Med Surg Exams 2-5

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A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this clients hygiene care to an unlicensed assistive personnel (UAP)? select all that apply A. wash your hands before touching the client B. wear gloves when bathing the client C. assess skin for breakdown during the bath D. apply lotion to lesions while the skin is wet E. use a damp cloth to scrub the lesions

A, B

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration

A, B, C, D

a client with a new PE is anxious. what nursing actions are most appropriate? select all that apply A. acknowledge the frightening nature of the illness B. delegate a back rub to the unlicensed assistive personnel (UAP) C. request a prescription for antianxiety medication E. stay with the client and speak in a quiet, calm voice

A, B, C, E

a nurse is caring for a client who is on mechanical ventilation. what actions will promote comfort in this client? select all that apply A. allow visitors at the clients bedside B. ensure the client can communicate if awake C. keep the TV turned to a favorite channel D. provide back and hand massages when turning E. turn the client every 2 hours or move

A, B, D, E

a nursing student studying acute coronary syndromes learns that the pain of a MI differs from stable angina in what ways? select all that apply A. accompanied by SOB B. feelings of fear or anxiety C. lasts less than 15 minutes D. no relief from taking nitroglycerin E. pain occurs without known cause

A, B, D, E

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacological comfort measures should the nurse implement? Select all that apply. A. music as a distraction B. tactile stimulation C. massage to injury sites D. cold compresses E. increasing client control

A, B, E

An older client asks the nurse why people my age have weaker immune system than younger people. What responses by the nurse are best? Select all that apply A. bone marrow produces fewer blood cells B. you may have decreased levels of circulating platelets C. you have lower levels of plasma proteins in the blood D. lymphocytes become more reactive to antigens E. spleen function declines after age 60

A, C

The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion

A, C

A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the clients plan of care? select all that apply. A. Height B. Allergies C. Alcohol use D. Prealbumin laboratory results E. Liver enzyme laboratory results

A, C, D

A nurse plans care for a client with burn injuries. Which interventions should the nurse inclued in this clients plan of care to ensure adequate nutrition? Select all that apply. A. provide at least 5000 kcal/day B. start an oral diet on the first day C. administer a diet high in protein D. collaborate with a registered dietitian E. offer frequent high-calorie snacks

A, C, D, E

A nurse cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? select all that apply. A. cool, moist compresses B. topical corticosteroids C. heating pad D. tepid bath with cornstarch E. back rub with baby oil

A, D

A nurse plans care for a client who is immobile. Which interventions should the nurse include in this clients plan of care to prevent pressure sores? select all that apply. A. place a small pillow between bony surfaces B. elevate the head of the bed to 45 degrees C. limit fluids and proteins in the diet D. use a life sheet to assist with re-positioning E. re-position the client who is in a chair every 2 hours F. keep the clients heels off the bed surfaces G use a rubber ring to decrease sacral pressure when up in the chair

A, D, F

a pt who was admitted for newly diagnosed heart failure is now being discharged the nurse instructs the pt and family on how to manage heart failure at home. what major self-management categories should the nurse include? select all that apply A. medications B. weight C. heart transplants D. activity E. diet F. what to do when symptoms get worse

A,B,D,E,F

the nurse is giving a community presentation about heart disease in women. what information does the nurse include in the presentation. select all that apply A. dyspnea on exertion may be the first and only symptom of heart failure B. symptoms are subtle or atypical C. pain is often relived by rest D. having a waist and abdominal obesity is a higher risk factor than having fat in buttocks and thighs E. pain always responds to nitro F. common symptoms include back pain, indigestion, nausea, vomiting, and anorexia

A,B,D,F

a pt is admitted with a vascular problem. based on the pathophysiology of systemic arterial pressure, the systemic arterial pressure is a product of what factures? select all that apply A. cardiac output B. norepinephrine C. preload D. total peripheral vascular resistance E. diastolic blood pressure F. afterload

A,D

a patient with renal failure that results in hypernatremia will require which interventions? select all that apply A. administration of furosemide B. hemodialysis C. IV infusion of 0.9% sodium chloride D. dietary sodium restriction E. administration of potassium supplement F. administration of demeclocycline

A. administration of furosemide B. hemodialysis D. dietary sodium restriction

which conditions could cause a pt to develop acidosis? select all that apply A. sepsis B. hypovolemic shock C. use of a mechanical ventilator D. prolonged nasogastric suctioning E. hypoventilation F. severe diarrhea

A. sepsis B. hypovolemic chock E. hypoventilation

which serum value does the nurse expect to see for a patient with hyponatremia? A. sodium less than 136 mEq/L B. chloride less than 95 mEq/L C. sodium less than 145 mEq/L D. chloride less than 103 mEq/L

A. sodium less than 136 mEq/L

After educating a caregiver of a home care client, a nurse assesses the caregiver's understanding. Which statement indicates that the caregiver needs additional education? a."I can help him shift his position every hour when he sits in the chair." b."If his tailbone is red and tender in the morning, I will massage it with baby oil." c."Applying lotion to his arms and legs every evening will decrease dryness." d."Drinking a nutritional supplement between meals will help maintain his weight."

a client has hemodynamic monitoring after a myocardial infarction. what safety precaution does the nurse implement for this client? A. document pulmonary artery wedge pressure (PAWP) readings and assess their trends C. ensure the balloon does not remain wedged C. keep the client on strict NPO status D. maintain the client in a semi-fowlers position

which term describing the difference between systolic and diastolic values is an indirect measure of cardiac output? A. paradoxical BP B. pulse pressure C. ankle brachial index D. normal BP

a nursing student learns about modifiable risk factors for coronary artery disease. which factors does this include? (select all that apply) A. age B. hypertension C. obesity D. smoking E. stress

B, C, D, E

A nursing student learns that many drugs can impair the immune system. Which drugs does this include? Select all that apply. A. acetaminophen (Tylenol) B. Amphotericin B (Fungizone) C. Ibuprofen (Motrin) D. Metformin (Glucophage) E. Nitrofurantonin (Macrobid)

B, C, E

an emergency room nurse is caring for a trauma client. which interventions should the nurse perform during the primary survey? select all that apply A. Foley catherization B. needle decompression C. initiating IV fluids D. splinting open fractures E. endotracheal intubation F. removing wet clothing G. laceration repair

B, C, E, F

the nurse is assessing a pt with left sided heart failure. which assessment findings does the nurse expect to see in this pt? select all that apply A. ascites B. S3 heart sound C. paroxysmal nocturnal dyspena D. jugular venous distension E. oliguria during the day F. wheezes or crackles

B, C, E, F

a hospital prepares for a mass casualty event. which functions are correctly paired with the personnel role? select all that apply A. paramedic decides the number, acuity, and resource needs of clients B. hospital incident commander assumes overall leadership for implementing the emergency plan C. public information officer provides advanced life support during transportation to the hospital D. triage officer rapidly evaluates each client to determine priorities for treatment E. medical command physician serves as a liaison between the health care facility and the media

B, D

a hospital prepares to receive large numbers of casualties from a community disaster. which clients should the nurse identify as appropriate for discharge or transfer to another facility? select all that apply A. older adult in the medical decision unit for evaluation of chest pain B. client who had an open reduction and internal fixation of a femur fracture 3 days ago C. client admitted last night with community-acquired pneumonia D. infant who has a fever of unknown origin E. client on the medical unit for wound care

B, E

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this clients psoriatic lesions? select all that apply A. have you eaten a large amount of chocolate lately? B. have you been under a lot of stress lately? C. have you recently used a public shower? D. have you been out of the country recently? E. have you recently had any other health problems F. have you changed any medications recently?

B, E, F

which factors can increase systemic arterial pressure? select all that apply A. decreased cardiac output B. increased heart rate C. increased peripheral vascular resistance D. increased stroke volume E. decreased BP F. decreased stroke volume

B,C,D

the nurse is conducting an initial cardiovascular assessment on a middle ages pt. what techniques does the nurse employ in the assessment? select all that apply. A. take blood pressure on the dominate arm B. palpate pulses at all major sites C. palpate for temperature differences in the lower extremites D. perform bilateral but separate palpation on the carotid arteries E. ausculate for bruites in the radial and brachial arteries F. check for orthostatic hypotension

B,C,D,F

what different pathophys conditions can the healthy heart adapt to? select all that apply A. menses B. stress C. GERD D infection E hemorrhage F. kidney stones

B,D,E

the nurse is caring for a pt at risk for heart problems. what are normal findings for the cardiovascular assessment of this pt select all that apply A. presence of a thrill B. splitting of S2; decreases with expiration C. jugular venous distension to level of mandible D. point of maximal impulse (PMI) in fifth intercostal space at midclavicular line E. paradoxical chest movement with inspiration and expiration F. accentuated or intensified S1 after exercise

B,D,F

the nurse is performing BP screening at a community center. which pts are referred for evaluation of their BP? select all that apply A. diabetic pt with a BP of 118/78 B. pt with heart disease with a BP of 134/90 C. pt with no known health problems with a BP of 125/86 D. diabetic pt with BP of 180/80 E. pt with no known halth problems who has a BP of 106/70 F. pt with muscle cramping who is prescribed a statin drug

B,D,F

the terminally ill pt who is near death has loud wet reqpirations that are disturbing to the family. which interventions by the nurse are appropriate at this time? select all that apply A. ausculate lung sounds and obtain a chest x-ray B. place a small towel under the pts mouth C. use oropharyngeal suctioning to remove secretions D. administer an ordered anticholinergic drug to dry the secretions E. assist the pt to cough and deep breath to mobilize secretions F. reposition the pt onto one side to reduce gurgling

B,D,F

on admission, a patient with pulmonary edema weighted 151 lbs now the patient's weight is 149 lbs. assuming the patient was weighed both times with the same clothing on the same scale, and at the same time of day, how many mLs of fluid does the nurse estimate the patient has lost? A. 500 B. 1000 C. 2000 D. 2500

B. 1000

which potassium levels are within normal limits? select all that apply A. 2.0 mmol/L B. 3.5 mmol/L C. 4.5 mmol/L D. 5.0 mmol/L E. 6.0 mmol/L

B. 3.5 mmol/L C. 4.5 mmol/L D. 5.0 mmol/L

the nurse is reviewing the laboratory calcium level results for a patient. which value indicates mild hypocalcemia? A. 5.0 mg/dL B. 8.0 mg/dL C. 10.0 mg/dL D. 12.0 mg/dL

B. 8.0 mg/dL

a pt is at risk for acid base imbalance. which lab value indicates that the pt has metabolic acidosis? A. paco2-55 mmHg B. HCO3 (bicarb)-17 mEq/L C. lactate-2.5 mmol/L D. ph-7.35

B. HCO3 (bicarb)-17 mEq/L

the patient with hypokalemia has an IV potassium supplement ordered. which IV potassium supplement can be administered safely? A. KCL 5 mEq in 20 mL NS B. KCL 10 mEq in 100 mL NS C. KCL 15 mEq in 50 mL NS D. KCL 20 mEq in 100 mL NS

B. KCL 10 mEq in 100 mL NS

which factors affect the amount and distribution of body fluids? select all that apply. A. race B. age C. gender D. height E. body fat F. weight

B. age C. gender E. body fat F. weight

the unlicensed assistive personnel (UAP) notifies the nurse that the patient with emphysema receiving o2 at 2L via nasal cannula is short of breath after morning care. What is the nurse's first action? A. notify the health car provider immediately B. ask the UAP to check the patient's SaO2 level C. instruct the UAP to check the vital signs D. document the incident in the patient's chart

B. ask the UAP to check the patients SaO2 level

the nurse assessing a patient notes a bounding pulse quality, neck vein distension when supine, presence of crackles in the lungs, and increasing peripheral edema. what fluid disorder do these findings reflect? A. fluid volume deficit B. fluid volume excess C. fluid homeostasis D. fluid dehydration

B. fluid volume excess

a patient with hypokalemia is likely to have which conditions? select all that apply. A. liver failure B. metabolic alkalosis C. Cushing's syndrome D. hypothyroidism E. paralytic ileus F. kidney failure

B. metabolic alkalosis C. Cushing's syndrome E. paralytic ileus

the patient has severe hypokalemia (2.4 mEq/L) for which intentional complication does the nurse monitor? A. hypoactive bowel sounds B. paralytic ileus C. nausea D. constipation

B. paralytic ileus

in addition to magnesium levels, which other lab values should the nurse be sure to monitor when a patient has hypomagnesemia? A. sodium and potassium B. potassium and calcium C. calcium and sodium D. chloride and sodium

B. potassium and calcium

which statement about compensation for acid base imbalance is accurate? A. the respiratory system is less sensitive to acid-base changes B. the respiratory system can begin compensation within seconds to minutes C. the renal system is less powerful than the respiratory system D. the renal system is more sensitive to acid base changes

B. the respiratory system can begin compensation within seconds to minutes

A patient's blood osmolarity is 302 mOsm/L. what manifestation does the nurse expect to see in the patient? A. increased urine output B. thirst C. peripheral edema D. nausea

B. thirst

A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? A. apply ice packs to the clients legs B. elevate the clients legs on pillows C. keep the lower extremities warm D. place elastic bandage wraps on the clients legs

A client has been treated for a deep vein thrombus and today presents to the clinic with petechiae. Lab results show a platelet count for 42,000/mm3. The nurse reviews the clients medication list to determine if the client is taking which drug? A. enoxaparin (Lovenox) B. Salicylates (aspirin) C. Unauctioned heparin D. warfarin (Coumadin)

A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition? A. I brush and use dental floss everyday B. I chew hard candy for my dry mouth C. I usually put ice on bumps or bruises D. nonslip socks are best when I walk

when working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible PE. select all that apply A. avoid drinking alcohol B. eat more omega-3 fatty acids C. exercise on a regular basis D. maintain a healthy weight E. stop smoking cigarettes

C, D, E

a client has an intra-arterial blood pressure monitoring line. the nurse notes bright red blood on the clients sheets. what action should the nurse perform first? A. assess the insertion site B. change the clients sheets C. put on a pair of gloves D. assess blood pressure

which patient is at a greatest risk of developing hypocalcemia? A. 30 year old asian woman with breast cancer B. 45 year old caucasian man with hypertension and diuretic therapy C. 60 year old africian american woman with a recent ileostomy D. 70 year old caucasian man on long term lithium therapy

C. 60 year old africian american woman with a recent ileostomy

A client is brought to the ED after sustaining injuries in a severe car crash. the clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. what action by the nurse is the priority? A. administer oxygen and reassess B. auscultate the clients lung sounds C. facilitate a portable chest x-ray D. prepare to assist with intubation

A client is having a radioisotopic imaging scan. What action by the nurse is most important? A. Assess the client for shellfish allergies B. place the client on the radiation precautions C. sedate the client before the scan D. teach the client about the procedure

A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best? A. assess that the client has been NPO as directed B. communicate this information with dietary staff C. document the information in the clients chart D. ensure the information is relayed to the surgical team

A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client? A. Bortezomib (Velcade) B. Dexamethasone (Decadron) C. Thalidomide (Thalomid) D. Zoledronic acid (Zometa)

A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? A. viral infection clindamycin (cleocin) B. bacterial infection acyclovir (Zyvox) C. yeast infection Linezolid (Zyvox) D. fungal infection ketoconazole (Nizoral)

A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? A. draw blood for albumin, prealbumin, and total protein B. prepare for and assist with obtaining a wound culture C. place the client in bed and instruct the client to elevate the foot D. assess the right leg for pulses, skin color, and temperature

A nurse is preparing to hang a blood transfusion. Which action is most important? A. documenting the transfusion B. placing the client on NPO status C. placing the client in isolation D. putting on a pair of gloves

What is the total time required for ventricular depolarization and repolarization as represented on the ECG? A. PR interval B. QRS complex C. ST segment D. QT interval

the nurse is caring for a patient with hypernatremia caused by fluid loss. what type of IV solution is best for treating this patient? A. hypotonic 0.225% sodium chloride B. small-volume infusions of hypertonic (2-3%) saline C. isotonic sodium chloride (NaCl) D. 0.9% sodium chloride

D. 0.9% sodium chloride

which body ph level can be fatal? A. 7.22 B. 7.11 C. 7.05 D. 6.85

D. 6.85

a patient ha a magnesium level of 0.8 mg/dL which treatment dos the nurse expect to be ordered for this patient? A. intramuscular magnesium sulfate B. increased intake of fruits and vegetables C. oral preparations of magnesium sulfate D. IV magnesium sulfate and discontinuation of diuretic therapy

D. IV magnesium sulfate and discontinuation of diuretic therapy

After a 5-km run on a hot summer day, a diaphoretic patient tells the volunteer nurse that she is very thirsty. What is the nurse's best action? A. instruct the patient to sit down. B. Apply ice to the patient's axilla areas. C. tell the patient to breathe slowly and deeply D. offer the patient bottled water to drink

D. Offer the patient bottled water to drink

what interventions are appropriate for a patient with hypernatremia caused by reduced kidney sodium excretion? select all that apply A. hypotonic solutions B. 0.45% sodium chloride intravenous infusion C. D5W intravenous infusion D. administration of bumetanide E. ensure adequate water intake F. diuretics such as furosemide

D. administration of bumetanide F. diuretics such as furosemide

a patient is at risk for fluid volume excess and dependent edema. which task does the nurse delegate to the unlicensed assistive personal (UAP)? A. massage the legs and heels to stimulate circulation B. evaluate the effectiveness of a pressure reducing mattress C. assess the coccyx, elbows, and hips daily for signs of redness D. assist the patient to change position every 2 hours

D. assist the patient to change position every 2 hours

a young adult patient is in the early stages of being treated for severe burns. which electrolyte imbalance does the nurse expect to assess in this patient? A. hypernatremia B. hypokalemia C. hypercalcemia D. hyperkalemia

D. hyperkalemia

Based on the etiology and the main cause of heart failure, which pt has the greatest need for health promotion measures to prevent heart failure? A. pt with alzheimer's B. pt with cystitis C. pt with asthma D. pt with hypertension

A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over the counter antihistamines. What response by the nurse is most appropriate? A. antihistamines do not help poison ivy B. there are different antihistamines to try C. you should be seen in the clinic right away D. you will need to take some IV steroids

A client has Crohns disease. What type of anemia is this client most at risk for developing? A. folic acid deficiency B. fanconis anemia C. Hemolytic anemia D. vitamin B12 anemia

A client has a platelet count of 9000/mm3. the nurse finds the client confused and mumbling. What action takes priority? A. calling the rapid response team B. delegating taking a set of vital signs C. instituting bleeding precautions D. placing the client on bedrest

A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test results would the nurse correlate to this condition? A. bence-jones protein in urine B. epstein-barr virus: positive C. hemoglobin: 18 mg/dL D. red blood cell count: 8.2/mm3

A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful? A. assist the client to make sick day plans for household responsibilities B. determine if there are family members or friends who can help the client C. help the client inform friends and family that they will have to help out D. refer the client to a social worker in order to investigate respite child care

A client hospitalized with sickle cell crisis frequently asks for opioid plan medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking when the client requests pain medication, what action by the nurse is best? A. give the client pain medication if it is time for another dose B. Instruct the client not to request pain medication too early C. request the provider leave a prescription for a placebo D. tell the client it is too early to have more pain medication

A client in the sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? A. 0.45% normal saline B. 0.9% normal saline C. Dextrose 50% (D50) D. lactated ringers solution

A client is having a bone marrow biopsy and is extremely anxious. What action by the nurse is best? A. assess client fears B. reassure the client this is a common test C. sedate the client prior to the procedure D. tell the client he or she will be asleep

A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? A. administer oxygen B. apply an oximetry probe C. give pain medication D. start an IV line

A client suffered an episode of anaphylaxis and has been stabilized in the ICU. when assessing the clients lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer? (click the audio button to hear the audio) A. albuterol (proventil) via nebulizer B. diphenhydramine (benadryl) IM C. epinephrine 1:10,000 5 mg IV push D. Methylpredniosolone (solu-Medrol) IV push

A clietn receiving rivaroxaban (Xarelto) and asks the nurse to explain how it works. what response by the nurse is best? A. it inhibits thrombin B. it inhibits fibrinogen C. it things your blood D. it works against vitamin K

A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therpy? A. creatinine B. red blood cells C. sodium D. magnesium

A nurse assess a client who has open lesions. Which action should the nurse take first? A. put on gloves B. ask the client about his or her occupation C. assess the client pain D. obtain vital signs

A nurse assess an older adult client with the skin disorder shown below: How should the nurse document this finding? A. petechiae B. ecchymoses C. actinic lentigo D. senile angiomas

A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder? A. clean hair and nails B. poor eye contact C. disheveled appearance D. drapes a scarf over the face

A nurse assesses a client who has a chronic wound. The client states, I do not clean the wound and change the dressing every day because it costs too much for supplies. How should the nurse respond? A. you can use tap water instead of sterile saline to clean your wound B. if you don't clean the wound properly, you could end up in the hospital C. sterile procedure is necessary to keep this wound from getting infected D. good hand hygiene is the only thing that really matters with wound care

A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer as shown below: Which diagnostic test should the nurse anticipate being ordered for this client? A. punch skin biopsy B. viral cultures C. woods lamp examination D. diascopy

A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the clients skin. How should the nurse document these lesions? A. two 2cm hyperpigmented patches B. two 1 inch erythematous plaques C. two 2mm pigmented papules D. two 1 inch moles

A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit useful information about the possible condition? A. what do you do for a living? B. are your nails professionally manicured? C. do you have diabetes mellitus? D. have you had a recent fungal infection?

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take? A. place the client in a single room B. administer an antihistamine C. assess the clients airway D. apply gloves to minimize friction

A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this clients plan of care? A. change the dressing every 6 hours B. assess the wound bed once a day C. change the dressing when it is saturated D. contact the provider when the dressing leaks

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? A. administer the prescribed intravenous morphine sulfate B. apply ice to skin around the burn wound for 20 minutes C. adminster prescribed intramuscular ketorolac (Toradol) D. decrease tactile stimulation near the burn injuries

A nurse caring for a client with sickle cell disease (SCD) reviews the clients laboratory work. Which finding should the nurse report to the provider? A. creatinine: 2.9 mg/dL B. hematocrit: 30% C. Sodium: 147 mEq/L D. WBC count 12,000/mm3

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). which statement should the nurse include when delegating this activity? A. keep the water temperature constant when showering the client B. assess the wound beds during hydrotherapy C. apply a topical enzyme agent after bathing the client D. use sterile saline to irrigate and clean the clients wounds

A nurse has educated a client on an epinephrine auto-injector (EpiPen). what statement by the client indicates additional instruction is needed? A. I don't need to go to the hospital after using it B. I must carry two EpiPens with me at all times C. I will write the expiration date on my calendar D. this can be injected right through my clothes

A nurse is assessing a dark-skinned client for pallor. What action is best? A. assess the conjunctiva of the eye B. have the client open the hand widely C. look at the roof of the clients mouth D. palpate for areas of mild swelling

A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first? A. client who had two blood diarrhea stools this morning B. client who has been premeditated for nausea prior to chemotherapy C. client with a respiratory rate change from 18 to 22 breaths per min D. client with an unchanged lesion to the lower right lateral malleolus

A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse? A. recent wound assessment, including size and appearance B. insurance information for billing and coding purposes C. complete health history and physical assessment findings D. resources available to the client for wound care supplies

A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus(MRSA)? a.Client admitted from a nursing home with furuncles and folliculitisb. b. Client with a leg cut and other trauma from a motorcycle crash c.Client with a rash noticed after participating in sporting events d.Client transferred from intensive care with an elevated white blood cell count

A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. Checking emergency equipment each morning b. Ensuring informed consent is obtained as needed c. Providing educational materials in several languages d. Teaching clients how to manage their allergies

An emergency room nurse assess a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? A. apply oxygen and continuous pulse oximetry B. provide small quantities of ice chips and sips of water C. request a prescription for an antitussive medication D. ask the respiratory therapist to provide humidified air

Emergency personnel discovered a patient lying outside in the cool evening air for an unknown length of time. The patient is in a hypothermic state and the metabolic needs of the tissues are decreased. What other assessment finding does the nurse expect to see? a. Blood pressure and heart rate lower than normal b. Heart rate and respiratory rate higher than normal c. Normal vital signs due to compensatory mechanisms d. Gradually improved vital signs with enteral nutrition

The EMTs arrive at the ED with an unresponsive client with an oxygen mask in place. What will the nurse do first? A. assess that the client is breathing adequately B. insert a large bore IV line C. please the client on a cardiac monitor D. assess for the best neurologic response

The nurse assess a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? A. It is normal to feel some depression B. I will go back to work immediately C. I will not feel anger about my situation D. once I get home, things will be normal

The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

The nurse is caring for a client with leukemia who has he priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met? A. doing activities of daily living using rest periods B. helping plan a daily activity schedule C. requesting a sleeping pill at night D. telling visitors to leave when fatigued

The nurse is performing a 12 lead ECG on a pt with chest pain. because the positioning of the electrodes is crucial, how does the nurse place the ECG electrodes? A. four leads are placed on the limbs and six are placed on the chest B. the negative electrode is placed on the right leg C. four leads are placed on the limbs and four are placed on the chest D. the negative electrode is placed on the right arm and the positive electrode is placed on the left leg

The pt's ECG rhythm strip is irregular. Which method does the nurse use for an accurate assessment? a. 6-second strip method b. Memory method c. Big block method d. Commercial ECG rate ruler

Which test is the best tool for diagnosing heart failure? A. echocardiography B. pulmonary artery catheter C. radionuclide studies D. mitigated angiographic (MUGA) scan

a client appears dyspneic, but the O2 sat is 97% what action by the nurse is best? A. assess for other manifestations of hypoxia B. change the sensor on the pulse oximeter C. obtain a new oximeter from central supply D. tell the client to take slow, deep breaths

a client has been brought to the ED after being shot multiple times. what action should the nurse perform first? A. apply personal protective equipment B. notify local law enforcement officials C. obtain universal donor blood D. prepare the client for emergency surgery

a client has been diagnosed with a very large PE and has dropping blood pressure. what medication should the nurse anticipate the client will need as the priority? A. alteplase (activase) B. enoxaparin (lovenox) C. unfractionated heparin D. warfarin sodium (coumadin)

a client in shock is apprehensive and slightly confused. what action by the nurse is best? A. offer to remain with the client for awhile B. prepare to administer antianxiety med C. raise all four siderails on the clients bed D. tell the client everything possible is being done

a client in the ED has several broken ribs. what care measure will best promote comfort? A. allowing the client to choose the position in bed B. humidifying the supplemental oxygen C. offering frequent, small drinks of water D. providing warmed blankets

a client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL the spouse asks why the client needs insulin as the client is not a diabetic. what response by the nurse is best? A. high glucose is common in shock and needs to be treated B. some of the medications we are giving are to raise blood sugar C. the IV solution has lots of glucose, which raises blood sugar D. the stress of this illness has made your spouse a diabetic

a client is in the clinic a month after having a MI the client reports sleeping well since moving into the guest bedroom. what response by the nurse is best? A. do you have any concerns about sexuality? B. Im glad to hear you are sleeping well now C. sleep near your spouse in case of emergency D. why would you move into the guest room?

a client is on a dopamine infusion via a peripheral line. what action by the nurse takes priority for safety? A. assess the IV site hourly B. monitor the pedal pulses C. monitor the clients vital signs D. obtain consent for a central line

a client is receiving norepinephrine (levophed) for shock. what assessment finding best indicates a therapeutic effect from this drug? A. alert and orientated, answering questions B. client denial of chest pain or chest pressure C. IV site without redness or swelling D. urine output of 30 mL/hr for 2 hours

a family in the ED is overwhelmed at the loss of several family members due to a shooting incident in the community. which intervention should the nurse complete first? A. provide a calm location for the family to cope and discuss needs B. call the hospital Chaplin to stay with the family and pray for the deceased C. do not allow visiting of the victims until the bodies are prepared D. provide privacy for law enforcement to interview the family

a nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about what action by the nurse is most appropriate? A. assess the cause of agitation B. reassure the client that he or she is safe C. restrain the clients hands D. sedate the client immediately

a nurse is caring for a client who is intubated and has an intra-aortic balloon pump. the client is restless and agitated. what action should the nurse perform first for comfort? A. allow family members to remain at the bedside B. ask the family if the client would like a fan in the room C. keep the TV tuned to the clients favorite channel D. speak loudly to the client in case of hearing problems

a nurse teaches a community health class about water safety. which statement by a participant indicates that additional teaching is needed? A. I can go swimming all by myself because I am a certified lifeguard B. i cannot leave my toddler alone in the bathtub for even a min C. i will appoint one adult to supervise the pool at all times during a party D. i will make sure that there is a phone near my pool incase of emergency

a nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff and first aid stations or community acute care centers in the event of disaster. which organization is the best fit for this nurses interests? A. the medical reserve corps B. the national guard C. the health department D. a disaster medical assistance team

a nurse wants to become part of a disaster medical assistance team (DMAT) but is concerned about maintaning licensure in several different states. which statement best addresses these concerns? A. deployed DMAT providers are federal employees, so their licenses are good in all 50 states B. the gov't has a program for quick licensure activation wherever you are deployed C. during a time of crisis, licensure issues would not be the gov'ts priority concern D. if you are deployed, you will be issued a temp license in the state in which you are working

a nursing student is caring for a client who had a myocardial infarction. the student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. what response by the faculty member is best? A. continue to educate the client on possible healthy changes B. emphasize complications that can occur with noncompliance C. tell the client that denial is normal and will soon go away D. you need to make sure the client understands this illness

a provider prescribes a rewarming bath for a client who presents with partial thickness frostbite. which action should the nurse take prior to starting this treatment? A. administer IV morphine B. wrap the limb with compression dressing C. massage the frostbitten areas D. assess the limb for compartment syndrome

a pt is prescribed niacin (niaspan) to lower LDL-C and very low density lipoprotein (VLDL) why are lower doses prescribed to the pt? A. to reduce side effects of flushing and feeling warm B. to prevent muscle myopathies C. to prevent elevation of blood pressure D. to prevent undesirable hypokalemia

a pts chart notes that the examiner has heard S1 and S2 on auscultation of the heart. what does this documentation refer to? 1st and 2nd heart sounds B. pericardial friction rub C. murmur D. gallop

a pts cholesterol screening shows a low density lipoprotein cholesterol (LDL-C) value greater than 190 mg/dL. what is the nurses best interpretation of these results? A. all pts with LDL-C equal to or greater than 190. should be evaluated for secondary causes of hyperlipidemia and treated with statin therapy B. any pt with low LDL-C value should be routinely followed with every 6 month lipid profile values monitoring to see trends in this value C. this pt should be taught to exercise 6-7 days/week to help lower LDL-C D. repeat total cholesterol and LDL-C cholesterol testing during the next routine exam

an ED nurse cares for a middle aged mountain climber who is confused and exhibits bizarre behaviors after administering oxygen, which priority intervention should the nurse implement? A. administer dexamethasone (Decadron) B. complete a monumental state examination C. prepare the client for computed tomography of the brain D. request a psychiatric consult

an Ed nurse assess a client admitted after a lightning strike. which assessment should the nurse complete first A. electrocardiogram (ECG) B. wound inspection C. creatinine kinase D. computed tomography (CT) of head

an older adult is on cardiac monitoring after a myocardial infarction. the client shows frequent dysrhythmias. what action by the nurse is most appropriate? A. assess for any hemodynamic effects of the rhythm B. prepare to administer antidysrhythmic medication C. notify the provider or call the rapid response team D. turn the alarms off on the cardiac monitor

in assessing a pt the nurse finds that the point of maximal impulse appears in more than one intercostal space and has shifted lateral to the midclavicular line. how does the nurse interpret this data? A. left ventricular hypertrophy B. superior vena cava obstruction C. pulmonary hypertension D. constrictive pericarditis

the advanced practice nurse is assessing the vascular status of a pts lower extremities using the ankle brachial index. what is the correct technique for this assessment method? A a BP cuff is applied to the lower extremities and the systolic pressure is measured by doppler ultrasound at both the dorsalis pedis and posterior tibial pulses B. the dorsalis pedis and posterior tibal pulses are manuall palpated and compared bilaterally for strength and equality and compared to the standard index C. a BP cuff is applied to the lower extremities to observe for an exagerated decrease in systolic pressure by more than 10 mmHg during inspiration D. BP on nthe legs is measured with the pt supine, then the pt stands for several mins and BP is measured in arms

the health care provider tells the nurse that a client is to be started on a platelet inhibitor. About what drug does the nurse plan to teach the client? A. Clopidogrel (Plavix) B. Enoxaparin (Lovenox) C. Reteplase (Retavase) D. Warfarin (Coumadin)

the hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. which statement by the debriefing team leader is most appropriate for this situation? A. you are free to express your feelings; whatever is said here stays here B. lets evaluate what went wrong and develop policies for future incidents C. this session is only for nursing and medical staff, not for ancillary personnel D. lets pass around the written policy compliance from for everyone

the nurse is caring for a terminally ill cancer pt who is near death. the pt reports an uncomfortable feeling of breathlessness. which therapy is the nurse most likely to administer A. 5mg of morphine B. 10 mg of lasix C. 2 L of O2 via nasal cannula D. albuterol via a metered-dose inhaler

the nurse is performing a cardiac assessment on an older adult. what is a common assessment finding for this pt? A S4 heart sound B. leg edema C. pericardial friction rub D. change in point of maximum impulse location

the nurse is providing health teaching for a pt at risk for heart disease. which factor is the most modifiable, controllable risk factor A. obesity B. diabetes C. ethnic background D. family history of cardiovascular disease

the nurse is reviewing preliminary ECG results of a pt admitted for mental status changes. the nurse alerts the health care provider about ST elevation or depression in the pt because it is an indication of which condition? A. myocardial injury or ischemia B. ventricular irritability C. subarachnoid hemorrhage D. prinzmetal's angina

the nurse is talking to a pt who has been trying to quit smoking. which statement by the pt indicates an understanding of cigarette usage as it relates to reducing cardiovascular risks A. i need to be completely cigarette-free for at least 3 years B. i don't smoke as much as i used to, i'm down to one pack/day C. i started smoking a while ago but ill quit in a couple of years D. i only smoke to relax when i drink or go out with friends

the nursing student is assisting in the care of a pt with advanced right sided heart failure. in addition to bringing a stethoscope what additional piece of equipment does the student bring in order to assess this pt? A. tape measure B. glasgow coma scale C. portable doppler D. bladder ultrasound scanner

the terminally ill pt is nearing death. his wife expresses concern that he has no appetite and eats very little. what is the nurse's best responce to this concern? A. teach the wife about risk of aspiration and explain that loss of appetite is normal when a pt nears death B. encourage the wife to feed the pt as much as he will take to maintain nutrition C. request the health care provider order a dietary nutrition consult to include foods that the pt perfers D. keep fluids and finger foods at the bedside for easy access whenever the pt is hungry or thirsty

what does the P wave in a ECG represent A. atrial depolarization B. atrial repolarazation C. ventricular depolarization D. ventricular repolarizaation

what is the normal measurement of QRS complex in ECG A. less than 0.12 seconds B. 0.10-0.16 seconds C. 0.12-0.20 seconds D. 0.16-0.24 seconds

what is the normal position of the ST segment in a ECG A. isoelectric B. elevated C. depressed D. biphasic

when heart failure develops, what is the initial compensatory mechanism of the heart that maintains cardiac output? A. sympathetic stimulation B. parasympathetic stimulation C. renin-angiotensin activation system (RAAS) D. myocardial hypertrophy

when the nurse assesses a patient with cardiovascular disease (CVD) there is difficulty auscultating the first heart sound S1. what is the nurses best action? A. ask the pt to lean forward or roll to his or her left side B. instruct the pt to take a deep breath and hold it C. auscultate with the bell instead of the diaphragm D. ask the unlicensed assistive personnel to complete a 12 lead ECG immediately

which category of cardiovascular drugs blocks sympathetic stimulation to the heart and decreases the heart rate A. beta blockers B. catecholamines C. steroids D. benzodiazepines

which pt is a candidate for proportionate palliative sedation A. pt is having refactory symptoms of distress that are not responding to treatments B. pt is seeking options and alternatives to passive euthanasia C. pt is extremely anxious that pain and suffering will not be adequately addressed D. pt is convinved that established pallative protocols will hasten death

which statement about the peripheral vascular system is true A. veins are equipped with valves that direct blood flow to the heart and prevent backflow B. the velocity of blood flow depends on the diameter of the vessel lumen C. blood flow decreases and blood tends to clot as the viscosity decreases D. the parasympathetic nervous system has the largest effect on blood flow to organs

while on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first? A. deliver rescue breaths B. wrap the client in dry blankets C. assess for signs of bleeding D. check for a carotid pulse

A nurse manages wound care for clients on a medical-surgical unit. Which client wounds are paired with the appropriate treatments? select all that apply A. client with a left heel ulcer with slight necrosis whirlpool treatments B. client with an eschar-covered sacral ulcer surgical dbridement C. client with a sunburn and erythema soaking in warm water for 20 minutes D. client with urticaria wet-to-dry dressing changes every 6 hours E. client with a sacral ulcer with purulent drainage transparent film dressing

A, B

A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this clients teaching? select all that apply. A. A look for asymmetry of shape and irregular borders B. Assess for color variation within each lesion C. examine the distribution of lesions over a section of the body D. monitor for edema or swelling of tissues E. focus your assessment on skin areas that itch

A, B

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? Select all that apply. A. administer analgesics B. prevent wound infections C. provide fluid replacement D. decrease core temperature E. initiate physical therapy

A, B, C

the nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. what actions are included in this practice? A. adherence to proper hand hygiene B. administering anti-ulcer medication C. elevating the head of the bed D. providing oral care per protocol E. suctioning the client on a regular schedule

A, B, C, D

the nurse is caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. what age related changes contribute to this? select all that apply A. chest wall stiffness B. decreased muscle strength . inability to cooperate D. less lung elasticity E. poor vision and hearing

A, B, D

A nurse cares for older adult clients in an long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? select all that apply A. use a lift sheet when moving the client in bed B. avoid tape when applying dressings C. avoid whirlpool therapy D. use loose dressing on all wounds E. implement pressure-relieving devices

A, B, E

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? Select all that apply. A. ask all family members and visitors to perform hand hygiene before touching the client B. carefully monitor burn wounds when providing each dressing change C. clean equipment with alcohol between uses with each client on the unit D. allow family members to only bring the client plants from the hospital gift shop E. use aseptic technique and wear gloves when performing wound care

A, B, E

A student nurse learns that the spleen has several functions. What functions do they include? Select all that apply. A. breaks down hemoglobin B. destroys old or defective RBCs C. forms vitamin K for clotting D. stores extra iron in ferritin E. stores platelets not circulating

A, B, E

a nurse teaches a client who has sever allergies to prevent bug bites. which statements should the nurse include in this clients training? select all that apply. A. consult an exterminator to control bugs in and around your home B. do not swat at insects or wasps C. wear sandals whenever you go outside D. keep your prescribed epinephrine auto injector in a bedside drawer E. use screens in your windows and doors to prevent flying insects from entering

A, B, E

an ED nurse is preparing to transfer a client to the trauma ICU which info should the nurse include in the nurse to nurse hand-off report? select all that apply A. mechanism of injury B. diagnostic test results C. immunizations D. list of home medications E. isolation precautions

A, B, E

an ED nurse moves to a new city where heat related illnesses are common. which clients does the nurse anticipate being at higher risk for heat related illnesses? select all that apply. A. homeless individuals B. illicit drug users C. white people D. hockey players E. older adults

A, B, E

the nurse is caring for a client with suspected severe sepsis. what does the nurse prepare to do within 3 hours of the client being identified as being at risk? select all that apply A. administer antibiotics B. draw serum lactate levels C. infuse vasopressors D. measure central venous pressure E. obtain blood cultures

A, B, E

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? Select all that apply? A. slower healing time increased risk for loss of function from contracture formation B. reduced inflammatory response deep partial thickness wound with minimal exposure C. reduced thoracic compliance increased risk for atelectasis D. high incidence of cardiac impairments increased risk for acute kidney injury E. thinner skin may not exhibit a fever when infection is present

A, C, D

the nursing student is studying hypersensitivitiy reactions. which reactions are correctly matched with their hypersensitivity types? Select all that apply A. Type 1 examples include hay fever and anaphylaxis B. type 2 medicated by action of immunoglobulin (IgM) C. type 3 immune complex deposits in blood vessel walls D. type 4 examples are poison ivy and transplant rejection E. type 5 examples include a positive tuberculosis test and sarcoidosis

A, C, D

A nurse working with clients with sickle cell disease (SCD) teaches about self management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? select all that apply. A. Dehydration B. exercise C. extreme stress D. high altitudes E. pregnancy

A, C, D, E

the nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? select all that apply A. assessing and identifying clients at risk B. monitoring the daily white blood cell count C. performing proper hand hygiene D. removing invasive lines as soon as possible E. using aseptic technique during procedures

A, C, D, E

a nurse is providing health education at a community center. which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? select all that apply. A. seek shelter inside a building or vehicle B. hide under a tall tree C. do not take a bath or shower D. turn off the TV E. remove all body piercings F. put down golf clubs or gardening tools

A, C, D, F

emergency medical services (EMS) brings a large number of clients to the ED following a mass casualty incident. the nurse identifies the clients with which injuries with yellow tags? select all that apply A. partial thickness burns covering both legs B. open fractures of both legs with absent pedal pulses C. neck injury and numbness of both legs D. small pieces of shrapnel embedded in both eyes E. head injury and difficult to arouse F. bruising and pain in the right lower abdomen

A, C, D, F

A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include? Select all that apply. A. chemical exposure B. genetically modified foods C. Ionizing radiation exposure D. vaccinations E. viral infections

A, C, E

a nurse is caring for a client who has coronary artery bypass grafting yesterday. what actions does the nurse delegate to the unlicensed assistive personnel (UAP)? select all that apply A. assist the client to the chair for meals and to the bathroom B. encourage the client to use the spirometer every 4 hours C. ensure the client wears TED house or sequential compression devices D. have the client rate pain on a 0-10 scale and report to the nurse E. take and record a full set of vital signs per hospital protocol

A, C, E

the nurse is assessing a pt with right sided heart failure which assessment findings does the nurse expect to see in this pt. select all that apply? A. dependent edema B. weight loss C. jugular venous distension D. hypotension E. hypotension F. hepatomegaly F. angina

A, C, E

a nurse triages clients arriving at the hospital after a mass casualty. which clients are correctly classified? select all that apply A. 35 year old female with severe chest pain: red tag B. a 42 year old male with full thickness body urns: green tag C. a 55 year old female with a scalp laceration: black tag D. a 60 year old male with an open fracture with distal pulses: yellow tag E. an 88 year old male with shortness of breath and chest bruises: green tag

A, D

a client is in the early stages of shock and is restless. what comfort measures does the nurse delegate to the nursing student? select all that apply A. bringing the client warm blankets B. giving the client hot tea to drink C. massaging the clients painful legs D. reorienting the client as needed E. sitting with the client for reassurance

A, D, E

a nurse is teaching a wilderness survival class. which statements should the nurse include about the prevention of hypothermia and frostbite? select all that apply A. wear synthetic clothing instead of cotton to keep your skin dry B. drink plenty of fluids brandy can be used to keep your body warm C. remove your hat when exercising to prevent the loss of heat D. wear sunglasses to protect skin and eyes from harmful rays E. know your physical limits. come in out of the cold when limits are reached

A, D, E

an emergency department nurse plans care for a client who is admitted with heat stroke. which interventions should the nurse include in this clients plan of care? select all that apply A. administer o2 via mask or nasal cannula B. administer ibuprofen, an antipyretic med C. apply cooling techniques until core body temp is less than 101 F D. infuse 0.9% sodium chloride via a large bore IV cannula E. obtain baseline serum electrolytes and cardiac enzymes

A, D, E

the complex care provided during an emergency requires interdisciplinary collaboration. which interdisciplinary team members are paired with the correct responsibilities? select all that apply A. psychatric crisis nurse interacts with clients and families when sudden illness, serious injury or death of a loved one may cause a crisis B. forensic nurse examiner performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment and prioritization of resources C. triage nurse provides basic life support interventions such as o2, basic wound care, splinting, spinal immobilization and monitoring of vital signs D. EMT obtains client histories, collects evidence, and offers counseling and follow up care for victims of rape, child abuse, and domestic violence E. paramedic provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

A, E

atherosclerousis affects which larger arteries? select all that apply A. renal B. femoral C. coronary D. brachial cephalic E. aorta F. carotid

A,B,C,E,F

an africian american male is being seen for a blister on the right toe, what factors increase this pts risk for developing atherosclerosis? select all that apply A. 20 ear history of type 1 diabetes B sedentary lifestyle C. father with history of colon cancer D. 35 lb overweight E. grandmother who died after myocardial infarction F. drinking 2-3 diet sodas per day

A,B,D,E

which bp readings require further assessment. select all that apply A. 90 systolic B. 139 systolic C. 115 systolic D. 66 diastolic E. 100 diastolic F. 96 diastolic

A,B,E,F

the nurse is assessing a pts nicotine dependence. which questions does the nurse ask for an accurate assessment? select all that apply A. how soon after you wake up in the morning do you smoke B. what kind of cigarettes do you smoke C. do you wake up in the middle of the night to smoke D. do you find it difficult not to smoke in places where smoking is prohibited E. do you smoke when you are ill F. what hapened the last time you tried to quit smoking

A,C,D,E

the pt has a diagnosis of angina. which assessment data would the nurse expect to find? select all that apply A. sudden onset of pain B. intermittent pain relieved with sitting upright C. substernal pain that may spread across chest, back and arms D. pain usually last less than 15 minutes E. sharp, stabbing pain that is moderate to severe F. pain releaved with rest

A,C,D,F

which are risk factors for cardiovascular disease (CVD) in women? select all that apply A. waist and abdominal obesity B. excess fat in the buttocks, hips and thighs C postmenopausal D. diabetes mellitus E. asian ethnicity F. elevated homocysteine level

A,C,D,F

which statements about BP are accurate? select all that apply A. pulse pressure is the difference between the systolic and diastolic pressures B. the right ventricle of the heart generates the greatest amount of blood pressure C. diastolic blood pressure is primarily determined by the amount of peripheral vasoconstriction D. to maintain adequate blood flow through the coronary arteries, mean arterial pressure (MAP) must be at least 60 E. diastolic blood pressure is the highest pressure during contraction of the ventricles F. systolic blood pressure is the amount of pressure/force generated by the left ventricle to distribute blood into the aorta with each contraction of the heart

A,C,D,F

which actions are the responsibilities of the monitor technician? select all that apply A. watch the bank of monitors on a unit B. notify the health care provider of any changes C. print routine ECG strips D. apply battery operated transmitter leads to patients E. interpret the rhythms F. report patient rhythm and significant changes to the nurse

A,C,E,F

a patient shows a positive trousseau's or chvostek's sign. the nurse prepares to give the patient which urgent treatment? A. IV calcium B. calcitonin C. IV potassium chloride D. large doses of oral calcium

A. IV calcium

which nursing interventions apply to patients with hypercalcemia? select all that apply A. administer IV normal saline (0.9% sodium chloride) B. measure the abdominal girth C. massage calves to encourage blood return to the heart D. monitor for ECG changes E. provide adequate intake of vitamin D F. during treatment, monitor for tetany

A. administer IV normal saline (0.9% sodium chloride) B. measure the abdominal girth D. monitor for ECG changes

which are appropriate interventions for a patient who has hypercalcemia? select all that apply A. administer IV normal saline (0.9% sodium chloride) B. administer hydrochlorothiazide (HCTZ) C. ensure adequate hydration D. administer calcium based antacid for GI upset E. discourage weight bearing activity such as walking F. provide continuous cardiac monitoring

A. administer IV normal saline (0.9% sodium chloride) C. ensure adequate hydration F. provide continuous cardiac monitoring

changes from normal ph can have what effects on which body functions? select all that apply A. alter fluid and electrolyte balance B. increase effectiveness of drugs C. reduce function of hormones D. increase function of enzymes E. increase excitability of the heart muscle F. cause increased activity of the GI tract

A. alter fluid and electrolyte balance C. reduce function of hormones E. increase excitability of the heart muscle F. cause increased activity of the GI tract

the nurse is assessing a patient with severe hypermagnesemia. which assessment findings are associated with this electrolyte imbalance? A. bradycardia and hypotension B. tachycardia and weak palpable pulse C. hypertension and irritability D. irregular pulse and deep respirations

A. bradycardia and hypotension

the provider has ordered therapy for a patient with low sodium and signs of hypervolemia which diuretic is best for this patient? A. conivaptan B furosemide C. hydrochlorothiazide D. bumetanide

A. conivaptan

which conditions cause a patient to be at risk for hypocalcemia? select all that apply. A. crohn's disease B. acute pancreatitis C. removal or destruction of parathyroid glands D. immobility E. use of digitalis F. GI wound drainage

A. crohn's disease B. acute pancreatitis C. removal or destruction of parathyroid glands D. immobility F. GI wound drainage

the nurse is interpreting the ABG results of a pt with acute respiratory insufficiency as the paco2 level increases, which result would the nurse expect? A. decreased ph B. decreased bicarb C. increased pao2 D. increased ph

A. decreased ph

the nurse monitors the effectiveness of magnesium sulfate by assessing which factor every hour? A. deep tendon refluxes B. vital signs C. serum laboratory values D. urine output

A. deep tendon reflexes

the patient with mild fluid fluid volume overload has between instructed by the provider to follow dietary sodium restriction. what would the nurse teach this patient about sodium restriction? A. do not add salt to ordinary table foods B. restrict sodium intake to 2 gm per day C. restrict sodium intake to 4 gm per day D. do not add salt when cooking or eating

A. do not add salt to ordinary table foods

a patient's potassium level is high secondary to kidney failure. what laboratory changes does the nurse expect to see? select all that apply A. elevated serum creatinine B. decreased blood pH C. elevated sodium D. low to normal hematocrit E. elevated hemoglobin F. decreased blood urea nitrogen

A. elevated serum creatinine B. decreased blood pH D. low to normal hematocrit

patients with which conditions are at greatest risk for deficient fluid volume? select all that apply. A. fever of 103 F (39.4 C) B. extensive burns C. thyroid crises D. water intoxication E. continuous fistula drainage F. diabetes insipidus

A. fever of 103 F (39.4 C) B. extensive burns C. thyroid crises E. continuous fistula drainage F. diabetes insipidus

the patient's potassium level is 2.5 mEq/L. which clinical findings does the nurse expect to see when assessing this patient? select all that apply A. general skeletal muscle weakness B. moist crackles and tachypnea C. lethargy D. decreased urine output E weak hand grasps F. weak, thready pulse

A. general skeletal muscle weakness C. lethargy E weak hand grasps F. weak, thready pulse

the nurse is giving discharge instructions to the patient with advanced heart failure who is at continued risk for fluid volume overload. for which physical change does the nurse instruct the patient to call the health care provider? A. greater than 3 lbs gained in a week or greater than 1-2 lbs gained in a 24-hour period B. greater than 5 lbs gained in a week or greater than 1-2 lbs gained in a 24 hour period C. greater than 15 lbs gained in a month or greater than 5lbs gained in a week D. greater than 20 lbs gained in a month or greater than 5 lbs gained in a week

A. greater than 3 lbs gained in a week or greater than 1-2 lbs gained in a 24-hour period

the emergency department (ED) nurse is caring for a patient who was brought in for significant alcohol intoxication and minor trauma to the wrist. what will serial hematocrits for this patient likely show? A. hemoconcentration B. normal and stable hematocrits C. progressively lower hematocrits D. decreasing osmolality

A. hemoconcentration

a patient with hyponatremia would have which gastrointestinal findings upon assessment? select all that apply. A. hyperactive bowel sounds on auscultation B. hard, dark brown stools C. hypoactive bowel sounds on auscultation D. frequent watery bowel movements E. abdominal cramping F. nausea

A. hyperactive bowel sounds on auscultation D. frequent watery bowel movements E. abdominal cramping F. nausea

the nurse is taking care of a trauma patient who was in a motor vehicle accident. the patient has a history of hypertension, which is managed with spironolactone. This patient is at risk for developing which electrolyte imbalance? A. hyperkalemia B. hypernatremia C. hypokalemia D. hypocalcemia

A. hyperkalemia

a patient with a recent history of anterior neck injury reports muscle twitching and spasms with tingling in the lips, nose and ears. the nurse suspects these symptoms may be caused by which condition? A. hypocalcemia B. hypokalemia C. hyponatremia D. hypomagnesemia

A. hypocalcemia

a patient with congestive heart failure is receiving a loop diuretic, the nurse monitors for which electrolyte imbalances? select all that apply A. hypocalcemia B. hypercalcemia C. hyponatremia D. hypernatremia E. hypokalemia F. hyperkalemia

A. hypocalcemia C. hyponatremia E. hypokalemia

on assessment, the patient has respiratory muscle weakness result in in shallow respirations. which electrolyte abnormality would the nurse suspect? A. hypokalemia B. hyperkalemia C. hypocalcemia D. hypercalcemia

A. hypokalemia

which are major causes of hypomagnesemia? select all that apply A. inadequate intake of magnesium B. inadequate intake of sodium C. use of potassium sparing diuretics D. decreased kidney execration of magnesium E. prescription of loop diuretics F. cessation of alcohol intake

A. inadequate intake of magnesium E. prescription of loop diuretics

which is a preventive measure for patients at risk for developing hypocalcemia? A. increase daily dietary calcium and vitamin D intake B. increase intake of phosphorus C. apply sunblock and wear protective clothing whenever outdoors D. administer calcium containing IV fluids to patients receiving multiple blood transfusions

A. increase daily dietary calcium and vitamin D intake

which assessment findings are related to mild hypercalcemia? select all that apply A. increased heart rate B. paresthesia C. decreased deep tendon reflexes D. hypoactive bowel sounds E. shortened QT interval F. profound muscle weakness

A. increased heart rate C. decreased deep tendon reflexes D. hypoactive bowel sounds E. shortened QT interval

a patient has hyperkalemia resulting from dehydration. which additional laboratory findings does the nurse anticipate for this patient? A. increased hematocrit and hemoglobin levels B. decreased serum electrolyte levels C. increased urine potassium levels D. decreased serum creatinine

A. increased hematocrit and hemoglobin levels

Which findings indicate that a patient may have hypervolemia? Select all that apply. A. increased, bounding pulse B. jugular venous distension C. presence of crackles D. excessive thirst E. elevated blood pressure F. orthostatic hypotension

A. increased, bounding pulse B. jugular venous distension C. presence of crackles E. elevated blood pressure

a patient with COPD has just developed respiratory distress. vital signs are pulse oximetry 88% on 2L nasal cannula o2, dyspnea at rest, and respirations 32 per min. the patient reports shortness of breath. which statements apply to this clinical situation? select all that apply. A. interference in alveolar-capillary diffusion results in carbon dioxide retention B. the nurse should instruct the patient to use pursed-lip breathing C. position the patient with the head of the bed at less than 20 degrees D. interference in alveolar-capillary diffusion results in acidemia E. the nurse should explain to the patient that rapid breathing will relieve the shortness of breath F. use of an as-needed bronchodilator may relieve the shortness of breath

A. interference in alveolar-capillary diffusion results in carbon dioxide retention B. the nurse should instruct the patient to use pursed-lip breathing D. interference in alveolar-capillary diffusion results in acidemia F. use of an as-needed bronchodilator may relieve the shortness of breath

a patient has a low potassium level, and the provider has ordered an IV infusion before starting an IV potassium infusion, what does the nurse assess? A. intravenous line patency B. oxygen saturation level C. baseline mental status D. apical pulse

A. intravenous line patency

which statement best explains how antidiuretic hormone (ADH) affects urine output? A. it increases permeability to water in the tubules, causing a decrease in urine output B. it increases urine output as a result of water being absorbed by the tubules C. urine output is reduced as the posterior pituitary decreases ADH production D. increased urine output results from increased osmolarity and fluid in the extracellular space

A. it increases permeability to water in the tubules, causing a decrease in urine output

what are the consequences for a patient who does not meet the obligatory urine output? select all that apply. A. lethal electrolyte imbalances B. alkalosis C. urine becomes diluted D. toxic buildup of nitrogen E. urine output increases F. acidosis

A. lethal electrolyte imbalances D. toxic buildup of nitrogen F. acidosis

what impacts does sodium have on body function? A. maintains electroneutrality B. maintains electrical membrane excitability C. aids in carbohydrate and lipid metabolism D. regulates water balance E. low sodium stimulates secretion of aldosterone F. regulates plasma osmolality

A. maintains electroneutrality D. regulates water balance E. low sodium stimulates secretion of aldosterone F. regulates plasma osmolality

the nurse is assessing a patient with a mild increase in sodium level. what early manifestation does the nurse observe in this patient? A. muscle twitching and irregular muscle contractions B. inability of muscles and nerves to respond to a stimulus C. muscle weakness occurring bilaterally with no specific pattern D. reduced or absent bilateral deep tendon reflexes

A. muscle twitching and irregular muscle contractions

the nurse is working in a long-term care facility where there are numerous patients who are immobile and at risk for dehydration. which task is best to delegate to the unlicenced assistive personnel (UAP)? A. offer patients a choice of fluids every 1 hour B. check patients at the beginning of the shift to see who is thirsty C. give patients extra fluids around medication times D. evaluate oral intake and urinary output

A. offer patients a choice of fluids every 1 hour

which patient is at risk for excess insensible water loss? A. patient with continuous GI suctioning B. patient with slow, deep respirations C. patient receiving oxygen therapy D. patient with hypothermia

A. patient with continuous GI suctioning

a pt is admitted to the hospital for DKA which arterial blood gas (ABG) results should the nurse expect? select all that apply A. ph 7.32 B. paCo2 55mmHg C. bicarb 18 mEq/L D. ph 7.46 E. bicarb 29 mEq/L F. paCo2 44 mmHg

A. ph 7.32 C. bicarb 18 mEq/L

which are typical nursing assessment findings for a patient with hypocalcemia? select all that apply A. positive Chvostek's sign B. hypertension C. diarrhea D. prolonged ST interval E. elevated T wave F positive trousseau's sign

A. positive Chvostek's sign C. diarrhea D. prolonged ST interval F positive trousseau's sign

which patients are at risk for developing hyponatremia? select all that apply A. postoperative patient who has been NPO for 24 hours with no IV fluid infusing B. patient with decreased fluid intake for three days C. patients receiving excessive intravenous fluids with 5% dextrose D. diabetic patient with blood glucose of 250 mg/dL E. patient with overactive adrenal glands F. tennis player in 100 F (37.7 C) weather who has been drinking water

A. postoperative patient who has been NPO for 24 hours with no IV fluid infusing C. patients receiving excessive intravenous fluids with 5% dextrose D. diabetic patient with blood glucose of 250 mg/dL F. tennis player in 100 F (37.7 C) weather who has been drinking water

which pt is most likely to have a decrease in bicarb? A. pt with pancreatitis B. pt with hypoventilation C. pt who is vomiting D. pt with emphysema

A. pt with pancreatitis

by which mechanisms does parathyroid hormone (PTH) increase serum calcium levels? Select all that apply. A. releasing free calcium from the bones B. increasing calcium excretion in the urine C. stimulating kidney reabsorption of calcium D. causing vitamin D activation E. increasing calcium absorption in the GI tract F. pulling calcium out of the cells

A. releasing free calcium from the bones C. stimulating kidney reabsorption of calcium D. causing vitamin D activation E. increasing calcium absorption in the GI tract

which statements correctly apply to acid base balance in the body? select all that apply A. renal mechanisms are stronger in regulating acid base balance but slower to respond than respiratory mechanisms B. the immediate binding of excess hydrogen ions occurs primarily in the red blood cells C. combined acidosis is less severe than either metabolic acidosis or respiratory acidosis alone D. respiratory acidosis is caused by a pt airway E. acid base balance occurs through control of hydrogen ion production and elimination F. buffers are the thritd line defense against acid base imbalance in the body

A. renal mechanisms are stronger in regulating acid base balance but slower to respond than respiratory mechanisms B. the immediate binding of excess hydrogen ions occurs primarily in the red blood cells E. acid base balance occurs through control of hydrogen ion production and elimination

the nurse is teaching a patient with hypokalemia about foods high in potassium which food items does the nurse recommend to this patient? select all that apply A. soybeans B. lettuce C. cantaloupe D. potatoes E. peaches F. bananas

A. soybeans C. cantaloupe D. potatoes F. bananas

which changes on a patient's electrocardiogram (ECG) reflect hyperkalemia? A. tall peaked T waves B. narrow QRS complex C. tall P waves D. normal P-R interval

A. tall peaked T waves

the patient who has undergone which surgical procedure is most at risk for hypocalcemia? A. thyroidectomy B. adrenalectomy C. pancreatectomy D. gastrectomy

A. thyroidectomy

a patient with bilateral lower lobe pneumonia is diagnosed with respiratory acidosis based on ABG results. what is the likely cause of the patient's respiratory acidosis? A. underlimination of carbon dioxide from the lungs B. buffering of extracellular fluid by ammonium C. overlimination of carbon dioxide D. an increased bicarbonate level due to respiratory elimination of acid

A. underlimination of carbon dioxide from the lungs

A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best? A. both you and the father are equally responsible for passing it on B. I can see you are upset. I can stay here with you a while if you like C. Its not your fault; there is no way to know who will have this disease D. there are many good treatments for sickle cell disease these days

A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best? A. encourage high-protein foods B. perform a hemoccult test on the clients stools C. offer frequent oral care D. prepare to administer cobalamin (Vitamin B12)

A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? A. assess the clients bedside glucose reading B. instruct the client not to get up without help C. monitor the client frequently for tachycardia D. record the clients intake, output, and weight

A client is having a bone marrow biopsy today. What action by the nurse takes priority? A. administer pain medication first B. ensure valid consent is on the chart C. have the client shower in the morning D. premediate the client with sedatives

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? A. documenting the events in the clients medical record B. double-checking the client and blood product identification C. placing the client on strict bedrest until the pain subsides D. reviewing the clients medical record for known allergies

A client with Sjgrens syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest? A. frequent eyedrops B. home humidifier C. strong moisturizer D. tear duct plugs

A nurse assess a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? A. partial pressure of arterial oxygen (PaO2) of 80 mmHg B. urine output of 20 mL/hr C. productive cough with white pulmonary secretions D. core temperature of 100.6 F (38C)

A nurse assess a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next? A. partial thromboplastin time B. hemoglobin and hematocrit C. liver enzymes D. basic metabolic panel

A nurse assesses a client who has psoriasis. Which action should the nurse take first? A. don gloves and an isolation gown B. shake the clients hands and introduce self C. assess for signs and symptoms of infections D. ask the client if she might be pregnant

A nurse assesses a wife who is caring for her husband. She has a braden scale score of 9. Which question should the nurse include in this assessment? A. do you have a bedpan at home? B. how are you coping with providing this care? C. what are you doing to prevent pediculosis? D. are you sharing a bed with your husband?

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? A. increase the clients oxygen and obtain blood gases B. draw blood for a carboxyhemoglobin level C. increase the clients intravenous fluid rate D. perform a thorough mini-mental state exam

A nurse evaluates the following data in a clients chart: Admission note-66 year old male with a health history of a cerebral vascular accident and left sided paralysis. Lab results-WBC count 8000/mm3, prealbumin: 15.2 mg/dL, Albumin: 4.2 mg/dL, lymphocyte count: 2000/mm3. Wound care note-sacral ulcer 4cm, 2cm, 1.5 cm Based on this information, which action should the nurse take? A. Perform a neuromuscular assessment B. request a dietary consult C. Initiate contact precautions D. assess the clients vital signs

A nurse evaluates the following data in a clients chart: Admission note-78 year old male with a past medical history of a-fib is admitted with chronic leg wound. Prescriptions-warfarin sodium (coumadin), sotalol (Betapace). Wound Care-vacuum assisted wound closure (VAC) treatment to leg wound Based on this information, which action should the nurse take first? A. Assess the clients vital signs and initiate continuous telemetry monitoring B. contact the provider and express concerns related to the wound treatment prescribed C. consult the wound care nurse to apply the VAC device D. obtain a prescription for a low-fat, high-protein diet with vitamin supplements

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first? A. client with a blood pressure of 180/98 mmHg B. Client who reports shortness of breath C. client who reports calf tenderness and swelling D. Client with a swollen and painful left great toe

A nurse is preparing to administer a blood transfusion. What action is most important? A. correctly identifying client using two identifiers B. ensuring informed consent is obtained if required C. hanging the blood product with ringers lactate D. staying with the client for the entire transfusion

A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? A. beige freckles on the backs of both hands B. Irregular blue mole with white specks on the lower leg C. large cluster of pustules in the right axilla D. thick, reddened papules covered by white scales

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? A. increase intravenous fluids by 100 mL/hr B. Administer furosemide (Lasix) 40 mg IV push C. continue to monitor urine output hourly D.. Draw blood for serum electrolytes STAT

A nurse suspects a client has serum sickness. Wat laboratory result would the nurse correlate with this condition? A. blood urea nitrogen: 12 mg/dL B. creatinine: 3.2 mg/dL C. hemoglobin: 8.2 mg/dL D. White blood cell count: 12,000/mm3

After teaching a client who has psoriasis, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching? A. at the next family reunion, I'm going to ask my relatives if they have psoriasis B. I have to make sure I keep my lesions covered, so I do not spread this to others C. I expect that these patches will get smaller when I lie out in the sun D. I should continue to use the cortisone ointment as the patches shrink and dry out

After teaching a client who is at risk for the formation of pressure ulcers, a nurse assess the clients understanding. Which dietary choice by the client indicates a good understanding of the teaching? A. low-fat diet with whole grains and cereals and vitamin supplements B. high-protein diet with vitamins and mineral supplements C. vegetarian diet with nutritional supplements and fish oil capsules D. low-fat, low-cholesterol, high-fiber, low-carbohydrate diet

During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the client's chest. Which descriptors should the nurse use to document these observations? a. Clustered and annular b. Linear and circinate c. Diffuse and serpiginous d. Coalesced and circumscribed

The family of a neutropenic client reports the client "is not acting right." What action by the nurse is the priority? A. ask the client about pain B. assess the client for infection C. delegate taking a set of vital signs D. look at todays lab results

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? A. use a disposable blood pressure cuff to avoid sharing with other clients B. change gloves between wound care on different parts of the clients body C. use the closed method of burn wound management for all wound care D. advocate for proper and consistent handwashing by all members of the staff

When is B-type natriuretic peptide (BNP) produced and released for a patient with heart failure? A. when a pt has an enlarged liver B. when a pt has fluid overload C. when a pts ejection fraction is lower than normal D. when a pt has ventricular hypertrophy

While assessing a client, a nurse detects a bluish tinge to the clients palms, soles, and mucous membranes, which action should the nurse take next? A. ask the client about current medications he or she is taking B. use pulse oximetry to assess the clients oxygen saturation C. auscultate the clients lung fields for adventitious sounds D. palpate the clients bilateral radial and pedal pulses

a client arrives in the ED after being in a car crash with fatalities. the client has a nearly amputated leg that is bleeding profusely. what action by the nurse takes priority? A. apply direct pressure to the bleeding B. ensure the client has a patent airway C. obtain consent for emergency surgery D. start two large-bore IV catheters

a client has intra-arterial blood pressure monitoring after a MI. the nurse notes the clients heart rate has increased from 88 to 110 beats/min and the blood pressure dropped from 120/82 to 100/60 mm Hg what action by the nurse is most appropriate? A. allow the client to rest quietly B. assess the client for bleeding C. document the findings in the chart D. medicate the client for pain

a client has presented to the emergency department with an acute MI what action by the nurse is best to meet the joint commissions core measures outcomes? A. obtain an electrocardiogram (ECG) now and in the morning B. give the client an aspirin C. notify the rapid response team D. prepare to administer thrombolytics

a client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. the clients sternal wound has not yet healed. what statement by the client most indicates a higher risk of developing sepsis after discharge? A. all my friends and neighbors are planning a party for me B. I hope I can get my water turned back on when I get home C. I am going to have my daughter scoop the cat litter bod D. my grandkids are so excited to have me coming home!

a client is being discharged soon on warfarin (coumadin) what menu selection for dinner indicates the client needs more education regarding this medication? A. hamburger and french fries B. large chefs salad and muffin C. no selection; spouse brings pizza D. tuna salad sandwich and chips

a client is hospitalized with a second episode of PE recent genetic testing reveals the client has an alteraction in the gene CYP2C19. what action by the nurse is best? A. instruct the client to eliminate all vitamin K from the diet B. prepare preoperative teaching for an inferior vena cava (IVC) filter C. refer the client to a chronic illness support group D. teach the client to use a soft bristled toothbrush

a client is in the hospital after suffering a myocardial infarction and has bathroom privileges. the nurse assists the client to the bathroom and notes the clients O2 saturation to be 95% pulse 88 bpm, and respiratory rate 16 breaths/min after returning to bed. what action by the nurse is best? A. administer oxygen at 2 L/min B. allow continued bathroom privileges C. obtain a bedside commode D. suggest the client use a bedpan

a client is on IV heparin to treat a pulmonary embolism. the clients most recent partial thromboplastin time (PTT) was 25 seconds. what order should the nurse anticipate? A. decrease the heparin rate B. increase the heparin rate C. no change to the heparin rate D. stop heparin; start warfarin (coumadin)

a client presents to the ED after prolonged exposure to the cold. the client is difficult to arouse and speech is incoherent which action should the nurse take first? A. reposition the client into a prone position B. administer warmed IV fluids to the client C. wrap the clients extremities in warm blankets D. initiate extracorporeal rewarming via hemodialysis

a client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. the clients spouse asks why the client needs this medication. what response by the nurse is best? A. the t-PA didnt dissolve the entire coronary clot B. the heparin keeps that artery from getting blocked again C. heparin keeps the blood as thin as possible for a longer time D. the heparin prevents a stroke from occurring as the t-PA wears off

a client with coronary artery disease (CAD) ask the nurse about taking fish oil supplements. what response by the nurse is best? A. fish oil is contraindicated with most drugs for CAD B. the best source is fish, but pills have benefits too C. there is no evidence to support fish oil use with CAD D. you can reverse CAD totally with diet and supplements

a dying pt is receiving morphine for severe pain. the health care provider informs the nurse that the pt is at risk for acute renal failure. what assessment will the nurse perform in order to determine if the kidney is failing to excrete the morphine metabolites? A. assess the pt for adequate pain relief B. observe for signs of confusion or delirium C. auscultate the lungs for crackles or wheezes D. observe the color, clarity, and amount of urine

a family member calls the nurse into the pts room and says i think mom just died what should the nurse do first? A. notify the nurseing supervisor to have the body moved to the morgue B. ascertain that the pt does not rouse to verbal or tactile stimuli C. make sure that the health care provider has completed and signed the death certificate D. provide privacy for the family and significant others with the deceased

a home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. what finding in the home most causes the nurse to consider additional referrals? A. dirty carpets in need of vacuuming B. expired food in the refrigerator C. old medications in the kitchen D. several cats present in the home

a hospice pt is deteriorating and the family is concerened about the restlessness and agitation. which intervention should the nurse perform? A. notify the primary health care provider and request orders for transfer to the hospital B. assess for pain, provide analgestics and make the pt as comfortable as possible C. initiate IV hydration to provide the pt with necessary fluids D. encourage the family to assist the pt to eat in order to gain energy

a nurse answers a call light and finds a client anxious, SOB, reporting chest pain and having a BP of 88/52 mm Hg on the cardiac monitor. what action by the nurse takes priorty? A. assess the clients lung sounds B. notify the rapid response team C. provide reassurance to the client D. take a full set of vital signs

a nurse is caring for a client after surgery who is restless and apprehensive. the UAP reports the vital signs and the nurse sees they are only slightly different from previous readings. what action does the nurse delegate next to the UAP? A. assess the client for pain or discomfort B. measure urine output from the catheter C. reposition the client to the unaffected side D. stay with the client and reassure him or her

a nurse is caring for a client after surgery. the clients respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 bpm since they were last assessed 4 hours ago. what action by the nurse is best? A. ask if the client needs pain meds B. assess the clients tissue perfusion further C. document the findings in the clients chart D. increase the rate of the clients IV infusion

a nurse is caring for four clients on IV heparin therapy. which lab value possibly indicates that a serious side effect has occurred? A. hemoglobin: 14.2 g/dL B. platelet count: 82,000/L C. RBC count 4.8/mm3 D. WBC count 8.7/mm3

a nurse is caring for four clients which client should the nurse assess first? A. client with an acute MI, pulse 102 bpm B. client who is 1 hour post angioplasty, has tongue swelling and anxiety C. client who is post coronary artery bypass, chest tube drained 100 mL/hr D. client who is post coronary artery bypass, potassium 4.2 mEq/L

a nurse is caring for several clients at risk for shock. which lab value requires the nurse to communicate with the health care provider? A. creatinine: 0.9 mg/dL B. lactate: 6 mmol/L C. sodium: 150 mEq/L D. WBC count 11,000/mm3

a nurse is evaluating levels and functions of trauma centers. which function is appropriately paired with the level of the trauma center? A. level 1 located within remote areas and provides advanced life support within resource capabilities B. level 2 located within community hospitals and provides care to most injured clients C. level 3 located in rural communities and provides only basic care to clients D. level 4 located in large teaching hospitals and provides a full continuum of trauma care for all clients

a nurse is in charge of the coronary ICU what client should the nurse see first? A. client on a nitroglycerin infusion after 5 mcg/min not titrated in the last 4 hours B. client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg C. client who is 1 day post percutaneous coronary intervention, going home this morning D. client who is 2 days post coronary artery bypass graft, became dizzy this morning while walking

a nurse is preparing to admit a client on mechanical ventilation from the ED what action by the nurse takes priority? A. assessing that the ventilator settings are correct B. ensuring there is a bag valve mask in the room C. obtaining personal protective equipment D. planning to suction the client upon arrival to the room

a nurse is teaching a client about warfarin (coumadin). what assessment finding by the nurse indicates a possible barrier to self-management? A. poor visual acuity B. strict vegetarian C. refusal to stop smoking D. wants weight loss surgery

a nurse is triaging clients in the ED which client should the nurse prioritize to receive care first? A. 22 year old with painful and swollen wrist B. 45 year old reporting chest pain and diaphoresis C. 60 year old reporting difficulty swallowing and nausea D. 81 year old with respiratory rate of 28 breaths/min and temp of 101F

a nurse plans care for a client admitted with a snakebite to the right leg. with whom should the nurse collaborate? A. the facility's neurologist B. the poison control center C. the physical therapy department D. a herpetologist (snake specialist)

a nurse works at a community center for older adults. what self-management measure can the nurse teach the clients to prevent shock? A. do not get dehydrated in warm weather B. drink fluids on a regular schedule C. seek attention for any lacerations D. take meds as prescribed

a provider prescribes diazepam (valium) to a client who was bitten by a black widow spider. the client asks what is this medication for? how should the nurse respond? A. this medication is an antivenom for this type of bite B. it will relieve your muscle rigidity and spasms C. it prevents respiratory difficulty from excessive secretions D. this med will prevent respiratory failure

a pt gets a new prescription for pravigard for treatment of high cholesterol because this is a combo drug. the nurse alerts the physician when the pt discloses an allergy to which drug? A. sulfa B. aspirin C. some calcium channel blockers D. some diuretics

a student is caring for a client who suffered massive blood loss after trauma. how does the student correlate the blood loss with the clients mean arterial pressure (MAP)? A. it causes vasoconstriction and increased MAP B. lower blood volume lowers MAP C. there is no direct correlation to MAP D. it raises cardiac output and MAP

a student nurse is preparing to administer enoxaparin (lovenox) to a client. what action by the student requires immediate intervention by the supervising nurse? A. assessing the client platelet count B. choosing an 18 gauge, 2 inch needle C. not aspirating prior to injection D. swabbing the injection site with alcohol

a trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. which action should the nurse take prior to providing advanced cardiac life support? A. contact the on call ortho surgeon B. don PPE C. notify the rapid response team D. obtain a complete history from the paramedic

after a hospitals ED has efficiently triaged, treated and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. which question should the nursing supervisor ask at this time? A. are you sure no more victims are coming into the ED B. do all areas of the hospital have the supplies and personnel they need? C. have all ED staff had the chance to eat and rest recently? D. does the chief medical officer agree this disaster is under control?

in a hypovolemic pt, stretch receptors in the blood vessels sense a reduced volume or pressure and send fewer impulses to central nervous system. as a result, which signs/symptoms does the nurse expect to observe in the pt A. reddish mottling to skin and a blood pressure elevation B. cool, pale skin and tachycardia C. warm, flushed skin, with low BP D. pale pink skin with bradycardia

on a hot humid day, an emergency deparment nurse is caring for a client who is confused and has these vitals: temp 104.1 F (40.1 C), pulse 132 bpm, resp. 26 breaths/min, BP 106/66 mmHg. which action should the nurse take? A. encourage the client to drink cool water or sports drinks B. start an IV line and infuse 0.9% saline solution C. administer acetaminophen (tylenol) 650 mg orally D. encourage rest and re-assess in 15 mins

the emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. what action should the nurse take first? A. request that the clients spouse sits in the waiting room B. ask the spouse if he wishes to be present during the resuscitation C. suggest that the spouse begin to pray for the client D> refer the clients spouse to the hospitals crisis team

the health care provider orders orthostatic vital signs on a pt who experienced dizziness and feeling lightheaded. what is the nurses first action A. instruct the pt to change position to sitting or standing B. measure the BP when the pt is supine C. place the pt in a supine positing for at least 3 mins D. wait for 1 min before auscultating BP and counting the radial pulse

the home health nurse is evaluating a pt being treated for heart failure. which statement by the pt is the best indicator of hope and well-being as a desired psychological outcome? A. I'm taking the medication and following the drs orders B. I'm looking forward to dancing with my wife on our wedding anniversary C. I'm planning to go on a long trip; I'll never go back to the hospital again D. I want to thank you for all that you have done. I know you did your best.

the nurse is analyzing the ECG rhythm strips for assigned pts. what is the nurses first action? A. analyze the P waves B. determine the heart rate C. measure the QRS duration D. measure the PR interval

the nurse is assessing a pt with CVD what is the priority med-surg concept for this pt A. fluid and electrolyte balance B. perfusion C. gas exchange D. acid base balance

the nurse is assessing a pts ECG rhythm strip and checking the regularity of the atrial rhythm. what is the correct technique? A. place one caliper point on a QRS complex; place the other point on the percise spot on the next QRS complex B. place one caliper point on a P wave; place the other point on the percise spot on the next P wave C. place one caliper point at the beginning of the P wave; place the other point at the end of the P-R segment D. place one caliper point at the beginning of the QRS complex; place the other point where the S-T segment begins

the nurse is caring for a 92 year old post op pt who has a DNR order. when the nurse assesses the pt he is diaphoretic and hyperalert and reports mild left anterior chest pain with SOB. What should the nurse do first? A. sit with the pt, talk calmly and be gently present B. administer o2 and alert the rapid responce team C. notify the person who has durable power of attorney for health D. monitor for cardiac or respiratory arrest and call the family

the nurse is caring for a client with a chest tube after a coronary artery bypass graft. the drainage slows significantly what action by the nurse is most important? A. increase the setting on the suction B. notify the provider immediately C. re-position the chest tube D. take the tubing apart to assess for clots

the nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type 2 hypersensitivity reaction? A. administering steroids for severe serum sickness B. correctly identifying the client prior to a blood transfusion C. keeping the client free of the offending agent D. providing a latex-free environment for the client

the nurse is counseling a group of women about cholesterol-lowering drugs. which drug will decrease BP while decreasing triglycerides (TGs) increasing high density lipoprotein (HDL) and lowering low density lipoprotein (LDL) A. Ezetimibe B. Caduet C. Vytorin D. Advicor

the nurse is interviewing a pt with a history of high BP and heart problems. which statement by the pts causes the nurse to suspect the pt may have heart failure? A. i noticed a very fine red rash on my chest B. i had to take off my wedding ring last week C. ive had fever quite frequently D. i have pain in my shoulder when i cough

the nurse is reviewing the lab results for a pt who was admitted with dyspnea. which diagnostic test best differentiates between heart failure and lung dysfunction? A. arterial blood gas B. B-type natriuretic peptide C. hemoglobin D. serum electrolytes

the nurse is working in a women's health clinic is reviewing the risk factors for several pts for stroke and MI which pt has the hightes risk for MI? A. 49 year old on estrogen replacement therapy B. 55 year old with unstable angina C. 23 year old with diabetes that is currently not well controlled D. 60 year old with well controlled hypertension

the primary pacemaker of the heart, the sinoatrial (SA) node is functional if a pts pulse is at what refular rate? A. fewer than 60 bpm B. 60-100 bpm C. 80-100 bpm D. more than 100 bpm

the pt has smoked half a pack of cigarettes per day for 2 years. how many pack years as this pt smoked A. 1/2 pack/year B. 1 pack/year C. 1.5 pack/year D. 2 pack/year

under what circumstances should the nurse contact the pts health care proxy? A. a pt has a sudden and unexpected episode of dizziness B. pt is discovered at 4am in a comatose state C. pt refuses to eat unless he gets a beer with dinner D. pt needs catherization for a urine specimen

what does stimulation of the sympathetic nervous system produce A. delayed electrical impulse causing hypotension B. increased the heart rate C. virtually no effect on the ventricles of the heart D. slowed atrioventricular (AV) conduction time that results in a slow heart rate

what is the correct technique for assessing a pt with arterial insufficiency in the right lower leg? A. use the doppler to find the dorsalis pedis and posterior tibial pulses on the right leg B. palpate the peripheral arteries in a head to toe approach with a side to side comparison C. check all the pulse points in the right leg in dependent and supine positions D. palpate the major arteries, such as radial and femoral and observe for pallor

which description best defines the cardiovascular concept of afterload A. degree of myocardial fiber stretch at end of diastole and just before heart contracts B. amount of resistance the ventricles must overcome to eject blood through the semilunar valves and into the peripheral blood vessels C. pressure that the ventricle must overcome to open the tricuspid valve D. force of contraction independent of preload

which patient has a disorder that would be considered among the leading causes of death in the US? A. history of alchol abuse B. alzheimer's disease C. positive for HIV D. pancreatitis

while assessing a clients lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next? A. ask about a family history of skin disorders B. palpate the clients pedal pulses bilaterally C. check for the presence of homans sign D. assess the clients skin for adequate skin turgor

a nurse is caring for clients in a busy ED which actions should the nurse take to ensure client and staff safety? select all that apply. A. leave the stretcher in the lowest position with rails down so that the client can access the bathroom B. use 2 identifiers before each intervention and before medication administration C. attempt de-escalation strategies for clients who demonstrate aggressive behaviors D. search the belongings of clients with altered mental status to gain essential medical information E. isolate clients who have immune suppression disorders to prevent hospital acquired infections

B, C, D

A client in the family practice clinic reports a 2-week history of an allergy to something. The nurse obtains the following assessment and lab data: physical assessment data lab results reports sore throat, runny nose, headache, posterior pharynx is reddened, nasal discharge is seen in the back of the throat, nasal discharge is creamy yellow in color, temperature 100.2F (37.9 C), red watery eyes, WBC count: 13,400/mm3, eosinophil count: 11.5%, neutrophil count: 82% About what medications and interventions does the nurse plan to teach this client? select all that apply A. elimination of any pets B. chlorpheniramine (chlor-trimation) C. future allergy scratch testing D. proper use of decongestant nose sprays E. taking the full dose of antibiotics

B, C, D, E

A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? select all that apply A. prepare a room for reverse isolation B. assess staff for a history of vaccination for chickenpox C. check the admission orders for analgesia D. choose a roommate who also is immune suppressed E. ensure that gloves are available in the room

B, C, E

A nurse works in a gerontology clinic. What age related changes cause the nurse to alter standard assessment techniques from those used for younger adults? Select all that apply. A. dentition deteriorates with more cavities B. nail beds may be thickened or discolored C. progressive loss of hair occurs with age D. sclerae begin to turn yellow or pale E. skin becomes dry as the client ages

B, C, E

a client is 1 day post op after a coronary artery bypass graft. what nonpharmacologic comfort measures does the nurse include when caring for this client? select all that apply A. administer pain medication before ambulating B. assist the client into a position of comfort in bed C. encourage high-protein diet selections D. provide complementary therapies such as music E. remind the client to splint the incision when coughing

B, D, E

a nurse is caring for five clients for which clients would the nurse assess a high risk for developing a PE? select all that apply A. client who had a reaction to contrast dye yesterday B. client with a new spinal cord injury on a rotating bed C. middle aged man with an exacerbation of asthma D. older client who is 1 day post hip replacement surgery E. young obese client with a fractured femur

B, D, E

the nurse educates and advises a pt to follow the DASH diet. which instructions does the nurse give to the pt? select all that apply A. consume a dietary pattern that emphasizes intake of lean protein B. consume low fat dairy products, poultry, and fish C. lower sodium intake to no more than 2400 mg per day D. engage in aerobic physical activity 6-7 times/week E. limit intake of sweets and red meats F. eat legumes, nontropical vegetable oils and nuts

B,C,E,F

the nurse is assessing a 62 year old native hawaiian woman. she is post menopausal, has had diabetes for 10 years, has smoked one pack a day of cigrettes for 20 years, walks twice a week for 30 mins, is an administrator, and describes her lifestyle as sedentary. for her weight and height she has a BMI of 32. which risk factors for this pt is controllable for CAD? select all that apply. A. ethnic background B. smoking C. age D. obsity E. postmenopausal F. sedentary lifestyle

B,D,F

what is the minimum amount of urine output per day needed to excrete toxic waste products A. 200-300 mL B. 400-600 mL C. 500-1000 mL D. 1000-1500 mL

B. 400-600 mL

which patient is at greatest risk for chronic hypocalcemia? A. 38 year old man with chronic kidney disease B. 50 year old postmenopausal woman C. 62 year old man with type 2 diabetes D. 78 year old woman with dehydration

B. 50 year old postmenopausal woman

which blood ph value does the nurse interpret as within normal limits? A. 7.27 B. 7.37 C. 7.47 D. 7.5

B. 7.37

an older adult patient needs an oral potassium solution but is refusing it because it has a strong and unpleasent taste. what is the best strategy the nurse can use to administer the drug? A. tell the patient that failure to take the drug could result in serious heart problems B. ask the patient's preference of juice and mix the drug with a small amount C. mix the solution into food on the patient's meal tray and encourage the patient to eat everything D. offer the drug to the patient several times, and then document the patient's refusal

B. ask the patient's preference of juice and mix the drug with a small amount

a pt admitted to the emergency department with DKA on intake assessment, the pt cannot recall the medications she takes. what first action does the nurse take? A. instruct the patient to compare a hospital list of medications to her home medications B. ask the patient's significant other to bring the patient's medications from home C. request that the patient complete a meal recall for the past 24 hours D. teach the patient about the importance of keeping a list of current medications in her purse

B. ask the patient's significant other to bring the patient's medications from home

the nurse caring for a patient with hypercalcemia anticipates orders for which medications? select all that apply A. magnesium sulfate B. calcitonin C. furosemide D. plicamycin E. calcium gluconate F. aluminum hydroxide

B. calcitonin C. furosemide D. plicamycin

the electrolyte magnesium is responsible for which functions? select all that apply. A. formation of hydrochloric acid B. carbohydrate metabolism C. contraction of skeletal muscle D. regulation of intracellular osmolarity E. vitamin activation F. blood coagulation

B. carbohydrate metabolism C. contraction of skeletal muscle E. vitamin activation F. blood coagulation

a patient's serum potassium value is below 2.8 mEq/L the patient is also on digoxin. the nurse quickly assesses the patient for which cardiac problem before notifying the provider? A. cardiac murmur B. cardiac dysrhythmia C. congestive heart failure D. cardiac tamponade

B. cardiac dysrhythmia

the nurse administering potassium to a patient carefully monitors the infusion because of the risk for which condition? A. pulmonary edema B. cardiac dysrhythmia C. postural hypotension D. renal failure

B. cardiac dysrhythmia

the nurse is caring for psychiatric patient who is continuously drinking water. the nurse monitors for which complication related to potential hyponatremia? A. proteinuria/prerenal failure B. change in mental status/increased intracranial pressure C. pitting edema/circulatory failure D. possible occult blood/gastrointestinal bleeding in stool

B. change in mental status/increased intracranial pressure

a patient with hypocalcemia needs supplemental diet therapy. which foods does the nurse recommend providing both calcium and vitamin D? select all that apply A. toufu B. cheese C. eggs D. broccoli E. milk F. salmon

B. cheese E. milk F. salmon

What is the term for a difference in concentration of particles that is greater on one side of a permeable membrane than on the other side? A. hydrostatic pressure B. concentration gradient C. passive transport D. active transport

B. concentration gradient

what are the functions of potassium in the body? select all that apply A. regulates hydration status B. controls intracellular osmolarity and volume C. stimulates the secretion of antidiuretic hormone (ADH) D. functions as the major cation of intracellular fluid (ICF) E. regulates glucose use and storage F. helps maintain normal cardiac rhythm

B. controls intracellular osmolarity and volume D. functions as the major cation of intracellular fluid (ICF) E. regulates glucose use and storage F. helps maintain normal cardiac rhythm

a pt has a new onset of shallow and slow respirations. while the pt's body attempts to compensate, what happens to the pt's ph level? A. increases B. decreases C. stabilizes D. fluctuates

B. decreases

the nurse is assessing a patient's urine specific gravity. the value is 1.035. how does the nurse interpret this result A. overhydration B. dehydration C. normal value for adult D. renal disease

B. dehydration

the nurse is caring for a patient who takes potassium and digoxin. for what reason does the nurse monitor both laboratory results? A. digoxin increases potassium loss through the kidneys B. digoxin toxicity can result if hypokalemia is present C. digoxin may cause potassium levels to rise to toxic levels D. hypokalemia causes the cardiac muscle to be less sensitive to digoxin

B. digoxin toxicity can result if hypokalemia is present

A patient with low potassium requires an IV potassium infusion. the pharmacy sends a 250 mL IV bag of dextrose in water with 40 mEq of potassium. the label is marked "to infuse over 1 hour" what is the nurse's best action? A. obtain a pump and administer the solution B. double check the provider's order and call the pharmacy C. hold the infusion because there is an error in labeling D. recalculate the rate so that it is safe for the patient

B. double check the provider's order and call the pharmacy

which foods will the nurse instruct a patient with kidney disease and hyperkalemia to avoid? select all that apply A. canned apricots B. dried beans C. potatoes D. cabbage E. cantaloupe F. canned sausage

B. dried beans C. potatoes E. cantaloupe F. canned sausage

a hospitalized patient who is known to be homeless has been diagnosed with severe malnutrition, end-stage renal disease, and anemia. he is transfused with three units of packed red blood cells. which potential electrolyte imbalance does the nurse anticipate could occur in this patient? A. hypernatremia B. hyperkalemia C. hypercalcemia D. hypermagnesemia

B. hyperkalemia

which clinical condition can result from hypocalcemia? A. stimulated cardiac muscle contraction B. increased intestinal and gastric motility C. decreased peripheral nerve excitability D. increased bone density

B. increased intestinal and gastric motility

the nurse is caring for an older adult patient whose serum sodium level is 150 mEq/L the nurse assesses the patient for which common signs and symptoms associated with this sodium level? select all that apply A. intact recall of recent events B. increased pulse rate C. rigidity of extremities D hyperactivity E. muscle weakness F. difficulty palpating peripheral pulses

B. increased pulse rate E. muscle weakness F. difficulty palpating peripheral pulses

the nurse is caring for a patient with hypovolemia secondary to severe diarrhea and vomiting. in evaluating the respiratory system for this patient what does the nurse expect to find on assessment? A. no changes, because the respiratory system is not involved B. increased respiratory rate, because the body perceives hypovolemia as hypoxia C. hypoventilation, because the respiratory system is trying to compensate for low pH D. normal respiratory rate, but a decreased oxygen saturation

B. increased respiratory rate, because the body perceives hypovolemia as hypoxia

which component has a high content of potassium and phosphorus? A. extracellular fluid B. intracellular fluid C. extracellular fluid and the intravascular space D. intracellular fluid and lymph fluid

B. intracellular fluid

the nurse is admitting a pt with acute kidney injury to the medical unit. which ABG results would she expect for this pt? A. respiratory acidosis B. metabolic acidosis C. respiratory alkalosis D. metabolic alkalosis

B. metabolic acidosis

a pt who has pancreatitis with nausea and vomiting will likely have which related alterations in acid base balance? select all that apply A. overproduction of hydrogen ions B. metabolic acidosis C. serum ph value that is directly related to the concentration of hydrogen ions D. underproduction of bicarb E. metabolic alkalosis F. respiratory acidosis

B. metabolic acidosis C. serum ph value that is directly related to the concentration of hydrogen ions D. underproduction of bicarb

the patient with a serum magnesium level of 2.9 mEq/L develops bradycardia with a prolonged P-R interval and widened QRS. what is the nurse's best first action? A. start an IV with 5% dextrose at 100mL/hour B. notify the health care provider immediately C. auscultate the patient's apical heart rate D. prepare to administer supplemental magnesium by IV

B. notify the health care provider immediately

a patient has an elevated potassium level. which assessment findings are associated with hyperkalemia? select all that apply A. wheezing on exhalation B. numbness in hands and feet and around the mouth C. frequent, watery stools D. irregular heart rate E. circumoral cyanosis F. muscle weakness

B. numbness in hands and feet and around the mouth C. frequent, watery stools D. irregular heart rate F. muscle weakness

a newly admitted patient with congestive heart failure has a potassium level of 5.7 mEq/L. how does the nurse identify contributing factors for the electrolyte imbalance? select all that apply. A. assess the patient for hypokalemia B. obtain a list of the patients home medications C. assess the patient for hyperkalemia D. ask about the patient's method of taking medications at home E. evaluate the patient's appetite F. ausculate for hypoactive bowel sounds

B. obtain a list of the patients home medications C. assess the patient for hyperkalemia D. ask about the patient's method of taking medications at home

which pt with the highest risk for acidosis must the nurse care for first? A. pt in mild pain with a kidney stone B. pt with COPD and pulse ox 88% on 2L o2 C. pt who had a seizure prior to admission with pulse ox of 91% D. pt with a rectal tube in place for frequent diarrhea

B. pt with COPD and pulse ox 88% on 2L o2

plasma is part of which body fluid space compartments? select all that apply A. the intracellular compartment B. the extracellular compartment C. all fluid within the cells D. interstitial fluid E. intravascular fluid F. fluid within joint capsules

B. the extracellular compartment D. interstitial fluid E. intravascular fluid

the nurse is caring for a patient with severe hypocalcemia. what safety measures does the nurse put in place for this patient? select all that apply A. encourage the patient to use a cane when ambulating B. turn on a bed alarm when the patient is in bed C. obtain an order for zolpidem (ambien) to ensure the patient sleeps at night D. place the patient on a low bed E. ensure the top side rails are up when the patient is in bed F raise all four side rails

B. turn on a bed alarm when the patient is in bed D. place the patient on a low bed E. ensure the top side rails are up when the patient is in bed

the nurse is teaching the patient about hypokalemia. which statement by the patient indicates a correct understanding of the treatment of hypokalemia? A. my wife does all the cooking. she shops for food high in calcium B. when i take the liquid potassium in the evening, i'll eat a snack beforehand C. i will avoid bananas, orange juice, and salt substitutes D. i hate being stuck with needles all the time to monitor how much sugar i can eat

B. when i take the liquid potassium in the evening, i'll eat a snack beforehand

A client is in the hospital and receiving IV antibiotics. when the nurse answers the clients call light, the client presents an appearance as shown below: A. administer epienphrine 1:1000, 0.3 mg IV push immediately B. apply oxygen by facemask at 100% and a pulse oximeter C. ensure a patent airway while calling the rapid response team D. reassure the client that these manifestations will go away

A nurse assesses a client on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? A. client with blood cultures pending B. client who has thin, serous wound drainage C. client with a white blood cell count of 23,000/mm3 D. client whose wound has decreased in size

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? A. I will allow my spouse to change my dressings B. I want to have surgical reconstruction C. I will bathe and dress before breakfast D. I have secured the pressure dressing as ordered

A nurse assesses a young female client who is prescribed isotretinoin (Accutane) which question should the nurse ask prior to starting this therapy? A. do you spend a great deal of time in the sun? B. have you or any family members ever had skin cancer? C. which method of contraception are you using? D. do you drink alcoholic beverages?

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? A. a 44 year old prescribed IV antibiotics for pneumonia B. A 26 year old who is bedridden with a fractured leg C. a 65 year old with hemi-paralysis and incontinence D. a 78 year old requiring assistance to ambulate with a walker

A nurse cares for a client who has facial burns. The client asks, will I ever look the same? How should the nurse respond? A. with reconstructive surgery, you can look the same B. we can remove the scars with the use of a pressure dressing C. you will not look exactly the same but cosmetic surgery will help D. you shouldnt start worrying about your appearance right now

A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take? A. administer it over 30 minutes using an IV pump B. Give the client diphenhydramine (Benadryl) before the drug C. assess the IV site at least every 2 hours for thrombophlebitis D. ensure that the client has increased oral intake during therapy

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? A. assess the level of consciousness and pupillary reactions B. Ascertain the time food or liquid was last consumed C. auscultate breath sounds over the trachea and bronchi D. measure abdominal girth and auscultate bowel sounds

A nurse cares for an older adult client who has a chronic skin disorder. The client states, I have not been to church in several weeks because of the discoloration of my skin. How should the nurse respond? A. I will consult the chaplain to provide you with spiritual support B. you do not need to go to church; god is everywhere C. tell me more about your concerns related to your skin D. religious people are nonjudgmental and will accept you

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best? A. arrange a visitation schedule among friends and family B. explain that this process is difficult but must be endured C. help the client find things to hope for each day of recovery D. provide plenty of diversionary activities for this time

A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority? A. genetic testing B. infection prevention C. sperm banking D. treatment options

A nurse is caring for four clients. After reviewing todays lab results, which client should the nurse see first? A. client with an international normalized ratio of 2.8 B. client with a platelet count of 128,000/mm3 C. client with a prothrombin time (PT) of 28 seconds D. client with a red blood cell count of 5.1 million/L

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, why am I taking this medication? How should the nurse respond? A. tagamet stimulates intestinal movement so you can eat more B. it improves fluid retention, which helps prevent hypovolemic shock C. it helps prevent stomach ulcers, which are common after burns D. Tagamet protects the kidney from damage caused by dehydration

A nurse reviews the following data in the chart of a client with burn injuries: Admission notes: 36 year old female with bilateral leg burns, NKDA, health history of asthma and seasonal allergies wound assessment: bilateral leg burns present with a white and leather like appearance. no blisters or bleeding present. client rates pain 2/10. Based on the data provided, how should the nurse categorize this clients injuries? A. partial-thickness deep B. partial-thickness superficial C. full thickness D. superficial

A nurse reviews the lab results for a client who was burned 24 hours ago. Which lab result should the nurse report to the health care provider immediately? A. arterial pH: 7.32 B. Hematocrit: 52% C. serum potassium: 6.5mEq/L D. serum sodium: 131 mEq/L

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching? A. you should change the batteries in your smoke detector once a year B. join a program that assists burn clients to reintegration into the community C. I will demonstrate how to change your wound dressing for you and your family D. let me tell you about the many options available to you for reconstructive surgery

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? A. 9% B. 18% C. 27% D. 36%

After assessing an older adult client with a burn wound, the nurse documents the findings as follows: vital signs-Pulse 110 bpm, BP 112/68mmHg, Resp 20, o2 rate 94% pain 3/10 laboratory results RBC 5,000,000/mm3, WBC 10,000/mm3, platelet count 200,000/mm3 Wound assessment left chest burn wound, 3cm, 2.5 cm, 0.5 cm wound bed pale, surrounding tissues with edema present. Based on the documented data, which action should the nurse take next? A. assess the clients skin for signs of adequate perfusion B. calculate intake and output ration for the last 24 hours C. prepare to obtain blood and wound cultures D. place the client in an isolation room

An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this clients care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

An intubated clients oxygen saturation has dropped to 88% what action by the nurse takes priory? A. determine if the tube is kinked B. ensure all connections are patent C. listen to the clients lung sounds D. suction the endotracheal tube

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? A. I get my chimney swept every other year B. My hot water heater is set at 120 degrees C. Sometimes I wake up at night and smoke D. I use a space heater when it gets below zero

The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."

When transferring a client into a chair a nurse notices that the pressure relieving mattress overlay has deep imprints of the clients buttocks, heels, and scapulae. Which action should the nurse take next? A. turn the mattress overlay to the opposite side B. do nothing because this is an expected occurrence C. apply a different pressure-relieving device D. reinforce the overlay with extra cushions

a client had an acute myocardial infarction what assessment finding indicates to the nurse that a client significant complication has occurred? A. blood pressure that is 20 mm Hg below baseline B. oxygen saturation of 94% on room air C. poor peripheral pulses and cool skin D. urine output of 1.2 mL/kg/hr four 4 hours

a client has a pulmonary embolism and is started on O2. the student nurse asks why the clients O2 saturation has not significantly improved. what response by the nurse is best? A. breathing so rapidly interferes with oxygenation B. maybe the client has respiratory distress syndrome C. the blood clot interferes with perfusion in the lungs D. the client needs immediate intubation and mechanical ventilation

a client has been brought to the emergency department with a life threatening chest injury. what action by the nurse takes priority? A. apply oxygen at 100% B. assess the respiratory rate C. ensure a patient airway D. start two large-bore IV lines

a client in shock has been started on dopamine. what assessment finding requires the nurse to communicate with the provider immediately? A. blood pressure of 98/68 mm Hg B. pedal pulses 1+/4+ bilaterally C. report of chest heaviness D. urine output of 32 mL/hr

a client in the cardiac stepdown unit reports severe crushing chest pain accompanied by nausea and vomiting what action by the nurse takes priority? A. administer an asprin B. call for an electrocardiogram (ECG) C. maintain airway patency D. notify the provider

a client is admitted with a PE the client is young, healthy and active and has no known risk factors for PE. what action by the nurse is most appropriate? A. encourage the client to walk 5 minutes each hour B. refer the client to smoking cessation classes C. teach the client about factor V leiden testing D. tell the client that sometimes no cause for disease is found

a client is on a ventilator and is sedated. what care may the nurse delegate to the unlicensed assistive personnel (UAP)? A. assess the client for sedation needs B. get family permission for residents C. provide frequent oral care per protocol D. use nonverbal pain assessment tools

a client is receiving an infusion of tissue plasminogen activator (t-PA). the nurse assesses the client to be disoriented to person, place, and time. what action by the nurse is best? A. assess the clients pupillary responses B. request a neurologic consolation C. stop the infusion and call the provider D. take and document a full set of vital signs

a client presents to the ED with an acute MI at 1500 (3pm) the facility has 24 hour catheterization laboratory abilities to meet the joint commissions core measures set, by what time should the client have a percutaneous coronary intervention performed? A. 1530 (3:30 pm) B. 1600 (4:00 pm) C. 1630 (6:30 pm) D. 1700 (5:00 pm)

a nurse assesses a client recently bitten by a coral snake. which assessment should the nurse complete first? A. unilateral peripheral swelling B. clotting times C. cardiopulmonary status D. electrocardiogram rhythm

a nurse cares for clients during community wide disaster drill. once of the clients asks, why are the indiciduals with black tags not receiving any care? how should the nurse respond? A. to do the greatest good for the greatest number of people it is necessary to sacrifice some B. not everyone will survive a disaster, so it is best to identify those people early and move on C. in a disaster, extensive resources are not used for one person at the expense of many others D. with black tags, volunteers can identify those who are dying and can give them comfort care

a nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temp 96.2 F. what action by the nurse takes priority? A. document the findings in the clients chart B. give the client warmed blankets for comfort C. notify the health care provider immediately D. prepare to administer insulin per sliding scale

a nurse is assisting the health care provider who is intubating a client. the provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? A. ensure the client has adequate sedation B. find another provider to intubate C. interrupt the procedure to give O2 D. monitor the clients O2 saturation

a nurse is caring for a client whos wife died in a recent mass casualty accident. the client says, I cant believe that my wife is gone and I am left to raise my children all by myself. how should the nurse respond? A. please accept my sympathies for your loss B. i can call the hospital chaplain if you wish C. you sound anxious about being a single parent D. at least your children still have you in their lives

a nurse is triaging clients in the ED which client should be considered urgent? A. 20 year old female with chest stab wound and tachycardia B. 45 year old homeless man with skin rash and sore throat C. 75 year old with cough and temp of 102 F D. 50 year old with new onset confusion and slurred speech

a nurse is triaging clients in the emergency department. which client should the nurse classify as nonurgent? A. 44 year old with chest pain and diaphoresis B. 50 year old with chest trauma and absent breath sounds C. 62 year old with simple fracture of the left arm D. 79 year old with temp of 104F

a provider prescribes crotalidae polyvalent immune fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. which assessment should the nurse complete prior to administering this medication? A. assess temperature and for signs of fever B. check the clients creatinine kinase level C. ask about allergies to pineapple or papaya D. inspect the skin for signs of urticaria (hives)

a pt comes to the clinic stating, my right foot turns a darkish red color when i sit too long, and when i put my foot up it turns pale. which condition does the nurse suspect? A. central cyanosis B. peripheral cyanosis C. arterial insufficiency D. venous insufficiency

a pt in the telemetry unit who has continuous ECG monitoring is scheduled for a test in the radiology department who is responsible for determining when monitoring can be suspended? A. telemetry technician B. charge nurse C. health care provider D. primary nurse

a pts bilateral radial pulses are occasionally weak and irregular. which assessment techniques does the nurse use first to investigate this finding? A. check the color and capillary refill in the upper extremities B. check the peripheral pulses in the lower extremities C. take the apical pulse for 1 min, noting any irregularity in heart rhythm D. check the cardiac monitor for irregularities in rhythm

a student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion what action by the student causes the registered nurse to intervene? A. assessing the IV site before giving the drug B. obtaining a programmable (smart) IV pump C. removing the IV bag from the brown plastic cover D. taking and recording a baseline set of vital signs

after teaching a client how to prevent altitude related illnesses, a nurse assesses the client understanding. which statement indicates the client needs additional teaching? A. if my climbing partner cant think straight we should descend to a lower altitude B. i will ask my provider about medication to help prevent acute mountain sickness C. my partner and I will plan to sleep at a higher elevation to acclimate more quickly D. i will drink plenty of fluids to stay hydrated while on the mountain

after teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients understanding. Which statement indicates the client has a good understanding of this condition? A. this rash is probably due to fluid overload B. I need to wash this daily with antibacterial soap C. I can use powder to keep this area dry D. I will schedule a mammogram as soon as I can

an ED case manager is consulted for a client who is homeless which intervention should the case manager provide? A. communicate client needs and restrictions to support staff B. prescribe low cost antibiotics to treat community-acquired infection C. provide referrals to subsidized community based health clinics D. offer counseling for substance abuse and mental health disorders

an ED nurse is caring for a client who is homeless. which action should the nurse take to gain the clients trust? A. speak in a quiet and monotone voice B. avoid eye contact with the client C. listen to the clients concerns and needs D. ask security to store the clients belongings

an Ed charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. which action should the nurse take? A. organize a pizza party for each shift B. remind the staff of the facility's sick-leave policy C. arrange for critical incident stress debriefing D. talk individually with staff members

an emergency room nurse is triaging victims of a multi-casualty event. which client should receive care first? A. 30 year old distraught mother holding her crying child B. 65 year old conscious male with head lac C. 26 year old male who has pale, cool, clammy skin D. a 48 year old with simple fracture of lower leg

based on the physiologic force that propels blood forward in the veins, which pt has the greatest risk for venous stasis? A. older adult pt with hypertension who rides a bike daily B. middle aged construction worker taking warfarin C. bedridden pt in the end stage of alzheimer's disease D. teenage pt with a broken leg who sits and plays video games

because cardiac dysrhythmias are abnormal rhythms of the heart's electrical system, the heart is unable to perform what function? A. it cannot oxygenate the blood throughout the body B. it cannot remove carbon dioxide from the body C. it cannot effectively effectively pump oxygenated blood throughout the body D. it cannot effectively conduct impulses with increased activity

in assessing a pt who has come to the clinic for a physical exam, the nurse notes that the pt has decreased skin temp what is this finding most indicative of A. anemia B. heart failure C. arterial insufficiency D. stroke

the UAP tells the nurse that the dying pt is manifesting a death rattle. which action would the nurse perform? A. instruct the UAP to initiate postmortem care B. notify the family that the pt has died C. turn the ppt on the side to reduce gurgling D. tell the UAP that this is expected and nothing can be done.

the night shift nurse is listening to report and hears that a pt has paroxysmal nocturnal dyspena. what does the nurse plan to do next? A. instruct the pt to sleep in a side lying position and then check on the pt every 2 hours to help with switching sides B. make the pt comfortable in a bedside recliner with several pillows to keep the pt more upright throughout the night C. check on the pt several hours after bedtime and assist the pt to sit upright and dangle the feet when dyspnea occurs D. check the pt frequently because the pt has insomnia due to a fear of suffociation

the nurse is performing an assessment on a cardiac pt. in order to determine if the pt has a pulse deficit, what does the nurse do? A. take the pts BP and subtract the diastolic from the systolic pressure B. take the pts pulse in a supine position and then in a standing position C. assess the apical and radial pulses for a full minute and calculate differences in rate D. take the radial pulse, have the pt rest for 15 mins and then retake the pulse

the nurse is reviewing ECG results of a pt admitted for fluid and electrolyte imbalances. the T waves are tall and peaked. the nurse reports this finding to the health care provider and obtains an order for which serum level test? A. sodium B. glucose C. potassium D. phosphorus

the nurse is taking a history on a pt recently diagnosed with heart failure. the pt admits to "sometimes having trouble catching my breath" but is unable to provide more specific details. what question does the nurse ask to gather more data about the pts symptoms? A. do you have any medical problems, such as high blood pressure? B. what did your dr tell you about your diagnosis? C. what was your most strenuous activity in the past week? D. how do you feel about being told that you have heart failure?

the nurse is taking report on a pt who will be transferred from the cardiac ICU to the general med-surg unit. the reporting nurse states that S4 is heard on ausculation of the heart. this is most closely associated with which situation A. heart murmur B. pericardial friction C. ventricular hypertrophy D. normal heart sounds

the nurse is taking vitals and reviewing the ECG of a pt who is training for a marathon. the heart rate is 45 bpm and the ECG shows sinus bradycardia. how does the nurse interpret this data? A. a rapid filling rate that lengthens diastolic filling time and leads to decreased cardiac output B. the bodys attempt to compensate for a decreased stroke volume by decreasing the heart rate C. an adequate stroke volume that is associated with cardiac conditioning D. a common finding in the health adult that would be considered normal

the nurse reads in a pts chart that a carotid bruit was heard during the last 2 annual checkups. today on ausculation the bruit is absent. how does the nurse evaluate this data? A. the problem has resolved spontaneously B. there may have been an anomaly in previous findings C. the occlusion of the vessel may have professed past 90% D. the antiplatelet therapy is working

the terminally ill patient has an advance directive living will, which indicates that no heroic measures such as CPR and intubation should be performed. She also has a DNR order in her chart written by the health care provider. as the patient nears death, her daughter tells the nurse that she wants everything possible done to save her mothers life. What is the nurses best action? A. call a code and bring the crash cart to the patient's bedside B. inform the health care provider of this change in the plan of care C. respect the patient's wishes and ask the chaplain to stay with the daughter D. inform the daughter that further interventions are not warranted

to qualify for medicare hospice benifits, a crierion for admission is that the pts prognosis must be limited to what amount of time? A. 2 weeks or less B. 3 months or less C. 6 months or less D. 1 year or less

what is the normal measurement of the PR interval in a ECG? A. less than 0.11 seconds B. 0.06-0.10 seconds C. 0.12-0.20 seconds D. 0.16-0.26 seconds

when the nurse assess the dying pt inadequate perfusion is suspected because the pts lower extremities are cold, mottled, and cyanotic. which intervention should the nurse perform? A. place the lower extremities in a dependent position B. give warm oral or IV fluids C. cover the pt with a warm blanket D. gently rub the extremities to stimulate circulation

which category of cardiovascular drugs increases heart rate and contractility A. diuretics B. beta blockers C. catecholamines D. benzodiazepines

which definition best describes left sided heart failure? A. increased volume and pressure develop and result in peripheral edema B. it can occur when cardiac output remains normal or above normal C. there is decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels D. it is the percentage of blood ejected from the heart during systole

which pt and family have the best understanding of home hospice? A. family believes that the dying pt receives care at home if there are no funds for hospitalization B. family expects that the pt will resist hospice, therefore, an involuntary order is requested C. the dying pt and family want to focus on facilizing quality of life the pt and family expect an RN to provide around the clock nursing care

which pt statement best represents the symptom that is most distressing and feared by terminally ill pts A. i get really nervous when i cant catch my breath B. my family will be so upset if i can't recognize them C. i'm hoping my dr prescribes alot of pain meds D. when i get nauseated, i wont be able to eat or drink

while caring for a pt of the orthodox jewish faith who is dying, what cultural concept should the nurse keep in mind A. traditionally, jewish cultures are male dominated B. expression of greif is open, especially among women C. a person who is extremely ill and dying should not be left alone D. family members are likely to avoid visiting the terminally ill family member

while triaging clients in a crowded emergency department a nurse assesses a client who presents with symptoms of TB which action should the nurse take first? A. apply o2 via nasal cannula B. administer IV 0.9% saline solution C. transfer the client to a negative pressure room D. obtain a sputum culture and sensitivity

the UAP informs the nurse that a patient with hypernatremia who was initially confused and disoriented on admission to the hospital is now trying to pull out the IV access and indwelling urinary catheter. what is the nurse's first action? A. place bilateral soft wrist restraints B. inform the provider of the patient's change in behavior and obtain an order for restraints C. assess the patient D. offer the patient oral fluids

C. assess the patient

the unlicensed assistive personal (UAP) reports to the nurse that a patient being evaluated for kidney problems has produced a large amount of pale-yellow urine. what does the nurse do next? A. instruct the UAP to measure the amount carefully and then discard the urine B. instruct the UAP to save the urine in a large bottle for a 24-hour urine specimen C. assess the patient for signs of fluid imbalance and check the specific gravity of the urine D. compare the amount of urine output to the fluid intake for the previous 8 hours

C. assess the patient for signs of fluid imbalance and check the specific gravity of the urine

Which condition places a patient at risk for hypocalcemia, hyperkalemia, and hypernatremia? A. hypothyroidism B. diabetes mellitus C. chronic kidney disease D. adrenal insufficiency

C. chronic kidney disease

the nurse is caring for a postoperative surgical patient in the recovery room. what is the main reason for carefully monitoring the patient's urine output? A. decreasing urine output indicates poor kidney function B. increasing urine output can indicate too much IV fluid during surgery C. decreasing urine output may mean hemorrhage and risk for shock D. increasing urine output may mean that kidney function is returning to normal

C. decreasing urine output may mean hemorrhage and risk for shock

a patient in the hospital has a severely elevated magnesium level. which intervention should the nurse complete first? A. discontinue oral magnesium B. administer furosemide (lasix) C. discontinue parenteral magnesium D. administer calcium to treat bradycardia

C. discontinue parenteral magnesium

which type of medication increases an older adult pt's risk for acid base imbalance? A. antilipidemic B. hormonal therapy C. diuretics D. antidysrhythmic

C. diuretics

the nurse is reviewing orders for several patients who are at risk for fluid volume overload. for which patient condition does the nurse question an order for diuretics? A. pulmonary edema B. congestive heart failure C. end-stage renal disease D. ascites

C. end-stage renal disease

which fluid has the highest corresponding electrolyte content? A. intracellular fluid is highest in potassium B. extracellular fluid is highest in sodium C. extracellular fluid is highest in sodium and chloride D. intracellular fluid is highest in magnesium and sodium

C. extracellular fluid is highest in sodium and chloride

the nurse is caring for several patients at risk for falls because of fluid and electrolyte imbalances. which task related to patient safety and fall prevention does the nurse delegate to the UAP? A. assess for orthostatic hypotension B. orient the patient to the environment C. help the incontinent patient to toilet every 1-2 hours D. encourage family members or significant other to stay with the patient

C. help the incontinent patient to toilet every 1-2 hours

a patient is talking to the nurse about sodium intake. which statement by the patient indicates an understanding of high-sodium intake. which statement by the patient indicates an understanding of high-sodium food sources? A. I have bacon and eggs every morning for breakfast B. we never eat seafood because of the salt water C. i love Chinese food, but i gave it up because of the soy sauce D. pickled herring is a fish and my doctor told me to eat a lot of fish

C. i love Chinese food, but i gave it up because of the soy sauce

the patient with hyperkalemia is prescribed patiromer. which statement most accurately describes the function of this drug? A. it works in the kidneys to increase excretion of potassium B. the drug prevents the kidneys from absorbing potassium C. it binds with potassium in the GI tract and decreases its absorption D. the drug increases motility in the GI tract, eliminating potassium in diarrhea stools

C. it binds with potassium in the GI tract and decreases its absorption

a pt's ABG results show an increase in ph. which condition is most likely to contribute to this lab value? A. mechanical ventilation B. diabetic ketoacidosis C. nasogastric suction D. diarrhea

C. nasogastric suction

a 65 year old patient has a potassium laboratory value of 5.0 mEq/L how does the nurse interpret this value? A. high for the patient's age B. low for the patient's age C. normal for the patient's age D. dependent upon the medical diagnosis

C. normal for the patient's age

the nurse instructs the UAP to use precautions with moving and using a lift sheet for which patient and using a lift sheet for which patient with an electrolyte imbalance A. young woman with diabetes and hyperkalemia B. patient with psychiatric illness and hypernatremia C. older woman with hypocalcemia D. child with severe diarrhea and hypomagnesemia

C. older woman with hypocalcemia

which precaution or intervention does the nurse teach a patient at continued risk for hypernatremia? A. avoid salt substitutes B. avoid aspirin and aspirin-containing products C. read labels on canned or packaged foods to determine sodium content D increase daily intake of caffeine-containing foods and beverages

C. read labels on canned or packaged foods to determine sodium content

patients with which conditions are at risk for developing hypernatremia? select all that apply. A. chronic constipation B. heart failure C. severe diarrhea D. decreased kidney function E. profound diaphoresis F. Cushing's syndrome

C. severe diarrhea D. decreased kidney function E. profound diaphoresis F. Cushing's syndrome

the nurse is caring for several older adult patients who are at risk for dehydration which task can be delegated to the unlicensed assistive personnel (UAP)? A. withhold fluids if patients have bowel or bladder incontinence B. assess for and report any difficulties that patients are having in swallowing C. stay with patients while they drink fluids and note the exact amount ingested D. divide the total amount of fluids needed over a 24 hour period and note in medical record

C. stay with patients while they drink fluids and note the exact amount ingested

the nurse is assessing the patient with a risk for hypocalcemia. what is the correct technique to test for chvostek's sign? A. patient flexes arms against chest and examiner attempts to pull the arms away B. place a blood pressure cuff around the upper arm and inflate the cuff to greater than the patients SBP C. tap the patients face just below and in front of ear to trigger facial twitching D. lightly tap the patient's patellar and Achilles tendons with a reflex hammer and measure the movement

C. tap the patients face just below and in front of ear to trigger facial twitching

A client is receiving plasmapheresis as treatment for goodpastures syndrome. When planning care, the nurse places highest priority on interventions for which client problem? A. reduced physical activity related to the diseases effects on the lungs B. inadequate family coping related to the clients hospitalization C. inadequate knowledge related to the plasmapheresis process D. potential for infection related to the site for organism invasion

A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important? A. preparing to administer a blood transfusion B. reinforcing the dressing and documenting findings C. removing the dressing and assessing the surgical site D. taking a set of vital signs and notifying the surgeon

A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). the client presents to the clinic reporting an increase in fatigue. What lab result should the nurse report immediately? A. hematocrit: 25% B. hemoglobin: 9.2 mg/dL C. potassium: 3.2 mEqL D. white blood cell count: 38,000/mm3

A hospitalized client has a platelet count of 58,000/mm3. What action by the nurse is best? A. encourage high protein foods B. institute neutropenic precautions C. limit visitors to healthy adults D. place the client on safety precautions

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? A. administer furosemide (Lasix) B. perform chest physiotherapy C. document and reassess in a hour D. place the client in an upright position

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? A. document the findings and reassess in 1 hour B. loosen any constrictive dressings on the chest C. raise the head of the bed to a semi-fowlers position D. gather appropriate equipment and prepare for an emergency airway

A nurse cares for a client who has burn injuries. The clients wife asks, when will his high risk for infection decrease? How should the nurse respond? A. when the antibiotic therapy is complete B. as soon as his albumin levels return to normal C. once we complete the fluid resuscitation process D. when all of his burn wounds have closed

A nurse teaches a client who has very dry skin. Which statement should the nurse include in this clients education? A. use lots of moisturizer several times a day to minimize dryness B. take a cold shower instead of soaking in the bathtub C. use antimicrobial soap to avoid infection of cracked skin D. after you bathe, put lotion on before your skin is totally dry

A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the clients white blood cell count is high. What responce by the registered nurse is best? A. if the WBCs are high, there already is an infection present B. the client is in a blast crisis and has too many WBCs C. there must be a mistake; the WBCs should be very low D. those WBCs are abnormal and don't provide protection

A nursing student is struggling to understand the process of graft vs host disease. What explanation by the nurse instructor is best? A. because of immunosuppression, the donor cells take over B. Its like a transfusion reaction because no perfect matches exist C. the clients cells are fighting donor cells for dominance D. the donors cells are actually attacking the clients cells

A nursing student wants to know why clients with COPD tend to be polycythemic. What response by the nurse instructor is best? A. it is due to side effects of medications for bronchodilation B. it is from overactive bone marrow in response to chronic disease C. it combats the anemia caused by an increased metabolic rate D. it compensates for tissue hypoxia caused by lung disease

After teaching a client how to care for a furuncle in the axilla, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching? A. I'll apply cortisone cream to reduce the inflammation B. I'll apply a clean dressing after squeezing out the pus C. I'll keep my arm down at my side to prevent spread D. I'll cleanse the area prior to applying antibiotic cream

The nurse assesses a clients oral cavity and makes the discovery shown in the photo below: What action by the nurse is most appropriate? A. encourage the client to have genetic testing B. instruct the client on high-fiber foods C. place the client in protective precautions D. teach the client about cobalamin therapy

The registered nurse assigns a client who has an open burn wound to a licenced practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? A. administer the prescribed tetanus toxoid vaccine B. assess the clients wounds for signs of infection C. encourage the client to breath deeply every hour D. wash your hands on entering the clients room

While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. Which action should the nurse take first? a. Elevate the site and notify the person's next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911.

a client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). the client is yelling at family members and tells the dr to just get this over with when asked to sign the consent form. what action by the nurse is best? A. ask the family members B. inform the client that this behavior is unacceptable C. stay out of the room to decrease the clients stress levels D. tell the client that anxiety is common and that you can help

a client is on mechanical ventilation and the clients spouse wonders why ranitidine (zantac) is needed since the client only has lung problems. what response by the nurse is best? A. it will increase the motility of the GI tract B. it will keep the GI tract functioning normally C. it will prepare the GI tract for enteral feedings D. it will prevent ulcers from the stress of mechanical ventilation

a client undergoing hemodynamic monitoring after a MI has a right atrial pressure of 0.5 mm Hg. what action by the nurse is most appropriate? A. level the transducer at the phlebostatic axis B. lay the client in the supine position C. prepare to administer diuretics D. prepare to administer a fluid bolus

a client who is hospitalized with burns after losing the family home in fire becomes angry and screams at a nurse when dinner is served late. how should the nurse respond? A. do you need something for pain right now? please stop yelling, i brought dinner as soon as i could C. i suggest that you get control of yourself D. you seem upset, i have time to talk if youd like

a nurse assess a client admitted with a brown recluse spider bite. which priority assessment should the nurse perform to identify complications of this bite? A. ask the client about purritus at the bite site B. inspect the bite site for a bluish purple vesicle C. assess the extremity for redness and swelling D. monitor the clients temp every 4 hours

a nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first? A. are you using lotion on your skin? B. do you have a family history of this? C. do your arms itch? D. what medications are you taking?

a nurse is assessing a client who had a MI upon ausculating heart sounds, the nurse hears the following sound. what actions by the nurse is most appropriate? (click the media button to hear the audio clip) A. assess for further chest pain B. call the rapid response team C. have the client sit upright D. listen to the clients lung sounds

a nurse is caring for a client on mechanical ventilation. when double checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? A. the client is able to initiate spontaneous breaths B. the inspired oxygen has adequate humidification C. the upper peak airway pressure limit alarm is off D. the upper peak airway pressure limit alarm is on

a nurse is field triaging clients after an industrial accident. which client condition should the nurse triage with a red tag? A. dislocated right hip and open fracture of the right lower leg B. large contusion to the forehead and a bloody nose C. closed fracture of the right clavicle and arm numbness D. multiple fractured ribs and SOB

a pt is admitted for heart failure and has edema, neck vein distension, and ascites. what is the most reliable way to monitor fluid gain or loss in this pt? A. check for pitting edema in the dependent body parts B. auscultate the lungs for crackles or wheezing C. assess skin turgor and the condition of mucous membranes D. weigh the patient daily at the same time with the same scale

a pt is at risk for heart failure but currently has no official medical diagnosis. while assessing the pts lungs the nurse hears profuse fine crackles. what does the nurse do next? A. report the finding to the health care provider B. document the finding as a baseline for later comparison C. give the pt low flow supplemental o2 D. ask the pt to cough and reauscultate the lungs

a pt is prescribed atrovastatin the nurse instructs the pt to watch for and report which side effect? A. nausea and vomiting B. cough C. headaches D. muscle cramps

a student nurse asks for an explanation of refractory hypoxemia. what answer by the nurse instructor is best? A. it is chronic hypoxemia that accompanies restrictive airway disease B. it is hypoxemia from lunch damage due to mechanical ventilation C. it is hypoxemia that continues even after the client is weaned from oxygen D. it is hypoxemia that persists even with 100% oxygen administeration

an ED nurse is caring for a client who has died from a suspected homicide. which action should the nurse take? A. remove all tubes and wires in preparation for the medical examiner B. limit the number of visitors to minimize the family's trauma C. consult the bereavement committee to follow up with the grieving family D. communicate the clients death to the family in a simple and concrete manner

during assessment of a pt with heart failure, the nurse notes that the pts pulses alternate in strength what does this assessment indicate to the nurse? A. pulses paradoxus B. orthostatic hypotension C. hypotension D. pulsus alternans

the dying pt reports shortness of breath and has an o2 saturation of 90% he refuses o2 therapy but requests that the nurse obtain a fan to increase the circulation of air. based on the concept of comfort, what should the nurse do first A. explain that the use of a fan will not increase the o2 level B. try a nonpharmcologic intervention such as position change or distraction C. call the health care provider and report the refusal of o2 D. offer morphine and advise the pt that a fan will be provided

the nurse is assessing a pt with suspected CVD when assessing the precordium which assessment technique does the nurse begin with? A. percussion B. palpation C. auscultation D. inspection

the nurse is caring for several patients in the telemetry unit who are being remotely watched by a monitor technician. what is the nurses primary responsibility in the monitoring process of these patients? A. watching the bank of monitors on the unit B. printing ECG rhythm strips routinely and as needed C. interpreting rhythms D. assessment and management of patients

the nurse is conducting dietary teaching with a pt. which statement by the pt indicates an understanding of fat sources and the need to limit saturated fats? A. coconut oil has a rich flavor and is a good cooking oil B. sunflower oil is high in saturated fats so I should avoid it C. meat and eggs mostly contain unsaturated fats D. canola oil has monounsaturated fat and is recommended

the nurse is notified by the telemetry monitor technician about a pts heart rate. which method does the nurse use to confirm the technicians report? A. count QRS complexes in a 6 second strip and multiply by 10 B. analyze an ECG rhythm strip by using an ECG caliper C. run an ECG rhythm strip and use the memory method D. assess the pts heart rate directly by taking an apical pulse

the nurse is performing a dietary assessment on a 45 ear old business executive at risk for CVD. which assessment method used by the nurse is the most reliable and accurate A. ask the pt to identify foods he or she eats that contain sodium, sugar, cholesterol, fiber and fat B. ask the pts spouse, who does the cooking and shopping to identify the types of foods that are consumed C. ask the pts how cultural beliefs and economic status influence the choice of food items D. ask the pt to recall the intake of food, fluids and alcohol during a typical 24 hour period

the nurse is preparing to change a clients sternal dressing. what action by the nurse is most important? A. assess the vital signs B. don a mask and gown C. gather needed supplies D. perform hand hygiene

the nurse is reviewing diagnostic test results for a pt who is hypertensive. which lab result is an early warning sign of decreased heart compliance and prompts the decreased heart compliance and prompts the nurse to immediately notify the health care provider? A. normal B-type natriuertic peptide B. decreased hemoglobin C. elevated thyroxine (T4) D. presence of microalbuminuria

the nurse is reviewing the dying pts med record and sees that one tab of hyoscyamine 0.125mg was administered 2 hours ago. which assessment will the nurse perform in order to determine if the medication is effective A. assess for agitation and restlessness B. ask the pt if the nausea has decreased C. palpate the bladder to assess for urinary retention D. observe for oral secretions or wet sounding respirations

what is an early sign of left ventricular failure that a pt is most likely to report? A. nocturia B. weight gain C. swollen legs D. nocturnal coughing

which action is an example of active euthanasia for a dying patient? A. discontinuing the mechanical ventilator B. terminating the IV fluids C. suspending telemetry heart monitoring D. giving a large dose of IV morphine

which blood pressure is considered normal for an adult pt over 60 years of age? A. 162/92 B. 150/94 C. 156/90 D. 144/88

which exercise regimen for an older adult meets the recommended guidelines for physical fitness to promote heart health A. 6 hour bike ride every saturday B. golfing for 4 hours two times/week C. running for 15 mins 3x per week brisk walk 30 mins/day

which intervention should be done when performing postmortum care A. place the head of the bed at 30 degrees B. remove pillows from under the head C. remove dentures and carefully clean and store them D. place pads under the hips and around the perineum

which pt has an abnormal heart sound A. S1 in a 45 year old pt B. S2 in a 30 year old pt C. S3 in a 15 year old pt D. S3 in a 54 year old pt

while listening to a pts heart sounds, the nurse detects a murmur. what does the nurse understand about the cause of murmurs? A. a murmur is caused by the closing of the aortic and pulmonic valves B. a murmur is caused when the blood flows from the atrium to a noncompliant ventricle C. a murmur is caused by anemia, hypertension, or ventricular hypertrophy D. a murmur is caused when there is turbulent blood flow through normal or abnormal valves

a nurse prepares to discharge an older adult client home from the ED. which actions should the nurse take to prevent future ED visits? select all that apply A. provide medical supplies to the family B. consult a home health agency C. encourage participation in community activites D. screen for depression and suicide E. complete a functional assessment

D, E

A nurse assesses an older adults skin. Which findings require immediate referral? select all that apply A. excessive moisture under axilla B. increased hair thinning C. increased presence of fungal toenails D. lesion with various colors E. spider veins on legs F. asymmetric 6-mm dark lesion on forehead

D, F

an ED charge nurse prepares to receive clients from a mass casualty within the community. what is the role of this nurse during the event? A. ask ED staff to discharge clients from the med surg units in order to make room for critically injured victims B. call additional med surg and critical care nursing staff to come to the hospital and assist when victims are brought in C. inform the incident commander at the mass casualty scene about how many victims may be handled by the ED D. direct med surg and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims

the nurse is evaluating the lab results of a patient with hyperaldosteronism. what abnormal electrolyte finding does the nurse expect to see? A. hyponatremia B. hyperkalemia C. hypocalcemia D. hypernatremia

D. hypernatremia

the health care provider orders magnesium sulfate for a patient with severe hypomagnesemia. what is the preferred route of administration for this drug? A. oral B. subcutaneous C. intramuscular D. intravenous

D. intravenous

The nurse is caring for several patients at risk for fluid and electrolyte imbalances. which patient problem or condition can result in a relative hypernatremia? A. use of a salt subsitute B. presence of a feeding tube C. drinking too much water D. long-term NPO status

D. long-term NPO status

An older adult patient at risk for fluid and electrolyte problems is carefully monitored by the nurse for the first indication of a fluid balance problem. What is this indication? A. fever B. elevated blood pressure C. poor skin turgor D. mental status changes

D. mental status changes

the nurse is assessing skin turgor in a 65-year-old patient what is the correct technique to use with this patient? A. observe the skin for dry, scaly appearance and compare it to a previous assessment B. pinch the skin over the back of the hand and observe for tenting: count the number of seconds for the skin to recover position C. observe the mucous membranes and tongue for cracks, fissures, or a pasty coating D. pinch the skin over the sternum and observe for tenting and resumption of skin to its normal position after release

D. pinch the skin over the sternum and observe for tenting and resumption of skin to its normal position after release

the nurse is caring for several patients with electrolyte imbalances. which intervention is included in the plan of care for a patient with hypomagnesemia? A. implementing an oral fluid restriction of 1500 mL/day B. implementing a renal diet C. providing moderate environmental stimulation with music D. placing the patient on seizure precautions

D. placing the patient on seizure precautions

which serum laboratory value does the nurse expect to see in a patient with hyperkalemia? A. calcium grater than 8.0 mg/dL B. potassium greater than 3.5 mEq/L C. calcium greater than 11.0 mg/dL D. potassium greater than 5.0 mEq/L

D. potassium greater than 5.0 mEq/L

Which serum laboratory value does the nurse expect to see in the patient with hypokalemia? A. calcium less than 8.0 mg/dL B. potassium less than 5.0 mEq/L C. calcium less than 11.0 mg/dL D. potassium less than 3.5 mEq/L

D. potassium less than 3.5 mEq/L

which intervention does the nurse implement for a patient with hypocalcemia? A. encourage activity by the patient as tolerated, including weight lifting B. encourage socialization and active participation in stimulating activities C. keep a tracheostomy tray at the bedside for emergency use D. provide adequate intake of vitamin D and calcium rich foods

D. provide adequate intake of vitamin D and calcium rich foods

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