final
56. The client was admitted to the emergency department after being injured in a drive-by shooting. Despite very serious injuries, the patient is awake and alert and cries continuously that "someone tried to kill me." The nurse tries to calm the client because 1. Increased heart rate 2. Increased blood pressure 3. Constriction of coronary vessels 4. Constriction of blood vessels in skeletal muscles 5. Increase in blood glucose
1. Increased heart rate 2. Increased blood pressure 5. Increase in blood glucose
The nurse has identified that a client who has hyperthyroidism has decreased cardiac output. Which interventions are indicated to address this diagnosis? (Select all that apply.) 1. Monitor for development of peripheral edema. 2. Keep the room warm. 3. Provide medications to manage pain. 4. Frequently reassure and calm the patient. 5. Monitor activity tolerance.
1. Monitor for development of peripheral edema. 3. Provide medications to manage pain. 4. Frequently reassure and calm the patient. 5. Monitor activity tolerance.
A patient has been tentatively diagnosed with adrenal insufficiency. Which findings will the nurse evaluate as supporting this diagnosis? (Select all that apply.) 1. The patient's low blood pressure is not responding to fluid infusion. 2. The patient's heart rate is consistently lower than 60 beats/min. 3. The patient has had a fever for a week. 4. Arterial blood gas results reveal acidosis. 5. The patient reports abdominal pain.
1. The patient's low blood pressure is not responding to fluid infusion. 3. The patient has had a fever for a week. 4. Arterial blood gas results reveal acidosis. 5. The patient reports abdominal pain.
A critically ill patient's plasma cortisol level is 2.6 mcg/dL. Which intervention does the nurse expect? 1. Treatment for adrenal insufficiency 2. Treatment for adrenal excess 3. Continued diagnostic testing of adrenal function 4. Emergency dialysis
1. Treatment for adrenal insufficiency
A client infected with HIV is being monitored for the development of AIDS. Which characteristics will the nurse monitor? (Select all that apply.) 1. White blood count 2. CD4+ T-cell count 3. Presence of recurrent E. coli urinary tract infection 4. Presence of Pneumocystis jiroveci (PJP) infection 5. Presence of cytomegalovirus (CMV)
2. CD4+ T-cell count 4. Presence of Pneumocystis jiroveci (PJP) infection 5. Presence of cytomegalovirus (CMV)
A patient diagnosed with diabetic ketoacidosis presents with Kussmaul respirations at a rate of 28. A newly licensed nurse asks the patient to try to slow his breathing. What instruction will the preceptor provide? 1. "Keep trying to slow the patient's respirations because breathing so fast is hard on his heart." 2. "If he keeps breathing like that he will develop respiratory acidosis." 3. "Let the patient set his respiratory rate as rapid breathing helps to compensate for his acidosis." 4. "The patient is breathing deeply to help offset diabetes-induced hypoxemia."
3. "Let the patient set his respiratory rate as rapid breathing helps to compensate for his acidosis."
A client with severe, deep partial-thickness burns experiences procedural, background, and breakthrough pain. What is the nurse's most important plan for controlling this patient's pain? 1. Administer pain medications prior to all procedures. 2. Maintain intravenous access for administration of pain medications. 3. Designate one pain assessment technique for use by all providers. 4. Expect that it will be necessary to exceed normally administered levels of analgesics.
3. Designate one pain assessment technique for use by all providers.
The arterial blood gases of a patient with a large mass in the right lung show increasing hypoxemia. In which position will the nurse place this patient to increase the ventilation n and perfusion of oxygen? 1. Flat in bed lying on the left side 2. Flat in bed lying on the right side 3. Lying on the left side with the head of the bed elevated to 30 degrees 4. Lying on the right side with the head of the bed elevated 30 degrees
3. Lying on the left side with the head of the bed elevated to 30 degrees
A client in the intensive care unit is surprised to learn that he has an elevated blood glucose level since he has not been diagnosed with diabetes. How will the nurse explain this elevation? 1. "Many people are not diagnosed with diabetes until they are admitted to an intensive care unit." 2. "Increasing blood glucose is the body's way of making sure there is enough energy for brain functioning." 3. "Many people have diabetes but are not aware of it." 4. "When stressed, the body releases more glucose into the blood, raising the blood glucose level."
4. "When stressed, the body releases more glucose into the blood, raising the blood glucose level."
A nurse assesses several patients who have a history of asthma. Which patient would the nurse assess first? A 66-year-old patient with a barrel chest and clubbed fingernails A 35-year-old patient who has a longer expiratory phase than inspiratory phase A 48-year-old patient with an oxygen saturation level of 95% at rest A 27-year-old patient with a heart rate of 130 beats per minute
A 27-year-old patient with a heart rate of 130 beats per minute
A client is chronically short of breath and yet has normal lung ventilation, clear lung, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has: A possible hematologic problem A psychosomatic Poor peripheral perfusion Left-sided heart failure
A possible hematologic problem
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse will anticipate that the client is at risk for which problem?
Acute renal failure
A patient who is being mechanically ventilated is demonstrating respiratory acidosis. The nurse suspects that which metabolic process is malfunctioning? Aerobic metabolism Catabolism Anabolism Anaerobic metabolism
Anaerobic metabolism
The nurse received a client from the postanesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report front he PACU nurse included drainage in the chest tube at 80 mLs of bloody fluid. 15 minutes after transfer from the PACU, the chest tube indicates and additional 120 mLs of bloody fluid. The client is reporting pain at 8 on a scale of 0-10. The first action of the nurse is to: Assess pulse and blood pressure Notify the physician Lay the client's head to a flat position Administer prescribed pain medication
Assess pulse and blood pressure
The nurse is preparing to suction a client with a tracheostomy. What will be the nurse's first step in the suctioning process? Explain the suctioning procedure to the client and reposition the client Turn on suction source at a pressure not exceeding 120mm Hg Assess the client's lung sounds and SaO2 via pulse oximeter Assess the client's lung sounds and SaO2 via pulse oximeter
Assess the client's lung sounds and SaO2 via pulse oximeter
The nurse is discussing macrovascular complications of diabetes with a client. The nurse will address what topic during this dialogue? A) The need for frequent eye examinations for patients with diabetes B) The fact that patients with diabetes have an elevated risk of myocardial infarction C) The relationship between kidney function and blood glucose levels D) The need to monitor urine for the presence of albumin
B) The fact that patients with diabetes have an elevated risk of myocardial infarction
A) A combination of protein and carbohydrates, such as a small cup of yogurt B) Two teaspoons of sugar dissolved in a cup of apple juice C) Half of a cup of juice, followed by cheese and crackers D) Half a sandwich with a protein-based filling
C) Half of a cup of juice, followed by cheese and crackers
A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS) and who is unresponsive. Which clinical manifestation indicates to the nurse that the therapy is ineffective?
Clients Glascow is unchanged
An older adult client with type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 623 mg/dL. The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A) Administration of anti-hypertensive medications B) Administering sodium bicarbonate intravenously for low bicarbonate levels C) Reversing acidosis by administering insulin D) Fluid and electrolyte replacement
D) Fluid and electrolyte replacement
The nurse is concerned that an older adult patient is at risk for developing acute renal failure. Which information in the patient's history support the nurse's concern? (Select all that apply.) Diagnosed with hypotension,.. Recent aortic valve replacement surgery.. Prescribed high doses of intravenous antibiotics
Diagnosed with hypotension,.. Recent aortic valve replacement surgery.. Prescribed high doses of intravenous antibiotics
A patient is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this patient's care?
Electrolyte and fluid imbalance
A patient who will require long-term mechanical ventilation has had a tracheostomy for two weeks. The nurse is concerned that stoma erosion is occurring. Which nursing assessment will support the nurse's concern? Granulation tissue is noted at the stoma site The skin at the stoma opening is flakey The patient has developed a dry cough Excessive amount of secretions are present at the stoma opening
Excessive amount of secretions are present at the stoma opening
A client is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HHS? (Select all that apply.) Glycosuria (excretion of glucose into the urine) Dehydration Hypernatremia Hyperglycemia
Glycosuria (excretion of glucose into the urine) Dehydration Hypernatremia Hyperglycemia
A patient with type 2 diabetes mellitus, lethargy, and a blood glucose level of 650 mg/dL has been diagnosed with hyperglycemic hyperosmolar syndrome (HHS). The nurse monitors this patient for the development of which complication?
HHS causes severe neurological changes such as seizures-secondary to dehydration
A diabetic patient becomes septic after a bowel resection and is having problems with respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50. PaCO2 30, HCO3 24, and PaO2 68. What does the nurse recognize as the primary factor causing this acid-base imbalance? Hyperventilation due to poor oxygenation Hypoventilation due to morphine PCA Atelectasis due to respiratory muscle fatigue Kussmaul respirations due to glucose of 102 mg/dL
Hyperventilation due to poor oxygenation
A nurse educator is teaching a group of recent nursing graduates about their occupational risk for contracting Hepatitis B. What preventative measures will the educator promote? SATA Consumption of a vitamin-rich diet Annual vitamin b12 injections Immunizations Annual vitamin k injections Proper disposal of sharps Use of standard precautions
Immunizations Proper disposal of sharps Use of standard precautions
A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mmHg, PaCO2 33 mmHg, and HCO3 18 mEq/L (18 mmol/L). Which manifestation does the nurse identify as an example of the patient's compensation mechanism?
Increased rate and depth of respirations
A nurse cares for a patient who had a chest tube placed six hours ago and refuses to take deep breaths because of the pain. What action will the nurse take? (SATA) Instruct the patient to take deep breaths Administer pain medication and encourage the patient to take deep breaths Encourage the patient to take shallow breaths to help with the pain Have the patient stay in bed Instruct the patient on proper incentive spirometer (IS) use
Instruct the patient to take deep breaths Administer pain medication and encourage the patient to take deep breaths Instruct the patient on proper incentive spirometer (IS) use
A patient has been admitted to the intensive care unit with the diagnosis of liver failure. Which assessment findings will the nurse anticipate in this patient? (SATA) Jaundice History of alcohol abuse INR greater than 1.5 Serum glucose greater than 145 Mental status changes
Jaundice INR greater than 1.5 Serum glucose greater than 145 Mental status changes
The nurse is assessing a patient with a diagnosis of prerenal acute kidney injury (AKI). Which condition will the nurse expect to find in the patient's recent history?
MI
A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding will the nurse attend to immediately? Absent cough and gag reflexes Blood tinged secretions Respiratory rate of 13 breaths/minute Oxygen saturation of 90%
Oxygen saturation of 90%
A patient's arterial blood gases (ABGs) are as follows: pH 7.30, PaCO2 30 mm HG, HCO3 14 mEq/L, and PaO2 50. The nurse evaluates these ABGs as representing which acid- base imbalances? Partially compensated metabolic acidosis and moderate hypoxemia Partially compensated respiratory alkalosis with mild hypoxemia Uncompensated respiratory alkalosis with moderate hypoxemia Compensated metabolic acidosis with severe hypoxemia
Partially compensated metabolic acidosis and moderate hypoxemia
What are the indications for chest drainage systems? SATA Need for postural drainage Spontaneous pneumothorax Chest trauma resulting in pneumothorax Post-thoracotomy Pleural effusion
Spontaneous pneumothorax Chest trauma resulting in pneumothorax Post-thoracotomy Pleural effusion
An emergency room nurse assesses a patient with potential liver trauma. Which clinical manifestations will alert the nurse to internal bleeding and hypovolemic shock? (SATA) Tachycardia Hypertension Confusion Tachypnea Flushed skin
Tachycardia Confusion Tachypnea
A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock will be reported with the healthcare provider? Tachycardia and bradypnea Bradycardia and tachypnea Tachycardia and tachypnea Bradycardia and bradypnea
Tachycardia and tachypnea
The nurse is assessing a patient recovering from surgery for abdominal compartment syndrome. Which findings will indicate a life-threatening condition may be developing in this patient? (SATA) Temperature 101.7 degrees F Complaint of dyspnea Poor skin turgor Blood pressure 136/88 mmHg Complaint of chest pain
Temperature 101.7 degrees F Complaint of dyspnea Complaint of chest pain
A patient is hospitalized with recurrent gastric ulcers. Which education will the nurse provide? SATA You may need to consider treating you chronic with some therapy besides NSAIDs You should monitor for symptoms such as bloating, nausea, and vomiting It is time for you to seriously consider smoking cessation You should contact a personal trainer to get your body in shape This antibiotic is different in that you only take it until you are pain free
You may need to consider treating you chronic with some therapy besides NSAIDs You should monitor for symptoms such as bloating, nausea, and vomiting It is time for you to seriously consider smoking cessation
The nurse caring for mechanically ventilated patients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (SATA) a. Adherence to proper hand hygiene b. suctioning the patient only when needed c. elevating the head of the bed d. maintain NPO status until extubated e. Providing Oral care per protocol
a. Adherence to proper hand hygiene b. suctioning the patient only when needed c. elevating the head of the bed e. Providing Oral care per protocol
1. A patient is diagnosed with rupture of an aortic aneurysm and surgery is imminent. What interventions will the nurse anticipate prior to surgery? a. Administration of blood b. Administration of anticoagulants to prevent clots in the prosthesis c. Administration of IV narcotic for pain d. Starting intravenous lines for fluid resuscitation e. Prepare for endotracheal intubation
a. Administration of blood c. Administration of IV narcotic for pain d. Starting intravenous lines for fluid resuscitation e. Prepare for endotracheal intubation
A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations will the nurse monitor the patient? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension
a. Deep and fast respirations c. Tachycardia e. Orthostatic hypotension
1. A patient has been ruled out for MI (myocardial infarction). What diagnostic findings would support this finding? a. EKG and cardiac markers remain unchanged for 12-24 hours b. Chest pain subsides within 30 minutes c. Serum cardiac markers return to normal after six hours d. There are no ST changes on the EKG
a. EKG and cardiac markers remain unchanged for 12-24 hours
An emergency room nurse assesses a female patient. Which assessment findings will alert the nurse to request a prescription for an electrocardiogram? a. Fatigue despite adequate rest b. Indigestion c. Shortness of breath d. Abdominal pain e. hypertension
a. Fatigue despite adequate rest b. Indigestion c. Shortness of breath
A patient admitted in hypertensive crisis is being cared for by a newly licensed nurse and his preceptor. The preceptor will consider which information when explaining the potential etiology of this crisis? a. How well has the patient's hypertension been controlled in the past? b. How long as the patient been hypertensive? c. Has the patient been following the prescribed therapy? d. What therapy was the patient prescribed? e. How old is the patient?
a. How well has the patient's hypertension been controlled in the past? c. Has the patient been following the prescribed therapy? d. What therapy was the patient prescribed?
A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia - Flaccid paralysis with respiratory depression b. Hyperphosphatemia - Paresthesia with sensations of tingling and numbness c. Hyponatremia - Decreased level of consciousness d. Hypercalcemia - Positive Trousseau's and Chvostek's signs e. Hypomagnesemia - Bradycardia, peripheral vasodilation, and hypotension
a. Hypokalemia - Flaccid paralysis with respiratory depression c. Hyponatremia - Decreased level of consciousness
A nurse assesses a client with untreated hypothyroidism who is admitted with acute appendicitis. The nurse notes that the patient's level of consciousness has decreased. What actions does the nurse perform? (Select all that apply.) a. Infuse intravenous fluids. b. Cover the client with warm blankets. c. Monitor blood pressure every 4 hours. d. Maintain a patent airway. e. Administer oral glucose as prescribed.
a. Infuse intravenous fluids. b. Cover the client with warm blankets. d. Maintain a patent airway.
A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions will the nurse anticipate the neurosurgeon taking? a. Invoking implied consent b. Prescribing naloxone to reverse the effects of the morphine c. Asking the client to sign the surgical consent form d. delaying the surgery until a member of client's the family is reached
a. Invoking implied consent
1. A patient has had a large ischemic stroke and is hospitalized in the hospital neurologic intensive care unit. What interventions will be provided for this patient to decrease intracranial pressure (ICP)? (Select all that apply.)
a. Maintain the partial pressure of carbon dioxide (PaCO2) within a range of 30 to 35 mmHg b. Administering mannitol d. Administering supplemental oxygen if the oxygen saturation is below 90% e. Elevating the head of the bed 30 degrees
The causes of acquired seizures include what? (Select all that apply.) a. Metabolic and toxic conditions b. Cerebral vascular disease c. Brain tumor d. Hypoxemia e. Drug and alcohol withdrawal
a. Metabolic and toxic conditions b. Cerebral vascular disease c. Brain tumor d. Hypoxemia e. Drug and alcohol withdrawal
An elderly client was admitted to the Medical-Surgical unit after a fall. What vital signs indicate Cushing's triad? (Select all that apply.) a. Moring vital signs include blood pressure of 110/70 Afternoon vital signs include blood pressure of130/50 b. Morning vital signs include heart rate of 62 Afternoon vital signs include heart rate of 52 c. Morning vital signs include heart rate of 62 Afternoon vital signs include heart rate of 70 d. Morning vital signs include respiratory rate of 10 Afternoon vital signs include respiratory rate of 15 e. Morning vital signs include blood pressure of 110/70 Afternoon vital signs include blood pressure of 110/72
a. Moring vital signs include blood pressure of 110/70 Afternoon vital signs include blood pressure of130/50 b. Morning vital signs include heart rate of 62
Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED. a. Oxygen therapy b. Administration of morphine c. Non-enteric-coated chewed aspirin d. Administration of nitroglycerine (NTG) e. Dopamine infusion
a. Oxygen therapy b. Administration of morphine c. Non-enteric-coated chewed aspirin d. Administration of nitroglycerine (NTG)
A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following is the priority action? a. Place the client in a sitting position b. Check the client's bladder for distention c. Examine the client for areas of breakdown d. Check the client for a fecal impaction
a. Place the client in a sitting position
1. A nurse assesses a patient who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? a. Serum potassium of 2.9 mEq/L (2.9mmol/L) b. Warmth and redness at the site c. Expanding groin hematoma d. Rhythm changes on the cardiac monitor e. Blood pressure 140/88 mmHg
a. Serum potassium of 2.9 mEq/L (2.9mmol/L) c. Expanding groin hematoma d. Rhythm changes on the cardiac monitor
A client has sought care stating that she developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed? a. Type I b. Type II c. Type III d. Type IV
a. Type I
The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) a. Type I - Examples include hay fever and anaphylaxis b. Type II - Mediated by action of immunoglobulin M (IgM) c. Type III - Immune complex deposits in blood vessel walls d. Type IV - Examples are poison ivy and transplant rejection e. Type V - Examples include a positive tuberculosis test and sarcoidosis
a. Type I - Examples include hay fever and anaphylaxis c. Type III - Immune complex deposits in blood vessel walls d. Type IV - Examples are poison ivy and transplant rejection
1. The nurse caring for hospitalized patients includes which actions on their care plan to help prevent the possibility of the patients developing shock? a. Using aseptic technique during procedures b. Monitoring the daily white blood cell count c. Removing invasive lines as soon as possible d. Assessing and identifying patients at risk e. Performing proper hand hygiene
a. Using aseptic technique during procedures c. Removing invasive lines as soon as possible d. Assessing and identifying patients at risk e. Performing proper hand hygiene
Clinical manifestations of neurogenic shock include which of the following? (Select all that apply.) a. Bradycardia b. Warm skin c. Tachycardia d. Venous pooling in the extremities e. Profuse bilateral swelling
a. bradycardia b. warm skin d. venous pooling in extremities
A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the physician or return to the ED if the client demonstrates reports which complications? (Select all that apply) a. Vomiting b. Irritability c. Sleeps for short periods of time d. Slurred speech e. Weakness on one side of the body
a. vomiting b. irritability d. slurred speech e. weakness on one side of the body
The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? a. Increased intravascular volume b. Activation of the inflammatory response c. Hypoperfusion of tissues d. Must produce energy through anaerobic metabolism e. Increase in cellular activity
b. Activation of the inflammatory response c. Hypoperfusion of tissues d. Must produce energy through anaerobic metabolism
The nurse is caring for a patient in neurologic shock due to a spinal cord injury. Vital signs include blood pressure 80/40 mmHg, heart rate 40 beats/ minute, respirations 24 breaths/ minute, oxygen saturation 88% on room air, and an oral temperature 96.8F. what interventions will the nurse include in the patient's care? a. Infusion of IV phenylephrine b. Begin an IV infusion for volume c. Stabilization of C-spine d. Application of 100% oxygen via facemask e. Give the patient a medication to increase the heart rate
b. Begin an IV infusion for volume c. Stabilization of C-spine d. Application of 100% oxygen via facemask e. Give the patient a medication to increase the heart rate
1. A patient is diagnosed with septic shock and has a decrease in afterload. The nurse would expect which initial changes in the patient's cardiac status? a. Increase in blood pressure b. Decrease in blood pressure c. Increase in cardiac output d. Decrease in cardiac output e. No change in blood pressure or cardiac output
b. Decrease in blood pressure c. Increase in cardiac output
A nurse assesses a client who experienced a spinal cord injury at the T% level 12 hours ago. Which manifestations would the nurse correlate with neurogenic shock? (Select all that apply) a. Blood pressure of 185/65 mmHg b. Decreased level of consciousness c. Urine output less than 30 mL/hr d. Heart rate of 34 beats/min e. Increased oxygen saturation
b. Decreased level of consciousness c. Urine output less than 30 mL/hr d. Heart rate of 34 beats/min
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar fracture. Which of the following correctly describes Battle's sign? a. Drainage of cerebrospinal fluid from the nose b. Ecchymosis over the mastoid c. Drainage of cerebrospinal fluid from the ears d. Bruising under the eyes
b. Ecchymosis over the mastoid
The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic value is the nurse most likely to assess? a. Low cardiac output and low pulmonary artery wedge pressure b. High cardiac output and low systemic vascular resistance c. High pulmonary artery wedge pressure and high cardiac output d. Low cardiac output and high systemic vascular resistance
b. High cardiac output and low systemic vascular resistance
The nurse is caring for a patient with multiple organ dysfunction syndrome. Which interventions will help optimize tissue perfusion for this patient? a. Assess pulse oximetry b. Maintain patency of the airway c. Administer pain medications as scheduled d. Maintain a darkened environment e. Keep the environment calm and quiet
b. Maintain patency of the airway c. Administer pain medications as scheduled e. Keep the environment calm and quiet
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 will the nurse a. It is possible for the inflammation to recur if you stop the medication. b. Once you start corticosteroids, you have to be weaned off them. c. You must decrease the dose slowly so your hormones will work again. d. The drug suppresses your immune system, which must be built back u
b. Once you start corticosteroids, you have to be weaned off them.
What are the cognitive deficits as a result of a neurologic event? (Select all that apply.) a. Expressive aphasia b. Poor abstract reasoning c. Short- and long-term memory loss d. Paresthesia e. Decreased attention span
b. Poor abstract reasoning c. Short- and long-term memory loss e. Decreased attention span
Which of the following is a clinical manifestation of pupillary changes that indicate increasing ICP? a. Pupils are fixed and dilated b. Pupils are showing progressive dilation c. Pupils are unequal in diameter d. Pupils are equal and normally reactive
b. Pupils are showing progressive dilation
A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mmHg. Which of the following findings will the nurse identify as a late sign of ICP? (Select all that apply.) a. Confusion b. Bradycardia c. Slurred speech d. Hypotension e. Nonreactive dilated pupils
b. bradycardia e. nonreactive dilated pupils
1. The nurse is performing an assessment on a patient with a central venous pressure (CVP) of 12mmHg. Which findings will the nurse anticipate? a. Presence of rales and rhonci b. Juglular vein distention c. Poor skin turgor d. Hepatomegaly e. Weak, thready pulse
b. jugular vein distention d. hepatomegaly
A nurse has been assigned to provide care for a 58-year-old man with a diagnosis of AIDS-related pneumonia. The nurse tells the charge nurse that she is unwilling to care for this client. What key component of critical thinking is most likely missing from this nurse's practice? a. Compliance with direction b. Withholding judgement c. Analyzing information and situations d. Respect for authority
b. withholding judgement
The nurse is caring for a client who has been intubated and on a mechanical ventilator and has been restrained with soft wrist restraints. The client no longer requires the restraints, so the nurse removes them. What type of ethical decision making does this nurse display? a. Autonomy b. Fidelity c. Beneficence d. Nonmaleficence
c. Beneficence
A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions will the nurse take? a. Respect the family's wishes and do nothing b. Call the provider for a STAT DNR order c. Call the emergency response team d. Seek immediate help from the risk manager
c. Call the emergency response team
The nurse is caring for a client with complex needs. When applying critical thinking skills to the client's care, the nurse will do which of the following action? a. Weigh each of the potential negative outcomes in a situation b. Disregard input from people who do not have to make the decision c. Examine and analyze all available information d. Set aside all prejudices and personal experiences when making decisions
c. Examine and analyze all available information
A nurse working in the emergency department (ED) reviews arterial blood gases (ABG) values for a patient diagnosed with heatstroke. Blood gas values are pH 7.48, pCO2 32, pO2 85, HCO2 22 and SO2 90%. Which of the following nursing interventions demonstrate the nurse's understanding of the patient's ABGs and knowledge of Maslow's hierarchy of needs when providing care for this patient? a. The nurse completes a spiritual assessment and provides appropriate clergy support for the patient b. The nurse immediately starts an intravenous line (IV) of dextrose 50% in water solution (D50W) c. The nurse prepares for endotracheal intubation and mechanical ventilation for the patient d. Lab values are within normal limits and contacts the patient's family to be with the patient while in the ED
c. The nurse prepares for endotracheal intubation and mechanical ventilation for the patient
A patient is scheduled for an echocardiogram with measurement of ejection fraction. The nurse explains to the patient that this test will provide the most information about which cardiac characteristic? a. The amount of blood in the heart before it beats b. The amount of resistance the heart beats against c. The strength of the heartbeat d. The amount of blood the heart pumps every minute
c. The strength of the heartbeat
1. Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness? a. Diffuse agonal injury b. Intracranial hemorrhage c. Concussion d. Contusion
c. concussion
A nurse is caring for a client who has expressive aphasia following a cerebral vascular accident (CVA). Which of the following parameters will the nurse use first in order to assess the client's pain level? a. Scheduled treatments and client illness b. Pulse and blood pressure findings c. Behavioral indicators and effect d. A self-report pain rating scale
d. A self-report pain rating scale
A client who fell and broke his hip while being assisted to the bathroom by the nurse states he plans to sue the nurse. The nurse will know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following? a. The client's attorney states that injury to the client could have been prevented b. An expert nurse provides testimony that the nurse should have handled the situation differently c. The client's provider testifies the nurse was at fault for the injury d. Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation
d. Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation
A nurse is evaluating a patient who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 breaths/min to 22 breaths/min b. Decreased skin turgor on the clients posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic light-headedness and dizziness
d. Decreased orthostatic light-headedness and dizziness
1A patient who had a radial artery catheter in place is complaining of numbness and tingling in the fingers. What is the nurse's priority assessment? a. Does the waveform have a characteristic appearance? b. Is blood easily obtained from the catheter? c. Does the patient have a fever? d. Is there a palpable pulse?
d. Is there a palpable pulse?
An 80-year-old female sustained a serious closed head injury following a fall. Family has decided to forgo placing the patient on mechanical ventilation and will not allow neurosurgery, electing to "let nature take it's course." The nurse is very upset by this decision, thinking that the patient has a strong chance of good quality life following standard interventions. What nursing interventions are indicated? (Select all that apply.) a. The nurse should contact hospital administration regarding legal action b. The nurse should try to persuade the family to allow treatment c. The nurse should ask the family to consider naming a legal guardian for the patient d. The nurse should be certain the family understands treatment options e. The nurse should transfer care to another nurse
d. The nurse should be certain the family understands treatment options e. The nurse should transfer care to another nurse
The nurse executive is planning education for new nurse managers regarding the AACN standards for a Healthy Work Environment. Which information will be included? a. In critical care units the need for expert clinical skills is more important than simple communication skills b. The critical partners in the organization are physicians, members of the administration, and nurse managers c. Staff nurses must embrace authentic leadership and value it to ensure an effectively running patient care unit d. True collaboration must be promoted to ensure a healthy work environment
d. True collaboration must be promoted to ensure a healthy work environment
A client arrives in the emergency department with facial and chest burns caused by a house fire. Which action will the nurse take first? a. Stay at the bedside and reassure the client. b. Administer the ordered morphine sulphate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.
d. Use pulse oximetry to check the oxygen saturation.
A postoperative patient's nasogastric drainage has been 500 mL in the last 8 hours. The nurse will assess this patient for findings associated with which acid-base imbalance? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis
metabolic alkalosis
A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members will the nurse include in this interdisciplinary team meeting? (Select all that apply.) registered dietician clinical pharmacist health care provider
registered dietician clinical pharmacist health care provider