All the Prepu's

The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply. Absence of brainstem reflexes No brain waves Apnea Coma

Absence of brainstem reflexes Apnea Coma

Which are possible long-term complications of spinal cord injury? Select all that apply. respiratory arrest areflexia autonomic dysreflexia respiratory infection

autonomic dysreflexia respiratory infection

Respiratory alkalosis is always caused by

hyperventilation,

. The nurse is admitting a client immigrating from a developed country with mitral valve regurgitation. What is the most common cause of mitral valve regurgitation in developed countries?

ischemia of the left ventricle

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

respiratory alkalosis

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

respiratory alkalosis blowing off all the Co2 which is acidic so alkalosis

A client seeks medical attention for a new onset of fatigue and changes in coordination. Which additional assessment finding indicates to the nurse that the client is demonstrating signs of low oxygenation? Select all that apply

• Shortness of breath • Impaired thought process • Agitation

En route to the emergency room, a client's systolic blood pressure (BP) was 96 mm Hg and falling. Which systolic BP supports the diagnosis of septic shock? Select all that apply 72 mm Hg 80 mm Hg 98 mm Hg 56 mm Hg

72 mm Hg 80 mm Hg 98 mm Hg

.The nurse is assisting in the triage of multiple trauma victims. Which clients will the nurse categorize as delayed in the yellow stage? Select all that apply.

A client with an eye injury

The nurse is assisting the client to manage the cardiovascular risk factors of hyperlipidemia and hypertension. The client asks the nurse what type of a diet would be best to follow. What is the best response by the nurse?

A diet low in sodium, fat, cholesterol

nurse is caring for a client with a cardiac disorder who is prescribed diuretics. What important factor should the nurse include in this client's teaching plan?

A discussion of the signs and symptoms of electrolyte and water loss.

The registered nurse reviewed the patient's vital signs and noted a consistent pattern of heart rate recordings between 48 and 58 bpm over a 24-hour period of time. What medication will cause bradycardia?

A. Atenolol Atenolol is a beta-blocker that can lower the heart rate. The other medications stimulate the sympathetic response which will increase heart rate

The nurse is planning care in the home for a client with rheumatoid arthritis. What instruction(s) should the nurse include in the plan of care? Select all that appl

Collaborate with occupational therapists for specialized equipment. Identify the exercise regimen planned by physical therapist. Provide nursing assistance for ADLs. Ensure the home environment is safe.

Corticosteroids are used in the management of brain tumors to

Corticosteroids are used in the management of brain tumors to

A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? Choose all correct options.

Death Permanent neurologic dysfunction Impaired cellular activity Seizures

A client is brought to the emergency department with injuries obtained from a motor vehicle crash. Which action will the nurse take during the secondary survey of the client? Select all that apply.

Head-to-toe assessment Results of laboratory tests History of the current event Splinting of suspected fractures

The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply heart rate urine output o2 creatinine clearence

Heart rate urine output

Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply Hemiparesis Tachypnea Decreased reactivity of the pupils Bradycardia Hypotension Coma

Hemiparesis Decreased reactivity of the pupils Bradycardia Coma

A client is diagnosed with polycystic ovarian syndrome. Which of the following findings would the nurse expect to assess? Select all that apply. Hirsutism Emaciated appearance Impaired glucose tolerance Sleep apnea Menorrhagia

Hirsutism Sleep apnea Impaired glucose tolerance

A client with acute myeloid leukemia (AML) is scheduled to begin induction therapy. Which treatments will the nurse expect to be prescribed to prevent life-threatening effects of this therapy? Select all that apply. Platelets Antibiotics Packed red blood cells Granulocytic growth factors Hematopoietic stem cell transplant

Platelets Antibiotics Packed red blood cells Granulocytic growth factors

. A nurse assesses a client with pneumonia. Which assessments are diagnostic for pneumonia? Select all that apply. • Presence of crackles • Egophony • Wheezes • Whispered pectoriloquy • Percussion dullness

Presence of crackles • Egophony • Wheezes • Whispered pectoriloquy • Percussion dullness

The nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs) for impaired tissue oxygenation resulting from hemorrhage. After 15 minutes of the transfusion, the nurse notes the client has a fever and shortness of breath. Place in order the steps the nurse should take in response to these findings. Use all options. -Assess the need for airway support -Ensure the normal saline IV is open -Notify the physician -Check full vital signs -Intervene for any S & S as appropriate -Stop the transfusion

• Stop the transfusion • Ensure the normal saline IV line is open • Assess need for airway support • Check full vital signs • Notify the physician • Intervene for any signs and symptoms as appropriate

A client being mechanically ventilated through an endotracheal tube for 14 days has a percutaneous tracheostomy inserted at the bedside. Which interventions will the nurse anticipate will be included in the client's plan of care? Select all that apply.

• Suction as necessary • Monitor oxygen saturation • Check cuff pressure every 8 hours • Change tape and dressing as needed

The nurse working in the medical intensive care unit is caring for a client admitted with mitral stenosis. What will the nurse assess is related to the pathophysiology of mitral stenosis? Select all that apply. • fatigue • low-pitched murmur • shortness of breath with activity • history of endocarditis • blood in urine • history of BPH

• l fatigue • low-pitched murmur • shortness of breath with activity • history of endocarditis

A client with a history of atrial fibrillation has experienced a TIA. What does the nurse expect will be the priority preventative medical treatment(s) to reduce the risk of a cerebrovascular accident (CVA)? Select all that apply.

•Cholesterol-lowering drugs • Anticoagulant therapy

. The nurse is creating a care plan for a client diagnosed with heart failure. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply.

•Facilitate the presence of friends and family whenever possible. • Provide supplemental oxygen, as needed. • Provide validation of the client's expressions of anxiety.

The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. Contractures Hemorrhage Pressure ulcers Venous thromboembolism Pneumonia

Pressure ulcers Venous thromboembolism Pneumonia Contractures

When a patient is taking an immunosuppressant following heart transplantation, the nurse would determine which of the following as the MOST important intervention?

assess Vital signs every 4 hours

An ED nurse is assessing a 71-year-old female client for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female clients? Select all that apply. a) Shortness of breath b) Chest pain c) Anxiety d) Indigestion e) Nausea

d) Indigestion e) Nausea

A client with frequent premature ventricular contractions is prescribed amiodarone. The nurse will withhold the medication until the completion of which diagnostic test?

pulmonary function

The nurse is caring for a client 48 hours after their burn injury. Which treatment will the nurse anticipate to reduce the client's risk of mortality remove burned tissue intubation topic anitmicrobial ointment

remove burned tissue

A young man incurred a spontaneous pneumothorax. The physician has just inserted a chest tube and has prescribed suction set at 20 cm of water. The nurse instills the fluid to this level in the appropriate chamber. Mark the level of fluid on the appropriate chamber of the closed drainage system

right below A

A 54-year-old male patient is admitted to the hospital with a case of severe dehydration. The nurse reviews the patient's laboratory results. Which of the following results are consistent with the diagnosis? Select all that apply.

• Blood urea nitrogen (BUN) of 23 mg/dL • Serum osmolality of 310 mOsm/kg • Serum sodium of 148 mEq/L • Urine specific gravity of 1.03

. When the nurse is assessing the older adult patient, what gerontologic changes in the respiratory system should the nurse be aware of? (Select all that apply.)

• Decreased gag reflex • Increased presence of collagen in alveolar walls • Decreased presence of mucus

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.)

• Decreases hypoxemia • Decreases patient anxiety • Sustains positive end expiratory pressure (PEEP)

The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply.

• Extravasation • Infection • Hematoma • Phlebitis

A nurse is providing initial first-aid care to a patient who was bitten by a snake. Place the following actions in the order in which the nurse would perform them. Use all options.

• Have the patient lie down • Remove constricting clothing • Provide warmth • Clean the wound • Cover the wound with a light sterile dressing • Immobilize the injury below the level of the heart

The nurse is completing a physical assessment of an older adult's respiratory system. Which finding(s) indicate to the nurse that the client is experiencing an age-related change to the chest wall and respiratory muscles? Select all that apply.

• Kyphosis • Barrel chest • Shortness of breath • Abdominal breathing • Reduced cough reflex

. A nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates the resolution of the infection? Select all that apply

• Lung fields documented as clear. • Palpable vibrations over the chest wall when the client speaks. • Decreased fremitus when the client speaks "99." • Bronchovesicular sounds heard over the upper lung fields.

.A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Select all that apply. • Manual resuscitation bag • Pulse oximeter • intubation kit

• Manual resuscitation bag • Pulse oximeter

Which assessments should a nurse perform when caring for a client following a cardiac catheterization? Select all that apply.

• Monitor BP and pulse frequently. • Inspect pressure dressing for signs of bleeding. • Palpate the pulse in different locations.

The nurse assisting at the scene of a terrorist bombing is assessing bystanders for quinary effects from the blast. The nurse assesses for which signs and symptoms? Select all that apply.

Hyperpyrexia Diaphoresis

The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage?

Hyperthermia

The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? Select all that apply.

confusion bradycardia

A nurse is caring for a client in cardiogenic shock. Which vasopressor agents may be used in the treatment of the client? Select all that apply.

norepinephrine epinephrine vasopressin phenylephrine

The nurse is caring for a client with atrial fibrillation. What procedure would be recommended if drug therapies did not control the dysrhythmia? a. Defibrillation b. Maze procedure c. Pacemaker implantation d. Elective cardioversion

d. Elective cardioversion

A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?

decompensation

The nurse is assessing an older adult's cardiovascular system. Which assessment finding indicates to the nurse that the client is experiencing age-related changes to the conduction system? Select all that appl

exercise intolerance bradycardia

Which particular area(s) should be examined to assess peripheral edema?

feet and ankles

A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment?

flaccid

Which of the following is an early sign of increasing intracranial pressure (ICP)?

headache

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis?

lactated ringers

A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid-base imbalance?

metabolic alkalosis

vomiting =

metabolic alkalosis

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure?

vasodilation

A client comes to the health clinic after a positive skin test for tuberculosis. What additional diagnostic tests should the nurse begin teaching the client? Select all that apply.

• A chest radiograph • Complete history and physical examination • Drug susceptibility testing

A client being treated for a chronic illness has a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which assessment findings will the nurse expect to assess in the client? Select all that apply.

• Anorexia • Muscle weakness • Abdominal distention

The nurse is seeing a client who has a pelvic infection. The client is upset and states, "I have been in a monogamous sexual relationship for 5 years, how is this possible?" Which questions should the nurse ask to be able to rule out sexual transmission of this infection? Select all that apply

"Do you have an intrauterine device inserted?" "Have you and your partner ever discussed your sexual health histories?" "Do you have Pap smears on a regular basis?" "Did you have the human papillomavirus vaccination before you were 26 years old?"

The nurse is assessing the client's cardiovascular system. The client asks the nurse why the nurse presses on the toenails. Which is the best reply by the nurse

"I can see how quickly the blood returns to assess blood flow."

The nurse is evaluating the effectiveness of discharge teaching for a client with an oxalate urinary stone. Which statement by the client indicates the need for further teaching by the nurse? Select all that apply.

"I will never have another urinary stone again." "I need to take allopurinol." "Tylenol is best to control my pain "I'm so glad I don't have to make any changes in my diet."

The client with which characteristic is considered at high risk for the development of infective endocarditis?

- Cyanotic congenital malformation

The nurse is caring for a client with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply.

Assess for the presence of peripheral edema. Assess the client's BP.

the nurse is caring for a client who sustained a gunshot wound from a drive-by shooting. Which action will the nurse take to protect the chain of evidence? Select all that apply.

- Hang wet clothing until dried, then label and give to law enforcement. - Place each piece of the client's clothing in seperate paper bags. - Photograph any wounds twice, and one photograph should include a reference ruler.

he nurse is caring for a client with mitral valve prolapse. Which symptoms would be consistent with this diagnosis? Select all that apply.

- anxiety - fatigue - palpitations

The nurse is caring for a client on telemetry. The client's ECG shows atrial fibrillation, wide QRS and a fast, irregular ventricular rhythm. What does this ECG show?

Wolff-Parkinson-White (WPW) syndrome

A nurse is caring for a client with a fluid and electrolyte imbalance. What urine specific gravity would the nurse expect to measure?

1.018 normal is 1.010 to 1.020

Which group represents the fastest-growing segment of the population with AIDS?

Women

Several clients in the emergency department are being categorized by the triage nurse. Which client will the nurse place in the urgent category?

A 54-year-old client with a history of diabetes presenting with anemia and abdominal pai

The nurse is preparing information to help a client with neutropenia and limited mobility reduce the risk of infection. Which information will the nurse include in this teaching? Select all that apply. Avoid working in the garden. Increase the intake of fluids to 3 L per day. Use the incentive spirometer every 4 hours. Report a new onset of fever to the health care provider. Encourage socialization with others.

Avoid working in the garden. Increase the intake of fluids to 3 L per day. Use the incentive spirometer every 4 hours. Report a new onset of fever to the health care provider.

A client diagnosed with bladder cancer wants to avoid surgery. For which intravesical treatment will the nurse prepare teaching for this client?

Bacillus Calmette Guerin (BCG) Live

The Emergency Department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

Bicarbonate - Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.

The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply.

Burns Dehydration

A patient has had an implantable cardioverter defibrillator inserted. What should the nurse be sure to include in the education of this patient prior to discharge? (Select all that apply.)

Call for emergency assistance if feeling dizzy. Avoid magnetic fields such as metal detection booths. Record events that trigger a shock sensation.

When the appropriate electrocardiogram (ECG) complex follows the pacing spike, it is said to be

Capture - is a term used to denote that the appropriate electrocardiogram (ECG) complex followed by the pacing spike. Triggered response means that the pacemaker will respond when it senses intrinsic heart activity. Inhibited response means that the response of the pacemaker is controlled by the activity of the client's heart.

A client is being seen by an urologist for perineal pain, low back pain, fever lasting 5 days, and painful urination. The diagnosis of prostatitis is confirmed. What teaching should the nurse include? Select all that apply.

Complete the prescribed antibiotic treatment . Avoid prolonged sitting. Regularly drain the gland. Avoid caffeine products.

An older client underwent a lumpectomy for a breast lesion that was determined to be malignant. Which factors increase the risk for breast cancer? Select all that apply. Daily alcohol intake Increased age Nulliparity Obesity Silicone breast implants

Daily alcohol intake Increased age Nulliparity Obesity

A client with heart failure is prescribed to receive 2 units of packed red blood cells. Which actions will the nurse take to decrease the client's risk of developing transfusion-associated circulatory overload? Select all that apply.

Elevate the head of the bed Place feet in a dependent position Reduce the rate of transfusion to 100 mL/hr Provide furosemide as prescribed before the transfusion

The nurse is providing care to a client who was brought to hospital with a opioid overdose. The nurse should expect to include which immediate interventions in the care of this client? Select all that apply.

Ensure the head of the bed remains elevated Monitor naloxone intravenous infusion

The client with a brain tumor may be at increased risk for aspiration. What does the nurse determine is the most important nursing intervention?

Evaluation of gag reflex and ability to swallow

The nurse is caring for a client scheduled for a cardiac stress test at 1100. When the nurse enters the client's room at 0800, the client requests toast or at least some coffee. What is the best response by the nurse?

Explain that no food or drink is allowed for 4 hours before the stress test.

Enlargement of the prostate causes which of the following to occur? Select all that apply.

Frequency Oliguria Anuria Obstruction of urine flow

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

Lungs and kidney

A client is recovering from a below-the-knee traumatic amputation and is 72 hours post surgery. Which actions will the nurse take to promote healing of the wound? Select all that apply.

Measure the residual limb every 8 to 12 hours. Assess neurovascular function of the residual limb. Apply an elastic compression bandage over the wound site.

Which of the following is a term used to describe excessive menstrual bleeding?

Menorrhagia

The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur?

Metabolic alkalosis

client with infective endocarditis is admitted to the hospital. While obtaining a history, what should the nurse ask the client about? Select all that apply. Nasal piercing •Recent urinary tract infection •Renal dialysis •Prosthetic cardiac valves •Intravenous (IV) drug use

Nasal piercing •Recent urinary tract infection •Renal dialysis •Prosthetic cardiac valves •Intravenous (IV) drug use

The nurse is preparing to provide wound care to a client with extensive burns. Which characteristic of the dressing will the nurse use to select the type of topical therapy? Select all that apply.

Penetrates eschar without toxicity Effectiveness against organisms Cost-effective and acceptable to the client Easy to apply and remove to minimize pain

What is the drug of choice for a stable client with ventricular tachycardia?

Procainamide

A nurse who will be working at a health fair is preparing a presentation on reproductive health and contraception. Which of the following would the nurse expect to include as advantages of combined hormonal contraception? Select all that apply. Reduced incidence of benign breast disease Improved acne control Reduced risk of ovarian cancer Decreased risk of gallbladder disease Decreased risk of anemia

Reduced incidence of benign breast disease Improved acne control Reduced risk of ovarian cancer Decreased risk of anemia

The nurse is discharging a client after a cardiac catheterization. What would the nurse include in the discharge teaching?

Report any numbness, tingling, or sharp pain in the extremity.

A nurse is providing discharge teaching for a client with a burn wound on the leg. What instructions are important to give the client? Select all that apply.

Report increased redness and wound drainage to the healthcare provider. Wash the wound with soap and water. Continue physical therapy exercises.

A 30-year old client presents to the clinic for an employment physical. The nurse notes protein in the client's urine. The nurse understands that transient proteiunuria can be caused by which factor(s)? Select all that apply

a. fever b. strenuous exercise d. prolonged standing

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what actions should the nurse perform? Select all that apply.

administer oxygen place the client in a upright position

Which is the most frequent cause of diarrheal disease in the United States?

campylobacter infection

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate?

cancer

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to:

promote carbon dioxide elimination.

. A client who has recently started working in a coal mine is concerned the effects on long-term health. How does the nurse advise the client to prevent occupational lung disease? Select all that apply

• Do not smoke, or quit smoking if currently smoking. • Wear appropriate protective equipment when around airborne irritants and dusts.

A client experiencing palpitations is diagnosed with mitral valve prolapse after having an echocardiogram. Which teachings will the nurse provide to the client about this condition? Select all that apply.

• Eliminate alcohol from the diet. • Abstain from all tobacco products.

. Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?

Record the observation

A client is seen in the emergency department and reports left arm pain, fatigue, palpitations, and shortness of breath. Which condition would the nurse suspect?

acute coronary syndrome

The nurse is teaching a client with heart failure about digoxin. What statements by the client indicate the teaching is effective? Select all that apply.

"I will watch my urine output to be sure that the medication is not affecting my kidneys." • "If I take my digoxin I should have limited episodes of shortness of breath."

he nurse is providing care for a client who just discussed palliative care with the primary health care provider. The client's family member was also part of the discussion and asks the nurse, "I feel like this kind of treatment means we've given up on trying." How should the nurse respond? Choose the best option.

"The goal of this type of care is to promote the best quality of life that is now possible."

Which is a true statement regarding pharmacologic aspects of aging?

Absorption may be affected by changes in gastric pH

The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the priority nursing action?

Administer acetaminophen per orders.

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply Administering prescribed antipyretics Elevating the head of the bed to 90 degrees Maintaining aseptic technique with an intraventricular catheter Encouraging deep breathing and coughing every 2 hours Frequent oral care

Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Frequent oral care

An older adult client at the free clinic has a history of seizures and presents with severe fatigue, frequent headaches, and a sore and beefy red tongue. Which of the following does the nurse suspect as causes of the client's current condition? Select all that apply. Alcoholism Intestinal disorders Not eating vegetables Poor nutrition

Alcoholism Intestinal disorders Not eating vegetables Poor nutrition

The client with prostatitis presents with low back pain, dysuria, and unusual sensation following ejaculation. Which treatment(s) does the nurse anticipate being prescribed? Select all that apply.

Analgesics Sitz baths Abstinence Treatment of sexual partner

A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client?

Anticonvulsant medications on day two of injury

The nurse recognizes that causes of acquired seizures include what? Select all that apply.

Cerebrovascular disease Metabolic and toxic conditions Hyponatremia Brain tumor Drug and alcohol withdrawal

When preparing a teaching presentation regarding reproductive health in women, which points should the nurse include when discussing the prevention of bacterial vaginosis? Select all that apply.

Choose clothing options that are loose around the genital area If you smoke, try to quit Keep the frequency of your sexual activity balanced Prevent unprotected sexual encounters

the nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. Cloudy cerebral spinal fluid Pain and stiffness of the extremities Purpura of hands and feet Low white blood cell (WBC) count Low red blood cell (RBC) count Low antidiuretic hormone (ADH) levels

Cloudy cerebral spinal fluid v

A client with an acute myocardial infarction demonstrates signs of cardiogenic shock. Which medications will the nurse expect to be prescribed for this client? Select all that apply.

Dopamine Dobutamine Nitroglycerin Vasopressin

The nurse and student nurse are observing a cardioversion procedure completed by a physician. At which time is the nurse most correct to identify to the student when the electrical current will be initiated? During stimulation of the SA node During repolarization of the heart During ventricular depolarization During the QRS complex

During ventricular depolarization Rationale:The electrical current is initiated at the R wave when ventricular depolarization occurs. The electrical current completely depolarizes the entire myocardium with the goal of restoring the normal pacemaker of the heart. The other options focus on an incorrect timing that will not restore the normal electrical conduction.

Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply. Eating Breathing Ambulating Transferring to a wheelchair Writing

Eating Breathing Transferring to a wheelchair Writing

A client is experiencing symptoms of infective endocarditis. Which tests will the nurse expect to be prescribed for this client? Select all that apply. • Echocardiogram • Two blood cultures • White blood cell count • Erythrocyte sedimentation rate • urinalysis

Echocardiogram • Two blood cultures • White blood cell count • Erythrocyte sedimentation rate

. A cattle rancher with a new onset of fever, chills, and headache is suspected of being exposed to tularemia. Which medication will the nurse anticipate being prescribed for this client? Select all that apply. Gentamicin Doxycycline Tetracycline Streptomycin Ciprofloxacin

Gentamicin Doxycycline Tetracycline Streptomycin Ciprofloxacin

A client seeks medical attention for a new onset of acute pain in the groin. Which additional finding(s) indicates to the nurse that the client is experiencing ureteral colic? Select all that apply

Hematuria Absent urine despite the urge to void

There is a high risk for ineffective coping in a client with a recent spinal cord injury. Which nursing interventions will assist the client with this process? Select all that apply.

Offer encouragement as the client makes progress. Involve the client actively in self care.

Enlargement of the prostate causes which of the following to occur? Select all that apply.

Oliguria obstruction of urine flow

A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply. Orthostatic hypotension Autonomic dysreflexia DVT Salt-wasting syndrome Increased ICP

Orthostatic hypotension Autonomic dysreflexia DVT

The nurse is providing care for a client who was admitted to the intensive care unit after suffering cardiovascular collapse secondary to a methamphetamine overdose. The client is semi-conscious and has a nasopharyngeal in place. The nurse anticipates this client may require which interventions? Select all that apply. Provide airway support and ventilation Minimize lights and noise disturbances Administer antipsychotic medication Follow the unit seizure protocol allow visitors

Provide airway support and ventilation Minimize lights and noise disturbances Administer antipsychotic medication Follow the unit seizure protocol

A 27-year-old client is a regular smoker and has diabetes. She has been diagnosed with hypertension and says she finds it cumbersome and time-consuming to visit the doctor regularly just to check her blood pressure. Her vital signs are temperature 98.8°F, pulse 72, respirations 12, BP 112/72 mm Hg. In addition, laboratory reports show a hemoglobin A1C level of 5%. The client is requesting contraceptive therapy. Which aspects of client teaching would the nurse recommend? Select all that apply Purchasing a self-monitoring cuff Discussing methods for stress reduction Advising a smoking cessation program Administering glycemic control Prescribing a combination oral contraceptive pill

Purchasing a self-monitoring cuff Discussing methods for stress reduction Advising a smoking cessation program Prescribing a combination oral contraceptive pill

The nurse is reviewing a patient's laboratory results. What findings does the nurse assess that are consistent with acute glomerulonephritis? Select all that apply.

Red blood cells in the urine Proteinuria

Which of the following are the immediate complications of spinal cord injury? Respiratory arrest Tetraplegia Spinal shock Paraplegia Autonomic dysreflexia

Respiratory arrest Spinal shock

A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply.

The client who is in the first 15 minutes of receiving 1 unit of PRBCs The 55-year-old client with spina bifida The client who reports an allergy to peanuts that causes throat swelling

Which of the following is an expected outcome for a client 24 hours after an abdominal hysterectomy?

The client will perform leg exercises hourly.

A patient has a suprapubic catheter inserted postoperatively. What would be the advantages of the suprapubic catheter versus a urethral catheter? Select all that apply.

The patient can void sooner than with a urethral catheter. The suprapubic catheter allows for more mobility. The suprapubic catheter permits measurement of residual urine without urethral instrumentation.

The nurse educator is explaining the difference between indications for nasopharyngeal airway insertion versus endotracheal intubation. Which responses from learners indicate correct reasons for the use of endotracheal tubes in clients? Select all that apply.

To bypass an upper airway obstruction To support connecting to mechanical ventilation To facilitate removal of tracheobronchial secretions

A client with a critical illness has a temperature of 38.5°C (101.3°F). Which parameters will the nurse use to determine if the client is developing sepsis? Select all that apply.

Urine output Bilirubin level Platelet count Blood pressure Respiratory rate

The nurse educator is discussing emerging diseases with a group of nurses. The educator should cite what causes of emerging diseases? Select all that apply.

Use of extended-spectrum antibiotics Population movements Increased global travel Globalization of food supplies

A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious administering oxygen?

Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia.

The nurse is seeing a client for follow up after chemotherapy in the outpatient clinic. The client states, "Over the last week, I've been losing handfuls of my hair in the shower. I don't want to shave my head but I don't want people to stare at me either." Based on the client's statement, what should the nurse include in the client's care plan? Choose the best answer.

You Selected: Risk for disturbed body image

The nurse educator is planning a health promotion class with a focus on sexually transmitted infections. What points regarding risk factors for chlamydia and gonorrhea should the nurse educator include? Select all that apply.

Your chances of contracting these infections are higher the more sexual partners you have." Young adults and teenagers are a high risk age group for both these infections."

The nurse is attempting to determine the ventricular rate and rhythm of a patient's telemetry strip. What should the nurse examine to determine this part of the analysis? a) RR interval b) PP interval c) TP interval d) QT interval

a) RR interval The rhythm is often identified at the same time the rate is determined. The RR interval is used to determine ventricular rhythm and the PP interval to determine atrial rhythm. If the intervals are the same or if the difference between the intervals is less than 0.8 seconds throughout the strip, the rhythm is called regular. If the intervals are different, the rhythm is called irregular

The nurse recognizes what conditions cause elevated prostate-specific antigen (PSA) levels in the absence of prostate cancer. Select all that apply. acute urinary retention acute prostatitis benign prostatic hyperplasia (BPH) transurethral resection of the prostate (TURP) erectile dysfunction

acute urinary retention acute prostatitis benign prostatic hyperplasia (BPH) transurethral resection of the prostate (TURP)

The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. What appropriate interventions should the nurse take? Select all that apply

administer pantoprazole IV daily monitor urine output every hour

A nurse is discussing cardiac hemodynamics with a client and explains the concept of afterload. What are other preexisting medical conditions to discuss that may increase afterload? Select all that apply

aging hypertension aortic valve stenosis

A nurse assesses a client with crackles. What medical condition should the nurse suspect? Select all that apply.

• Asthma • Chronic bronchitis • A collapsed alveoli • Pulmonary fibrosis

. A client with infective endocarditis is admitted to the hospital. While obtaining a history, what should the nurse ask the client about? Select all that apply.

• Renal dialysis • Intravenous (IV) drug use • Nasal piercing • Prosthetic cardiac valves • Recent urinary tract infection

The nurse is administering medications to a client with pericarditis. What medications will be commonly prescribed to treat pericarditis? Select all that apply.

•colchicine • ibuprofen • prednisone

In the prevention of occupational lung diseases, the nurse would direct preventive teaching to which high-risk occupations? Select all that apply.

rock quarry worker Miner

Which of the following are the immediate complications of spinal cord injury? Respiratory arrest Tetraplegia Spinal shock Paraplegia Autonomic dysreflexia

spinal shock Respiratory arrest

A client has a heart rate greater than 155 beats/minute and the ECG shows a regular rhythm with a rate of 162 beats/minute. The client is intermittently alert and reports chest pain. P waves cannot be identified. What condition would the nurse expect the physician to diagnose?

supreventrivcular tachycardia ** key is that the P wave cannot be identified and in normal sinus tachycardia waves can be identified but they are just repeated quicker

A nurse is teaching a client about why ovarian cancer is largely considered to be a lethal cancer of the female reproductive system. What should the nurse include in the teaching? Select all that apply. Tumors are typically far advanced and inoperable by the time of diagnosis. Ovarian cancer's vague symptoms are often ignored. Tumors present with nonspecific symptoms. There is no effective screening test. Tumor-specific antigens are helpful in screening.

tumors are typically far advanced and inoperable by the time of diagnosis. Ovarian cancer's vague symptoms are often ignored. Tumors present with nonspecific symptoms. There is no effective screening test.

.An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. The ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? Select all that apply.

• Before meals • At bedtime

At what point in shock does metabolic acidosis occur?

decompensation ( progressive)

The nurse is caring for a client recovering from extracorporeal shock wave lithotripsy (ESWL). Which client statement(s) indicates that teaching about self-care has been effective? Select all that apply.

"I will take my temperature every day." "I may expect to experience some pain and discomfort." "The bruise on my back is from the treatment." "I need to increase my intake of fluids every day." "Blood in my urine should go away by day 4 or 5."

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L.These ABG values suggest which disorder?

- metabolic acidosis

which of the following is a potential cause of transient incontinence? Select all that apply.

Delirium Restricted activity Infection of urinary tract Atrophic vaginitis Stool impaction

a nurse is assessing an uncircumcised male. Which client symptoms would the nurse expect to find when assessing a client with phimosis? Select all that apply

Difficulty cleaning under the foreskin Painful erections

Which of the following should be included when teaching a client about the management of benign prostatic hyperplasia (BPH)? Select all that apply. Moderate use of alcohol is useful for bladder relaxation. Do not delay the urge to void. Low-dose Benadryl will promote restful sleep. Prolonged exposure to heat increases bladder spasms. Painless hematuria is a common symptom of BPH. Schedule digital rectal exams.

Do not delay the urge to void. Schedule digital rectal exams.

The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply. Hypertension Tachycardia Fever Diaphoresis Nasal congestion

Hypertension Diaphoresis Nasal congestion

which of the following are dominant findings related to a transurethral resection syndrome? Hyponatremia Hypervolemia Hyperammonemia Hypernatremia Hypovolemia

Hyponatremia Hyperammonemia Hypovolemia

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply. Hypotension Tachycardia Venous pooling Diaphoresis Tachypnea Hypothermia

Hypotension Venous pooling Tachypnea Hypothermia

the nurse is providing discharge teaching to a client with a spinal cord tumor and instructs the client to avoid hot water bottles and heating blankets for what reason?

Impaired sensory perception

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?

Increased arterial pH - Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.

The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client?

Increased intracranial pressure

The nurse is caring for a female client who has been diagnosed with Neisseria gonorrhoeae. The nurse is aware that if this client had not received treatment, what other serious issues could have resulted from this disease? Select all that apply.

Increased risk of HIV infection Infection and scarring of the Fallopian tubes Eye infection in an infant born to a woman with this disease

A client is prescribed amitriptyline, an antidepressant for incontinence. The nurse understands that this drug is an effective treatment for which reason? Select all that apply.

Increases bladder neck resistance Decreases involuntary bladder contractions

The nurse cares for several clients with hematological conditions. Which assessment needs will the nurse prioritize for the client with aplastic anemia? Select all that apply. Infection Bleeding Injury Oxygenation Perfusion

Infection Bleeding

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action?

Participate in interventions to increase cerebral perfusion pressure (CPP).

. The nurse is reviewing the medical records of several patients who have been diagnosed with the following infections: Patient A: MumpsPatient B: Respiratory syncytial virus Patient C: Tuberculosis Patient D: Impetigo Patient E: Scabies The nurse would implement contact precautions for which patients? Select all that app

Patient B patient D patient E

Which of the following arterial blood gas results would be consistent with metabolic alkalosis?

Serum bicarbonate of 28 mEq/L - Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.

The nurse learns that victims of a blast are being transported to the emergency department for treatment. Which type of injury will the nurse expect when informed that the bulk of the victims have injuries caused by a secondary phase blast injury? Select all that apply.

Soft tissue injures Extremity fractures Traumatic amputations

A nurse is giving an educational class to members of the local disaster team. What should the nurse instruct members of the disaster team to do in a chemical bioterrorist attack?

Stand up.

A client is hospitalized for cutaneous exposure to anthrax. Which treatment option will the nurse anticipate for this client? Select all that apply.

Standard precautions Ciprofloxacin orally for 60 days

The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and reports severe chest tightness. What is the most appropriate initial action for the nurse to take?

Stop the transfusion immediately.

.A client with end stage heart disease has a ventricular assist device (VAD) implanted. Which assessment finding(s) indicates to the nurse that the client is experiencing a complication from this device? Select all that apply.

peripheral edema Elevated body temp reduced urine output

Clinical manifestations of neurogenic shock include which of the following? Select all that apply. Venous pooling in the extremities Bradycardia Warm skin Tachycardia Profuse bilateral sweating

Venous pooling in the extremities Bradycardia Warm skin

A client with asthma is prescribed an inhaled corticosteroid. For which reason will the nurse recommend that a small volume nebulizer (SVN) be used to provide the medication to the client?

client has rheumatoid arthritis

A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit?

compensatory respiratory alkalosis

. The nurse is teaching a client who underwent a skin graft for a burn injury about the use of pressure garments. What instruction(s) should the nurse include in the teaching? Select all that apply.

contact the primary provider if the garment does not seem to fit properly. Massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.

The nurse is caring for a client experiencing a rapidly developing pericardial effusion. Which assessment findings indicate to the nurse that the client is developing cardiac tamponade? Select all that apply

dyspnea tachycardia distant heart sounds JVD

Which activity should be avoided in clients with increased intracranial pressure (ICP)?

enemas

The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following?

heart failure

The health care provider prescribes esmolol for a client with supraventricular tachycardia. During esmolol therapy, what should the nurse monitor?

heart rate and blood pressure

client seeks medical attention for symptoms of a sexually transmitted infection (STI). Which information will the nurse collect when completing the client's sexual history? Select all that apply. history of sexual practices Number of sexual partners Past history of STIs Prevention of pregnancy method used

history of sexual practices Number of sexual partners Past history of STIs Prevention of pregnancy method used all of the above

A client seeks medical attention for new onset of a cough and sputum production. The client is producing sputum that is yellowish-green in color. The nurse anticipates which action for these types of symptoms? a) abx B) immediate admission c) notify provider

immediate admission

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:

increase the frequency of the catheterizations.

A client is recovering from the creation of an ileal conduit with stents. Which action(s) will the nurse take if the conduit and stents stop draining urine? Select all that apply.

insert a catheter through the stoma irrigate the stents with 5 to 10 mL sterile normal saline.