selecting a site Ideally, both arms and hands are inspected closely before insertion of an IV catheter. Instruct the patient to hold their arm in a dependent position to increase blood flow. Never leave a tourniquet on for more than 2 minutes. The site does not have to be devoid of hair.

A nurse is preparing an IV infusion for a client. Which of the following statements does the nurse know as TRUE when comparing plastic and glass IV infusion containers? SATA: a. Plastic containers are more expensive b. It is easier to measure the contents in glass containers c. Glass containers need to be vented before using d. Some medications may bind to plastic containers e. Glass containers are safer to use than plastic

b. Easier to measure in glass c. Need to be vented d. Medications may bind to plastic

The primary reason for infusing blood over four hours is to prevent which of the flowing complications? a. Emboli formation b. Fluid volume overload c. Red blood cell hemolysis d. Allergic reaction

b. Fluid volume overload

The nurse is caring for a patient after a hysterectomy. The patient presents with increased HR, decreased BP, weak pedal pulses, and decreased UOP. Which complication of a hysterectomy should the nurse be concerned about? a. Bladder dysfunction b. Hemorrhage c. Pain d. VTE

b. Hemorrhage Signs of hemorrhage are the ones she is presenting with.

The nurse is caring for a client with heart failure who has orthopnea. In which of the following positions should the nurse place the client? a. Semi-Fowler's with legs elevated on pillows b. High-fowler's with legs dangling off the side c. Side lying with a pillow between the legs d. Lying in the prone position with legs elevated

b. High-Fowler's with legs dangling off the side This decreases the rate of venous return

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary HTN. What clinical manifestations are most likely to be assessed in this client? SATA: a. Crackles in the lung bases b. Increased abdominal girth c. JVD d. Edema of lower extremities e. Orthopnea

b. Increased abdominal girth c. JVD d. Edema Signs of right sided HF include: ascites (which will increase the abdominal girth), JVD, and edema of the lower extremities. Crackles and orthopnea are signs or left sided HF.

Which medication blocks synthesis of thyroid hormone? a. Dexamethesone b. Methimazole c. Potassium iodide d. Sodium iodide

b. Methimazole

A nurse is helping to prepare a client for thoracentesis. What should the nurse include in this client's teaching? SATA: a. "You should be NPO for 6 hours" b. "You need to sign a consent form for the procedure" c. "You will assume a sitting position at the side of the bed" d. "This is an aseptic procedure, so the site is cleaned" e. "You will need to take frequent deep breaths during this procedure" f. "The physician will collect fluid from the space between your lung and the chest wall."

b. Need a signed consent form c. Assume a sitting position at side of bed d. Aseptic procedure f. Fluid collected from space between lung and chest wall

The nurse is caring for a client who has been receiving oxygen per nonrebreathing mask for 4 days. The client begins complaining of dyspnea, substernal chest pain, and paresthesia. The nurse reviews the client's chest x-ray report which shows pulmonary infiltrates. Which of the following is the most likely cause of this client's presentation? a. Pulmonary embolus b. Oxygen toxicity c. Myocardial infarction d. Circulatory hypoxia

b. Oxygen toxicity

The nurse is caring for a client who has returned to the unit following a bronchoscopy. They are asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids? a. Absence of nausea and vomiting b. Presence of a cough and gag reflex c. Ability to demonstrate deep inspiration d. Oxygen saturation of greather than 92%

b. Presence of a cough and gag reflex

A client is being discharged home after a total laryngectomy. What should the nurse include in the discharge instructions? a. Perform oral care every other day b. Provide adequate humidification in the home c. Maintain a soft, low calorie, bland diet d. Limit activity to shoulder and neck exercises

b. Provide adequate humidification in the home This prevents the airway secretions from drying out

A client with COPD is experiencing severe dyspnea. The physician orders oxygen per rebreathing mask. Which of the following assessments is a priority for this client? a. Neuro b. RR c. CV d. GI

b. Respiratory rate

The nurse is assessing a client who just had a thoracentesis for recurrent pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which of the following assessment findings will the nurse report to the physician immediately? a. Client is crying and states she cannot continue the treatment much longer. b. The client's breath sounds are diminishing on the side of the procedure c. Client's BP is at 110/48 and the HR is 94 d. There is a 1 cm drainage on the thoracentesis drainage

b. The client's breath sounds are diminishing on the side of the procedure This is a sign of a collapsed lung

The client has a unit of blood infusing. Which effect does the nurse expect when transfusion is complete? a. This client's BP will increase b. The client's Hemoglobin levels will improve c. There is no need to worry about a transfusion reaction d. This client should be assessed for emotional depression

b. The client's hemoglobin levels will improve

The nurse is admitting a client with HF related fluid overload. Which action should the nurse complete FIRST? a. administer oxygen b. assess breath sounds c. initiate cardiac monitoring d. insert a PIV catheter

b. assess breath sounds Fluid overload will either cause pulmonary or peripheral edema.

A client has a Mantoux test of 8-mm induration. The test is considered positive when the client: a. lives in a long term facility b. is immunocompromised c. has no known risk factors d. works as a health care provider

b. is immunocompromised An induration of 5mm or greater is significant in a patient who is immunocompromised. An induration of 10mm or greater is considered significant in patient who is normal or has mildly impaired immunity.

A client with PAD is visiting the health clinic. The nurse completes a health assessment. Which statement by the client indicates a need for teaching? a. "I always take my Zocor in the evening" b. "I use a heating pad on my feet when they are cold" c. "I've been walking on my treadmill for 15 minutes every day" d. "I've noticed that I don't have much hair on my lower legs"

b. using a heating pad on feet This can cause a thermal injury

The nurse is preparing to initiate a blood transfusion. The client is receiving a PIV infusion of a medication into their left arm. The nurse prepares to initiate a PIV in the right arm. The client states "Can't you use the one I already have. I really don't want to be stuck again." How should the nurse respond to this client? a. "I need to assess the IV site before making a decision" b. "I will notify the physician of your preference." c. "Blood has to be transfused through a separate IV" d. "That will be fine. It will be okay to use the existing IV"

c. "Blood has to be transfused through a separate IV"

How long does a patient taking bisphosphates need to stay upright after administration? a. 10 minutes b. 20 minutes c. 30 minutes d. 120 minutes

c. 30 minutes Bisphosphates are administered on arising in the am with a full glass of water on an empty stomach, pt must stay upright for 30-60 minutes

The nurse is providing care for a client who needs a blood transfusion. The client states they are a universal recipient. The nurse knows that the client's blood type is most likely: a. A b. B c. AB d. O

c. AB Blood type AB is the universal recipient. Blood type O is the universal donor.

The nurse is preparing to insert a peripheral IV catheter into a client who will require IV fluids and antibiotics. How should the nurse ALWAYS start the process of insertion? a. Leave one hand ungloved to assess the site b. Cleanse skin with normal saline c. Assess patient for allergies d. Remove hair from selected site

c. Assess patient for allergies Always assess for allergies first. Both hands should be gloved when preparing for IV insertion. Normal saline is usually not used to cleanse the skin. Hair removal comes secondary to assessing the patient for allergies.

A client is receiving 1,000 mL NS with 40 mEq of KCl IV which has been prescribed to infuse @125 mL/hr. The client states "My IV hurts." What should the nurse do FIRST? a. Restart the IV in a new site b. Stop the IV infusion and call the physician. c. Assess the IV site for infection and extravasation d. Check the IV tubing label to determine when last changed

c. Assess the IV site for infection and extravasation K can be irritating the vein. The nurse should assess the IV site before doing any of the other actions listed. The infusion may have to be stopped and the physician contacted.

A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site? a. Leave the hair intact b. Shave the hair with a disposable razor c. Clip the hair in the area d. Remove the hair with a depilatory

c. Clip the hair in the area Hair can be a source of infection and should be removed by clipping.. do not leave it at the site. Shaving the area with a disposable razor can cause skin abrasions, and depilatories can irritate the skin.

A client with pneumonia is having a difficult time raising secretions for a sputum culture. Which action should the nurse take first? a. Administer a bronchodilator b. Suction the client to obtain a specimen c. Encourage the client to take deep breaths d. Obtain the specimen with a cotton-tip swab

c. Encourage the client to take deep breaths Deep breathing can trigger a cough and help raise sputum. Suction and bronchodilators are more invasive and would not be performed first. A cotton-tip swab is used to obtain a throat culture, not a swab specimen.

The nurse is assisting a physician peforming a thoracentesis. The client is too weak to sit up for the procedure. Which of the following would be the nurses best action? a. Cancel the procedure and contact the physician b. Position the client supine with the bed in a flat position c. Position on unaffected side and elevate HOB 30 degrees d. Position on affected side and elevate HOB 90 degrees

c. Position on unaffected side and elevate HOB 30 degrees Only elevate HOB 30-45 degrees

A nurse is caring for a client with pneumonia whose respiratory status is declining. Which of the following interventions would a nurse perform first? a. Administer oxygen via NC @2L/min b. Call the client's attending physician c. Position the client at a 45 degree angle d. Prepare suctioning equipment at the bedside e. Administer ordered bronchodilators

c. Position the client at a 45 degree angle This is the first thing a nurse should do. Fowler's position facilitates the relaxing of tension of the abdominal muscles, allowing for improved breathing.

A nurse has the following orders for a client diagnosed with suspected TB. Which order should the nurse carry out first? a. Oxygen @2L/min b. Sputum for acid fast bacilli c. Respiratory isolation d. Routine vital signs

c. Respiratory isolation This needs to be done first to prevent further spread.

A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of peripheral arterial occlusive disease by: a. scanning the affected extremity and identifying the areas of volume changes b. using sound waves to estimate velocity changes c. showing the location of the obstruction and the collateral circulation d. determining changes in brachial index pressure when the client walks

c. showing the location of the obstruction and the collateral circulation Injects dye into an artery to show the location of the obstruction and the collateral circulation present.

Inflammation of the gallbladder

cholecystitis

Viral Rhinitis

common cold, which is very contagious Interventions: fluids, rest, warm salt gargles, NSAIDs, antihistamines, expectorants, decongestants

Cretinism

condition of congenital hypothyroidism in children that results in a lack of mental development and dwarfed physical stature; the thyroid gland is either congenitally absent or imperfectly developed

A nurse is applying a transparent, semipermeable membrane dressing to an IV site. The nurse should take care to place the dressing so that it:

covers the area surrounding the IV site up to the top margin of the cannula hub.

A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client? a. "Hold it at your lips and breathe in and out like you normally would" b. " When you're ready, blow hard into the spirometer for as long as you can" c. "Take a deep breath and blow short, forceful breaths into the spirometer" d. " Breath in deeply through the spirometer, hold your breath briefly, then exhale"

d. "Breathe in deeply through the spirometer, hold your breath briefly, then exhale" Hold breath at the end of expiration for about 3 seconds

The nurse is assessing a client suspected of having PAD. Which statement made by the client is consistent with PAD? a. "At the end of the day, my socks and shoes are tight." b. "I have a slow healing sore on my right ankle" c. "My legs swell when I stand for extended periods" d. "When I sit down and elevate my legs, the pain increases"

d. "When I sit down and elevate my legs, the pain increases" When the legs of a client with PAD are elevated, the circulation to the legs is affected and the pain will increase.

A client on Lasix becomes hypovolemic secondary to diuresis. What is the nurse's most appropriate action? a. add sodium to the client's IV as ordered b. administer an IV vasoconstrictor as ordered c. stop administering the diuretic as ordered d. administer NS IV as ordered

d. Administer NS IV as ordered The treatment for hypovolemia is the administration of fluids

A 24 hour urine collection is scheduled to start at 0100. When should the nurse start the procedure? a. At 0100, with or without a specimen b. At the first specimen that was voided at 0400 c. 2 hours after the urine was discarded d. After discarding the 0100 specimen

d. After discarding the 0100 specimen

A client's plan of care specifies postural drainage. What action would be most appropriate for the nurse to perform when providing this noninvasive therapy? a. Administer the treatment in a High-Fowler's position b. Perform procedure immediately following morning meal c. Instruct client to remain in the position for atleast 30 minutes d. Assist the client into a position that will allow gravity to move secretions

d. Assist the client into a position that will allow gravity to move secretions Performed 2-4x per day. Gravity moves secretions. Only stay in each position 10-15 minutes.

The nurse had entered a client's room and found the client unresponsive and not breathing. What is the nurse's appropriate next action? a. Palpate the client's carotid pulse b. Give the client 2 breaths c. Begin chest compressions d. Call and activate a code blue

d. Call/activate code blue

The nurse in the outpatient procedure unit is caring for a patient immeditaley post bronchoscopy to obtain a lung biopsy. Which assessment data indicate the nurse needs to contact the physician immediately? a. Absence of gag reflex b. Blood tinged sputum c. Complaint of headache d. Decreasing oxygen saturation

d. Decreasing oxygen saturation

A nurse instructs the client in the use of incentive spirometry. What is an expected outcome of this treatment? a. Increases lung surface available for exchange b. Increases blood flow to the lung tissues c. Controls the rate of airflow to the alveoli d. Expands the alveoli and prevents collapse

d. Expands the alveoli and prevents collapse The purpose of the incentive spirometer is to maximize lung inflation and prevent atelectasis.

The nurse observes that a patient's TPN was infusing at an incorrect rate and is now 2 hours behind. what action is MOST appropriate for the nurse to take to correct the problem? a. Readjust the solution rate to infuse the desired amount b. Continue the current infusion and increase the rate of the next bag c. Double the infusion rate for 2 hours, then adjust it after d. Notify the physician and infuse at the rate of the physician's orders

d. Notify the physician and infuse at the rate of the physician's orders.

The nurse is teaching a client how to manage a nose bleed. Which instructions given to the client are most appropriate? a. "Tilt your head backward and pinch the soft part of your nose: b. Lie down flat and apply an ice pack to your nose c. Blow your nose gently while turning your head to the side d. Sit down, lean forward, and pinch the soft part of your nose

d. Sit down, lean forward, and pinch the soft part of your nose This prevents swallowing of blood.

Which diuretic medication would most often be used for a patient with ascites? a. Actazolamide (Diamox) b. Ammonium chloride c. Furosemide (Lasix) d. Spironolactone (Aldactone)

d. Spironolactone (Aldactone) This drug is most often the first-line therapy in patients with ascites from cirrhosis.

The nurse is assessing a client recovering from viral rhinosinusitis. Which of the following would the nurse be most concerned about? a. The client's daily fluid intake is 2.5 L b. The client states they can breath easier c. The client is taking expectorant as prescribed d. The client is coughing up green sputum

d. The client is coughing up green sputum Patient's with upper respiratory viruses need to increase their fluid intake to thin secretions. 2.5 l is adequate hydration. Coughing of green sputum could indicate a secondary infection

Which of the following is an expected outcome of pursed-lip breathing? a. To promote oxygen intake b. To strengthen the diaphragm c. To strengthen the intercostal muscles d. To prevent airway collapse

d. To prevent airway collapse Pursed-lip breathing helps to prevent airway collapse secondary to lung elasticity.

A client has been diagnosed with a malignant tumor in the bronchial tube. The nurse should recognize this can cause a disturbance in what aspect of normal respiratory function? a. Acid-base balance b. Diffusion c. Perfusion d. Ventilation

d. Ventilation Obstruction of the airway increases airway resistance which affects ventilation.

The nurse is assessing an 88-year old client who is taking digoxin daily. Which finding is most important to communicate to the client's physician? a. Pulse of 68 that is irregularly irregular b. crackles in lungs that clear with coughing c. client takes digoxin with morning meal d. client complains of vision being "fuzzy"

d. client complains of vision being "fuzzy" Changes in vision are a sign of digoxin toxicity

The nurse is planning care for a client diagnosed with peripheral vascular disease (PVD) and a history of heart failure. The nurse should develop a plan of care based on the fact the client may have a low tolerance for exercise related to: a. increased blood viscosity b. increased blood flow c. decreased blood viscosity d. decreased blood flow

d. decreased blood flow PVD is decreased blood flow. Blood viscosity is not an issue in PVD.

What is the primary rationale that supports multidrug treatment for client's with TB? Multiple drugs: a. reduce undesirable adverse affects b. potentiate the actions of the drugs c. allow reduced drug dosages to be given d. reduce development of resistant strains

d. reduce development of resistant strains

What color are pigment stones

dark brown

Older patients may have atypical S.S of HF.. what are they?

fatigue, weakness, somnolence, confusion

Urge incontinence

the loss of urine in response to a sudden, urgent need to void; the person cannot get to a toilet in time

Functional incontinence

urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation