Final - Oral Review
The nurse is conducting an admission assessment and interview of a client who is believed to have Guillain- Barre syndrome. Which comment by the client has the most significance to this diagnosis?
"About two weeks ago, I missed a day of work because I had a bad cold"
Which statement would the nurse consider characteristic of a client diagnosed with diabetes insipidus(DI)? "I am always thirsty and crave cold water" "I stay hungry all of the time" "I have gaineda lot of weight" "I urinate about 4 times a day, and it is straw-colored"
"I am always thirsty and crave cold water"
The nurse has been providing education regarding thyroid hormone replacement therapy. Which statement by the pt reflects a need for further teaching? "I will take this pill in the morning." "Sometimes this medicine can make my heart skip beats, but that's a normal side effect." "I need to take this pill on an empty stomach and wait about 30-60 min before eating." "I will be sure to go to the clinic and have my thyroid levels tested regularly."
"Sometimes this medicine can make my heart skip beats, but that's a normal side effect."
How do you know that a burn patient is receiving adequate fluid infusion?
***at least 30 mL urine output***
A patient weighing 187 lbs. has 38% total body surface area burns. Using the Parkland formula, how much fluid should this patient receive over the first eight hours after the burn occurred? Record your answer as a whole number.
- 6460 mL
A patient has returned to the unit after having a parathyroidectomy. What drug is kept at the bedside for emergency use?
- Calcium gluconate
A patient who has had a total parathyroidectomy has returned to the unit from the PACU. The nurse caring for the patient knows he should assess for what complication following this surgery?
- Tetany
The nurse is preparing equipment to administer a unit of blood to a patient. Which type of fluid would the nurse piggyback with the blood transfusion?
0.9 % normalsaline
A patient with hypothyroidism is prescribed levothyroxine (Synthroid). At which time should the nurse schedule this medication to be administered?
0800 hours
A patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have? -
18%
A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the Rule of Nines.
22.5% (use picture as reference)
The nurse is assessing a patient who is admitted with a persistent cough and is diagnosed with pulmonary edema. Which assessment finding supports the patient's diagnosis?
3) Large amounts of frothy, pink tinged sputum
Which laboratory test should the nurse anticipate when providing care to a patient with a clotting disorder caused by the intrinsic pathway?
4) Partial thromboplastin time (PTT
A patient is diagnosed with pheochromocytoma. Which manifestation should the nurse expect as a result of catecholamine secretion?
4) Widening pulse pressure
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 client with a C-7 spinal cord injury is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?
A distended bladder
Prioritization - which patient will you assess first? - Which patient should the nurse assess first?
A patient with smoke inhalation who has wheezes and altered mental status
Iron deficiency anemia usually exhibits a red blood cell morphology that is: A) microcytic and hypochromic. B) macrocytic and normochromic. C) normocytic and normochromic. D) macrocytic and hypochromic.
A) microcytic and hypochromic. Answer Feedback: Iron deficiency anemia usually exhibits a red blood cell morphology that is microcytic and hypochromic. Low hemoglobin content in the erythrocyte results in smaller cell volumes.
A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first?
Administer oxygen via nasal cannula.
Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?
Ask the patient to extend both arms forward.
To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?
Assist to plan a prescribed bowel program
During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse evaluates that the teaching is effective when the client states which information?
Avoid people with respiratory infections.
A patients enteral feedings have been determined to be too concentrated based on the patients development of dumping syndrome. What physiologic phenomenon caused this patient complication of enteral feeding?
B) Entry of large amounts of water into the small intestine because of osmotic pressure
A patient who has had a total parathyroidectomy has returned to the unit from the PACU. The nurse caring for the patient knows he should assess for what complication following this surgery?
B) Hypercalcemia (from recording: which will cause polyuria)
What intervention is most important to include in the nursing care plan of a client who is receiving chemotherapy and has a platelet count of 30,000/mm3?
B) assess the client for abnormal bleeding
A patient with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery
Blood glucose
A patient with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery?
Blood glucose
A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the patient's bleeding and established that his vital signs are stable. What should be the nurse's next action?
C) Prepare for the administration of factor VIII
The nurse notes that a female client with a T-tube excreted a total of 300 ml of greenish-brown drainage in the sixteen hours since her cholecystectomy. What nursing action has the highest priority at this time?
C) document findings in the client record
A client has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse are most appropriate? (Select all that apply.)
C. Placing the client in protective precautions d. Teaching visitors appropriate hand hygiene e. Telling visitors not to bring live flowers or plants
Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately?
C. Upper airway stridor
A client with hyperparathyroidism reports increasing lethargy and seems confused. It is most important for the nurse to obtain which serum lab test results?
Calcium. <(hypercalcemia)
A patient is recovering from a thyroidectomy. Which observation needs to be reported immediately to the health-care provider?
Changes in voice tone
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to: -
Check the client status and lead placement.
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which is the priority action of the nurse?
Check the client's status and lead placement.
Some of the things you're going to do that has peritoneal dialysis get reduced outflow? The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Select all nursing actions in the situation that apply Check the level of the drainage bag. Reposition the client to his or her side. lace the client in good body alignment. Check the peritoneal dialysis system for kinks.
Check the level of the drainage bag. Reposition the client to his or her side. lace the client in good body alignment. Check the peritoneal dialysis system for kinks.
A client had thoracic surgery. The nurse should monitor for what clinical manifestations that may indicate acute pulmonary edema? Select all that apply Crackles Cyanosis (Pink )Frothy Sputum
Crackles Cyanosis (Pink )Frothy Sputum
A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take first? A Alert the cardiac arrest team. B Call the laboratory to repeat the test. C Take vital signs and notify the primary healthcare provider. D Obtain an electrocardiogram (ECG) strip and obtain an antiarrhythmic medication.
D Obtain an electrocardiogram (ECG) strip and obtain an antiarrhythmic medication.
A patient who undergoes hemodialysis three times weekly is on a fluid restriction of 1000 mL/day. The nurse sees the patient drinking a 355-mL (12 ounce) soft drink after the patient has already reached the maximum intake of fluid for the day. What action should the nurse take?
D) Reinforce the importance of the fluid restriction and document the teaching and the intake of extra fluid
A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurse's priority action?
Discontinue the transfusion.
A patient with hyperthyroidism is prescribed propylthiouracil (PTU). What should the nurse include in the teaching plan when explaining the mechanism of this medication?
Diverts iodine pathways (antithyroid hormone)
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate?
Do nothing, because this is an expected finding.
A nurse teaches the signs of organ rejection to a client who had a kidney transplant. What should be included in the education?
Elevated blood pressure
A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patient's care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include?
Excess fluid volume related to generalized edema (anasarca)
A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?
Extremity movement
A patient with myasthenia gravis is experiencing sweating and pallor. After administering edrophonium (Tensilon), which finding suggests the patient is experiencing a cholinergic crisis?
Fasciculations
The nurse is preparing to assess a patient with diabetes insipidus (DI). Which manifestations should the nurse expect? Select all that apply. Fatigue Extreme thirst Large amounts of urine output Waking up to urinate in the night
Fatigue Extreme thirst Large amounts of urine output Waking up to urinate in the night
A nurse is caring for a client newly admitted with a diagnosis of pheochromocytoma. Which clinical findings does the nurse expect when assessing this client? Select all that apply. Headache Palpitations Diaphoresis
Headache Palpitations Diaphoresis
The nurse is reviewing patient data. Which information suggests this patient has pheochromocytoma? Select all that apply. Headache Palpitations Hypertension Hyperglycemia
Headache Palpitations Hypertension Hyperglycemia
Patient that has sickle cell anemia - treatment A patient with sickle cell disease is admitted with a vaso-occlusive crisis (painful episode). What are the priority nursing concerns? Select all that apply. Hydration Pain management Oxygen supplementation
Hydration Pain management Oxygen supplementation
A nurse is caring for a client with a diagnosis of chronic kidney failure who has just been told by the primary healthcare provider that hemodialysis is necessary. Which clinical manifestation indicates the need for hemodialysis?
Hyperkalemia
Which clinical findings indicate to the nurse that a 6-year-old child has nephrotic syndrome (NS) rather than acute poststreptococcal glomerulonephritis (APGN)? Select all that apply.
Hypoalbuminemia Massive proteinuria Generalized edema (anasarca)
The nurse is providing patient education to a patient taking corticosteroids. When would the nurse advise the patient to take their medication?
Immediately on awakening in the morning
A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)?
Impairment of respiratory muscles
When completing a neurological assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion?
Inability to stand with feet together when eyes are closed
A few hours after returning to the surgical nursing unit, a patient who has undergone a subtotal thyroidectomy develops laryngeal stridor and a cramp in the right hand. Which action will the nurse anticipate taking next?
Infuse IV calcium gluconate.
Propylthiouracil is prescribed for a client diagnosed with hyperthyroidism. The client asks the nurse, "Why do I have to take this medication if I am going to get radiation therapy?" What explanation does the nurse provide?
It decreases production of thyroid hormones.
What nursing intervention is anticipated for a client with Guillain-Barré syndrome? -
Maintaining ventilator settings to support respiration
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?
Malaise
The nurse responding to a ventilator alarm finds the patient lying in bed gasping and the endotracheal tube on the floor. Which action should the nurse take next?
Manually ventilate the patient with 100% oxygen
A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the nurse monitor this client?
Metabolic acidosis
A client with small cell carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH). What signs should the nurse expect to observe? Select all that apply.
Oliguria Seizures Vomiting
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?
Pain, especially with inspiration
The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?
Perform the Valsalva maneuver.
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?
Place the patient on 100% O2 using a nonrebreather mask
The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system?
Plastic tubing located at the chest insertion site
A patient with Guillain-Barr syndrome has experienced a sharp decline in vital capacity. What is the nurses most appropriate action?
Prepare to assist with intubation
A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end-stage renal disease (ESRD)?
Protein
A patient has been prescribed mafenide acetate (Sulfamylon) cream for burn treatment. The nurse should educate the patient regarding which of the following?
Severe burning pain for up to 20 minutes
A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action?
Slow the infusion rate and monitor the patient closely.
A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?
Sodium deficit
The nurse caring for a patient admitted with septic shock is aware of the need to assess for the development of acute respiratory distress syndrome (ARDS). Which early clinical manifestation would indicate the development of ARDS?
Tachypnea
A nurse assesses a client who is recovering from a transsphenoidal hypophysectomy. The nurse notes nuchal rigidity. Which action should the nurse take first?
Take vital signs, including temperature.
The low-pressure alarm sounds on a ventilator. A nurse assess the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action?
Ventilates the client manually.
V-tach
Ventricular tachycardia (an increased ventricular heart rate).
A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply. Anorexia Vomiting Muscle weakness Irregular heart rate
Vomiting Muscle weakness Irregular heart rate
A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, I do not want to be placed on a mechanical ventilator. How should the nurse respond? -
What would you like to be done if you begin to have difficulty breathing?
After performing an ECG on an adult client, the nurse reports that the PR interval reflects normal sinus rhythm. What is the PR interval for a normal sinus rhythm?
b. 0.12 and 0.2 seconds
A patient seen in the emergency department for severe headache and acute confusion has a serum sodium level of 118 mEq/L. The nurse should anticipate the need for which diagnostic test?
b. Antidiuretic hormone level
A nurse cares for a client who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The client's serum sodium level is 114 mEq/L. Which action should the nurse take first?
b. Restrict the client's fluid intake to 600 mL/day.
The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?
b. The patient's hands flap back and forth when the arms are extended.
Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy?
c) Monitor oxygen saturation using pulse oximetry.
Which question should the nurse ask when assessing a 60-year-old patient who has a history of benign prostatic hyperplasia (BPH)?
c. "Has there been a decrease in the force of your urinary stream?"
At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. What should the nurse teach the patient to do?
c. Lie down for about 30 minutes after eating.
A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first?
d. Contact the provider and prepare for intubation
A hospitalized client has a platelet count of 58,000/mm3. What action by the nurse is best?
d. Place the client on safety precautions.
Asystole
flat line
normal sinus rhythm
heart rhythm originating in the sinoatrial node with a rate in patients at rest of 60 to 100 beats per minute
A client is on daily doses of prednisone. To minimize adrenal suppression, the nurse's instructions for administration should include to take the medication:
in the morning.
To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about
occurrence of a weak urinary stream.
V fib
ventricular fibrillation
The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm?
Atrial fibrillation
A patient is being prepared for a tensilon test. What should the nurse ensure is available prior to the beginning of this test
Atropine sulfate
A client recovering from surgery to remove a pituitary tumor has an 8- hour urine output of 1500 mL and a specific gravity of 1.001. This finding is consistent with which complication from the surgery?
Diabetes insipidus.
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? -
Notify the health care provider.
The nurse is reviewing the laboratory test results for a client receiving chemotherapy. The nurse notes that the white blood cell count is extremely low and places the client on neutropenic precautions. Which interventions are a component of these types of precautions? Select all that apply.
Removing fresh-cut flowers from the client's room Instructing family members on the proper technique for hand washing Instructing family members to wear a mask when entering the client's room
Parkland formula and calculations of fluids - goes up to the infusion rate. Have to calculate the amount and speed you'll give infusion or 8 hours or 16 hours?
The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.) Answer: 12160 Rationale: 4ml x 67kg x 40 (bsa) =12,160 ml
Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action?
The patient is continuously drooling saliva
A nurse is caring for a client with bleeding esophageal varices who was treated with a double balloon tamponade (Sengstaken Blakemore tube). Several hours after the gastric and esophageal balloons were inflated, the nurse notes that the client has become increasingly agitated, and respirations are 36/min and shallow. Which of the following is an appropriate nursing action?
Use scissors to cut the tubing in front of the nose guard or sponge
A nurse is caring for a patient who is undergoing chemotherapy to treat leukemia. What is the priority nursing action?
Using techniques to minimize risk of infection
states pt has fluid overload
place high fowler position
A patient admitted with burns over 30% of the body surface 2 days ago now has dramatically increased urine output. Which action should the nurse plan to support maintaining kidney function?
- Continuing to measure the urine output
The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the clients oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what?
- Diminished or absent breath sounds on the affected side
A patient with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the patient should prioritize what question when addressing potential complications?
- Do you feel any muscle twitches or spasms?
The critical care nurse is caring for a patient with a central venous pressure (CVP) monitoring system. The nurse notes that the patients CVP is increasing. Of what may this indicate?
- Hypervolemia
A patient has returned to the floor after having a thyroidectomy for thyroid cancer. The nurse knows that sometimes during thyroid surgery the parathyroid glands can be injured or removed. What laboratory finding may be an early indication of parathyroid gland injury or removal?
- Hypocalcemia
The nurse provides teaching regarding levothyroxine to a 55-year-old patient diagnosed with Hashimoto's disease. What statement made by the patient does the nurse interpret to mean that the drug teaching had been understood?
- I should take this medication on an empty stomach in the morning
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?
- Paradoxical chest movement
The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate?
- Possible hypovolemia
Potassium, sodium, hematocrit during emergent phase in burn patients? The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse?
- Serum potassium 6.1 mEq/L
A nurse is caring for a client with the diagnosis of Guillain-Barré syndrome with nasal cannula oxygen. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention?
- Suction the client's oropharynx
The nurse explains to the family of a client suspected of having myasthenia gravis that edrophonium (Enlon) is used to establish the diagnosis. An increase in which factor will confirm the diagnosis? -
- muscle strength
A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse's first action?
- palpate the area over the bladder for distension
A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré syndrome. Which question by the nurse will best elicit information that supports this diagnosis?
-"Have you experienced an infection recently?"
How long should the person wear elastic pressure garment? A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?
-Continuously
The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the dwell time for the dialysis at the prescribed time because of the risk of:
-Hyperglycemia
The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?
-Monitor blood pressure frequently
A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self- management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider?
-Muscle cramping
The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured?
27%
An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)?
36%
After an abdominal cholecystectomy, a client has a T-tube attached to a collection device. On the day of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 6:30 AM the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information?
3. Mechanical problems may have developed with the T-tube.
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/hr
A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following?
A: Sharp pleuritic pain that worsens on inspiration
A client with myasthenia gravis continues to become weaker despite treatment with neostigmine (prostigmin). what reason should the nurse identify for the health care provider's prescription for edrophonium (enlon)?
rule out cholinergic crisis
A physician has prescribed propylthiouracil (PTU) for a client with hyperthyroidism and the nurse develops a plan of care for the client. A priority nursing assessment to be included in the plan regarding this medication is to assess for: relief of pain signs of renal toxicity signs and symptoms of hyperglycemia signs and symptoms of hypothyroidism
signs and symptoms of hypothyroidism
Priority of acute phase in burn patients? The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? -
Acute
Interventions for acute pancreatitis? The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. Administer antacids as prescribed. Encourage coughing and deep breathing. Administer anticholinergics as prescribed. Give opioid analgesics as prescribed for pain.
Administer antacids as prescribed. Encourage coughing and deep breathing. Administer anticholinergics as prescribed. Give opioid analgesics as prescribed for pain.
To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level? -
Assist to plan a prescribed bowel program
A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?
Asterixis
A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: -
Atrial fibrillation
A nurse is caring for a client with end-stage renal disease who has a mature arteriovenous (AV) fistula. What nursing care should be included in the client's plan of care? Select all that apply. Auscultate for a bruit Palpate the site to identify a thrill Avoid drawing blood from the affected extremity
Auscultate for a bruit Palpate the site to identify a thrill Avoid drawing blood from the affected extremity
Which action will the nurse include in the plan of care to maintain the patency of a patient's left arm arteriovenous fistula?
Auscultate for a bruit at the fistula site.
The nurse caring for a patient in ICU diagnosed with Guillain-Barr syndrome should prioritize monitoring for what potential complication?
Autonomic dysfunction
A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this clients discharge teaching?
Avoid crowds and people with colds.
A male client with multiple myeloma is admitted with pneumonia and pancytopenia. The nurse reviews the complete blood cell count findings and identifies a platelet count of 20,000 cells/mm3. Which intervention should the nurse include in the client's plan of care
Avoid intramuscular injections
A client with acute kidney injury states, "Why am I twitching and my fingers and toes tingling?" Which process should the nurse consider when formulating a response to this client?
Calcium depletion
An unresponsive Caucasian patient has been brought to the emergency room by EMS. While assessing this patient, the nurse notes that the patients face is a cherry-red color. What should the nurse suspect?
Carbon monoxide poisoning
The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicates that additional fluid resuscitation is required? Blood pH 7.39 Heart rate 112 bpm Blood pressure 110/60 mm Hg Central venous pressure 2 mm Hg
Central venous pressure 2 mm Hg
A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?
Chest pain the occurs suddenly
A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care?
D) Assess for a thrill or bruit over the vascular access site each shift
What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours?
D) Diabetes insipidus
The nurse would suspect excessive thyroid replacement in a patient taking levothyroxine (Synthroid) and exhibiting which adverse effect?
D) Irritability
A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patient's diet to maximize the therapeutic effect and minimize the risks of complications. The patient's diet should include which of the following modifications? Select all that apply. Decreased protein intake Decreased sodium intake Fluid restriction
Decreased protein intake Decreased sodium intake Fluid restriction
The clinic nurse is assessing the client. The nurse evaluates that the client's levothyroxine dose is too low when which findings are noted on assessment? Decreased sweating Apathy and fatigue Parathesis Slowed mental processes
Decreased sweating Apathy and fatigue Parathesis Slowed mental processes
When receiving hemodialysis, the client may develop hyponatremia. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply. Diarrhea Seizures Hyperactivity Restlessness
Diarrhea Seizures
The nurse will be teaching self-management to patients after gastric bypass surgery. Which information will the nurse plan to include? Drink fluids between meals but not with meals. (little fluids) Choose high-fat foods for at least 30% of intake. Developing flabby skin can be prevented by exercise. Choose foods high in fiber to promote bowel function.
Drink fluids between meals but not with meals. (little fluids)
Burn patient - may have risk for intestinal bacteria. How do we reduce risk? A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? -
Early enteral feeding
The healthcare provider prescribes several medications for a client diagnosed with myasthenia gravis (MG) Which medication would the nurse expect to use to differentiate a myasthenic crisis from a cholinergic crisis? -
Edrophonium (Tensilon)
A nurse is assessing a client with a diagnosis of diabetes insipidus. For which signs indicative of diabetes insipidus should the nurse assess the client? Select all that apply. Excessive thirst Dry mucous membranes Decreased urine specific gravity
Excessive thirst Dry mucous membranes Decreased urine specific gravity
What medication does a nurse expect to administer to control bleeding in a child with hemophilia A?
Factor VIII concentrate
A client has a kidney transplant. The nurse should monitor for which assessment findings associated with rejection of the transplant? Select all that apply. Fever Oliguria Weight gain
Fever Oliguria Weight gain
Signs and symptoms of acute kidney rejection that the nurse should teach the patient to observe for include:
Fever and painful transplant site
What will the physician order for burn patients?
Fluid resuscitation
What will the nurse ask the patient about to determine the severity of benign prostatic hyperplasia (BPH) symptoms?
Force of urinary stream
What will the nurse will ask the patient about to determine the severity of benign prostatic hyperplasia (BPH) symptoms?
Force of urinary stream
Which question should the nurse ask when assessing a 60-year-old patient who has a history of benign prostatic hyperplasia (BPH)?
Has there been a decrease in the force of your urinary stream?"
A 3-year-old child is to receive a liquid iron preparation. What should the nurse teach the mother in relation to this medication? Monitor stools for the occurrence of diarrhea. Administer the iron at least an hour before meals. Avoid giving the child orange juice with the iron solution. Have the child drink the diluted iron preparation through a straw.
Have the child drink the diluted iron preparation through a straw.
Laboratory results have been posted for a male patient experiencing manifestations of diabetes insipidus (DI). Which results would confirm the diagnosis? Select all that apply.
Hematocrit 52% Serum sodium 150 mEq/L Urine specific gravity 1.002
The nurse is caring for a client who has been diagnosed with Acute post streptococcal glomerulonephritis. Which initial urinary finding supports this dx? Select all that apply.
Hematuria Mild proteinuria Cola-colored pee (or tea colored)
A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding?
Highly dilute urine
Assessment for patient burns in face, neck, and chest A patient is brought to the emergency department (ED) following an inhalation injury. The patient has sustained burns on the face, neck, and chest due to a fire in the home. Which would help to confirm the diagnosis of upper airway injury? Select all that apply. Hoarseness Singed nasal hair Difficulty swallowing
Hoarseness Singed nasal hair Difficulty swallowing
A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what? Hyperkalemia hyponatremia elevated hematocrit metabolic acidosis
Hyperkalemia hyponatremia elevated hematocrit metabolic acidosis
A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what?
Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? -
Hyponatremia and decreased urine output
A client is receiving fluid replacement with LR after 40% of his body was burned 10 hours ago. The assessment reveals: Temp 36.2, HR 122, BP 84/42, CVP 2 mm, and urine output 25 mL for the last two hours. The IV rate is currently at 375 mL/hr. Using the SBAR technique for communication, the nurse calls the healthcare provider with the recommendation for? furosemide fresh frozen plasma IV rate increase dextrose 5%
IV rate increase
The home care nurse is conducting patient teaching with a patient on corticosteroid therapy. To achieve consistency with the bodys natural secretion of cortisol, when would the home care nurse instruct the patient to take his or her corticosteroids?
In the morning between 7 AM and 8 AM
A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient?
In the morning, with frequent rest period
S/S of thyroid storm A nurse is caring for a client after a thyroidectomy. Which symptoms indicating thyroid storm should the nurse monitor the client for? Select all that apply. Increased heart rate Increased temperature
Increased heart rate Increased temperature
A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer?
Methylprednisolone (Medrol)
The registered nurse (RN) assigns a task to a licensed practical nurse (LPN) to take care of a client admitted with severe burns. Which tasks are being performed by the LPN in this situation? Select all that apply. Monitoring heart rate Monitoring blood pressure Administering the oral medication
Monitoring heart rate Monitoring blood pressure Administering the oral medication
A client with superficial burns to the face, neck, and hands resulting from a house fires is admitted to the burn unit. Which assessment finding indicates to the nurse that the client should he monitored for carbon monoxide poisoning?
Mucous membranes cherry red color
When receiving hemodialysis, the complication of the removal of too much sodium may occur. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply. Chvostek sign Muscle cramps Extreme fatigue Cardiac dysrhythmias Increased temperature
Muscle cramps Extreme fatigue
What would you teach your patient who is diagnosed with hemophilia a on what kind of activities they should participate in?
NO CONTACT sports and swimming would be best
The nurse is discharging a patient with a new prescription for levothyroxine. What would the nurse teach the patient to report to her health care provider? (Select all that apply.)
Nervousness Insomnia Chest pain
A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as:
Normal sinus rhythm
The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The P waves and QRS complexes are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 82 beats/min. The nurse interprets the cardiac rhythm to be which rhythm?
Normal sinus rhythm
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics?
Normal sinus rhythm
The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of a headache and nausea and is extremely restless. Which of the following is the most appropriate nursing action?
Notify the physician
What type of causes for SIADH? A client with small cell carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH). What signs should the nurse expect to observe? Select all that apply. Oliguria Seizures Vomiting
Oliguria Seizures Vomiting
The nurse is providing care to a patient who is status post partial gastrectomy for the treatment of gastric carcinoma. Which should the nurse include in the plan of care to decrease the risk of dumping syndrome?
Providing smaller meals at more frequent intervals
A nurse is caring for a patient whose chemical injury has necessitated a skin graft to his left hand. The nurse enters the room and observes that the patient is performing active range of motion (ROM) exercises with the affected hand. How should the nurse best respond?
Remind the patient of the need to immobilize the graft to facilitate healing
With mechanical debridement in burn patients? The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve which of the following procedures?
Removal of eschar until the point of pain and bleeding occurs
A patient with hyperparathyroidism is experiencing flank pain. For which health problem should this patient be assessed?
Renal calculi
Priority action of a patient with electrical burn injury -spinal cord injury Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line?
Stabilize the cervical spine.
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication?
Stools for occult blood
What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Check all that apply
The RR intervals are relatively consistent One P wave precedes each QRS complex
What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply.
The RR intervals are relatively consistent. One P wave precedes each QRS complex.
A 26 year old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
The client experiences......PALPATIONS AND SHORTNESS OF BREATH
A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patient's current health status is most likely to have precipitated this event?
The patient's urinary catheter became occluded.
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse indicates a need for further teaching?
The patient's visitors bring in fresh peaches
A nurse tells a patient to take a prescribed glucocorticoid in the morning based on the understanding that
This time mimics the normal peak diurnal concentration levels.
