Fundamentals II Exam 4

Upon arrival to the emergency room, the mother of a patient involved in a motor vehicle accident becomes upset when she learns her son is unconscious and unstable. The mother begins to yell at the emergency room staff in unintelligible words, and she is trembling. She becomes short of breath and yells she can't breathe. What is the mother likely experiencing? a) Severe anxiety b) A panic attack c) Mild anxiety d) Moderate anxiety

A panic attack Explanation: Panic causes the person to lose control and experience dread and terror. Panic is characterized by a disorganized state, increased physical activity, difficulty communicating, agitation, trembling, dyspnea, palpitations, a choking sensation, and sensations of chest pressure or pain. Severe anxiety creates a narrow focus on specific detail; moderate anxiety leads to a focus on immediate concerns; and mild anxiety is often present in day-to-day living, and it increases alertness and perceptual fields.

A client, who lives alone in the country, was admitted to the hospital two days ago. The client begins to show signs of confusion and disorientation. You would most suspect which of the following problems as most contributing to the confusion and disorientation? [Hint] A.changes in quantity and quality of sensory stimuli B. changes in the amount or type of medication C. excessive worry about a variety of things D. a mental condition that has previously gone undetected

A. changes in quantity and quality of sensory stimuli

A home health nurse is assembling a puzzle with an older-adult patient and notices that the patient is having difficulty connecting two puzzle pieces. Which aspect of sensory deprivation will the nurse document as being most affected? a. Perceptual b. Cognitive c. Affective d. Social

ANS: A Alterations in spatial orientation and in visual/motor coordination are signs of perceptual dysfunction. Cognitive function is the ability to think and the capacity to learn; the patient is not disoriented or unable to learn. Affective problems include boredom and restlessness; the patient is participating in an activity. The patient is interacting with the home health nurse, so socialization is not a problem.

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? A) Remove the IV from the site and start at another location. B) Immediately notify the primary care provider. C) Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. D) Aspirate the catheter and attempt to flush again.

ANS: A Feedback: a. If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location. The primary care provider does not need to be notified first. The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? A) Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. B) Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. C) Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. D) Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

ANS: A Feedback: a. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? A) Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. B) Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. C) Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. D) Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

ANS: A Feedback: a. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient? a. Speaking with hands, face, and expressions b. Using a loud voice, enunciating every syllable c. Having direct conversation with the patient in the affected ear d. Repeating the phrase again, if the patient does not understand what the nurse said

ANS: A Use visible expressions. Speak with your hands, your face, and your eyes. Do not shout. Speaking in loud tones can distort a patient's ability to hear; the nurse should speak in normal low tones. If the patient does not understand the first time, try rephrasing instead of repeating the message. The nurse can direct conversation toward the patient's unaffected ear

Which of the following clients are at risk of insensible fluid loss ? ( Select all that apply) A) thyroid crisis B) 2nd degree burns on 20% of body C) continuous bumetanide drip D) Trauma with open wounds E) Continuous nasogastric suctioning F) Temperature 100.8

ANS: A ,B,D, ,F from class

Which things create acid- basre balance? A) Rate and depth of breathing B) Arterial blood gasses C) Kidneys absorbing/excreting bicarb D) Diffusion

ANS: A -rate and depth of breathing- blow off CO2 or retain it- will alter immediately- if lungs are not working patient can have chronic balance issues- breathing heavy means they are getting rid of acid quickly, alkalosis C-kidney and lungs are main control systems of this- take a day or two to start helping out- with renal failure we need to supplement and have them on dialysis from class

The nurse would be most concerned about the risk of malnutrition for a patient with which sensory deficit? a. Xerostomia b. Disequilibrium c. Cataracts d. Peripheral neuropathy .

ANS: A Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems. The other options do not address taste- or nutrition-related concerns

Which is respiratory acidosis ? A) pH= 7.23;CO2=50;HCO3=25 B) pH=7.36; CO2=50;HCO3=25 C) pH=7.23;CO2= 25; HCO3=20

ANS: A high CO2 means they are full of acidosis ROME- respiratory opposite metabolic equal - most concerning symptoms would be tingling from class

A peripheral IV site must be discontinued how frequently ? A) 72- 96 hr B) 24-36 hr C) 48 - 72 hr D)

ANS: A) 72- 96 hr from class

A patient has lethargy, fatigue and confusion. Which of the following lab values correlates most closely with these symptoms? A) Calcium 16 B) Potassium 5 C) CO2 46 D) pH 7.36

ANS: A) Calcium 16 Feedback: Normal value: Calcium = 8.5-10.5 Potassium= 3.5-5 pH= 7.35-7.45 C02 = 35-45 from class

A patient has a sodium value of 125 mEq/L. The nurse documents this as which of the following ? A) Hyponatremia B) Hypokalemia C) hypocalcemia D) Hypochloremia

ANS: A) Hyponatremia Feedback: B) Hypokalemia-- potassium less then 3.5 mmol/L C) hypocalcemia-- Calcium less then 8.5 D) Hypochloremia--Chloride less then 98 mmol/L

A patient has had diarrhea for 3 days. Which of the following electrolyte imbalance would you expect from prolonged diarrhea? A) Potassium 2.9 B) Fluid balance -880 C) Sodium 155 D) calcium 8

ANS: A) Potassium 2.9- too low - body likes get rid of K Feedback: B) Fluid balance -880-- didnt ask about fluid C) Sodium 155-- too high D) calcium 8- low but doesnt have to do with the given issue from class

A patient is having arrhythmias and has the following lab values should the nurse adress first ? A) Potassium 3.3 B) Calcium 8.5 C) Magnesium 1.5 D) Sodium 160

ANS: A) Potassium 3.3 Feedback: Though the sodium is extremly high the potassium is causing the arrhythmias from class

A client has heart failure with peripheral edema,. Which is a correct explanation of this edema.? A) Rise in capillary pressures compared to ow interstitial pressure B) Rise in arterial pressure compare to low venous pressure C) Too much oral fluid intake D) too little urinary output

ANS: A) Rise in capillary pressures compared to ow interstitial pressure from class

The nurse administers a blood produt. The client becomes short of breath.. What does the nurse need to do? A) Stop the transfusion B) Obtain vital signs C) Apply oxygen D) Notify health care provider

ANS: A) Stop the transfusion from class

The nurse administers blood. Vital signs at 15 minutes are 80/60. 88. 26. 90% . 100.9 . What does the nurse do first ? A) Stop the transfusion B) Obtain vital signs C) Apply oxygen D) Notify health care provider

ANS: A) Stop the transfusion from class

Sodium is 160. Which oder most concerns the nurse? A) fluid restrictions B) Draw CMP in AM C) Normal saline ( 0.9%) at 75 mL/hr D) Up ad lip

ANS: A) fluid restrictions Feedback: Sodium normal= 135-145- this will cause cognitive issues. from class

Which of the following patients would most concern a nurse? A) A patient with a heart Rate irregular and 155 B) A patient who is Orientated x 2 C) A patient who's skins is Tenting skin D) A patient who is experiencing Muscle weakness

ANS: A) heart Rate irregular and 155 the nurse needs to look at this patients potassium from class

Which is metabolic acidois? A) pH= 7.01; CO2=40 HCO3=10 B) pH= 7.36; CO2=40;HCO3=10 C) pH=7.45;CO2=35;HCO3=18

ANS: A) pH= 7.01; CO2=40 HCO3=10 -- look at pH first then bicarb for metabolic acidosis look at CO2 for respitory acidosis normal lab values : normal C02 = 35-45 normal pH =7.35-7.45 normal PO2= 80-100 normal HCO3= 22-28 from class

A patient is experiencing a Air embolism. The nurse translates this to mean which of the following ? A)blockage of blood supply caused by air bubbles in a blood vessel of the heart. B)a condition in which the liquid portion of the blood plasma is too high C)a medication leak into the surrounding tissue D)nflammation of a vein.

ANS: A)blockage of blood supply caused by air bubbles in a blood vessel of the heart. Feedback: B)a condition in which the liquid portion of the blood plasma is too high---Hypervolemia C)a medication leak into the surrounding tissue-- Infiltration D)nflammation of a vein---Phlebitis

A nurse suspects a patient of having fluid overload. The nurse recognizes which of the following as being signs of fluid overload? ( Select all that apply) A) Heart rate 110 B) BP 90/55 C) skin tenting D) Pulsating neck veins

ANS: A, D-- the neck vein dentition is the most indicative of the fluid overload Feedback: B) BP 90/55- sign of dehydration C) skin tenting-sign of dehydration from class

A nurse notices that a patient is suffering with metabolic acidosis. The nurse knows that which of the following things could cause metabolic acidosis? ( Select all that apply) A) Diabetic ketoacidosis B) Renal failure C)Chronic obstructive pulmonary disease D)Severe pneumonia E)Potassium deficit

ANS: A,B Feedback: more things that cause metabolic acidosis: Lactic acidosis Starvation Severe diarrhea Renal tubular acidosis C)Chronic obstructive pulmonary disease-has to do with Respiratory acidosis D)Severe pneumonia--has to do with respiratory acidosis E)Potassium deficit-- has to do with metabolic alkalosis

A nurse is assessing a patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? (Select all that apply. ) A) Changes in appetite B) Changes in elimination patterns C) Decreased pulse and respirations D) Use of ineffective coping mechanisms E)Withdrawal

ANS: A,B Feedback: Physiologic effects of stress include changes in appetite and elimination patterns as well as increased (not decreased) pulse and respirations. Using ineffective coping mechanisms, becoming withdrawn and isolated, and exhibiting attention-seeking behaviors are psychological effects of stress.

A patient has a respiratory alkalosis. Which of the following interventions would be most appropriate for this patient? A) Prevent further losses of hydrogen, potassium, calcium, chloride ions B)Ventilation support C) Restore fluid balance D) Modify or stop gastric suctioning, IV solutions with base, drugs that promote hydrogen ion excretion E) Focus is on improving ventilation and oxygenation, maintaining patent airway

ANS: A,C,D Feed back: B)Ventilation support E) Focus is on improving ventilation and oxygenation, maintaining patent airway -- these have to do with respiratory acidosis

A patient has metabolic alkalosis. Which of the following would be an appropriate interventions for this patient ? ( Select all that apply) A) Prevent further losses of hydrogen, potassium, calcium, chloride ions B)Focus is on improving ventilation and oxygenation, maintaining patent airway C) Restore fluid balance D) Monitor changes, provide safety E) Modify or stop gastric suctioning, IV solutions with base, drugs that promote hydrogen ion excretion

ANS: A,C.D.E Feedback: B)Focus is on improving ventilation and oxygenation, maintaining patent airway-- this is an intervention for respiratory acidosis

A nurse would be most concerned about which of the following patients when assessing for sensory vision issues? A) diabetic retinopathy B) peripheral neuropathy C) Dysequilibrium D) Xerostomia

ANS: A-- you would also be worried about someone with a brain injury C) Dysequilibrium - this effects balance D) Xerostomia - this effects the salivary glands resulting in malnutrition

A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis. Which assessment of the patient would indicate an adaptation to the sensory deficit? a. The patient frequently cleans out his ears with a cotton swab. b. The patient turns one ear toward the nurse during conversation. c. The patient isolates himself from social situations. d. The patient asks the nurse to speak loudly during conversations.

ANS: B Adaptation for a sensory deficit indicates that the patient alters his behavior to accommodate for his sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the ear would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive. Asking the nurse to speak loud alters the environment but does not adapt the patient's behavior

A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the: A) Kidneys B) Lungs C) Adrenal glands D) Blood vessels

ANS: B Feedback: b. The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.

Which client is at most risk of insensible fluid loss? A) On Furosemide qid B) Tachypnea and anxiety C) Fluid restriction of 1200 mL/ day D) Vomiting and diarrhea

ANS: B -- insensible refers to something you can not measure from class

A young adult's chief complaint is "seizure fits." A chart review shows a negative EEG report and a normal neurological consultation report. A psychosocial history reveals increased family stress, bankruptcy, and a recent divorce. The nurse recognizes that this young man's pseudo-seizures most likely are an example of which unconscious coping mechanism? a. Compensation b. Conversion c. Dissociation d. Denial

ANS: B A conversion reaction is an ego defense mechanism that involves repressing an anxiety-producing conflict and transforming it into a nonorganic symptom such as difficulty sleeping, loss of appetite, or sudden blindness without medical cause. Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Dissociation involves experiencing a subjective sense of numbing and a reduced awareness of one's surroundings. Denial is seen as avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain

The process of passively moving water from an area of lower particle concentration to an area of higher particle concentration is known as a. Hydrolysis. b. Osmosis. c. Filtration. d. Active transport.

ANS: B The process of moving water from an area of low particle concentration to an area of higher particle concentration is known as osmosis. Hydrolysis is not a term related to fluid and electrolyte balance. Filtration is mediated by fluid pressure from an area of higher pressure to an area of lower pressure. Active transport requires metabolic activity and is not passive.

The nurse is administering potassium IV. What rate should this this be programmed to deliver? A) 5 mEq/ hr;50 mL/hr B) 10 mEq/hr;100 mL/hr C) 30 mEq/hr;150 mL/hr D) 20 mEq/hr; 200 mL/hr

ANS: B) 10 mEq/hr;100 mL/hr from class

Which of the following patients would most likely be a fall risk? A) A patient with Xerostomia B) A patient with meniere's disease C) A patient with a broken arm D) A patient on contact MRSA

ANS: B) A patient with meniere's disease-- this is an inner ear disease that typically affects one ear. This disease can cause pressure or pain in the ear, severe cases of dizziness or vertigo, hearing loss and a ringing or roaring noise, also known as tinnitus.

IV is infusing at 100 mL/hr. What signs indicate phlebitis? A) Site edema B) Cord- like vein C) IV pump keeps beeping that it is occluded D) pain in affected extrimity

ANS: B) Cord- like vein from class

A person feels dehydrated after a night of vomiting and diarrhea. Which replacement is best? A) water B) Gatorade C) Tea D) IV fluids

ANS: B) Gatorade-- losing fluid, acid, base and electrolytes FEEDBACK: Give IV if the patient was confused or restless or had a irregular heart rate. Or if the patient has not urinated since yesterday evening from class

Which of the following is the best for ongoing maintenamce fluid? A) 1/2 NS B) LR C) D5 0.9% NS D) 0.225% NS

ANS: B) LR ( lactated ringers) - this has fluid and electrolytes-- good fluid for replacing Feedback A) 1/2 NS--- this is basically taking fluid away and moves the sodium around C) D5 0.9% NS D) 0.225% NS ---quarter normal is used for a patient that have too mush sodium -- 3% for too much sodium from class

The nurse is reviewing the standing orders for a patient who was admitted for evaluation of chest pain. The patient has a history of chronic obstructive pulmonary disease (COPD), and his laboratory results and assessment reveal that he has mild respiratory acidosis. The nurse would question which order? A) Encourage oral fluids B) Oxygen therapy at 4 L/min as needed C) Keep head of bed elevated D) Bedrest with bathroom privileges only

ANS: B) Oxygen therapy at 4 L/min as needed

A nurse notices that a patient has an inflammation of a vein. The nurse recognizes this as which of the following ? A) Hypervolemia B) Phlebitis C) Infiltration D) Air embolism

ANS: B) Phlebitis Feedback: A) Hypervolemia- a condition in which the liquid portion of the blood plasma is too high C) Infiltration-a medication leak into the surrounding tissue D) Air embolism-blockage of blood supply caused by air bubbles in a blood vessel of the heart.

The client has a potassium level of 2.7 which intervention is most appropriate? A) Encourage the client to eat potatoes or bananas B) Use available protocol to administer PO and IV potassium C) Notify the HCP of the lab value D) Teach the client to alert the nurse for heart palpitations

ANS: B) Use available protocol to administer PO and IV potassium Feedback: Regular potassium: 3.5-5.0 from class

A patient is experiencing Respiratory alkalosis. Which symptoms would the nurse expect to see? ( Select all that apply) A) decreased blood pressure B)Lethargy C) Light-headedness D) Nervousness E) Dysrhythmias

ANS: B,C,E Feedback: Confusion and tachycardia go with this. A) decreased bp-- has to do with metabolic acidosis D) Nervousness these go with metabolic alkalosis

The nurse is caring for a group of patients and is monitoring for sensory deprivation. Which patient will the nurse monitor most closely? a. A patient in the ICU under constant monitoring following a myocardial infarction b. A patient on the unit with tuberculosis on airborne precautions c. A patient who recently had a stroke and has left-sided weakness d. A patient receiving hospice care for end-stage lung cancer

ANS: B-- A group at risk includes patients isolated in a health care setting or at home because of conditions such as active tuberculosis. Sensory deprivation occurs when a person has decreased stimulation and limited sensory input. A patient in isolation (airborne precautions) is at risk for sensory deprivation because of limited exposure to meaningful stimuli. A patient in the ICU would be at risk for sensory overload with all the monitors and visitors. A patient with a stroke may have difficulty with tactile sensation but is not at as high a risk for sensory deprivation as is one in isolation. A patient with lung cancer may have deficits, but hospice is present so the patient is at home with others.

The client has some equipment that is noisy, and the roommate also has equipment that makes noise, and the room is close to a noisy nursing station, where they can be watched a little closer. Which of the following interventions by the nurse would be best for the client as well as reduce the risk of sensory overload? A. Move the client away from the nurses' station area. B. Explain the sounds in the environment. C. Tell the client to ignore the sounds. D. Play the client's favorite music louder than the sounds.

ANS: B. Explain the sounds in the environment.

The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit? a. Body image disturbance b. Social isolation c. Risk for falls d. Fear

ANS: C A visual disturbance poses great risk for injury due to falling from impaired depth perception and inability to see obstacles. Body image disturbance, social isolation, and fear are all valid nursing diagnoses that apply to a patient with vision deficit; however, they do not address the greatest risk for injury.

A person states that he was not shoplifting from the store despite very clear evidence on the store surveillance tape. This person is demonstrating which ego defense mechanism? a. Dissociation b. Conversion c. Denial d. Compensation

ANS: C Denial consists of avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Dissociation involves creating subjective numbness and less awareness of surroundings. Conversion involves repressing anxiety and manifesting it into a physiological problem. Compensation occurs when an individual makes up for a deficit by strongly emphasizing another feature.

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic acidosis D) Metabolic alkalosis

ANS: C Feedback: c. A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? A) A pinched and drawn facial expression B) Deep, rapid respirations. C) Moist crackles heard upon auscultation D) Tachycardia

ANS: C Feedback: c. Moist crackles may indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit.

Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment? a. Self-care deficit b. Risk for falls c. Social isolation d. Impaired physical mobility

ANS: C In focusing on the psychological aspect of care, the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment. Both self-care deficit and fall risk are physiological risks for the patient. Impaired physical mobility would not apply to this patient.

A nurse is administering a vaccine to a 4-year-old child who is visually impaired. After the needle enters the arm, the child says, "Ow, that was sharp!" The nurse knows that the ability to recognize and interpret stimuli is known as a. Sensation. b. Reception. c. Perception. d. Reaction.

ANS: C Perception occurs when the person becomes conscious of stimuli and interprets information signals. Reception refers to receiving stimuli and creating a nerve impulse. Reaction is how a person responds to a perceived stimulus. Sensation is a general term that refers to awareness of sensory stimuli through the body's sense mechanisms.

A teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. Given appropriate tertiary level interventions, the nursing intervention would be to a. Teach the patient about the food pyramid. b. Administer antidiarrheal medications with meals. c. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends. d. Admonish the teen and her parents regarding her consistently poor diet choices.

ANS: C Tertiary level interventions have the purpose of assisting the patient in readapting to life with an illness. By adjusting the diet to meet dietary guidelines and also addressing adolescent emotional needs, the nurse will help the teen to eat an appropriate diet without health complications and see herself as a "typical and normal" teenager. Teaching about the food pyramid will not address the real issue, which is that the teen is still eating what she knows will make her ill. Administering antidiarrheal medications may help but is not a tertiary level intervention. Admonishing the teen and parents is not a tertiary level intervention, and because this approach is nontherapeutic, it may cause communication problems

Which of the following are signs of hypercalciumia? A) Ca 10.5 B) Tingling in fingers C) Bone pain and confusion D) Tetany

ANS: C) Bone pain and confusion Feedback: Normal Calcium= 8.5-10.5 This is caused by anything that can open up the bone and release calcium. from class

Which of the following is a sign of hypernatremia? A) Na150 B) Restlessness C) Confusion D) Hypotension

ANS: C) Confusion Feedback: hypernatremia- this is high sodium soduim will effect the brain whether its low or high. normal sodium : 135-145 to correct low sodium you give a hyper tonic solution For a high sodium give hypo tonic solution. You can not correct this quickly. from class

Continuous gastric suctioning. Which is most concerning for metabolic alkalosis? A) Irritablity B) Tingling fingers( parethesias) C) Deep and slow respirations D) increased UOP

ANS: C) Deep and slow respirations- this would be most concerning because it is no expected. signs of alkalosis : nausea, confusion, light headedness, numbness and tingling from class

A patient is experiencing a medication leak into the surrounding tissue. The nurse documents this as which of the following? A) Hypervolemia B) Phlebitis C) Infiltration D) Air embolism

ANS: C) Infiltration Feedback: A) Hypervolemia- a condition in which the liquid portion of the blood plasma is too high B) Phlebitis- inflammation of a vein D) Air embolism - blockage of blood supply caused by air bubbles in a blood vessel of the heart.

After a CVAD is inserted, what does the nurse do next? A) Begin the prescribed infusion B) Check the IV solution to ensure its clear C) Look at the X- ray results for"lies in superior vena cava" D) Place order stating the line is ready to use.

ANS: C) Look at the X- ray results for"lies in superior vena cava" from class

A client has a new onset of chest pain and COPD. Which order most concerns the nurse? A) Encourage oral fluids B) Up ad lib( get up when they want to) C) O2 at 4L PNC D) ABGs every 6 hours

ANS: C) O2 at 4L PNC-- this is supposed to be only 2 L so this much could cause an acid base imbalance in this patient. Feedback: A) Encourage oral fluids-- may need a surgery B) Up ad lib( get up when they want to) -- risk for falls D) ABGs every 6 hours -- this is fine from class

A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which nursing intervention is an example of this type of stress management? A) The nurse teaches a patient rhythmic breathing to perform prior to the procedure. B) The nurse tells a patient to focus on a pleasant place, mentally place himself in it, and breathe slowly in and out. C) The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it. D) The nurse teaches a patient to create and focus on a mental image during the procedure in order to be less responsive to the pain.

ANS: C) The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it. Feedback: Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When the patient know what to expect—for example, when the nurse tells the patient about the pain he or she should expect to experience during a procedure, and describes related pain relief measures—the patient's anxiety is reduced. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique

IV infusing at 125 mL/hr. what signs indicate infiltration A) Pain at site B) Site erthmema C) cool site D) Site feels hard

ANS: C) cool site-- at this time take IV out from class

The client blw 3 IV sites overnight. What does the nurse do during the next morning? A) Insert 2 PIVs B) Place an order for a port-a-cath C) request a PICC line D) Insert a mid-line catheter

ANS: C) request a PICC line-- request early D) regular nurses cant do this. from class

What is the involuntary motion of retracting the body from painful stimuli? a. Sensation b. Reception c. Perception d. Reaction

ANS: D

The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over the inability to sleep. Which action by the nurse is most appropriate for this patient? a. Administer an opioid medication to help the patient sleep. b. Keep the door open during the night. c. Open the shades at night. d. Provide the patient with earplugs.

ANS: D Control of excessive stimuli becomes an important part of a patient's care; earplugs provide relief. Quiet time means dimming the lights throughout the unit, closing the shades, and shutting the doors. Allow patients to shut their room door to decrease noise. Opioid medications (for pain relief) should not be the first option; however, antianxiety medications and sleep aids may be considered.

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? A) Reposition the extremity and raise the height of the IV pole. B) Apply pressure to the dressing on the IV. C) Pull the catheter out slightly and reinsert it. D) Put on gloves; remove the catheter

ANS: D Feedback: d. This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the insertion site without applying pressure. The nurse should assess the area distal to the venous access device for capillary refill, sensation and motor function and restart the IV in a new location. Finally the nurse should estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment, notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines (INS, 2016b), and record site assessment and interventions, as well as site for new venous access.

During the evaluation stage of the critical thinking model applied to a patient coping with stress, the nurse will a. Select nursing interventions to promote the patient's adaptation to stress. b. Establish short- and long-term goals with the patient experiencing stress. c. Identify stress management interventions for achieving expected outcomes. d. Reassess patient's stress-related symptoms and compare with expected outcomes.

ANS: D During the evaluation stage, the nurse compares current stress-related symptoms against established measurable outcomes to evaluate the effectiveness of the intervention. Selecting appropriate interventions and establishing goals are part of the planning process.

An adult who was in a motor vehicle accident is brought into the emergency department by paramedics, who report the following in-transit vital signs: Oral temperature: 99.0° F Pulse: 102 beats per minute Respiratory rate: 26 breaths per minute Blood pressure: 140/106 The nurse can identify that which hormones are the likely causes of the abnormal vital signs? a. ADH and ACTH b. ACTH and epinephrine c. ADH and norepinephrine d. Epinephrine and norepinephrine

ANS: D Epinephrine and norepinephrine are catecholamine hormones secreted by the adrenal medulla that rapidly elevate heart rate and blood pressure. ACTH originates from the anterior pituitary gland and stimulates cortisol release; ADH originates from the posterior pituitary and increases renal reabsorption of water. ACTH, cortisol, and ADH do not increase heart rate

The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient? a. Speaking in a loud voice, enunciating every syllable b. Having direct conversation with the patient in his affected ear c. If the patient does not understand what the nurse is saying, repeating the phrase again d. Speaking with hands, face, and expressions

ANS: D Using gestures other than just speaking helps the patient understand what you are saying and makes it a meaningful stimulus. Speaking in loud tones can distort a patient's ability to hear; the nurse should speak in normal low tones. If the patient does not understand the first time, try rephrasing instead of repeating the message. The nurse can direct conversation toward the patient's unaffected ear.

Which of the following are signs of hypokalemia? A) K 2.8 B) Fluid retention C) Muscle weakness D) Cardiac arryhthmia

ANS: D) Cardiac arryhthmia Feedback A) K 2.8 - this is hypokalemia not a sign of hypokalemia C) Muscle weakness-- low K causes cramps and high would cause weakness from class

A patient has signs of fluid overload. The nurse would be most concerned about which of the following signs of fluid overload? A) bounding pulse B)Pitting edema C) Neck vein distention D) Lung crackles

ANS: D) Lung crackles-- means there is fluid in the lungs from class

A patient is brought to the ED after being hit by a car while biking. He is unresponsive, has shallow breathing, and has an open femur fracture from which he has lost a significant amount of blood. The nurse anticipates which acid-base imbalance? A) Metabolic alkalosis B) Respiratory acidosis C) Metabolic alkalosis and respiratory alkalosis D) Metabolic acidosis and respiratory acidosis

ANS: D) Metabolic acidosis and respiratory acidosis Feedback: Acute blood loss leads decreased cardiac output, tachycardia, hypotension, and hypovemic shock. Inadequate organ perfusion and O2 delivery interfere with aerobic metabolism. This leads to production of lactic acid and metabolic acidosis. The shallow breathing would lead to the accumulation of carbon dioxide which would lead to respiratory acidosis.

The nurse is evaluating the laboratory work of a patient who has uncontrolled metabolic acidosis. Which outcome would result from this condition? A) pH 7.40 B) Bicarbonate 38 mEq/L C) Pao2 98 mm Hg D) Serum potassium 5.7 mEq/L

ANS: D) Serum potassium 5.7 mEq/L normal: pH - 7.35-7.45 CO2- 35-45 HCO3- 23-27 low pH = Acidosis Low Co2 = Alkalosis Low HCO3 = Acidosis

Which result does the nurse report immediately? A) Potassium 3.3 B) Calcium 8.5 C) Magnesium 1.5 D) Sodium 160

ANS: D) Sodium 160 Feedback Normal range: Potassium= 3.5 -5 Calcium= 8.5-10.5 Magnesium= 1.5- 2 Sodium= 135- 145 from class

A patient presents with hypoventalation, hypoxia, a decreased blood pressure, flushed and states he feels incredibly dizzy. The nurse can assume this patient is experiencing which of the following? A) Metabolic acidosis B) respiratory alkalosis C) Metabolic alkalosis D) respiratory acidosis

ANS: D) respiratory acidosis Feedback: A) Metabolic acidosis--would present with, Drowsiness, Confusion, Headache, Coma, Nausea, vomiting, diarrhea, abdominal pain and Dysrhythmias B) respiratory alkalosis-present with symptoms such as: Tachycardia Dysrhythmias (related to hypokalemia from compensation, Tetany, Numbness, Tingling of extremities, Hyperreflexia, Seizures C) Metabolic alkalosis - would present with symproms such as:Tachycardia Dysrhythmias (related to hypokalemia from compensation,Tetany, Tremors, Tingling of fingers and toes, Muscle cramps, hypertonic muscles Seizures

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. A) 5% dextrose in 0.9% NaCl B) 0.9% NaCl (normal saline) C) Lactated Ringer's solution D) 0.33% NaCl (⅓-strength normal saline) E) 0.45% NaCl (½-strength normal saline) F) 5% dextrose in Lactated Ringer's solution

ANS: D,E Feedback: d, e. 0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. 5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 5% dextrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.

A person has shallow breathing. Which lab finding is likely? A) Metabolic alkalosis B) Respritory alkalosis C) Respiratory acidosis D) Metabolic acidosis

ANS: Respiratory Acidosis from class

A nurse witnesses a street robbery and is assessing a patient who is the victim. The patient has minor scrapes and bruises, and tells the nurse, "I've never been so scared in my life!" What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? (Select all that apply.) A) Increased heart rate B) Decreased muscle strength C) Increased mental alertness D) Increased blood glucose levels E) Decreased cardiac output F) Decreased peristalsis

ANS: a, c, d. Feedback: The sympathetic nervous system functions under stress to bring about the fight-or-flight response by increasing the heart rate, increasing muscle strength, increasing cardiac output, increasing blood glucose levels, and increasing mental alertness. Increased peristalsis is brought on by the parasympathetic nervous system under normal conditions and at rest.

A nurse is caring for an older adult in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on the patient's condition, what would be a priority intervention for this patient? A) Monitoring food and drink temperatures to prevent burns B) Providing adequate pain relief measures to reduce stress C) Monitoring for depression related to social isolation D) Providing meals high in carbohydrates to promote healing

ANS: a. Feedback: A patient with a damaged neurologic reflex arc would have a diminished pain reflex response, which would put the patient at risk for burns as the sensors in the skin would not detect the heat of the food or liquids. All patients should be provided adequate pain relief, but this is not the priority intervention in this patient. Monitoring for depression would be an intervention for this patient but is not related to the damaged neurologic reflex arc. A patient who is immobile should eat a balanced diet based on the Dietary Guidelines for Americans from the U.S. Department of Health and Human Services and U.S. Department of Agriculture.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? A) Encourage foods and fluids with high sodium content. B) Administer oral K supplements as ordered. C) Caution the patient about eating foods high in potassium content. D) Discuss calcium-losing aspects of nicotine and alcohol use.

ANS: b Feedback: b. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress? A) An infant who learns to turn over B) A school-aged child who learns how to add and subtract C) An adolescent who is a "loner" D) A young adult who has a variety of friends

ANS: c. Feedback: The adolescent who is a loner is not meeting a major task (being a part of a peer group) for that level of growth and development.

A nurse is caring for a patient in the shock or alarm reaction phase of the GAS. Which response by the patient would be expected? A) Decreasing pulse B) Increasing sleepiness C) Increasing energy levels D) Decreasing respirations

ANS: c. Feedback: The body perceives a threat and prepares to respond by increasing the activity of the autonomic nervous and endocrine systems. The initial or shock phase is characterized by increased energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness. 7

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? A) 1+ pitting edema B) 2+ pitting edema C) 3+ pitting edema D) 4+ pitting edema

ANS: c. 3+ pitting edema Feedback: 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. 4+ is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.

Which patient is at more risk for an electrolyte imbalance?* A. An 8 month old with a fever of 102.3 'F and diarrhea B. A 55 year old diabetic with nausea and vomiting C. A 5 year old with RSV D. A healthy 87 year old with intermittent episodes of gout

ANS:A ) An 8 month old with a fever of 102.3 'F and diarrhea

The culturally sensitive nurse will realize which of the following about a client from a large active Latino family who is put into isolation for a communicable disease? A. The number of visitors greatly needs to be restricted. B. may be accustomed to, and need, high stimulation level C. is a likely candidate for sensory overload D. will need more personal space than other clients

ANS:B. may be accustomed to, and need, high stimulation level

Which ABGs represent respiratory alkalosis? A) ph: 7.28; CO2 35; HCO3 28 B) pH 7.48;CO2 29; HCO3 23 C) pH7.45;CO2 45;HCO3 22 D) pH7.55; CO2 29; HCO3 20

ANS:D) pH7.55; CO2 29; HCO3 20 Feedback: normal lab values : normal C02 = 35-45 normal pH =7.35-7.45 normal PO2= 80-100 normal HCO3= 22-26 from class

An adolescent entering high school voices anxiety over changing schools. Stating anxiety is an act of a) Valuation b) Adaptation c) Evaluation d) Reaction

Adaptation Explanation: Adaptation is generally considered a person's capacity to flourish and survive, even with diversity.

A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion.

Ans: 50 gtts/min. When administering 500 mL of solution over 10 hours, and the set delivers 60 gtts/mL, the nurse would use the following formula:

The client most likely to be experiencing a negative situational stress response is: A. An 18-year-old beginning college in a new state B. An 80-year-old victimized by a telephone scam C. A 5-year-old adjusting to a new baby sister D. A 23-year-old mother of two preschoolers who is beginning college

B. An 80-year-old victimized by a telephone scam Rationale: An 18-year-old beginning college in a new state is experiencing a situational stress response. The other answers are examples of developmental stressors.

A client recovering from a spinal cord injury becomes angry with the nurse and uses obscenity. The nurse's best response is: A. To laugh in order to relieve the tension B. "Stop it right now. This is uncalled for." C. "I'm listening. Tell me what this is about." D. "What did I do to make you so angry?"

C. "I'm listening. Tell me what this is about." Rationale: Clients with trauma have a need to express anger and have it acknowledged. Laughing does not acknowledge the client's need to express strong displeasure with a severe injury. The client's anger is best acknowledged in such a manner that the client does not suppress future attempts to express emotion. The client owns the anger, and needs to assume responsibility for the anger and deal with it.

Which of the following are considered defense mechanisms? (Select all that apply.) A. Projection B. Minimization C. Compensation D. Reinventing A. Projection B. Minimization

C. Compensation Rationale: Defense mechanisms may be adaptive or maladaptive. Compensation, denial, displacement, identification, intellectualization, introjection, minimization, projection, rationalization, reaction formation, regression, repression, sublimation, substitution, and undoing are considered defense mechanisms.

A bystander at an automobile accident is excited and alarmed. He feels nauseated and dizzy, has difficulty focusing, and the pulse is elevated. What level of anxiety is the bystander feeling? A. Mild B. Moderate C. Severe D. Panic

C. Severe Rationale: Mild anxiety symptoms include increased arousal, few if any gastric symptoms, and minor if any respiratory or circulatory changes. Moderate anxiety symptoms include a narrowed focus of attention; selectively inattentive, slightly increased heart and respiratory rate; and "butterflies in the stomach." Panic symptoms include agitation, unpredictable responses, distorted perception, dyspnea, palpitations, and feelings of impending doom.

The children of a 60-year-old woman are distraught at her apparent lack of recovery following a stroke several weeks earlier. The patient's daughter has frequently directed harsh criticism toward the nurses, accusing them of a substandard effort in rehabilitating her mother despite their best efforts. What defense mechanism may the patient's daughter be exhibiting? a) Sublimation b) Regression c) Displacement d) Denial

Displacement Explanation: The daughter may be transferring her feelings about her mother's health status to the care providers, an act that involves the displacement of the emotional reaction to another person. Denial about her mother's potential for recovery may underlie her response, but this is not demonstrated as clearly as displacement.

The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client? a) Secondary stage b) Exhaustion stage c) Alarm stage d) Resistance stage

Exhaustion stage Explanation: The client is in the exhaustion stage when one or more adaptive/resistive mechanisms can no longer protect the person experiencing a stressor; this results in exhaustion. The effects of stress-related neurohormones suppress the immune system and the body is open to various ailments. In the alarm stage, the person is prepared for a fight-or-flight response. In the resistance stage, the client's body is returned to the homeostasis state. Consequently, one or more organs or physiologic processes may eventually lead to increased vulnerability to stress-related disorders or progression to the stage of exhaustion. The secondary stage is not a stage related to stress.

1. IV infusing at 100 mL/hr. what signs indicate phlebitis? a. Site edema b. CORD-LIKE VEIN c. IV pump beeps d. Pain in affected extremity

b. CORD-LIKE VEIN

A nurse began transfusing a blood product, the patient then started showing signs of hypotension, tachypnea, hypocia, and is febrile. Which does the nurse do first? A) Notify Health care Provider. B) stop infusion C) Obtain vital signs D) Apply oxygen

ANS: B) stop the tranfusion from class

A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan? a. Risk for falls b. Self-care deficit c. Social isolation d. Impaired physical mobility

ANS: C In focusing on the psychological aspect of care, the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment. Self-care deficit, impaired physical mobility, and fall risk are physiological risks for the patient.

Which of the following are signs of hypomagnesemia? A) Mag 1.2 B) Vomiting C) Tetany D) Loss of deep tendon reflexes

ANS: C) Tetany Feedback : normal 1.5-2.5 mEq/L low mag. excites the muscles and the high mag. causes weakness from class

The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care? a. Patient will carry a pen and a pad of paper around for communication. b. Patient will recover full use of speech vocabulary in 1 day. c. Patient will thicken drinks to prevent aspiration. d. Patient will communicate nonverbally.

ANS: D

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? A) Recording intake and output. B) Testing skin turgor. C) Reviewing the complete blood count. D) Measuring weight daily.

ANS: D Feedback: d. Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

A client has metaboloc acidosis. Which value is associated with this? A) pH 7.40 B) Bicarbonate 38 C) PaO2 95 D) K 5.7

ANS: D) K 5.7-- this has to do with cellular death. B) Bicarbonate 38 -- doesn't have to do with acidosis from class

Which of the following is a physiological response experienced during the exhaustion stage of general adaptation syndrome? a) Increased mental alertness b) Vasoconstriction c) The initiation of neuroendocrine activity d) Decreased blood pressure

Decreased blood pressure Explanation: The stage of exhaustion is often accompanied by decreased blood pressure and vasodilation. Increased mental alertness and the initiation of neuroendocrine activity are associated with the alarm reaction of the GAS.