Final: Jeopardy

A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement? A. "I'll start to have symptoms when I drink less fluid." B. "I'll start to have symptoms when I have fewer platelets." C. "I'll start to have symptoms when I decrease the iron in my diet." D. "I'll start to have symptoms when I have fewer white blood cells."

A. "I'll start to have symptoms when I drink less fluid."

A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? A. A 65-year-old with pulmonary fibrosis B. A 24-year-old with uncontrolled type 1 diabetes C. A 45-year-old who has been vomiting for 3 days D. A 54-year-old who takes sodium bicarbonate for indigestion

A. A 65-year-old with pulmonary fibrosis

A client's serum potassium level is below the normal range. Which clinical indicators should the nurse determine are consistent with hypokalemia? Select all that apply. A. Abdominal cramping B. Tall, peaked T wave C. Irregular heart rate D. Muscular weakness E. Decreased bowel sounds F. Hyperactive deep tendon reflexes

A. Abdominal cramping C. Irregular heart rate D. Muscular weakness E. Decreased bowel sounds

A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication? A. Aspirin B. Midazolam C. Gabapentin D. Alprazolam

A. Aspirin

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply. A. Chemotherapy B. Repositioning C. Regular oral care D. Blood transfusion E. Radiation therapy

A. Chemotherapy D. Blood transfusion E. Radiation therapy

The nurse is preparing discharge instructions for a client who was prescribed enalapril for treatment of hypertension. Which instruction is appropriate for the nurse to include in the client's teaching? A. Do not change to a standing position suddenly. B. Lightheadedness is a common adverse effect that need not be reported. C. The medication may cause a sore throat for the first few days. D. Schedule blood tests weekly for the first 2 months.

A. Do not change to a standing position suddenly.

Which nursing intervention should the nurse consider to be a priority for clients with fluid overload? A. Ensuring client safety B. Providing drug therapy C. Providing nutritional therapy D. Preventing future fluid overload

A. Ensuring client safety

The nurse is assessing the respiratory status of the client at 2-hour intervals as a nursing safety priority. Which condition is affecting the client? A. Hypokalemia B. Hyperkalemia C. Hyponatremia D. Hypernatremia

A. Hypokalemia (causes shallow respirations)

A client who is suspected of having Cushing syndrome is admitted to the hospital. When checking the laboratory reports, which condition should the nurse expect? A. Hypokalemia B. Hypovolemia C. Hypocalcemia D. Hyponatremia

A. Hypokalemia (hyperaldosterone saves water and sodium, excretes potassium)

What interventions should the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply. A. Instituting fall risk precautions B. Restricting fluids to 2 L per day C. Placing the client in high-Fowler position D. Monitoring for and reporting neurologic changes

A. Instituting fall risk precautions D. Monitoring for and reporting neurologic changes

A 3-month-old infant who has a 3-day history of diarrhea is admitted to the pediatric unit. The nurse obtains the infant's vital signs, performs a physical assessment, and reviews the infant's arterial blood gas results. Which acid- base imbalance does the nurse suspect? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

The nurse is teaching a client who underwent a hypophysectomy for hyperpituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply. A. Nose blowing B. Teeth brushing C. Bending forward D. Breathing through the mouth E. Lying in a semi-Fowler's position

A. Nose blowing B. Teeth brushing C. Bending forward

The home health nurse is visiting a client with multiple health problems that include a history of chronic atrial fibrillation. The nurse obtains a radial rate of 136 beats per minute. What should the nurse do first? A. Obtain the other vital signs. B. Recheck the pulse to verify the rate. C. Stay with the client until an ambulance arrives. D. Alert the primary healthcare provider of the client's status.

A. Obtain the other vital signs.

A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia? A. Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques B. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion C. Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture D. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes

A. Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate? A. Remove secretions by suctioning. B. Lower the setting of the tidal volume. C. Check that tubing connections are secure. D. Obtain a specimen for arterial blood gases (ABGs).

A. Remove secretions by suctioning.

The nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually results in central cyanosis? A. Shunting of blood from right to left B. Shunting of blood from left to right C. Obstruction of blood flow from the left side of the heart D. Obstruction of blood flow between the left and right sides of the heart

A. Shunting of blood from right to left

While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation? A. Stop the blood transfusion immediately. B. Report to the primary healthcare provider. C. Recheck identifying tags and numbers on the client. D. Maintain a patent intravenous (IV) line with saline solution.

A. Stop the blood transfusion immediately.

The client determines treatment according to their wishes.

Advance Directive, or Living Will

Medication that decreases the irritability of the ventricles by prolonging the duration of the action potential and refractory period. Used to tx ventricular dysrhythmias such as V-tach.

Amiodarone

A client has a platelet count of 49,000/mL (40 × 10 9/L). The nurse should instruct the client to avoid which activity? A. Ambulation B. Blowing the nose C. Visiting with children D. The semi-Fowler position

B. Blowing the nose

The nurse is caring for a client with a respiratory tract infection that started with a common cold but has progressed to whooping cough. The client also has coughing fits that last for several minutes. Which organism is responsible for the client's condition? A. Bacillus anthracis B. Bordetella pertussis C. Streptococcus pneumonia D. Mycobacterium tuberculosis

B. Bordetella pertussis

A client presents to the emergency department with symptoms of acute myocardial infarction (MI). Which results will the nurse expect to find upon assessment? A. Decreased breath sounds B. Elevated serum troponin C. Decreased creatine kinase-MB (CK-MB) D. Elevated brain natriuretic peptide (BNP) level

B. Elevated serum troponin

A 13-year-old child with type 1 diabetes is receiving 15 units of regular insulin and 20 units of NPH insulin at 7:00 AM each day. At what time does the nurse anticipate a hypoglycemic reaction from the NPH insulin to occur? A. Before noon B. In the afternoon C. Within 30 minutes D. During the evening

B. In the afternoon

A 3-year-old child with mild iron deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit? A. Cold, clammy skin B. Increased pulse rate C. Increased blood pressure D. Cyanosis of the nail beds

B. Increased pulse rate

A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery? A. Constipation B. Muscle spasms C. Hypoactive reflexes D. Increased specific gravity

B. Muscle spasms

A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply. A. Supple skin turgor B. Rapid, thready pulse C. Decreased hematocrit D. Elevated specific gravity E. Adventitious breath sounds

B. Rapid, thready pulse D. Elevated specific gravity

A client receiving morphine is being monitored by the nurse for adverse effects of the drug. Which clinical findings warrant immediate follow up by the nurse? Select all that apply. A. Polyuria B. Sedation C. Bradycardia D. Dilated pupils E. Slow respirations

B. Sedation C. Bradycardia E. Slow respirations

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client? A. The signs and symptoms of pericarditis B. The signs and symptoms of heart failure C. That cardiac surgery will have to be done eventually for the other valves D. That cardiac surgery will have to be done every six months to replace the valve

B. The signs and symptoms of heart failure

A client who is admitted to the hospital and requires a colon resection states, "I want to be a do not resuscitate (DNR)." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order? A. "My doctor will know what to do." B. "My family can make the decisions for me." C. "If something happens to me, I do not want CPR." D. "If I have a heart attack, I do not want any medication."

C. "If something happens to me, I do not want CPR."

A client who had a myocardial infarction is in the coronary care unit on a cardiac monitor. The nurse observes runs of ventricular tachycardia on the screen. What medication should the nurse prepare to administer? A. Digoxin B. Furosemide C. Amiodarone D. Norepinephrine

C. Amiodarone

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? A. Red blood cell count B. Sputum culture C. Arterial blood gas D. Total hemoglobin

C. Arterial blood gas

Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO 2 53 mm Hg, and HCO 3 25 mEq/L (25 mmol/L). Which action should the nurse take? A. Obtain a prescription for a diuretic. B. Have the client breathe into a rebreather bag. C. Encourage the client to take deep, cleansing breaths. D. Request a prescription for the administration of sodium bicarbonate.

C. Encourage the client to take deep, cleansing breaths.

A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause? A. Increased serum glucose B. Deficient renal perfusion C. Inadequate antidiuretic hormone (ADH) secretion D. Excess amounts of intravenous (IV) fluid

C. Inadequate antidiuretic hormone (ADH) secretion

A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement? A. Turning on the television for diversion B. Calling the primary healthcare provider for another analgesic prescription C. Placing the prescribed as-needed warm, wet compress on the elbow D. Informing her gently that she must wait until the pump reactivates to get more medication

C. Placing the prescribed as-needed warm, wet compress on the elbow

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? A. "My ankles are swollen." B. "I am tired at the end of the day." C. "When I eat a large meal, I feel bloated." D. "I have trouble breathing when I walk rapidly."

D. "I have trouble breathing when I walk rapidly."

A client's arterial blood gas report indicates the pH is 7.52, PCO 2 is 32 mm Hg, and HCO 3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? A. Airway obstruction B. Inadequate nutrition C. Prolonged gastric suction D. Excessive mechanical ventilation

D. Excessive mechanical ventilation

A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan to encourage this client to modify dietary intake? A. Increased amounts of potassium are needed to replace renal losses. B. Increased protein is needed to heal the adrenal tissue and thus cure the disease. C. Supplemental vitamins are needed to supply energy and assist in regaining the lost weight. D. Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium.

D. Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium.

Which is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease? A. Incisional pain B. Popliteal pulse rate C. Degree of hair growth D. Lower extremity color

D. Lower extremity color

On the second day after surgery, a client reports pain in the right calf. What should the nurse do first? A. Apply a warm soak. B. Document the symptom. C. Elevate the leg above the heart. D. Notify the primary healthcare provider.

D. Notify the primary healthcare provider.

The nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which arterial blood gas report is indicative of diabetic ketoacidosis? A. PCO 2: 49, HCO 3: 32, pH: 7.50 B. PCO 2: 26, HCO 3: 20, pH: 7.52 C. PCO 2: 54, HCO 3: 28, pH: 7.30 D. PCO 2: 28, HCO 3: 18, pH: 7.28

D. PCO 2: 28, HCO 3: 18, pH: 7.28

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? A. Chest tube insertion B. Aggressive diuretic therapy C. Administration of beta-blockers D. Positive end-expiratory pressure (PEEP)

D. Positive end-expiratory pressure (PEEP)

Trigger for sickling of RBCs.

Dehydration

When should the nurse notify the HCP r/t hyperkalemia?

HR <60 or T waves spiked

Cushing's Syndrome

High levels of cortisol (too much water/sodium, too little potassium; aldosterone saves water/sodium and excretes potassium)

Electrolyte imbalance r/t parathyroid surgery

Hypocalcemia

HCT r/t dehydration

Increased d/t hemoconcentration

MOA Digoxin

Increases contractility of heart; slows and strengthens ventricular contractions

ABG for DM Type 1

Metabolic Acidosis

s/s Hyponatremia

Muscle weakness, immediately assess resp effectiveness

s/s Hypokalemia

Nerve and muscle weakness Irregular heartbeat Dysrhythmias Decreased bowel sounds, abdom cramping and paralytic ileus (decrease GI) T wave depression or flattened Hypo-reflexes

A nurse is obtaining a health history from the newly-admitted client who has chronic pain in the right knee. What should the nurse include in the pain assessment? Select all that apply. Pain history, including location, intensity, and quality of pain Client's purposeful body movement in arranging the papers on the bedside table Pain pattern, including precipitating and alleviating factors Vital signs, such as increased blood pressure and heart rate The client's family statement about increases in pain with ambulation

Pain history, including location, intensity, and quality of pain Pain pattern, including precipitating and alleviating factors

s/s Severe Anemia

Pallor, cool/clammy skin

The client gives power to another person to make healthcare decisions on their behalf.

Power of Attorney

Risks associated w/ valve disorders

Prone to HF, infective endocarditis

Priority interventions for FVE

Safety (neuro changes d/t hyponatremia in FVE) Restore normal fluid balance to prevent complications (pulm edema and HF)

Order of interventions for a hemolytic reaction r/t blood transfusion

Stop the blood transfusion Report it to the healthcare provider Recheck the client's ID tags and numbers Maintain a patent IV line with saline solution Continue to monitor the client

Addison's Disease

Too little cortisol/aldosterone (so not enough water/sodium, increased potassium; aldosterone saves water/sodium and excretes potassium)

Cause of metabolic alkalosis

Vomiting Excess bicarb

Priority assess for hypernatremia

q1h for excessive loss of fluid, sodium, or potassium