Med Surg Exam 3
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
"I will receive parenteral vitamin B12 therapy for the rest of my life."
When packed red blood cells (PRBCs) or whole blood is transfused, the blood should be administered within a ____-hour period because warm room temperatures promote bacterial growth.
4
A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in her teaching?
"Cover the stoma whenever you shower or bathe."
Fat emboli are a major cause of death for patients with fractures. What are the significant signs and symptoms? Select all that apply.
-Petechiae possibly due to a transient thrombocytopenia -Substernal chest pain -Hypoxia
The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least ______ mm Hg and an arterial oxygen saturation (SaO2) of at least ___%.
60 mm Hg; 90%
Which of the following is a symptom of Hemochromatosis?
Bronzing of the skin
Which medication directly inhibits osteoclasts thereby reducing bone loss and increasing BMD?
Calcitonin (Miacalcin)
An important nursing assessment, post fracture, is to evaluate neurovascular status. Therefore, the nurse should check for:
Cap refill
A client with a history of sickle cell anemia has developed iron overload from repeated blood transfusions. What treatment does the nurse anticipate will be prescribed?
Chelation therapy
An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this?
Comminuted
A patient with chronic kidney disease is being examined by the nurse practitioner for anemia. The nurse has reviewed the laboratory data for hemoglobin and RBC count. What other test results would the nurse anticipate observing?
Decreased level of erythropoietin
A patient with multiple myeloma is complaining about pain. What instructions will the nurse give the patient to help to reduce pain during activity?
Do not lift more than 10 pounds.
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
Hypercapnia, hypoventilation, and hypoxemia
A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important?
Immediately stop the transfusion, infuse normal saline solution, call the physician, and notify the blood bank.
The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in?
Lateral position with one leg flexed
The nurse is assessing a patient for obstructive sleep apnea (OSA). Which of the following are signs and symptoms of OSA? Select all that apply.
Polycythemia Loud snoring Insomnia
In adults, bone marrow is usually aspirated from which area?
Posterior iliac crest
In chronic osteomyelitis, antibiotics are adjunctive therapy in which of the following situations?
Surgical debridement
The nurse is preparing a client to have his cast cut off after having it for 6 weeks to treat a fracture tibia. What should the nurse inform the client prior to the cast being removed?
The skin may be covered with a yellowish crust that will shed in a few days.
A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
Use the smallest needle possible for injections.
A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client?
Vascular occlusion in small vessels decreasing blood and oxygen to the tissues.
Which of the following may occur if a client experiences compartment syndrome in an upper extremity?
Volkmann's contracture
A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him:
a bedpan
Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including
a low-fat, low-cholesterol diet, and increasing exercise.
The nurse is caring for patient with a hip fracture. The physician orders the patient to start on a bisphosphonate. Which medication would the nurse document as given?
Alendronate (Fosamax)
Which of the following is the only curative treatment for chronic myeloid leukemia (CML)?
Allogeneic stem cell transplant
Which of the following cells are capable of differentiating into plasma cells?
B lymphocytes
A patient describes numbness in the arms and hands with a tingling sensation. The patient also frequently stumbles when walking. What vitamin deficiency does the nurse determine may cause some of these symptoms?
B12
Which type of chest configuration is typical of the patient with COPD?
Barrel chest
Of the following, which is not a risk factor for osteoporosis?
Being male
Which of the following vitamins enhance the absorption of iron?
C
Which of the following is the initial diagnostic test for a stroke?
CT
Patients with ____ or other cerebrovascular disorders should lose weight and therefore should minimize their volume of food consumption. To ensure this, the nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs. Patients should avoid eating high-fat foods, and serving foods hot or tepid will not minimize the volume consumed by the patient. Foods such as peanut butter, bread, tart foods, dry or crisp foods, and chewy meats should also be avoided because they cause choking.
CVA
A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?
Chest pain and dyspnea
Which type of fracture produces several bone fragments?
Comminuted
The nurse is assessing a patient who has been admitted with possible ARDS. What findings would distinguish ARDS from cardiogenic pulmonary edema?
Common diagnostic tests performed in patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema.
The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?
Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.
The patient presents to the emergency room with an open fracture of the femur. Which action would the nurse implement to prevent the most serious complication of an open fracture?
Cover the wound with a sterile dressing to prevent infection.
A patient is prescribed a mast cell stabilizer for the treatment of asthma. Which commonly used medication will the nurse educate the patient about?
Cromolyn sodium (Crolom, NasalCrom) and nedocromil (Alocril, Tilade) are mild to moderate anti-inflammatory agents and are considered alternative medications for treatment.
The nurse is caring for a client who had undergone hemodilution during surgery. Immediately after surgery, the nurse expects to see which lab result?
Decreased hematocrit
Which of the following exposures accounts for the majority of cases with regard to risk factors for chronic obstructive pulmonary disease (COPD)?
Exposure to tobacco smoke
When assessing a female patient with a disorder of the hematopoietic or the lymphatic system, which of the following assessments is most essential?
Health history, such as bleeding, fatigue, or fainting
A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for?
Hemorrhage
A client has been diagnosed with multiple myeloma. Which of the following laboratory values should the nurse expect to find in a client with multiple myeloma?
Increased urinary protein
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Increased urine output
The nurse is caring for a client with a new tracheostomy. Which of the following nursing diagnoses are priorities? Select all that apply.
Ineffective Airway Clearance related to increased secretions Impaired Gas Exchange related to shallow breathing and anxiousness
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
Left-sided cerebrovascular accident (CVA)
Which of the following community-acquired pneumonias demonstrates the highest occurrence during summer and fall?
Legionnaires' disease
Which assessment findings would the nurse expect in a client diagnosed with osteomyelitis?
Leukocytosis and localized bone pain
Which nursing intervention is most appropriate for a client with multiple myeloma?
Preventing bone injury
The nurse is working at a blood donation clinic. What teaching should the nurse provide to the donor immediately after blood donation?
Remain for observation after eating and drinking.
A nurse is giving instructions to a client who's going home with a cast on his leg. Which teaching point is most critical?
Reporting signs of impaired circulation
A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?
Respiratory rate of 22 breaths/minute
Which of the following principles apply to the patient in traction?
Skeletal traction is never interrupted.
Which of the following is the hallmark of polycythemia vera (PV)?
Splenomegaly
Which of the following devices is designed specifically to support and immobilize a body part in a desired position?
Splint
Which of the following terms refers to an injury to ligaments and other soft tissues of a joint?
Sprain
The term that is used to refer to a primitive cell, capable of self-replication and differentiation, is which of the following?
Stem Cell
A 45-year-old softball player arrives at the emergency department following his injury while sliding into a base during a game. After his examination and radiographs, the physician diagnoses muscle strain and prescribes appropriate treatment. What does the physician mean with the term "strain"?
Stretched or pulled beyond its capacity
A client has been treated for migraine headaches for several months and comes to the clinic stating he is getting no better. The nurse is talking with the client and hears an audible click when the client is moving his jaw. What does the nurse suspect may be happening?
Temporomandibular disorder
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?
Test the nasal drainage for glucose.
Which of the following statements is accurate regarding care of a plaster cast?
The cast can be dented while it is damp.
A young male client is diagnosed with a mild form of hemophilia. He is experiencing bleeding in the joints with pain. In preparing the client for discharge, the nurse educates the client to
Wear a medical identification bracelet.
The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene?
Weights hanging and touching the floor
To reduce the incidence of complications in a client in traction, which intervention should be included in the care plan?
Increase fiber intake.
Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)?
It is the most contagious during the second week of illness
A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan?
Keeping a pillow between the client's legs at all times
Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called which of the following?
Megaloblasts
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?
Noncontrast computed tomogram
Which of the following orthopedic surgeries is done to correct and align a fracture after surgical dissection and exposure of the fracture?
Open reduction
Which is the following is the most obvious sign of anemia?
Pallor
The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:
Right-sided paralysis.
You are assisting your client with multiple myeloma to ambulate. What is the most important nursing diagnosis to help prevent fractures in this client?
Safety
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?
See if there are leaks in the system.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
Semi-Fowler's
Which of the following is a priority nursing intervention that the nurse should perform for a patient who has undergone surgery for a nasal obstruction?
Ensure mouth breathing
A nurse is caring for an elderly female client with osteoporosis. When teaching the client, the nurse should include information about which major complication?
Bone fracture
Which of the following is an appropriate nursing intervention in the care of the patient with osteoarthritis?
Encourage weight loss and an increase in aerobic activity
Which of the following is the strongest predisposing factor for asthma?
Allergy
The three most common symptoms of ______ are cough, dyspnea, and wheezing. In some instances, cough may be the only symptom.
asthma
A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:
diminished or absent breath sounds on the affected side.
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?
"Because I had a previous reaction to the test, this time I need to get a chest X-ray."
A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer?
"My cough has changed from a dry cough to one with lots of sputum production."
A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?
"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."
A 42-year-old female client is scheduled for endotracheal intubation prior to her surgery. Which of the following can the nurse instruct this client?
"The ET tube will maintain your airway while you're under anesthesia."
A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient?
"You should switch to wearing your glasses while taking this medication."
The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm?
"Your physician wants to evaluate the location and condition of the aneurysm."
A client is prescribed 325 mg/day of oral ferrous sulfate. The nurse includes in client teaching, "Take your iron pill
1 hour before breakfast"
Preoperative autologous donations are ideally collected __ to ___weeks before surgery. The nurse should first explain that time frame to this client.
4 to 6
What dietary recommendations should a nurse provide a patient with a lung abscess?
A diet rich in protein
Emphysema is described by which of the following statements?
A disease of the airways characterized by destruction of the walls of overdistended alveoli
The client displays manifestations of compartment syndrome. The nurse expects the client to be scheduled for:
A fasciotomy
Which of the following is accurate regarding status asthmaticus?
A severe asthma episode that is refractory to initial therapy
You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following?
Acute respiratory distress syndrome
A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be?
Administering ordered analgesics and monitoring their effects
For a client diagnosed with idiopathic thrombocytopenia purpura (ITP), which nursing intervention is appropriate?
Administering stool softeners, as ordered, to prevent straining during defecation
A client presents at an ambulatory clinic with complaints of pain and aching in the lower left leg. After examining the client, a physician determines the client has experienced a strain related to the client's exercise regimen. The treatment plan includes analgesics, rest, and cold and heat therapies. Which guideline should be included in the care plan?
After 24 hours, apply heat for periods of 15 to 30 minutes.
A nurse is assigned to care for a patient with ascites, secondary to cirrhosis. The nurse understands that the fluid accumulation in the peritoneal cavity results from a combination of factors including an alteration in oncotic pressure gradients and increased capillary permeability. Therefore, the nurse monitors the serum level of the plasma protein responsible for maintaining oncotic pressure, which is:
Albumin
A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, you find evidence of petechiae and ecchymoses. You note that the spleen appears enlarged. What would you suspect is wrong with this client?
Aplastic anemia
The nurse is caring for a patient admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been completed. Which of the following interventions should the nurse include in the patient's care?
Apply a ice pack
Which of the following nursing actions would help prevent deep vein thrombosis in a patient who has had an orthopedic surgery?
Apply antiembolism stockings
A client's cast is removed. The client is worried because the skin appears mottled and is covered with a yellowish crust. What advice should the nurse give the client to address the skin problem?
Apply lotions and take warm baths or soaks.
Which of the following nursing interventions should be incorporated into the plan of care to manage the delayed clotting process in a patient with leukemia?
Apply prolonged pressure to needle sites or other sources of external bleeding
The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes measures to assist the client in reducing the pain associated with his headache. Which of the following appropriate nursing interventions may be provided by the nurse to assist this client in reducing or eliminating his pain?
Apply warm or cool cloths to the forehead or back of the neck.
A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks?
Applying nasal packing
Which of the following is a potential complication of a low pressure in the endotracheal cuff?
Aspiration pneumonia
A patient presents with peripheral neuropathy and hypothesia of the feet. What is the best nursing intervention?
Assess for signs of injury.
The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?
Auscultate lung sounds.
When teaching a patient with iron deficiency anemia about appropriate food choices, the nurse will encourage the patient to increase the dietary intake of which of the following foods?
Beans, dried fruits, and leafy green vegetables
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?
Bleeding
Following the use of a thrombolytic agent in the management of cerebrovascular accident (CVA) client, which is the priority nursing assessment?
Blood pressure
A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?
Blood-tinged sputum
_________ relieve bronchospasm by altering smooth muscle tone and reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation.
Bronchodilators
A patient's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which of the following statements made by the nurse correctly explains the cause of DIC?
DIC is caused by an abnormal activation of clotting pathway causing excessive amounts of tiny clots to form inside organs.
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?
Encouraging increased fluid intake
The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia?
Erythrocytes that are microcytic and hypochromic
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?
Every 15 minutes
You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?
Fibrotic changes in lungs
A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions?
Form words that are understandable or comprehend the spoken word
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal
A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign?
Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg.
A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?
High-protein
A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator.
Hoarseness of more than 2 week's duration
Which of the following terms will the nurse use when referring to blindness in the right or left halves of the visual fields of both eyes?
Homonymous hemianopsia
For a patient with Hodgkin disease, who is at a risk for an ineffective airway clearance and an impaired gas exchange, the nurse places the patient in a high Fowler's position to do which of the following?
Increase the lung expansion.
A patient with severe anemia is complaining of the following symptoms: tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Lab results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which of the following nursing diagnoses is most appropriate for this patient?
Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit
You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has?
Ischemic; about 80% of strokes are the ischemic variety.
The nurse is preparing a client for a hip replacement with the use of porous-coated cementless joint components. What does the nurse know is the benefit of this type of component?
It allows the bone to grow into the prosthesis and securely fix the joint replacement in place.
Which of the following is a benefit of a continuous passive motion (CPM) device when applied after knee surgery?
It promotes healing by increasing circulation and movement of the knee joint.
Dark, green vegetables contain vitamin ____, which reverses the effects of warfarin.
K
Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following?
Liver
Which of the following is accurate regarding a hemorrhagic stroke?
Main presenting symptom is an "exploding headache."
Which nursing intervention is appropriate for minimizing muscle spasms in the client with a hip fracture?
Maintain Buck's traction
Which of the following is the most common joint affected in gout?
Metatarsophalangeal
A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms
Multiple myeloma
Which of the following are usually the first choice in the treatment of rheumatoid arthritis (RA)?
NSAIDs
A nurse reading a chart notes that the patient had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result?
Negative
Which of the following is the leading cause of disability and pain in the elderly?
Osteoarthritis
Which of the following is the most common and most fatal primary malignant bone tumor?
Osteogenic sarcoma (osteosarcoma)
You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
Pain in the calf
A patient is diagnosed as being in the early stage of laryngeal cancer of the glottis with only 1 vocal cord involved. For what type of surgical intervention will the nurse plan to provide education?
Partial laryngectomy
Which of the following is a symptom of severe thrombocytopenia?
Petechiae
A young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by
Placing the client prone with the head turned to the side
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?
Platelet count, prothrombin time, and partial thromboplastin time
The nurse is completing a physical assessment on a client's lymphatic system. The nurse should palpate for enlarged nodes in which areas? Select all that apply.
Popliteal Inguinal Submental Neck
A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan?
Putting on an individually fitted mask when entering the client's room
The nurse is educating the patient with low back pain about the proper way to lift objects. What muscle should the nurse encourage the patient to maximize?
Quadriceps
As status asthmaticus worsens, the nurse would expect which acid-base imbalance?
Respiratory acidosis
One hour after a transfusion of packed red cells is started; a patient develops redness on his trunk and complains of itching. The nurse stops the red blood cell (RBC) infusion and administers the ordered diphenhydramine (Benadryl) 25 mg po. Thirty minutes later, the redness and itching is gone. What is the next action the nurse should take?
Resume the transfusion
A client is brought to the emergency department by a softball team member whostates the client and another player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a fractured clavicle does the nurse recognize?
Right shoulder slopes downward and droops inward.
A client is about to have a cast applied to his left arm. The nurse would alert the client to which of the following as the cast is applied?
Sensation of warmth or heat with application
A patient comes to the clinic for the third time in 2 months with chronic bronchitis. What clinical symptoms does the nurse anticipate assessing for this patient?
Sputum and a productive cough
A patient is having low back pain. What position can the nurse suggest to relieve this discomfort?
Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees
Morton's neuroma is exhibited by which of the following clinical manifestations?
Swelling of the third (lateral) branch of the median plantar nerve
The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?
Tachypnea
The nurse is educating a patient taking imatinib mesylate (Gleevec) for treatment of leukemia. What should the nurse be sure to include when educating the patient on the best way to take the medication to optimize absorption?
Take antacids if needed for gastrointestinal (GI) upset 2 hours after taking Gleevec.
What intervention will best help the patient with ankylosing spondylitis (AS)?
Teach the patient to use a walker or cane.
After a patient has undergone a series of diagnostic tests for tuberculosis, the diagnosis is confirmed by:
The ELISA test.
The nurse is administering a blood transfusion to a patient over 4 hours. After 2 hours, the patient complaints of chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this patient?
The patient is having a febrile nonhemolytic reaction.
An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?
Three hours
Which sign may be helpful in identifying carpal tunnel syndrome?
Tinel's
The Pediatric Nurse Practitioner is doing a physical examination of a client with sickle cell anemia. Why would the nurse practitioner auscultate the lungs and heart?
To detect the abnormal sounds suggestive of acute chest syndrome and heart failure
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
Total laryngectomy
Which of the following is the chief cause of intracerebral hemorrhage (ICH)?
Uncontrolled hypertension
The client is to receive a unit of packed red blood cells. The first intervention of the nurse is to
Verify that the client has signed a written consent form.
The nurse caring for a patient with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6
During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin?
Vitamin K
Plaster casts require a longer time for _____, but mold better to the client, and are initially used until the swelling subsides. Fiberglass casts dry more quickly, are lighter in weight, longer-lasting, and breathable.
drying
A physician diagnoses primary osteoporosis in a client who has lost bone mass. In this metabolic disorder, the rate of bone resorption accelerates while bone formation slows. Primary osteoporosis is most common in:
elderly postmenopausal women.
When iron is given intravenously, the nurse should have emergency medications, such as ________, available in case of anaphylaxis.
epinephrine
The most common symptom in hematologic diseases is extreme ________.
fatigue
A patient has completed induction therapy and has diarrhoea and severe mucositis. What is the appropriate nursing goal?
maintain nutrition
A fracture is termed pathologic when the fracture
occurs through an area of diseased bone.
A sprain is the result of an injury to ligaments that is caused by a twisting motion. A _______-degree sprain is an incomplete tear of the ligament that results in painful weight bearing. A third-degree sprain involves a complete ligament tear with loss of weight-bearing function.
second
A junior-level nursing class has just finished learning about the management of clients with chronic pulmonary diseases. They learned that a new definition of COPD leaves only one disorder within its classification. Which of the following is that disorder?
Emphysema
A physician stated to the nurse that the patient has fluid noted in the pleural space and will need a thoracentesis. The nurse would expect that the physician will document this fluid as which of the following?
Pleural effusion
On auscultation, which finding suggests a right pneumothorax?
Absence of breath sounds in the right thorax
You are caring for a client who is 42-years-old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect?
Edema of the upper airway
