Exam 2
A patient with cirrhosis is noted to have low serum albumin levels. The patient is to receive 200 mL of albumin in 30 minutes. The drop factor for the IV set is 15 gtt/mL. The nurse correctly adjusts the IV rate to what rate?
100 gtts/min
An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will give during the first 8 hours?
600 mL
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be given in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?
938 mL/hour
A nurse assesses patients at a community health fair. Which patient is at greatest risk for the development of hepatitis B? a. A 20-year-old college student who has had several sexual partners b. A 46-year-old woman who takes acetaminophen daily for headaches c. A 63-year-old businessman who travels frequently across the country d. An 82-year-old woman who recently ate raw shellfish for dinner
ANS: A
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Insert a feeding tube and initiate enteral feedings. b. Infuse total parenteral nutrition via a central catheter. c. Encourage an oral intake of at least 5000 kcal per day. d. Administer multiple vitamins and minerals in the IV solution.
ANS: A
A patient is being admitted with a diagnosis of Cushing syndrome. Which finding will the nurse expect during the assessment? a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair
ANS: C Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency.
A nurse is teaching a client who has chronic pancreatitis about how to prevent exacerbations of the disease. Which health teaching items will the nurse include? (Select all that apply.) a. "Avoid alcohol ingestion." b. "Be sure and balance rest with activity." c. "Avoid caffeinated beverages." d. "Avoid green, leafy vegetables." e. "Eat small meals and high-calorie snacks."
ANS: A, B, C, E
A nurse plans care for a patient who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which healthcare team members would the nurse collaborate to provide appropriate nutrition to this patient? (Select all that apply.) a. Registered dietitian b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Health care provider
ANS: A, C, E Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.
A nurse assesses bilateral wheezes in a patient with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. What action would the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowler's position. d. Gather appropriate equipment and prepare for an emergency airway.
ANS: D
An emergency room nurse assesses a patient with potential liver trauma. Which clinical manifestations would alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respirations
ANS: B,D Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion.
A nurse cares for a patient with hepatitis C. The patient's brother states, "I do not want to contract this infection, so I will not go into his hospital room." How would the nurse respond? a. "If you wear a gown and gloves, you will not get this virus." b. "Viral hepatitis is not spread through casual contact." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."
ANS: BAlthough family members may be afraid that they will contract hepatitis C, the nurse should educate the client's family about how the virus is spread. Viral hepatitis, or hepatitis C, is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the client's status with the brother
The provider has ordered Kayexalate and sorbitol to be administered to a patient. The nurse caring for this patient would expect which serum electrolyte values prior to administration of this therapy? a. Sodium 125 mEq/L and potassium 2.5 mEq/L b. Sodium 150 mEq/L and potassium 3.6 mEq/L c. Sodium 135 mEq/L and potassium 6.9 mEq/L d. Sodium 148 mEq/L and potassium 5.5 mEq/L
ANS: C Severe hyperkalemia, with a potassium level of 6.9 mEq/L, requires aggressive treatment with Kayexalate and sorbitol to increase the bodys excretion of potassium. The normal range for serum potassium is 3.5 to 5.5 mEq/L, so patients with the other potassium levels would not be treated aggressively or would need potassium supplementation.
Which assessment finding for an adult admitted with Graves' disease requires the most rapid intervention by the nurse? a. Bilateral exophthalmos b. Heart rate 136 beats/minute c. Temperature 103.8° F (40.4° C) d. Blood pressure 166/100 mm Hg
ANS: C The patient's temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the temperature are needed immediately. The other findings also require intervention but do not indicate potentially life-threatening complications
A nurse cares for a patient who has burn injuries. The patient's wife asks, "When will his high risk for infection decrease?" How would the nurse respond? a. "When the antibiotic therapy is complete." b. "As soon as his albumin levels return to normal." c. "Once we complete the fluid resuscitation process." d. "When all of his burn wounds have closed.
ANS: D
A nurse cares for a patient who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. What action would the nurse take first? a. Sedate the client to prevent tube dislodgement. b. Maintain balloon pressure at 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Assess the client for airway patency.
ANS: D
In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Give IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.
ANS: D, E, C, A, B
The nurse is planning care for a client with acute severe pancreatitis. What is the highest priority patient outcome? -
Maintaining normal respiratory function
In reviewing the medical record for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen's sign. Indicate the area in the accompanying figure where the nurse will assess for this change. -
Umbilicus
A nurse cares for a patient with a deficiency of aldosterone. Which assessment finding would the nurse correlate with this deficiency? a. Increased urine output b. Vasoconstriction c. Blood glucose of 98 mg/dL d. Serum sodium of 144 mEq/L
ANS: A Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A client with an aldosterone deficiency will have increased urine output. Vasoconstriction is not related. These sodium and glucose levels are normal; in aldosterone deficiency, the client would have hyponatremia and hyperkalemia.
A nurse cares for a patient with end-stage pancreatic cancer. The patient asks, "Why is this happening to me?" How would the nurse respond? a. "I don't know. I wish I had an answer for you, but I don't." b. "It's important to keep a positive attitude for your family right now." c. "Scientists have not determined why cancer develops in certain people." d. "I think that this is a trial so you can become a better person because of it."
ANS: A The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the client's emotions or current concerns. The nurse would validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may negatively impact the client-nurse .
A 40-year-old patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask? a. "Have you had a recent head injury?" b. "Do you have to wear larger shoes now?" c. "Is there a family history of acromegaly?" d. "Are you experiencing tremors or anxiety?"
ANS: B
A client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client? a. Apply an ice pack to the right hand. b. Place the hand in cool water. c. Be sure to rupture any blister formation. d. Go immediately to the doctor's office
ANS: B
A telehealth nurse speaks with a patient who is recovering from a liver transplant 2 weeks ago. The patient states, "I am experiencing right flank pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? a. The anti-rejection drugs you are taking make you susceptible to infection. b. You should go to the hospital immediately to have your new liver checked out. c. You should take an additional dose of cyclosporine today. d. Take acetaminophen (Tylenol) every 4 hours until you feel better.
ANS: B Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.
A nurse plans care for a patient with acute pancreatitis. Which intervention would the nurse include in this patient's plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowler's position with the head of bed elevated.
ANS: B The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.
The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching? a. "I frequently eat at restaurants, and my food has a lot of added salt." b. "I had the flu earlier this week, so I couldn't take the hydrocortisone." c. "I always double my dose of hydrocortisone on the days that I go for a long run." d. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon."
ANS: B The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison's disease.
A nurse cares for a patient who has hypothyroidism as a result of Hashimoto's thyroiditis. The patient asks, "How long will I need to take this thyroid medication?" How does the nurse respond? a. "You will need to take the thyroid medication until the goiter is completely gone." b. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication." c. "You'll need thyroid pills for life because your thyroid won't start working again." d. "When blood tests indicate normal thyroid function, you can stop the medication."
ANS: C
Which problem should the nurse anticipate for a patient admitted to the hospital with diabetes insipidus? a. generalized edema b. fluid volume overload c. disturbed sleep pattern d. decreased gas exchange
ANS: C Nocturia occurs because of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected.
The nurse is caring for a patient following an adrenalectomy. What is the highest priority in the immediate postoperative period? a. protect the patient's skin. b. monitor for signs of infection. c. balance fluids and electrolytes. d. prevent emotional disturbances.
ANS: C After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances.
A nurse cares for a patient who has chronic cirrhosis from substance abuse. The patient states, "All of my family hates me." How would the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous."
ANS: C Clients who have chronic cirrhosis may have alienated relatives over the years because of substance abuse. The nurse should assist the client to identify a friend, neighbor, or person in his or her recovery group for support. The nurse should not minimize the client's concerns by brushing off the client's comment. Attending AA may be appropriate, but this response doesn't address the client's concern. Making peace with the client's family may not be possible. This statement is not client-centered.
The nurse is performing an admission assessment on a female patient who reports taking extra-strength acetaminophen (Tylenol) regularly to treat daily headaches. The nurse will notify the patient's provider and discuss an order for a. a selective serotonin receptor agonist (SSRA). b. hydrocodone with acetaminophen for headache pain. c. liver enzyme tests. d. serum glucose testing.
ANS: C Large doses or overdoses of acetaminophen can be toxic to hepatic cells, so when large doses are administered over a long period, liver function should be assessed.
Which assessment finding in a patient who had a bilateral adrenalectomy requires the most rapid action by the nurse? a. The blood glucose is 176 mg/dL. b. The lungs have bibasilar crackles. c. The blood pressure (BP) is 88/50 mm Hg. d. The patient reports 5/10 incisional pain.
ANS: C The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered. The nurse should also address the elevated glucose, incisional pain, and crackles with appropriate collaborative or nursing actions, but prevention and treatment of acute adrenal insufficiency is the priority after adrenalectomy.
A nurse assesses patients on the medical-surgical unit. Which patient is at greatest risk for the development of carcinoma of the liver? a. A 22-year-old with a history of blunt liver trauma b. A 48-year-old with a history of diabetes mellitus c. A 66-year-old who has a history of cirrhosis d. An 82-year-old who has chronic malnutrition
ANS: C The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. Blunt liver trauma, diabetes mellitus, and chronic malnutrition do not increase a person's risk for developing liver cancer
A nurse assesses a patient who is recovering from a total thyroidectomy and notes the development of stridor. What action does the nurse take first? a. Reassure the client that the voice change is temporary. b. Document the finding and assess the client hourly. c. Place the client in high-Fowlers position and apply oxygen. d. Contact the provider and prepare for intubation.
ANS: D
Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)? a. The patient has a recent weight gain of 9 lb. b. The patient complains of dyspnea with activity. c. The patient has a urine specific gravity of 1.025. d. The patient has a serum sodium level of 118 mEq/L.
ANS: D A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.
What risk factor will the nurse specifically ask about when a patient is being admitted with acute pancreatitis? a. diabetes mellitus. b. high-protein diet. c. cigarette smoking. d. alcohol consumption
ANS: D Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.
A 35-year-old woman reports lethargy, difficulty remembering things, facial edema, dry skin, and cessation of menses. The nurse notes a heart rate of 60 beats per minute and a weight increase of 5 pounds from a previous visit. The nurse will notify the provider of which possible condition? a. Cretinism b. Early menopause c. Hyperthyroidism d. Myxedema
ANS: D Myxedema is severe hypothyroidism characterized by this woman's symptoms. Cretinism is congenital hypothyroidism. Early menopause is not characterized by memory loss, facial edema, dry skin, or bradycardia. Hyperthyroidism would include tachycardia and weight loss.
A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.
ANS: D Signs of carbon monoxide poisoning
A nurse assesses a patient who potentially has hyperaldosteronism. Which serum laboratory values would the nurse associate with this disorder? (Select all that apply.) a. Sodium: 150 mEq/L b. Sodium: 130 mEq/L c. Potassium: 2.5 mEq/L d. Potassium: 5.0 mEq/L e. pH: 7.28 f. pH: 7.5
ANS: A, C, F Aldosterone increases reabsorption of sodium and excretion of potassium. Hyperaldosteronism causes hypernatremia, hypokalemia, and metabolic alkalosis. Hyponatremia, hyperkalemia, and acidosis are manifestations of adrenal insufficiency.
The nurse learns that which age-related changes increase the potential for complications of burns? (Select all that apply.) a. slower healing time b. thinner skin c. increased inflammatory compliance d. increased pulmonary compliance e. altered glucose metabolism f. history of heart failure
ANS: A,B,E,F
The home health nurse is admitting a client diagnosed with cancer of the pancreas. Which information is the most important for the nurse to discuss with the client? a. Determine the client's food preferences. b. Ask the client if there is an advance directive. c. Find out about insurance/Medicare reimbursement. d. Explain that the client should eat as much as possible.
ANS: B
A nurse assesses patients for potential endocrine dysfunction. Which patient is at greatest risk for a deficiency of gonadotropin and growth hormone? a. A 36-year-old female who has used oral contraceptives for 5 years b. A 42-year-old male who experienced head trauma 3 years ago c. A 55-year-old female with a severe allergy to shellfish and iodine d. A 64-year-old male with adult-onset diabetes mellitus
ANS: B Gonadotropin and growth hormone are anterior pituitary hormones. Head trauma is a common cause of anterior pituitary hypofunction. The other factors do not increase the risk of this condition
A nurse cares for a patient with adrenal hyperfunction. The patient screams at her husband, bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, "I feel like I am going crazy." How would the nurse respond? a. "I will ask your doctor to order a psychiatric consult for you." b. "You feel this way because of your hormone levels." c. "Can I bring you information about support groups?" d. "I will close the door to your room and restrict visitors."
ANS: B Hypercortisolism can cause the client to show neurotic or psychotic behavior. The client needs to know that these behavior changes do not reflect a true psychiatric disorder and will resolve when therapy results in lower and steadier blood cortisol levels. The client needs to understand this effect and does not need a psychiatrist, support groups, or restricted visitors at this time
A nurse cares for a patient who is recovering from an open Whipple procedure. What action would the nurse take? a. Clamp the nasogastric tube. b. Place the client in semi-Fowler's position. c. Assess vital signs once every shift. d. Provide oral rehydration.
ANS: B Postoperative care for a client recovering from an open Whipple procedure should include placing the client in a semi-Fowlers position to reduce tension on the suture line and anastomosis sites, setting the nasogastric tube to low suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid and electrolyte complications, and providing intravenous fluids.
Which topic is most important to include in teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis? a. Taking lactulose b. Avoiding alcohol ingestion c. Maintaining good nutrition d. Using vitamin B supplements
ANS: B The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.
A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving. Discharge is expected to occur in two days. Which teaching strategy is likely to result in effective patient self-management at home? a. Delay teaching until closer to discharge date. b. Provide written reminders of information taught. c. Offer multiple options for management of therapies. d. Ensure privacy for teaching by asking the family to leave.
ANS: B Written instructions will be helpful to the patient because initially the hypothyroid patient maybe unable to remember to take medications and other aspects of self-care. Because the treatment regimen is somewhat complex, teaching should be initiated well before discharge. Family members or friends should be included in teaching because the hypothyroid patient is likely to forget some aspects of the treatment plan. A simpler regimen will be easier to understand until the patient is euthyroid.
A nurse assesses a patient who is recovering from a transsphenoidal hypophysectomy. The nurse notes nuchal rigidity. What action would the nurse take first? a. Encourage range-of-motion exercises. b. Document the finding and monitor the client. c. Take vital signs, including temperature. d. Assess pain and administer pain medication.
ANS: C Nuchal rigidity is a major manifestation of meningitis, a potential postoperative complication associated with this surgery. Meningitis is an infection; usually the client will also have a fever and tachycardia. Range-of-motion exercises are inappropriate because meningitis is a possibility. Documentation should be done after all assessments are completed and should not be the only action. Although pain medication may be a palliative measure, it is not the most appropriate initial action.
Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns? a. ketorolac b. lorazepam (Ativan) c. gabapentin (Neurontin) d. hydromorphone (Dilaudid)
ANS: D Opioid pain medications are the best choice for pain control. The other drugs are used as adjuvants to enhance the effects of opioids
Which focused data should the nurse assess after identifying 4+ pitting edema on a patient who has cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level
ANS: D The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters are not directly associated with the patient's edema
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet.
ANS: A
The nurse assesses a patient who has a severe burn injury. Which statement indicates that the patient understands the psychosocial impact of a severe burn injury? a. "It is normal to feel some depression." b. "I will go back to work immediately." c. "I will not feel anger about my situation." d. "Once I get home, things will be normal."
ANS: A
The nurse is caring for a patient with an acute burn injury. What action would the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the client's body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.
ANS: B
What information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider? a. Patient's blood pressure is 148/94 mm Hg. b. Patient has bilateral 2+ pitting ankle edema. c. Patient stopped taking the medication 2 days ago. d. Patient has not been taking the prescribed vitamin D.
ANS: C Sudden cessation of corticosteroids after taking the medication for a week or more can lead to adrenal insufficiency, with problems such as severe hypotension and hypoglycemia. The patient will need immediate evaluation by the health care provider to prevent and/or treat adrenal insufficiency. The other information will also be reported, but does not require rapid treatment
When taking the blood pressure (BP) on the right arm of a patient who has severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patients blood pressure. c. Check the calcium level on the chart. d. Notify the health care provider immediately.
ANS: C The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseaus sign. The health care provider should be notified after the nurse checks the patients calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.
A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider? a. Asterixis and lethargy b. Jaundiced sclera and skin c. Elevated total bilirubin level d. Liver 3 cm below costal margin
ANS: A The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center. The other findings are typical of patients with hepatic failure and would be reported but would not indicate a need for an immediate change in the therapeutic plan.
A nurse plans care for a patient with hyperparathyroidism. Which intervention does the nurse include in this patient's plan of care? a. Ask the client to ambulate in the hallway twice a day. b. Use a lift sheet to assist the client with position changes. c. Provide the client with a soft-bristled toothbrush for oral care. d. Instruct the unlicensed assistive personnel to strain the clients urine for stones.
ANS: B
A nurse evaluates the following laboratory results for a client who has hypoparathyroidism: Calcium 7.2 mg/dL Sodium 144 mEq/L Magnesium 1.2 mEq/L Potassium 5.7 mEq/L Based on these results, which medications should the nurse anticipate administering? (Select all that apply.) a. 3% Sodium Chloride solution b. Intravenous calcium chloride c. Oral potassium chloride d. No medication, but implement a water restriction
ANS: B
After teaching a patient who has been diagnosed with hepatitis A, the nurse assesses the patient's understanding. Which statement by the patient indicates a correct understanding of the teaching? a. Some medications have been known to cause hepatitis A. b. I may have been exposed when we ate shrimp last weekend. c. I was infected with hepatitis A through a recent blood transfusion. d. My infection with Epstein-Barr virus can co-infect me with hepatitis A.
ANS: B
A patient just arrived in the postanesthesia recover unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon? a. Observe the dressing for bleeding. b. Check the blood pressure and pulse. c. Assess the patient's respiratory effort. d. Support the patient's head with pillows.
ANS: C Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding
A patient with Graves disease exhibits tachycardia, heat intolerance, and exophthalmos. Prior to surgery, which drug is used to alter thyroid hormone levels? a. Liotrix (Thyrolar) b. Propranolol (Inderal) c. Propylthiouracil (PTU) d. Thyroid (Thyrotab
ANS: C Propylthiouracil is a potent antithyroid drug used in preparation for a subtotal thyroidectomy. Liotrix and thyroid are used as thyroid replacement. Propranolol is used to treat hypertension associated with hyperthyroidism.
A patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium level of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care? a. Institute routine seizure precautions. b. Monitor for positive Chvosteks sign. c. Encourage the patient to remain on bed rest. d. Encourage 3000 to 4000 mL of oral fluids daily.
ANS: D
A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with syndrome of inappropriate antidiuretic hormone (SIADH). Which initial laboratory result should the nurse expect? a. elevated hematocrit. b. decreased serum sodium. c. increased serum chloride. d. low urine specific gravity.
ANS: B When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level.
Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)? a. Teach symptoms of variceal bleeding. b. Draw blood for hepatitis serology testing. c. Discuss the need to increase caloric intake. d. Review the patient's current medication list
ANS: D Some medications can increase the risk for NAFLD, and they should be eliminated. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with asymptomatic NAFLD
A patient presents to the emergency room complaining of vomiting with severe back and leg pain. The patient's home medications include daily oral corticosteroids. Vital signs reveal a low blood pressure and there are peaked T waves on the electrocardiogram. What is the nurse's priority intervention? a. Start an intravenous line b. Collect urine specimen c. Administer antiemetic d. Administer narcotic analgesia
ANS: A The patient is exhibiting signs of adrenal insufficiency (Addison's disease) given the regular use of corticosteroids. Cortisone, hydrocortisone (Cortef), prednisone, and fludrocortisone (Florinef) are used for the treatment of adrenocorticoid deficiency. Treatment of Addisonian crisis includes administration of hydrocortisone, saline solution, and sugar (dextrose) to correct the insufficiency. The priority intervention is to start an intravenous line so that appropriate treatments may be administered. A urine specimen may be collected but is not the priority intervention. Since the patient is vomiting, administration of antiemetics or analgesia would be given through an intravenous line. The nurse should also assess for changes in the level of consciousness; so administration of analgesia may be contraindicated if any decrease in level of consciousness occurs.
A nurse cares for a patient with hepatic portal-systemic encephalopathy (PSE). The patient is thin and cachectic in appearance, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help prevent confusion associated with liver failure." c. "Increasing dietary protein will help the client gain weight and muscle mass." d. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."
ANS: B A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the client's dietary protein will cause complications of liver failure and should not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.
A nurse cares for a patient who has facial burns. The patient asks, "Will I ever look the same?" How would the nurse respond? a. With reconstructive surgery, you can look the same." b. "We can remove the scars with the use of a pressure dressing." c. "You will not look exactly the same but cosmetic surgery will help." d. "You shouldn't start worrying about your appearance right now."
ANS: C
A nurse uses the rule of nines to assess a patient with burn injuries to the entire posterior chest and entire left arm. How would the nurse document the percentage of the patient's body that sustained burns? a. 9 b. 18 c. 27 d. 36
ANS: C
The nurse is assessing a male patient diagnosed with a pituitary tumor causing panhypopituitarism. Which assessment finding is consistent with panhypopituitarism? a. high blood pressure. b. elevated blood glucose. c. decreased facial hair. d. tachycardia and palpitations
ANS: C
A nurse prepares to assess the emotional state of a patient with end-stage pancreatic cancer. What action would the nurse take first? a. Bring the client to a quiet room for privacy. b. Pull up a chair and sit next to the client's bed. c. Determine whether the client feels like talking about his or her feelings. d. Review the health care provider's notes about the prognosis for the client.
ANS: C Before conducting an assessment about the client's feelings, the nurse should determine whether he or she is willing and able to talk about them. If the client is open to the conversation and his or her room is not appropriate, an alternative meeting space may be located. The nurse should be present for the client during this time, and pulling up a chair and sitting with the client indicates that presence. Because the nurse is assessing the client's response to a terminal diagnosis, it is not necessary to have detailed information about the projected prognosis; the nurse knows that the client is facing an end-of-life illness.
A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be helpful for the patient problem of disturbed body image related to changes in appearance? a. Reassure the patient that the physical changes are very common in patients with Cushing syndrome b. Discuss the use of diet and exercise in controlling the weight gain associated with Cushing syndrome. c. Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance d. Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery
ANS: D The most reassuring communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. Reassurance that the physical changes are expected or that they are more serious physiological change are caused by the high hormone levels, not by the patient's diet or exercise choices.
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess oral temperature. b. Check a potassium level. c. Place on cardiac monitor. d. Assess for pain at contact points.
After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. Assessing the oral temperature is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important. However, it will take time before the laboratory results are back. The first intervention is to place the patient on a cardiac monitor and assess for dysrhythmias, so that they can be treated if occurring. A decreased or increased potassium level will alert the nurse to the possibility of dysrhythmias. The cardiac monitor will alert the nurse immediately of any dysrhythmias. Assessing for pain is important, but the patient can endure pain until the cardiac monitor is attached. Cardiac dysrhythmias can be lethal
