Lifespan Exam 3 STUDY QUESTIONS
The nurse is caring for a patient in septic shock due secondary to pneumonia. The nurse knows that evidence-based guidelines for the treatment of septic shock include which interventions? (Select all that apply.) a. Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. b. Administer low-dose dopamine to maintain urine output greater than 30 mL/h. c. Start enteral nutrition within the first 48 hours after diagnosis of septic shock. d. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L. e. Perform an adrenocorticotropic hormone (ACTH) stimulation test to identify patients who need hydrocortisone
- Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. - Start enteral nutrition within the first 48 hours after diagnosis of septic shock. - Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L.
What is the pH of gastric juices prior to being mixed with food? a. 1.0 b. 3.0 c. 5.0 d. 7.0
1.0
Identify in the correct order the five layers of the skin from the surface inward. 1. Stratum granulosum 2. Stratum corneum 3. Stratum germinativum 4. Stratum lucidum 5. Stratum spinosum a. 2, 4, 1, 5, 3 b. 2, 4, 5, 1, 3 c. 4, 2, 5, 1, 3 d. 4, 5, 1, 3, 2
2, 4, 1, 5, 3
Using the Rule of Nines calculate the percent of injury in an adult who was injured as follows: the patient sustained partial and full thickness burns to half of his left arm, his entire left leg, and his perineum. a. 28% b. 16% c. 23.5% d. 45.5%
23.5%
The nurse is caring for a patient with acute liver failure. What laboratory value would the nurse expect to decrease in this situation? a. Albumin b. Total bilirubin c. Alkaline phosphatase d. Aspartate aminotransferase
Albumin
The nurse is caring for a patient with a traumatic brain injury. The nurse suspects the patient is developing diabetes insipidus. Which test or procedure would confirm this diagnosis? a. Antidiuretic hormone (ADH) stimulation test b. Water deprivation test c. Serum glucose levels d. Skill radiographs
Antidiuretic hormone (ADH) stimulation test
A patient is admitted with GI hemorrhage due to esophagogastric varices. The patient has been started on a vasopressin drip. The nurse would monitor for which side effect of the medication? a. Constipation b. Bleeding c. Diarrhea d. Chest pain
Chest pain
Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action? a. Daily assessment for proper fit and effectiveness b. Removal of splints during showers and dressing changes c. Allowing for frequent breaks from splint use d. Passive and active range of motion may be used instead of splints
Daily assessment for proper fit and effectiveness
What is the main function of bile? a. Emulsify fat globules b. Serve as a reservoir for bilirubin c. Maintain triglyceride levels in the blood d. Aid in detoxification of drugs in the liver
Emulsify fat globules
The nurse is caring for a patient with an upper gastrointestinal bleed. What procedure would the nurse expect the practitioner to order to confirm this diagnosis? a. Endoscopic retrograde cholangiopancreatography (ERCP) b. Colonoscopy c. Endoscopy d. Angiography
Endoscopy
The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which medical intervention would the nurse expect to be ordered for this patient? a. Extensive hydration b. Oral hypoglycemic agents c. Large doses of intravenous (IV) insulin d. Limiting food and fluids
Extensive hydration
A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock? a. Anorexia leads to loss of gastric enzymes b. Lack of food ingestion leads to intestinal hypomotility c. Hypoperfusion results in loss of gut barrier function d. Low cardiac output causes decreased hydrochloric acid secretion
Hypoperfusion results in loss of gut barrier function
What is the most common location for a male to have a hernia? a. Femoral b. Umbilical c. Inguinal d. Abdominal
Inguinal
A patient has been admitted with ulcerative colitis. Which information from the patient's history would be consistent with this diagnosis? a. Drug abuse b. Jewish ancestry c. Pericardial disease d. Asian ancestry
Jewish ancestry
A patient is undergoing a hepatobiliary scan to assess the progression of cirrhosis of the liver. The nurse would anticipate which result? a. Nonvisualization b. Little or no uptake c. Increased uptake d. Normal uptake
Little or no uptake
A patient with a history of chronic alcoholism was admitted with acute pancreatitis. What intervention would the nurse include in the patient's plan of care? a. Monitor the patient for hypovolemic shock from plasma volume depletion. b. Observe the patient for hypoglycemia and hypercalcemia. c. Initiate enteral feedings after the nasogastric tube is placed. d. Place the patient on a fluid restriction to avoid the fluid sequestration.
Monitor the patient for hypovolemic shock from plasma volume depletion.
Which component of gastric juice is necessary for the breakdown of proteins? a. Hydrochloric acid (HCl) b. Pepsin c. Intrinsic factor d. Potassium
Pepsin
How is food is propelled through the esophagus? a. Gravity b. Salivary fluids c. Cardiac sphincter suction d. Peristalsis
Peristalsis
A patient is admitted with severe hyperglycemia. The patient is very lethargic and has a "fruity" odor to his breath. The nurse knows the odor on the patient's breath is indicative of which situation? a. Alcohol intoxication b. Lack of sodium bicarbonate c. Hypokalemia d. Presence of acetone
Presence of acetone
A Salem sump nasogastric tube has two lumens. The first lumen is for suction and drainage. What is the purpose of the second lumen? a. Allows for administration of tube feeding b. Allows for testing of gastric secretions c. Prevents the tube from adhering to the gastric wall d. Prevents the tube from advancing
Prevents the tube from adhering to the gastric wall
A patient is admitted to the burn unit after electrocution. The patient sustained extensive burns. The nurse should have a high suspicion for what complication associated with this type of burn injury? a. Venous thromboembolism b. Stress ulcers c. Pneumothorax d. Rhabdomyolysis
Rhabdomyolysis
The nurse has been caring for a patient with liver dysfunction. The practitioner has just performed a liver biopsy at the bedside. Following a liver biopsy, how would the nurse position the patient? a. Left side for 2 hours b. Right side for 2 hours c. Left side for 6 to 8 hours d. Right side for 6 to 8 hours
Right side for 2 hours
What intestinal hormone is responsible for stimulating the pancreas to secrete fluid into the duodenum? a. Secretin b. Chyme c. Gastrin d. Pepsin
Secretin
A patient has been admitted with abdominal pain. The practitioner suspects the patient has gallstones. Which diagnostic procedure would the nurse expect the practitioner to order to confirm this diagnosis? a. Ultrasonography b. Abdominal radiography c. Angiography d. Liver scan
Ultrasonography
A patient has been admitted with acute liver failure. Which interventions would the nurse expect as part of the interprofessional collaborative management plan? (Select all that apply.) a. Benzodiazepines for agitation b. Pulse oximetry and serial arterial blood gas measurements c. Insulin drip for hyperglycemia and hyperkalemia d. Monitoring electrolyte blood levels e. Assessing for signs of cerebral edema
b. Pulse oximetry and serial arterial blood gas measurements d. Monitoring electrolyte blood levels e. Assessing for signs of cerebral edema
A patient is admitted with multiple trauma. Which hormone would the nurse expect to be increased in response to physiologic stress? a. Cortisol b. Corticosteroid c. Glucocorticoid d. Mineralocorticoid
cortisol
Roughly 80% of burns in children are classified as what type of burn? a. Radiation b. Chemical c. Electrical d. Thermal
thermal
A patient has been admitted with septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to note to support this diagnosis? a. Cardiac output (CO) of 8 L/min b. Right atrial pressure (RAP) of 17 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 23 mm Hg d. Systemic vascular resistance (SVR) of 1100 dyne/s/cm-5
Cardiac output (CO) of 8 L/min
A patient is admitted with severe malnutrition. A central venous catheter is placed in the right subclavian vein and total parenteral nutrition (TPN) is started. On the third day of infusion, the patient develops symptoms of fever and chills. What complication should the nurse suspect? a. Air embolism b. Pneumothorax c. Central venous thrombosis d. Catheter-related sepsis
Catheter-related sepsis
An older patient reports taking cimetidine for several years. The nurse knows that this medication can cause central nervous system side effects. For what side effect would the nurse monitor the patient? a. Tremors b. Dizziness c. Confusion d. Hallucinations
Confusion
The nursing management plan for a patient with full-thickness burns includes which intervention? a. Daily replacement of autografts b. Daily wound care with premedication c. Weekly wound care until all eschar is debrided d. Surgical skin grafting within 8 hours of admission
Daily wound care with premedication
A patient has been admitted with hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis? a. Distended neck veins b. Decreased level of consciousness c. Bounding radial and pedal pulses d. Widening pulse pressure
Decreased level of consciousness
A patient is admitted after being burned in a car fire. The wound surface is red with patchy while areas that blanch with pressure but no blister formation. What kind of burn would the nurse document in the patients record? a. Superficial partial thickness burn b. Full thickness burn c. Moderate partial thickness burn d. Deep dermal partial thickness
Deep dermal partial thickness
Decreased urine osmolality is a sign of which disorder? a. Hyperglycemia b. Diabetes insipidus c. Thyroid crisis d. Syndrome of inappropriate secretion of antidiuretic hormone
Diabetes insipidus
A patient is admitted with a long history of mental illness. The patient's spouse states the patient has been drinking up to 10 gallons of water each day for the past 2 days and refuses to eat. The patient is severely dehydrated and soaked with urine. The nurse suspects the patient has which problem? a. Central diabetes insipidus (DI) b. Nephrogenic DI c. Dipsogenic DI d. Iatrogenic DI
Dipsogenic DI
When the ileum is distended, the ileogastric reflex inhibits what process? a. Gastric absorption b. Absorption in the jejunum c. Gastric motility d. Ileum motility
Gastric motility
A patient has been admitted in acute liver failure. Which laboratory value would the nurse expect to support this diagnosis? a. Elevated blood glucose level b. High levels of unconjugated bilirubin c. Decreased prothrombin time d. Decreased partial thromboplastin time
High levels of unconjugated bilirubin
A patient has developed septic shock. The nurse knows that the clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which finding would the nurse expect to note to support this diagnosis? a. Elevated serum creatinine b. Decreased bilirubin c. Jaundice d. Decreased serum transaminase
Jaundice
Where in the gastrointestinal tract are Bacteroides, Lactobacillus, and Clostridium organisms commonly found? a. Stomach b. Small intestine c. Large intestine d. Liver
Large intestine
A patient is admitted with an upper gastrointestinal bleed. Which disorder is the leading cause of upper gastrointestinal (GI) hemorrhage? a. Stress ulcers b. Peptic ulcers c. Nonspecific erosive gastritis d. Esophageal varices
Peptic ulcers
A patient has been admitted with hyperosmolar hyperglycemic state (HHS). The nurse knows that intravenous insulin is usually administered at what dosage? a. 0.1 U/kg/h b. 1.0 U/kg/h c. 2.0 U/kg/h d. 5.0 U/kg/h
0.1 U/kg/h
A patient was admitted with pancreatitis. The nurse is auscultating the patient's abdomen. How long must the nurse listen to be able to accurately chart that bowel sounds are absent? a. 30 seconds b. 1 minute c. 3 minutes d. 5 minutes
5 minutes
A patient is admitted with severe malnutrition. A central venous catheter is placed in the right subclavian vein and total parenteral nutrition (TPN) is started. For which complication should the patient be evaluated immediately after insertion of the catheter? a. Pneumothorax b. Hypoglycemia c. Central venous thrombosis d. Pulmonary aspiration
Pneumothorax
A patient has been admitted with diabetic ketoacidosis, and treatment has been initiated. Which findings would lead the nurse to suspect the patient is dehydrated? a. Poor skin turgor and flat neck veins b. Dyspnea and crackles c. Presence of Chvostek and Trousseau signs d. Extra heart sounds and 3+ edema
Poor skin turgor and flat neck veins
As a patient with diabetic ketoacidosis (DKA) receives insulin and fluids, the nurse knows careful assessment must be given to which electrolyte? a. Potassium b. Sodium c. Phosphorus d. Calcium
Potassium
What is the name of the portion of the stomach that connects the antrum to the duodenum? a. Fundus b. Body c. Cardiac orifice d. Pylorus
Pylorus
The nurse understands that the onset of seizures in the patient with diabetes insipidus (DI) is indicative of which situation? a. Increased potassium levels b. Hyperosmolality c. Severe dehydration d. Toxic ammonia levels
Severe dehydration
Which topical antimicrobial agent is commonly used as a broad-spectrum and fights against gram-positive and -negative bacteria? a. Pure silver b. Bacitracin c. Mafenide acetate cream d. Silver sulfadiazine
Silver sulfadiazine
Which organ lies obliquely beneath the cardiac sphincter and above the pyloric sphincter? a. Esophagus b. Stomach c. Duodenum d. Ileum
Stomach
The nurse is caring for a patient after an esophagectomy. The nurse knows the patient is at risk for an anastomotic leak. Which finding would indicate this occurrence? a. Crackles in the lung bases b. Subcutaneous emphysema c. Incisional bleeding d. Absent of bowel sounds
Subcutaneous emphysema
The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called? a. Absolute hypovolemia b. Distributive hypovolemia c. Relative hypovolemia d. Compensatory hypovolemia
Absolute hypovolemia
The nurse is caring for a patient with gastrointestinal bleeding. The practitioner was unable to locate the bleed with an endoscopy. Which procedure would the nurse expect the practitioner to order next? a. Plain abdominal series b. Magnetic resonance imaging c. Angiogram d. Computed tomography
Angiogram
A patient has been admitted with abdominal pain with right lower quadrant guarding and tenderness, fever, and an elevated white blood cell count. The nurse suspects that the patient has which disorder? a. Appendicitis b. Hepatitis c. Cecal volvulus d. Perforated duodenal ulcer
Appendicitis
Through what mechanism does the endocrine system help maintain equilibrium? a. Control of smooth muscle b. Hormones c. Neuronal control d. Control of skeletal muscle
hormones
A patient was admitted after a Roux-en-Y gastric bypass (RYGBP). A nursing student asks the nurse what type of surgery an RYGBP is. What would be an appropriate response from the nurse? a. "It is an esophagectomy performed using the transthoracic approach." b. "It is an esophagectomy performed using a transhiatal approach." c. "It is a combination of restrictive and malabsorption types of bariatric surgery." d. "It is a standard operation for pancreatic cancer."
"It is a combination of restrictive and malabsorption types of bariatric surgery."
A patient has thyroid storm. The nurse is providing medication instruction for home. The patient asks, "If I have a fever, should I take Tylenol or aspirin?" Which response would be the most appropriate? a. "Either one is fine because they do not affect the antithyroid medication." b. "Take Tylenol rather than aspirin because aspirin increases the amount of free thyroid hormone in circulation." c. "Take aspirin rather than Tylenol because Tylenol increases the amount of free thyroid hormone in circulation." d. "They both prevent the antithyroid medication from working correctly. I would recommend an NSAID."
"Take Tylenol rather than aspirin because aspirin increases the amount of free thyroid hormone in circulation."
A patient with a history of type 2 diabetes was admitted after aneurysm repair. The patient's serum glucose levels have been elevated for the past 2 days, and the patient is concerned about becoming dependent on insulin. Which statement is the nurse's best response to the patient's concerns? a. "This surgery may have damaged your pancreas. We will have to do more evaluation." b. "Perhaps your diabetes was more serious from the beginning." c. "You will need to discuss this with your physician." d. "The stress on your body has temporarily increased your blood sugar levels."
"The stress on your body has temporarily increased your blood sugar levels."
A patient was admitted with severe epigastric pain and has been diagnosed with cancer. The patient is scheduled for an esophagectomy. The patient asks about the procedure. What would be an appropriate response from the nurse? a. "This procedure is usually performed for cancer of the proximal esophagus and gastroesophageal junction." b. "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction." c. "This procedure is usually performed for cancer of the pancreatic head." d. "The procedure is usually performed for varices of the distal esophagus and gastroesophageal junction."
"This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction."
A patient is admitted with extreme fatigue, vomiting, and headache. This patient has type 1 diabetes that has been well controlled with an insulin pump. The patient states, "I know it could not be my diabetes because my pump gives me 24-hour control." Which reply would be the nurse's best response? a. "You know a lot about your pump, and you are correct." b. "You're right. This is probably a virus." c. "We'll get an abdominal CT and see if your pancreas is inflamed." d. "We'll check your serum blood glucose and ketones."
"We'll check your serum blood glucose and ketones."
What are the common causes of pancreatitis? (Select all that apply) a. Gall stone migration b. Hyperkalemia c. Alcoholism d. Hepatitis
- Gall stone migration - Alcoholism
A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply.) a. Warm, dry skin b. Heart rate greater than 100 beats/min c. Weak, thready pulse d. Increased right atrial pressure e. Decreased pulmonary artery occlusion pressure
- Heart rate greater than 100 beats/min - Weak, thready pulse - Increased right atrial pressure
A patient was admitted with DKA. Glucose 349, K+ 3.7, and pH 7.10. Which of the following interventions would you expect? (Select all that apply.) a. NS 1.5 L fluid bolus b. Vasopressin 10 units IM every 3 hours c. Insulin infusion at 5 units/ hr d. Potassium 20 meq/ L of IV fluid e. Sodium bicarbonate 50 mmol IV push
- NS 1.5 L fluid bolus - Insulin infusion at 5 units/ hr - Potassium 20 meq/ L of IV fluid
The nurse is managing a patient with hyperglycemia. Which findings would the nurse expect to note to support this diagnosis? (Select all that apply) a. Change of level of consciousness b. Bradycardia c. Abdominal pain d. Anorexia e. Fluid overload f. Kussmaul respirations
- change of level of conciousness - abdominal pain - anorexia - kussmaul respirations
The neuroendocrine stress response produces which findings? (Select all that apply.) a. Elevated blood pressure b. Decreased gastric motility c. Tachycardia d. Heightened pain awareness e. Increased glucose
- elevated blood pressure - decreased gastric motility - tachycardia - increased glucose
According to the American College of Surgeons, burns to which body surfaces are best treated in a burn center? a. Face b. Arms c. Chest d. Genitalia e. Perineum
- face - genitalia - perineum
The pancreas has both exocrine and endocrine properties. Which substances are produced by the exocrine function? (Select all that apply.) a. Gastrin b. Trypsin c. Amylase d. Lipase e. Insulin
- trypsin - amylase - lipase
A patient is admitted with septic shock. The nurse appreciates that the key to treatment is finding the cause of infection. Which cultures would the nurse obtain before initiating antibiotic therapy? (Select all that apply) a. Complete blood count with differential b. Urine cultures c. Blood cultures X 2 d. Wound cultures e. Sputum cultures
- urine cultures - blood cultures x2 - wound cultures - sputum cultures
A patient with hyperglycemic hyperosmolar state (HHS) has a serum glucose level of 400 mg/dL and a serum sodium level of 138 mEq/L. What is the intravenous fluid of choice? a. D5W c. 0.9% NS b. 0.45% NS d. D5/NS
0.9% NS
Using the Parkland formula for fluid resuscitation and your knowledge of injury calculations using the Rule of Nines, calculate the estimated fluid requirements during the first 8 hours for a 50 kg patient with full thickness burns to the back, entire right arm, and perineum. a. 5600 b. 10,000 c. 4600 d. 2800
2800
Using the Parkland formula for fluid resuscitation and your knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum, and entire right leg. a. 2775 mL b. 5550 mL c. 8325 mL d. 11,100 mL
5550 mL
A patient is brought to the ED after a house fire. He fell asleep with a lit cigarette and the couch ignited. Total body surface is estimated at 25% deep partial thickness burns to areas of the chest, back and left arm and 20% full thickness burns to the right arm, right upper leg and areas of the face. The patients weight estimated at 85 kg. What is the initial plan for fluid replacement? a. 7650 ml lactated ringer solution for the first 8 hours then7650 ml over the next 16 hours b. 11475 ml lactated ringer solution evenly divide over the first 24 hours c. 2868 ml of normal saline for the first 8 hours then 5737 ml of hypertonic NS over the next 16 hours d. 11900 ml of dextran evenly divided over the first 24
7650 ml lactated ringer solution for the first 8 hours then 5950 ml over the next 16 hours
A patient is admitted with severe malnutrition. A central venous catheter is placed in the right subclavian vein and total parenteral nutrition (TPN) is started. What medical interventions may be initiated with the onset of hyperglycemia? a. Discontinuing the infusion b. Adding insulin to the TPN c. Weaning from the TPN over a 6-hour period d. Starting an infusion of 0.9% normal saline
Adding insulin to the TPN
A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next? a. Ask the practitioner to order a STAT chest radiograph. b. Apply a pulse oximeter to one of his unburned fingers. c. Call the local hyperbaric chamber to check on its availability. d. Administer 100% high-flow oxygen via a nonrebreathing mask.
Administer 100% high-flow oxygen via a nonrebreathing mask.
A patient with acute pancreatitis is complaining of a pain in the left upper quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8. What intervention would the nurse include in the patient's plan of care to facilitate pain control? a. Administer analgesics only as needed. b. Administer analgesics around the clock. c. Educate the patient and family on lifestyle changes. d. Teach relaxation and distraction techniques.
Administer analgesics around the clock.
A patient is admitted with DKA. The patients arterial blood gas indicates the patient has uncompensated metabolic acidosis. The patient has rapid, regular respirations. Which medical intervention would the nurse expect to initiate to correct the acidosis? a. Prepare for intubation b. Administer insulin and fluids intravenously c. Administer sodium bicarbonate d. Initiate oxygen therapy via face mask
Administer insulin and fluids intravenously
A patient is admitted with diabetic ketoacidosis (DKA). The patient's arterial blood gas indicates the patient has an uncompensated metabolic acidosis. The patient has rapid, regular respirations. Which medical intervention would the nurse expect to initiate to correct the acidosis? a. Initiate oxygen therapy via a face mask. b. Administer sodium bicarbonate. c. Administer insulin and fluids intravenously. d. Prepare for intubation.
Administer insulin and fluids intravenously.
The nurse is caring for a patient in shock with an elevated lactate level. Which order should the nurse question in the management of this patient? a. Start an insulin drip for blood sugar greater than 180 mg/dL. b. Administer sodium bicarbonate to keep arterial pH greater than 7.20. c. Start a norepinephrine drip to keep mean arterial blood pressure greater than 65 mm Hg. d. Administer crystalloid fluids.
Administer sodium bicarbonate to keep arterial pH greater than 7.20.
A patient has been admitted with diabetic ketoacidosis (DKA). The nurse knows that the top priority in the initial treatment of DKA is which intervention? a. Lowering the blood sugar as quickly as possible b. Administering intravenous fluids c. Administering sodium bicarbonate d. Determining the precipitating cause
Administering intravenous fluids
What is a major/ primary nursing intervention with pancreatitis? a. Administration of pain medication b. Providing the patient a regular diet c. Prevention of pressure ulcers d. Teaching the patient relaxation techniques
Administration of pain medication
The patient is brought to the ED after a house fire. The patient sustained an inhalation injury. The nurse is aware that this injury predisposes the patient to the development of what complication? a. Lung cancer b. Adult respiratory distress syndrome (ARDS) c. Asthma d. Tension pneumothorax
Adult respiratory distress syndrome (ARDS)
In caring for a patient with a thyrotoxicosis, the nurse would expect to observe which neurologic symptom? a. Lethargy b. Depression c. Seizures d. Agitation
Agitation
Patients discharged with antithyroid medications should be alerted to which potential side effect? a. Hyperthermia b. Agranulocytosis c. Tachypnea d. Diaphoresis
Agranulocytosis
A patient with a history of chronic alcoholism was admitted with acute pancreatitis. The nurse is developing a patient education plan. Which topic would the nurse include in the plan? a. Diabetes management b. Alcohol cessation c. Occult blood testing d. Anticoagulation management
Alcohol cessation
A patient was admitted with pancreatitis. Which laboratory value would the nurse expect the practitioner order to confirm this diagnosis? a. Bilirubin b. Amylase c. Lactate dehydrogenase d. Ammonia
Amylase
Which finding is expected in the patient with hypothyroidism? a. Increased T4 b. Anemia c. Decreased thyroid stimulating hormone d. Hyperglycemia
Anemia
A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority? a. Clean the wounds and remove blisters. b. Assess the airway and provide 100% oxygen. c. Place a urinary drainage catheter and assess for myoglobin. d. Place a central intravenous access and provide antibiotics.
Assess the airway and provide 100% oxygen.
The nurse and a new graduate nurse are caring for a patient with extensive burns. They are discussing skin grafts. Which statement indicates the new graduate understood the information? a. Autografts are procured from both live and deceased donors. b. Autografts can placed at the bedside or in the operating room. c. Autografts can transmit disease and be rejected. d. Autografts provide permanent coverage and are the least expensive.
Autografts provide permanent coverage and are the least expensive.
A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock? a. Bacterial toxins lead to vasodilation. b. White blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. Decreased red blood cell production and fluid loss
Bacterial toxins lead to vasodilation.
The patient presents to the Emergency Department with the signs and symptoms of a gastrointestinal bleed. On exam the nurse notes that the patient has melena. What is this describing? a. Bleeding from the mouth b. Bright red stools c. Bright red or "coffee ground" emesis d. Black, tarry, or dark red stools
Black, tarry, or dark red stools
The nurse is caring for a patient with extensive burns. Which intervention should be included in the nursing management plan to prevent cross-contamination and decrease the risk of infection in the burn-injured patient? a. Gloves are the only personal protective equipment worn when changing dressings that are in direct contact of body fluids. b. Family members only have to wear a gown when visiting a patient because masks will increase anxiety in the patient. c. Changing gloves and handwashing should be done when moving from area to area on the same patient. d. Sharing of equipment between patients in the same room does not show evidence of cross-contamination.
Changing gloves and handwashing should be done when moving from area to area on the same patient.
What intervention should be included in the nursing management of the patient undergoing an angiogram? a. Maintain the patient flat for 24 hours. b. Insert a nasogastric tube before the procedure. c. Administer tap water enemas until clear. d. Check the pulse distal to the injection site every 15 minutes.
Check the pulse distal to the injection site every 15 minutes.
A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The patient has been started on a vasopressin drip. The nurse would monitor the patient for which side effect of the medication? a. Constipation b. Diarrhea c. Chest pain d. Bleeding
Chest pain
The nurse has been caring for a patient with severe pancreatitis. The practitioner suspects the patient has developed a pseudocyst. Which diagnostic procedure would the nurse expect the practitioner to order to confirm this diagnosis? a. Plain film radiography b. Abdominal ultrasonography c. Computed tomography (CT) of abdomen d. Magnetic resonance imaging (MRI) of the abdomen
Computed tomography (CT) of abdomen
The nurse is caring for a patient in cardiogenic shock. Which hemodynamic parameters would the nurse expect to note to support this diagnosis? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index
Decreased cardiac index
A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to note to support this diagnosis? a. Decreased fibrinogen degradation products b. Decreased D-dimer concentrations c. Decreased platelet counts d. Increased serum glucose levels
Decreased platelet counts
A patient is admitted with diabetic ketoacidosis (DKA) and is experiencing polyuria. Which electrolyte disturbances would the nurse expect to see at this phase of DKA? a. Decreased calcium and increased phosphorus levels b. Decreased potassium and sodium levels. c. Increased sodium and decreased phosphorus levels d. Decreased calcium and potassium levels.
Decreased potassium and sodium levels.
Less than 24 hours ago a patient sustained full thickness burns to his face, chest, back and bilateral upper arms in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is showing signs of increasing agitation and risking peak airway pressures. The nurse suspects the patients change in condition is due to what problem? a. Uncontrolled pain b. Decreased pulmonary compliance c. Hypovolemia d. Worsening hypoxemia
Decreased pulmonary compliance
A patient has been admitted in acute liver failure. The nurse knows that the synthesis of fibrinogen is affected and will result in what problem? a. Jaundice b. Fluid retention and ascites c. Delayed clotting d. Hepatomegaly
Delayed clotting
Patients who have sustained head trauma or have undergone resection of a pituitary tumor have an increased risk of developing which disorder? a. Type 1 diabetes b. Thyrotoxicosis c. Diabetes insipidus d. Myxedema coma
Diabetes insipidus
Upon auscultation, the nurse hears borborygmi. The nurse suspects the patient may be developing which problem? a. A complete ileus b. Early intestinal obstruction c. Abnormality of blood flow d. Peritonitis
Early intestinal obstruction
The nursing management plan for a patient at risk for aspiration should include which intervention? a. Administer intermittent feedings b. Add thickening agents to the tube feeding solution c. Suction the patient hourly d. Elevate the head of the bed 30 to 45 degrees
Elevate the head of the bed 30 to 45 degrees
Which nursing intervention is a priority for a patient with gastrointestinal hemorrhage? a. Positioning the patient in a high-Fowler position b. Ensuring the patient has a patent airway c. Irrigating the nasogastric tube with iced saline d. Maintaining venous access so that fluids and blood can be administered
Ensuring the patient has a patent airway
A patient is being admitted with cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient? a. Epinephrine b. Nitroprusside c. Dobutamine d. Nitroglycerine
Epinephrine
A patient with a known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administer first? a. Methylprednisolone b. Gentamicin c. Atropine d. Epinephrine
Epinephrine
A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next? a. Escharotomy b. Silver sulfadiazine application c. Splint application d. Xenograft application
Escharotomy
A patient on mechanical ventilation is receiving total parenteral nutrition (TPN). Which statement is true? a. Excessive calorie intake can cause an increase in PaCO2. b. The patient's head should remain elevated at 45 degrees to avoid aspiration. c. Lipid intake should be maintained at greater than 2 g/kg/day. d. TPN is preferred over the use of enteral feeding to avoid the complication of aspiration.
Excessive calorie intake can cause an increase in PaCO2.
The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which symptom is most suggestive of DKA? a. Irritability b. Excessive thirst c. Rapid weight gain d. Peripheral edema
Excessive thirst
A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC? a. Hypersensitivity response to an antigen b. Excessive thrombosis and fibrinolysis c. Profound vasodilatation d. Loss of intravascular volume
Excessive thrombosis and fibrinolysis
The practitioner has ordered a magnetic resonance imaging (MRI) of the liver. What would the nurse do to prepare the patient for the examination? a. Explain the patient must lie still during the procedure. b. Explain the patient may experience deep pressure sensation. c. Inform the patient that he or she will have to drink contrast. d. Inform the patient that the procedure will be performed at the bedside.
Explain the patient must lie still during the procedure.
A patient has been admitted with septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention? a. Limiting fluids to minimize the possibility of heart failure b. Finding and eradicating the cause of infection c. Discontinuing invasive monitoring as a possible cause of sepsis d. Administering vasodilator substances to increase blood flow to vital organs
Finding and eradicating the cause of infection
An older patient presents with a serum glucose level of 900 mg/dL, hematocrit of 55%, and no serum ketones. Immediate attention must be given to which intervention? a. Evaluating clotting factors b. Fluid administration c. Insulin administration d. Sodium replacement
Fluid administration
The patient has been admitted from a skilled nursing facility with urinary sepsis. The patient has severe muscle wasting. What is the process by which fat and protein are converted to glucose for fuel? a. Glycogenolysis b. Digestion c. Biotransformation d. Gluconeogenesis
Gluconeogenesis
A patient is admitted to the intensive care unit and is at risk of developing a stress ulcer. What medication might the patient be given to decrease these risks? a. H2 antagonist b. Antacids c. Vasopressin d. Heparin
H2 antagonist
The nurse is caring for a patient with acute liver failure. The practitioner asks the nurse to assess the patient for asterixis. How should the nurse assess for this symptom? a. Inflate a blood pressure cuff on the patient's arm. b. Have the patient bring the knees to the chest. c. Have the patient extend the arms and dorsiflex the wrists. d. Dorsiflex the patient's foot.
Have the patient extend the arms and dorsiflex the wrists.
A patient is admitted with a severe head injury. The nurse knows that critically ill patients are at risk for gastrointestinal hemorrhage due to stress-related mucosal disease. The nurse would monitor the patient for which signs and symptoms? a. Metabolic acidosis and hypovolemia b. Decreasing hemoglobin and hematocrit c. Hyperkalemia and hypernatremia d. Hematemesis and melena
Hematemesis and melena
A patient is presenting with signs of diabetes insipidus (DI). Which findings would confirm this diagnosis? a. Hyperosmolality and hypernatremia b. Hyperosmolality and hyponatremia c. Hypoosmolality and hypernatremia d. Hypoosmolality and hyponatremia
Hyperosmolality and hypernatremia
A patient is receiving insulin due to the development of steroid- induced hyperglycemia. In addition to lower blood glucose levels, what other physiologic effect may occur when insulin is administered? a. Breakdown of proteins b. Hypokalemia c. Cellular dehydration d. Hypercalcemia
Hypokalemia
A patient is brought to the ED with extensive burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase? a. Application of splints and initiation of total parental nutrition b. Oral anti-inflammatory drugs and preparation for insertion of an arterial line c. Measurement of sedimentation rate systemic antibiotics d. IV opiates and assessment of pulses in both arms
IV opiates and assessment of pulses in both arms
A patient is admitted to the burn unit with extensive burns after a house fire. The patients vital signs and physical exam includes a heart rate of 140 beats/ min, a urine output of 25 ml/ hr and clear lung sounds. What adjustment, if any needs to be made to the fluid resuscitation plan? a. Fluids should be switched to be packed red blood cells b. IV rate should be decreased, and colloids started c. IV rate should be increased and fluid status closely watched d. Continue as planned; everything looks normal
IV rate should be increased and fluid status closely watched
Which pathophysiologic mechanism occurs in the patient with type 2 diabetes? a. Lack of insulin production b. Imbalance between insulin production and use c. Overproduction of glucose d. Increased uptake of glucose in the cells
Imbalance between insulin production and use
The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem? a. Inability of the heart to pump blood forward b. Loss of circulating volume and subsequent decreased venous return c. Disruption of the conduction system when reentry phenomenon occurs d. Suppression of the sympathetic nervous system
Inability of the heart to pump blood forward
Decreased insulin and increased glucagon result in what psychologic process? a. Increased glycogenolysis b. Decreased ketosis c. Increased glycogen storage d. Decreased fat mobilization
Increased glycogenolysis
A patient with type 2 diabetes is admitted. He is very lethargic and hypotensive. A diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is given. Which findings support this diagnosis? a. Decreased serum glucose and increased serum ketones b. Increased urine ketones and decreased serum osmolality c. Increased serum osmolality and increased serum potassium d. Increased serum osmolality and increased serum glucose
Increased serum osmolality and increased serum glucose
A patient is admitted with severe hyperglycemia due to new onset type I diabetes. Which signs and symptoms obtained as a part of the patients history might indicate the presence hyperglycemia? a. Increased thirst and increased urinary output b. Period of hyperactivity with weight gain c. Decreased urine output accompanied by peripheral edema d. Recent episodes of tachycardia and missed heart beats
Increased thirst and increased urinary outpu
A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid? a. Inserting a large-diameter peripheral intravenous catheter b. Positioning the patient in the Trendelenburg position c. Encouraging the patient to drink at least 240 mL of fluid each hour d. Administering intravenous fluids under pressure with a pressure bag
Inserting a large-diameter peripheral intravenous catheter
A patient is being admitted from the emergency department (ED) with cardiogenic shock secondary to unstable angina unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to initiate when the practitioner arrives in the unit? a. Administration of sodium bicarbonate b. Rapid infusion of crystalloids c. Insertion of an intraaortic balloon pump (IABP) d. Insertion of dialysis catheters for continuous renal replacement therapy (CRRT)
Insertion of an intraaortic balloon pump (IABP)
The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which statement best describes the rationale for administrating potassium supplements with the patient's insulin therapy? a. Potassium replaces losses incurred with diuresis. b. The patient has been in a long-term malnourished state. c. Intravenous (IV) potassium renders the infused solution isotonic. d. Insulin drives the potassium back into the cells.
Insulin drives the potassium back into the cells.
A patient with diabetic ketoacidosis (DKA) has an insulin drip infusing, and the nurse has just administered subcutaneous insulin. The nurse is alert for signs of hypoglycemia, which would include what findings? a. Kussmaul respirations and flushed skin b. Irritability and paresthesia c. Abdominal cramps and nausea d. Hypotension and itching
Irritability and paresthesia
The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the practitioner to order for this patient? a. Insulin b. Vitamin K c. Lactulose d. Lorazepam
Lactulose
A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process? a. Loss of sympathetic nervous system innervation b. Parasympathetic nervous system stimulation c. Injury to the hypothalamus d. Focal injury to cerebral hemispheres
Loss of sympathetic nervous system innervation
The nursing management plan for a patient with thyrotoxicosis would include which intervention? a. Providing diversional stimuli b. Restricting fluids c. Maintaining a quiet, restful environment d. Administering thyroid supplements at the same time each day
Maintaining a quiet, restful environment
What is the name of the portion of the stomach that allows for expansion and secretion of gastric juice? a. Serosa b. Muscularis c. Submucosa d. Mucosa
Mucosa
Which layer of the large intestine consists of longitudinal and circular muscles? a. Serosa layer b. Muscularis layer c. Submucosa layer d. Mucosa layer
Muscularis layer
A patient is being given Vasopressin to control variceal bleeding. The nurse knows this medication causes splanchnic and systemic vasoconstriction, subsequently reducing portal blood flow and pressure. The nurse also knows this medication can cause systemic vasoconstriction. What medication might be given to offset the systemic side effects of Vasopressin? a. Dopamine b. Heparin c. Nitroglycerin d. Dobutamine
Nitroglycerin
The nurse is caring for a patient who what just admitted with septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order? a. Administer fresh frozen plasma b. Obtain a serum lactate level c. Administer epinephrine d. Measure central venous pressure
Obtain a serum lactate level
A patient was admitted with an abdominal mass. Which assessment technique would the nurse find most useful in detecting this pathologic condition? a. Percussion b. Palpation c. Inspection d. Auscultation
Palpation
A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record? a. Superficial, first-degree burn b. Partial-thickness, second-degree burn c. Deep dermal partial-thickness, second-degree burn d. Full-thickness, third-degree burn
Partial-thickness, second-degree burn
The nurse is caring for a patient with multiple-organ dysfunction syndrome (MODS). The nurse understands that earlier nutritional support is critical for the patient to prevent profound weight loss. Why does this occur in patient MODS? a. Patient experiences hypometabolism. b. Patient experiences hypermetabolism. c. Patient experiences anorexia. d. Patient has gut dysfunction.
Patient experiences hypermetabolism.
A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism? a. Peripheral vasodilation b. Increased venous return c. Increased alveolar ventilation d. Decreased myocardial contractility
Peripheral vasodilation
The nurse is caring for a critically ill patient with type 1 diabetes. The nurse understands that the patient is at risk for developing diabetic ketoacidosis (DKA) secondary to what etiology? a. Excess insulin administration b. Inadequate food intake c. Physiologic and psychologic stress d. Increased release of antidiuretic hormone (ADH)
Physiologic and psychologic stress
What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn? a. The heat from the burn leads to immediate vascular wall destruction and extravasation of intravascular fluid. b. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema. c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. d. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia.
Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space.
What vessel delivers nutrient-rich blood from the gut, pancreas, spleen, and stomach to the liver? a. Hepatic artery b. Hepatic vein c. Portal vein d. Interlobular veins
Portal Vein
The nurse is caring for a patient who has been newly diagnosed with type I diabetes. Which laboratory result would the nurse note this diagnosis. a. Hemoglobin A1c of 3% b. Presence of ketones in the blood c. Glucose of mg/ dl d. Presence of ketones in the urine
Presence of ketones in the urine
A nursing instructor is discussing the difference between primary and secondary multiple-organ dysfunction syndrome (MODS) with a nursing student. Which statement indicates the student understood the information? a. Primary MODS is the result of inflammation in organs not involved in the initial insult. b. Primary MODS is the result of a direct organ injury. c. Primary MODS is due to a disorganization of the inflammatory immune system response. d. Primary MODS is due to disruption of the coagulation system.
Primary MODS is the result of a direct organ injury.
The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which medical intervention would the nurse expect to see ordered for this patient? a. Rapid rehydration with intravenous fluids b. Insertion of a pulmonary artery catheter c. Administration of high-dose intravenous insulin d. Hourly monitoring of urine glucose and ketone levels
Rapid rehydration with intravenous fluids
What are the goals of the rehabilitation phase of burn management? a. Recuperation and healing physically and emotionally b. Hydrotherapy and splinting c. Reverse wound isolation and surgical grafting d. Bed rest and splinting
Recuperation and healing physically and emotionally
A patient is admitted with a traumatic head injury. The patient starts to exhibit signs of a decrease in antidiuretic hormone (ADH). What is the function of ADH? a. Control blood pressure b. Normalize potassium levels c. Maintain hemostasis d. Regulate fluid balance
Regulate fluid balance
A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the patient is probably having an immunoglobulin E (IgE)-mediated response as a result of what physiologic mechanism? a. Direct activation of mast cells and basophils b. Nonimmunologic stimulation of biochemical mediators c. Repeat exposure to an antigen in the presence of preformed IgE antibodies d. Activation of the systemic inflammatory response
Repeat exposure to an antigen in the presence of preformed IgE antibodies
An elderly patient is admitted with pneumonia. This morning the patient is febrile, tachycardic, tachypneic, and confused. The nurse suspects the patient may be developing what problem? a. Sepsis b. Delirium c. Adult respiratory distress syndrome d. Acute kidney injury
Sepsis
The nurse caring for a patient with systemic inflammatory response SIRS pneumonia. What is SIRS due to infection called? a. Acute respiratory distress syndrome (ARDS) b. Anaphylaxis c. Infectivity d. Sepsis
Sepsis
The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due to infection called? a. Infectivity b. Anaphylaxis c. Sepsis d. Acute respiratory distress syndrome (ARDS)
Sepsis
The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which findings would the nurse expect to observe in this patient? a. Hyperglycemia with low serum osmolality b. Severe hyperglycemia with minimal or absent ketosis c. Little or no ketosis in serum with rapidly escalating ketonuria d. Hyperglycemia and ketosis
Severe hyperglycemia with minimal or absent ketosis
A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information? a. Shock is a physiologic state resulting in hypotension and tachycardia. b. Shock is an acute, widespread process of inadequate tissue perfusion. c. Shock is a degenerative condition leading to organ failure and death. d. Shock is a condition occurring with hypovolemia that results in hypotension.
Shock is an acute, widespread process of inadequate tissue perfusion.
A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies during the early phase of recovery? a. Large doses of opioids given intramuscularly b. Intravenous opioids used in combination with oral antidepressants c. Large doses of opioids given subcutaneously d. Small doses of intravenous opioids titrated to effect
Small doses of intravenous opioids titrated to effect
A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock? a. Ischemic stroke b. Spinal cord injury c. Guillain-Barré syndrome d. Brain tumor
Spinal cord injury
A patient was admitted with acute liver failure. The patient is lethargic, confused, and has marked asterixis. The nurse suspects the patient is in what stage of hepatic encephalopathy. a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4
Stage 2
Preprocedural teaching of a patient undergoing a liver scan should include which instruction? a. Drink at least 500 mL of fluids before the procedure. b. Remain flat in bed for 12 hours after the procedure. c. Stay flat and still during the procedure. d. Sedation will be provided during the procedure.
Stay flat and still during the procedure.
The practitioner has ordered a test for steatorrhea. The nurse knows this is determined by which laboratory study? a. Gastric acid stimulation b. Urea breath test c. Culture and sensitivity d. Stool studies
Stool studies
A patient is admitted after surgery with a history of hyperthyroidism. The nurse suspects the patient may be developing thyroid storm. Which finding would confirm this suspicion? a. Tachycardia b. Hypotension c. Decreased appetite d. Hypothermia
Tachycardia
A patient has been admitted with perforated duodenal ulcer. Which findings would the nurse expect to note to support this diagnosis? a. Tenderness in the epigastric area b. Jaundice c. Vomiting d. Cullen sign
Tenderness in the epigastric area
A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center? a. The size and depth of burn injury and the burning agent b. The age and present medical history of the patient c. The depth of the burn injury and the presence of soot in the sputum d. The medical history of the patient and the size and depth of the burn injury
The medical history of the patient and the size and depth of the burn injury
The nurse is caring for a patient with sepsis due to necrotic tissue. The nurse knows that necrotic tissue can stimulate the inflammatory immune response. Which biochemical mediator is secreted in response to endotoxin or tissue injury? a. Arachidonic acid metabolite b. Platelet-activating factor c. Tumor necrosis factor d. Interleukin
Tumor necrosis factor
A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. The nurse knows that the patient's symptoms are most likely attributable to what cause? a. Blood loss associated with burns and pain b. Hemodynamic stability related to adequate fluid resuscitation. c. Overresuscitation related to overestimation of the burn area involved d. Underresuscitation because of probable wound conversion
Underresuscitation because of probable wound conversion
A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect the practitioner to order for this patient? a. Histamine2 (H2) antagonists b. Vasopressin c. Heparin d. Antacids
Vasopressin
A patient has been admitted with pyloric obstruction. Which findings would the nurse expect to note to support this diagnosis? a. Left lower quadrant tenderness b. Jaundice c. Diarrhea d. Visible peristaltic waves
Visible peristaltic waves
The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage? a. Zone of coagulation b. Peripheral zone c. Zone of stasis d. Zone of hyperemia
Zone of coagulation
A patient has been admitted with a brain tumor. The patient starts to exhibit signs of an increase in antidiuretic hormone (ADH). When amounts of ADH are released, the nurse should anticipate what charge in the patients sodium levels? a. Increase b. Rapid increase then decrease c. Depends on the potassium level d. Decrease
decrease
A patient is receiving total parental nutrition (TPN). During rounds the dietitian states that she believes the patient is getting too much glucose. Identify one area in which excess glucose is stored as glycogen. a. Pancreas b. Gall bladder c. Stomach d. Hepatic cells
hepatic cells
A patient with thyrotoxicosis has been admitted. What effect of increased T3 and T4 levels might the nurse expect to see in this patient? a. Increased oxygen consumption b. Decreased cardiac output c. Increased calcium levels
increased oxygen consumption
What is a leading cause of death in the hospitalized burn patient? a. Smoke inhalation b. Infection c. Burn shock d. Renal failure
infection
A patient has a partial-thickness burn wound that is being treated with porcine xenograft (pigskin). The nurse knows that pigskin usually dissolves in 5 to 7 days because of what reason? a. Infection b. Lack of blood supply c. Lack of lymphatic drainage d. Contamination
lack of blood supply
A nurse is caring for a patient who was burned 2 weeks ago. The nurse knows the patient has entered the next phase of healing, which is characterized by rapid synthesis of collagen. What phase is the patient in? a. Wound phase b. Inflammatory phase c. Proliferative phase d. Maturation phase
proliferative phase
The nurse understands that the onset of seizures in the patient with diabetes insipidus (DI) is indicative of which situation? a. Toxic ammonia levels b. Severe dehydration c. Hyperosmolality d. Increased potassium levels
severe dehydration
A patient is admitted with diabetic ketoacidosis (DKA). The patient presents with dry, cracked lips and is begging for something to drink. What reply would be the nurse's best response? a. "We can't give you anything to drink until we get your blood sugar under control." b. "You can have one cup of coffee without sugar." c. "You can drink anything you want as long as it's sugar free." d. "You can drink as much water has you can handle."
"We can't give you anything to drink until we get your blood sugar under control."
Which disorders or conditions are potential causes of acute liver failure? (Select all that apply.) a. Ischemia b. Hepatitis A, B, C, D, E, non-A, non-B, non-C c. Acetaminophen toxicity d. Wilson disease e. Reye syndrome f. Diabetes
- Ischemia - Hepatitis A, B, C, D, E, non-A, non-B, non-C - Acetaminophen toxicity - Wilson disease - Reye syndrome
The nurse is caring for a patient with an upper gastrointestinal bleed. The practitioner has just performed an endoscopy at the bedside. What complications would the nurse monitor the patient for after the procedure? (Select all that apply.) a. Perforation b. Hemorrhage c. Oversedation d. Constipation e. Aspiration
- Perforation - Hemorrhage - Oversedation - Aspiration
Which statements are correct regarding epithelial cells of the gastric mucosa? (Select all that apply.) a. They prevent diffusion of hydrogen into the mucosa. b. They secrete bicarbonate to neutralize hydrogen ions. c. They have the ability to increase blood flow to facilitate removal of toxic metabolites. d. They break down prostaglandins. e. They are impervious to alcohol and aspirin.
- They prevent diffusion of hydrogen into the mucosa. - They secrete bicarbonate to neutralize hydrogen ions. - They have the ability to increase blood flow to facilitate removal of toxic metabolites.
A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? (Select all that apply.) a. Calcium b. Serum amylase c. Serum glucose d. Potassium e. White blood cells f. Serum triglycerides
- serum amylase - serum glucose - white blood cells - serum triglycerides
The gastrointestinal system plays a vital role in detoxification and elimination of what substances? (Select all that apply.) a. Viruses b. Chemical toxins c. Drugs d. Bacteria e. Bile
- viruses - chemical toxins - drugs - bacteria
A patient has been admitted with severe abdominal pain. When examining the patient, the nurse notes hypoactive bowel sounds, abdominal guarding, distention, and a discoloration around the umbilicus. The nurse suspects the patient may have which condition? a. Peptic ulcer disease b. Esophageal varices c. Acute liver failure d. Acute pancreatitis
Acute pancreatitis
A patient presents with ketoacidosis and a blood glucose level of 125 mg/dL. Diabetic ketoacidosis has been ruled out. The nurse knows that ketoacidosis can occur in which condition? a. Acute pancreatitis b. Drug overdose c. Hyperglycemic hyperosmolar state d. Hyperaldosteronism
Acute pancreatitis
The nurse knows that during the resuscitation of a patient with diabetic ketoacidosis (DKA), the intravenous (IV) line should be changed to a solution containing glucose when what happens? a. Patient becomes more alert b. IV insulin has been infusing for 4 hours c. Blood glucose drops to 200 mg/dL d. Blood glucose drops to 100 mg/dL
Blood glucose drops to 200 mg/dL
What role does the liver play in maintaining normal blood sugar levels? a. Produces insulin to breakdown glucose b. Synthesizes amino acids from ketoacids c. Converts glycogen to glucose d. Synthesizes glycogen from carbohydrates
Converts glycogen to glucose
How would the nurse administer sucralfate through a gastric tube? a. Crushed and mixed with 10 mL of water b. Dissolved in 10 mL of water to form a slurry c. Mixed in 15 mL of water to form a solution d. Administered as a whole pill with a 35-mL water flush
Dissolved in 10 mL of water to form a slurry
A patient is admitted with diabetic ketoacidosis (DKA). The nurse knows that the lack of insulin results in which process? a. Decreased glucagon release b. Decreased glycogenolysis c. Decreased ketone production d. Increased gluconeogenesis
Increased gluconeogenesis
Stimulation of the parasympathetic nervous system produces which effect on the gastrointestinal system? a. Decreased peristalsis b. Increased secretion of watery saliva c. Decreased colonic activity d. Increased release of gastrointestinal hormones
Increased secretion of watery saliva
A patient is admitted with diabetic ketoacidosis (DKA). The nurse knows that the dehydration associated with DKA results from which pathophysiologic mechanism? a. Increased serum osmolality and urea b. Decreased serum osmolality and hyperglycemia c. Ketones and potassium shifts d. Acute renal failure
Increased serum osmolality and urea
A patient in diabetic ketoacidosis (DKA) is comatose with a temperature of 102.2° F. The nurse suspects the patient may have which secondary disorder? a. Head injury b. Hypothalamus infarction c. Infection d. Heat stroke
Infection
A patient was admitted with pancreatitis. In which order would the nurse perform an assessment of the gastrointestinal system? a. Inspection, palpation, percussion, auscultation b. Palpation, percussion, inspection, auscultation c. Inspection, auscultation, percussion, palpation d. Palpation, inspection, auscultation, percussion
Inspection, auscultation, percussion, palpation
A patient has been admitted after surgery for removal of a brain tumor. The nurse suspects the patient may be developing diabetes insipidus (DI). Which findings would confirm the nurse's suspicion? a. Hyperglycemia and hyperosmolarity b. Hyperglycemia and peripheral edema c. Intense thirst and passage of excessively large quantities of dilute urine d. Peripheral edema and pulmonary crackles
Intense thirst and passage of excessively large quantities of dilute urine
The nurse is caring for a patient after an esophagectomy. In the immediate postoperative period, which nursing intervention would have the highest priority? a. Preventing atelectasis b. Managing pain c. Promoting ambulation d. Preventing infection
Managing pain
A patient was admitted with diabetic ketoacidosis (DKA) an hour ago and is on an insulin drip. Suddenly, the nurse notices frequent premature ventricular contractions (PVCs) on the electrocardiogram. The nurse notifies the practitioner. The nurse would anticipate an order for which intervention? a. A lidocaine bolus b. Stopping the insulin drip c. Synchronizing cardioversion d. Obtaining serum electrolytes
Obtaining serum electrolytes
The nurse is caring for a critically ill patient with type 1 diabetes. The nurse understands that the patient is at risk for developing diabetic ketoacidosis (DKA) secondary to what etiology? a. Excess insulin administration b. Inadequate food intake c. Physiologic and psychologic stress d. Increased release of antidiuretic hormone (ADH)
Physiologic and psychologic stress
A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism? a. Portal hypertension resulting in diversion of blood from a high-pressure area to a low-pressure area b. Superficial mucosal erosions as a result of increased stress levels c. Loss of protective mechanisms resulting in the breakdown the mucosal resistance d. Inflammation and ulceration secondary to nonsteroidal antiinflammatory drug use
Portal hypertension resulting in diversion of blood from a high-pressure area to a low-pressure area
When a patient with diabetic ketoacidosis (DKA) has insulin infusing intravenously, the nurse expects a drop in the serum levels of which electrolytes? a. Sodium and potassium b. Potassium and phosphate c. Bicarbonate and calcium d. Sodium and phosphate
Potassium and phosphate
A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs as a result of what pathophysiologic mechanism? a. Uncontrolled hypoglycemia caused by an increased release of insulin b. Loss of storage capacity for senescent red blood cells c. Premature activation of inactive digestive enzymes, resulting in autodigestion d. Release of glycogen into the serum, resulting in hyperglycemia
Premature activation of inactive digestive enzymes, resulting in autodigestion
The nurse is caring for a patient with a head injury who has developed diabetes insipidus (DI). What medication would the nurse expect to be prescribed for the patient? a. Vasopressin b. Insulin c. Glucagon d. Propylthiouracil
Vasopressin
Which finding is considered an abnormal gastrointestinal assessment finding? a. Visible peristaltic waves b. Hyper-resonance of the intestine c. High-pitched gurgling sounds in the small intestine d. Dull sounds over the liver and spleen
Visible peristaltic waves
What purpose does saliva serve in the process of digestion? a. Washes away bacteria b. Provides the body's main source of potassium c. Contains hydrochloric acid for breakdown of protein d. Stimulates the sympathetic nervous system
Washes away bacteria
A patient weighs 140 kg and is 60 inches tall. The patient's blood sugar is being controlled by glipizide. Which topic would be important for the nurse to include in the patient's discharge education plan? a. Signs of hyperglycemia b. Proper injection technique c. Weight loss d. Increased caloric intake
Weight loss
A patient has been admitted with pancreatitis. Which clinical manifestations would the nurse expect to observe in support of this diagnosis? (Select all that apply.) a. Epigastric and abdominal pain b. Nausea and vomiting c. Diaphoresis d. Jaundice e. Hyperactive bowel sounds f. Fever
a. Epigastric and abdominal pain b. Nausea and vomiting d. Jaundice f. Fever
