Exam 2 Practice

A patient is diagnosed with diabetic ketoacidosis. Which of the following ABG values is consistent with the diagnosis? 1. pH 7.41 Pco2 42 Po2 85 HCO3 23 2. pH 7.36 Pco2 40 Po2 88 HCO3 23 3. pH 7.40 Pco2 38 Po2 86 HCO3 22 4. pH 7.29 Pco2 32 Po2 88 HCO3 17

4. pH 7.29 Pco2 32 Po2 88 HCO3 17

•A clients ABG's reflect DKA. Which clinical indicator should the nurse expect to identify when monitoring this client's laboratory values? 1.Increased pH 2.Decreased Po2 3.Increased Pco2 4.Decreased HCO3

4.Decreased HCO3

A nurse in post anesthesia care unit is caring for a client who just had a thyroidectomy. For which client response is it most important for the nurse to monitor? • 1.Urinary retention 2.Signs of restlessness 3.Decreased blood pressure 4.Signs of respiratory obstruction

4.Signs of respiratory obstruction

An older client with history of pulmonary embolism is in ED with shortness of breath. The nurse starts a Heparin GTT has ordered. Which of the following is the least likely to be included in the plan of care? 1. Ambulate in hallways as tolerated 2. Obtain a PTT Q 6 hours until two therapeutic levels reached then QAM 3. Hold Heparin infusion for 60 minutes if PTT > 100 then restart at reduced rate per protocol 4. Obtain ECG with new onset of chest pain

1. Ambulate in hallways as tolerated

A female client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, nurse Tyzz notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with which problem? • 1. Depression 2. Neuropathy 3. Hypoglycemia 4. Hyperthyroidism

1. Depression

Which on of the following indicates that treatment of a client with diabetes insipidus has been effective? • 1. Fluid intake is less than 2,500 ml/day. 2. Urine output measures more than 200 ml/hour. 3. Blood pressure is 90/50 mm Hg. 4. The heart rate is 126 beats/minute.

1. Fluid intake is less than 2,500 ml/day.

Patient is receiving mechanical ventilation for ARDS with increased PEEP. The patient had developed a tension pneumothorax. A nurse recognizes the following signs of tension pneumothorax. Select ALL that apply 1. Hypotension 2. Jugular Venous Distention 3. Bradycardia 4. Tracheal deviation ( tracheal shift) 5. Hyperemia 6. Tachypnea

1. Hypotension 2. Jugular Venous Distention 4. Tracheal deviation ( tracheal shift) 6. Tachypnea

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT). 4. Call a code for respiratory arrest.

1. Perform endotracheal intubation and initiate mechanical ventilation.

Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis? • 1. Receives long term steroid therapy 2. Has a history of hypoparathyroidism 3. Engages in strenuous physical activity 4. Consumes high doses of the hormone estrogen

1. Receives long term steroid therapy

The ICU nurse is caring for a client requiring mechanical ventilation. Which of the following actions should you take to prevent ventilator acquired pneumonia (VAP)? Select all that apply 1. Reposition client Q 2 hours and maintain HOB at 30- 45 degrees 2. Promote nutrition with use of NGT and high calorie feedings 3. Suction oral and pharyngeal secretions and provide oral care at least every 2 hours 4. Assess client's readiness for sedation reduction and readiness for weaning and extubation (daily) 5. Perform hand hygiene before and after care of the client, and implement prophylactic IV antibiotic therapy ( partially correct) 6. Drain accumulated water from the ventilator circuit once per shift 7. Keep Ambu bag and trach kit at the bedside 8. Check the circuit temperature for overheating q 4 hours and PRN

1. Reposition client Q 2 hours and maintain HOB at 30- 45 degrees 3. Suction oral and pharyngeal secretions and provide oral care at least every 2 hours 4. Assess client's readiness for sedation reduction and readiness for weaning and extubation (daily) 5. Perform hand hygiene before and after care of the client, and implement prophylactic IV antibiotic therapy ( partially correct)

You are caring for a client admitted with Hyperthyroidism. Which of the following indicates that client may be experiencing complications? Select all that apply 1. Temperature of 104.1 F 2. Heart rate of 123 bpm 3. Respirations of 39 4. Heart rate of 24 bpm 5. Intolerance to cold 6. Restlessness

1. Temperature of 104.1 F 2. Heart rate of 123 bpm 3. Respirations of 39 6. Restlessness

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the UAP who will help the patient with ADLs? (Select all that apply.) 1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 4. Use a rectal thermometer to obtain a more accurate body temperature. 5. Be sure the patient's footwear has a firm sole when the patient ambulates.

1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care.

The patient with hyperthyroidism is undergoing ablation therapy with radioactive iodine. The precaution the nurse will employ is to: 1. take radioactive precautions with syringes and bedpans. 2. use Standard Precautions only. 3. enforce isolation for 3 days. 4. wear a mask and eye protectors when caring for patient.

1. take radioactive precautions with syringes and bedpans.

A nurse is assessing a client for possible laryngeal nerve injury following a thyroidectomy. Which action should the nurse implement on an hourly basis? 1.Ask the client to speak 2.Instruct the client to swallow 3.Have the client hum a familiar tune 4.Swab the client's throat to test the gag reflex

1.Ask the client to speak

A client is admitted to the hospital with diagnosis of DKA. What is the initial intervention that the nurse should expect the health care provider to prescribe for this client? 1.IV fluids 2.Potassium 3.NPH Insulin( Novolin N) 4.Sodium Polystyrene Sulfonate (Keyealate)

1.IV fluids

For which client response should the nurse assess the client when concerned about an accidental removal of the parathyroid glands during thyroidectomy surgery? 1.Tetany 2.Myxedema 3.Hypovolemic shock 4.Adrenocortical stimulation

1.Tetany

A physician ordered insulin GTT for a patient with DKA to infuse at 5 Units/hr. Pharmacy sent you a 250 ml 0.9% NS containing 100 units of Regular Insulin. How would you set the pump in Units and milliliters per hour? 1. 10 ml/hr 2. 12.5 ml/hr 3. 25 ml/hr 4. 5 ml/hr

2. 12.5 ml/hr

The nurse assessing a client with Addison's disease expects to note which of the following? 1. Weight gain 2. Anorexia 3. Yellow skin discoloration 4. A craving for sweets

2. Anorexia

The nurse is preparing a client newly diagnosed with Addison's disease for discharge. Which of the following statements by the client indicates a need for further instructions from the nurse? • 1. I understand that I'll need a lifelong cortisone replacement therapy 2. During times of stress, I'll need to decrease my medications 3. I must be careful not to injure myself 4. I should always carry a medical identification card

2. During times of stress, I'll need to decrease my medications

You are assuming care for a 55 year old male with ARDS following complicated mitral valve surgery five days ago requiring multiple transfusions of blood products. He is sedated, on the ventilator. One hour prior to your shift the PEEP was increased from 7 cm to 10 cm due to poor oxygenation per latest ABG; As you walk into the patients room you notice that his BP is down from 110/70 to 85/65; his HR is 120, RR 30, trachea is deviated to the left and his left jugular vein is distended. You immediately: • 1. Assess the patients lungs 2. Initiate the Rapid Response Team 3. Prepare the patient for Chest tube insertion 4. Increase oxygen to 100 % FiO2

2. Initiate the Rapid Response Team

Which of these signs suggests that a male client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications? • 1. Tetanic contractions 2. Neck vein distention 3. Weight loss 4. Polyuria

2. Neck vein distention

64 y/o male with history of smoking 40 PPD, presents in ED with a new onset of shortness of breath and sharp stabbing chest pain. CXR and ECG and labs are obtained upon arrival. There were no significant findings. Troponin was negative. Hemoglobin and Hematocrit were elevated consistent with his long history of smoking. While he is awaiting a transport to radiology for a CT scan ABG is obtained and results are as following: pH 7.50, pCo2 32 mmHg, paO2 79 mmHg, HCO3 23, O2Sat 88%. Based on provided information what is the reason for his chest pain and shortness of breath? 1. Exacerbation of COPD 2. Pulmonary embolism 3. Respiratory failure 4. Pneumonia

2. Pulmonary embolism

A nurse cares for a client who possibly has a syndrome of inappropriate antidiuretic hormone (SIADH). The client's serum sodium level is 114 mEq/L. Which action should the nurse take first? 1. Consult with the dietitian about increased dietary sodium 2. Restrict the client's fluid intake to 600 mL/day. 3. Handle the client gently by using turn sheets for re-positioning 4. Instruct unlicensed assistive personnel to measure intake and output.

2. Restrict the client's fluid intake to 600 mL/day.

The nurse evaluates the care provided to a client hospitalized for treatment of adrenal crisis. Which of the following changes would indicate to the nurse that the client is responding favorably to medical and nursing treatment? 1. The client's urinary output has increased 2. The client's blood pressure has increased 3. The client has lost weight 4. The client's peripheral edema has decreased

2. The client's blood pressure has increased

A patient who had a hypophysectomy 3 days ago begins to have 3000 mL of urine output every shift and complains of thirst and a dry mouth. The nurse interprets these signs as possible: 1. overreaction to diuretics. 2. diabetes insipidus. 3. diabetes mellitus. 4. glucose intolerance.

2. diabetes insipidus.

A patient is diagnosed with respiratory failure. Which of these ABG values are consistent with diagnosis? 1. pH 7.41 Pco2 42 Po2 82 HCO3 23 2. pH 7.25 Pco2 52 Po2 66 HCO3 24 3. pH 7.35 Pco2 45 Po2 80 HCO3 26 4. pH 7.29 Pco2 32 Po2 88 HCO3 17

2. pH 7.25 Pco2 52 Po2 66 HCO3 24

The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next? • 1.Reassure the patient that the ventilator will do the work of breathing for him. 2.Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. 3.Increase the fraction of inspired oxygen (Fio2) on the ventilator to 100% in preparation for endotracheal suctioning. 4.Insert an oral airway to prevent the patient from biting on the endotracheal tube.

2.Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.

A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The client's symptoms have now resolved and the client asks, "When can I stop taking these medications?" How should the nurse respond? 1."It is possible for the inflammation to recur if you stop the medication." 2."Once you start corticosteroids, you have to be weaned off them." 3. "You must decrease the dose slowly so your hormones will work again." 4. "The drug suppresses your immune system, which must be built back up

3. "You must decrease the dose slowly so your hormones will work again."

The nurse is caring for clients on the surgical floor and has received report from the previous shift. Which of the following clients should the nurse see first? 1. A 34 y/o admitted 3 hours ago with a gunshot wound; 1.5 cm area of dark drainage note on his dressing 2. A 44 y/o who had a mastectomy 2-days ago; 20 ml of sero-sanguineous fluid noted in Jackson Pratt drain 3. A 58 y/o with a collapsed lung after the car accident; no drainage noted in the previous 8 hours 4. A 61 y/o who had an abdominal perineal resection three days ago and reports chills.

3. A 58 y/o with a collapsed lung after the car accident; no drainage noted in the previous 8 hours

Which nursing intervention is the priority when a client is first admitted with HHS ( Hyperglycemic hyperosmolar syndrome)? 1. Provide Oxygen at 2 liters via nasal cannula 2. Order a low carb diet 3. Administer fluid replacement therapy 4. Reconcile clients home medications

3. Administer fluid replacement therapy

After the nurse receives the change of shift report, which client should the nurse assess"FIRST"? 1. Client with asthma who has shortness of breath and high pitched expiratory wheezing 2. Client with diabetes and a stasis leg ulcer dressing saturated with serosanguinenous drainage. 3. Client with heart failure who is short of breath coughing up pink frothy sputum. 4. Client with left pleural effusion and absent breath sounds in the left base.

3. Client with heart failure who is short of breath coughing up pink frothy sputum.

You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately? 1. Assessing for bilateral breath sounds and symmetrical chest movement 2. Auscultating over the stomach to rule out esophageal intubation 3. Marking the tube 1 cm from where it touches the incisor tooth or nares 4. Ordering a chest radiograph to verify that tube placement is correct

3. Marking the tube 1 cm from where it touches the incisor tooth or nares

You are providing care to a patient experiencing HHS. The patient is on an insulin drip at 4 units/hr and the current glucose level is 435. In addition to this, the patient also has 0.9% NS infusing in the right antecubital vein at 100 ml/hr. Which of the following causes concern? 1. Urine specific gravity is 1.001. 2. Patient has a potassium level of 3.5 3. Patient's skin and mucous membranes are dry. 4. Urine is negative for ketones •

3. Patient's skin and mucous membranes are dry.

A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? • 1. Infusing I.V. fluids rapidly as ordered 2. Encouraging increased oral intake 3. Restricting fluids 4. Administering glucose-containing I.V. fluids as ordered

3. Restricting fluids

The nurse is performing an initial post-operative assessment on a client who has just returned from surgery with a chest tube and water seal drainage system. The nurse should immediately intervene if she makes any of the following observations? 1. There are no dependent loops in the chest tube 2. The chest tube is not clamped 3. The chest tube and drainage system is above the client's chest 4. The fluid level in the water seal is at the 2 cm

3. The chest tube and drainage system is above the client's chest

When a client suffers a complete pneumothorax there is a danger of mediastinal shift. If such a shift occurs, what potential effect is a cause for concern? 1. Rupture of the pericardium 2.Infections of the sub pleural lining 3.Decreased filling of the right heart 4.Increased volume of the unaffected lung

3.Decreased filling of the right heart

You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? • 1.Administer ordered antibiotics as scheduled. 2.Hyperoxygenate the patient before suctioning. 3.Maintain the head of bed at a 30- to 45-degree angle. 4.Suction the airway when coarse crackles are audible.

3.Maintain the head of bed at a 30- to 45-degree angle.

A nurse is caring for a client after radioactive iodine is administered for Graves disease. What information about the client's condition after this therapy should the nurse consider when providing care? 1.Not radioactive and can be handled as any other individual 2.Highly radioactive and should be isolated as much as possible 3.Mildly radioactive but should be treated routine safety precautions 4.Not radioactive but may still transmit some dangerous radiations and must be treated with precautions

3.Mildly radioactive but should be treated routine safety precautions

What should a nurse do immediately after a client returns from the post anesthesia care unit following a subtotal thyroidectomy? 1.Inspect the incision 2.Instruct the client not to speak 3.Place a tracheostomy kit at the bedside 4.Place a client in the supine position for 24 hours

3.Place a tracheostomy kit at the bedside

You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician? • 1.The patient starts crying and says she can't go on with treatment much longer. 2.The patient reports sharp, stabbing chest pain with every deep breath. 3.The blood pressure is 100/48 mm Hg and the heart rate is 102 beats/min. 4.The dressing at the thoracentesis site has 1 cm of bloody drainage. •

3.The blood pressure is 100/48 mm Hg and the heart rate is 102 beats/min.

You are making a home visit to a 50-year-old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient's only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician? • 1.The patient says that her right leg aches all night. 2.The right calf is warm to the touch and is larger than the left calf. 3.The patient is unable to remember her husband's first name. 4.There are multiple ecchymotic areas on the patient's arms.

3.The patient is unable to remember her husband's first name.

After change of shift, you are assigned to care for the following patients. Which patient should you assess first? • 1. 68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory 2. 57-year-old with COPD and a pulse oximetry reading from the previous shift of 90% saturation 3. 72-year-old with pneumonia who needs to be started on IV antibiotics 4. 51-year-old with asthma who reports shortness of breath after using a bronchodilator inhaler

4. 51-year-old with asthma who reports shortness of breath after using a bronchodilator inhaler

A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the HCP what action should the nurse take? • 1. Place the client on the unaffected side 2. Administer 60% oxygen via Venturi mask 3. Prepare for IV administration of electrolytes 4. Give Oxygen at 2 liters via Nasal cannula

4. Give Oxygen at 2 liters via Nasal cannula

The nurse is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave's disease. The nurse would be most concerned if which of the following was observed? 1. The client's BP is 132/82, pulse 82, RR 14, oral temperature 99 F 2. The client supports his head and neck when turning his head to the right 3. The client spontaneously flexes his wrist when the blood pressure is obtained 4. The client appears anxious, short of breath and reports heart fluttering

4. The client appears anxious, short of breath and reports heart fluttering

The nurse assesses a client with a history of Addison's disease who has received steroid therapy for several years. The nurse could expect the client to exhibit which of the following changes in appearance? 1. Buffalo hump, girdle obesity, gaunt facial appearance 2. Tanning of the skin, discoloration of the mucous membranes, alopecia, weight loss 3. Emaciation, nervousness, breast engorgement, hirsutism 4. Truncal obesity, purple striations on the skin, moon face

4. Truncal obesity, purple striations on the skin, moon face

When assessing a male client with pheochromocytoma, a nurse is most likely to detect: • 1. a blood pressure of 130/70 mm Hg. 2. a blood glucose level of 130 mg/dl. 3. bradycardia. 4. a blood pressure of 176/88 mm Hg.

4. a blood pressure of 176/88 mm Hg.

When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, you find that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1.Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. 2.Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. 3.Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. 4.Switch the patient to a nonrebreather mask at 95% to 100% FIO2 and call the physician to discuss the patient's status.

4.Switch the patient to a nonrebreather mask at 95% to 100% FIO2 and call the physician to discuss the patient's status.

After the respiratory therapist performs suctioning on a patient who is intubated, the UAP measures vital signs for the patient. Which vital sign value should the UAP report to the RN immediately? 1.Heart rate of 98 beats/min 2.Respiratory rate of 24 breaths/min 3.Blood pressure of 168/90 mm Hg 4.Tympanic temperature of 101.4° F (38.6° C)

4.Tympanic temperature of 101.4° F (38.6° C)

A nurse is caring for a client who had an adrenalectomy procedure . For what client response should the nurse monitor while steroid therapy is being regulated? • • •1. Hypotension •2. Hyperglycemia •3. Sodium retention •4. Potassium excretion

•1. Hypotension

•After a head injury a client develops a deficiency od antidiuretic hormone ( ADH). What should the nurse consider about the response to secretion of ADH before assessing this client? • •1. Serum osmolarity increases •2. Urine concentration decreases •3. GFR decreases 4. Tubular reabsorption of water increases

•1. Serum osmolarity increases

•After surgical clipping of cerebral aneurysm , the client develops the syndrome of inappropriate secretion of antidiuretic hormone. For which manifestation of excessive levels of ADH should the nurse assess the client? Select all that apply • •1. Polyuria •2. Weight gain •3. Hypotension •4. Hyponatremia •5. Decreased urine specific gravity

•2. Weight gain •4. Hyponatremia