MedSurg 4
The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds (59 kg) who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer's (LR) × patient's weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post-burn injury?
3422
A child tips a pot of boiling water onto his bare legs. The mother should:
Immerse the child's legs in cool water.
A client diagnosed with end-stage kidney injury receives continuous ambulatory peritoneal dialysis (PD). The nurse observes that the dialysate drainage fluid is cloudy. Which is/are the nurse's most appropriate action(s)? Select all that apply.
Inform the primary care provider (PCP) immediately. Assess the client for signs of infection. Send a sample of the dialysate drainage for culture and sensitivity testing.
A patient is placed on hemodialysis for the first time. The patient complains of a headache with nausea and begins to vomit, and the nurse observes a decreased level of consciousness. What does the nurse determine has happened?
The patient is experiencing a cerebral fluid shift.
The provider prescribes additional urodynamic testing to determine the cause of urinary retention. The client states being very anxious and embarassed about the testing. The nurse recognizes the anxiety as a common reaction to testing that should be addressed. What nursing intervention(s) should the nurse include in the plan of care to achieve the desired goals?
Answer all client questions. Assess client's level of anxiety. Demonstrate equipment when possible. Provide privacy for the client by keeping them covered when possible. Explain all aspects of the procedure. Use simple terminology.
A client presents with severe diarrhea and a history of chronic renal failure to the emergency department. Arterial blood gas results are as follows: pH 7.30 PaO2 97 PaCO2 37 HCO3 18 The nurse would expect which of the following sets of assessment findings?
Clammy skin, blood pressure 86/46, headache
The nurse has been asked to provide health information to a female patient diagnosed with a urinary tract infection. What appropriate instructions will the nurse provide? Select all that apply.
Cleanse around the perineum and urethral meatus after each bowel movement to reduce pathogens. Drink liberal amounts of fluid to flush out bacteria. Void every 2-3 hours to prevent overdistention of the bladder
A nurse is reviewing a journal article about benign prostatic hyperplasia and possible risk factors associated with this condition. Which factor would the nurse most likely find as playing a role in increasing a client's risk for this condition? Select all that apply.
Smoking Hypertension Diabetes
The nurse cares for a client with superficial partial-thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because
tissue edema may interfere with drug absorption via other routes.
The client has a CT of the abdomen, and the nurse performs a postvoid bladder scan and notes the findings. The client has ----- most likely caused by ------.
urinary retention advanced age
A client is receiving hemodialysis for acute kidney failure. Which assessment finding(s) indicates to the nurse that the client is experiencing dialysis disequilibrium? Select all that apply.
Nausea Vomiting Headache Confusion
A client has been scheduled to undergo a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH). The nurse knows that the client understands preoperative teaching when he makes which statement?
"I understand I may develop urethral strictures as a result of having the TURP."
A client comes to the clinic reporting urinary symptoms. Which statement would most likely alert the nurse to suspect benign prostatic hyperplasia (BPH)?
"I've had trouble getting started when I urinate, often straining to do so."
A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as
18%.
A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock?
A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume.
A client has returned to the floor after undergoing a transurethral resection of the prostate (TURP). The client has a continuous bladder irrigation system in place. The client reports bladder spasms. What is the most appropriate nursing action to relieve the discomfort of the client?
Administer a smooth-muscle relaxant as ordered.
The nurse in the medical intensive care unit is caring for a client who is in respiratory acidosis due to inadequate ventilation. Which diagnosis could the client have that could cause inadequate ventilation?
Guillain-Barré syndrome
The nurse is admitting a client with prerenal acute kidney injury (AKI). Which health history is identified by the nurse to be most significant for this diagnosis? Select all that apply.
Heart failure Obstructed renal artery
The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply.
Heart rate Urine output
A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what event?
Hemodynamic instability
The nurse is caring for a client hospitalized with a diagnosis of acute kidney injury (AKI) experiencing hyperkalemia with a peaked T-wave. Which medication therapy will the nurse prepare to implement? Select all that apply.
IV insulin IV Glucose Oral polystyrene sulfonate
A client that is receiving peritoneal dialysis is identified as being at risk for the development of peritonitis. Which nursing action(s) is/are the best preventative measure(s) to address this complication? Select all that apply.
Maintain aseptic technique when administering dialysate. Wear a mask during dressing changes.
An emergency department nurse is caring for a trauma patient with arterial blood gas (ABG) results of pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would the nurse interpret these results?
Metabolic acidosis with compensatory respiratory alkalosis
A 65-year-old client with possible pyloric stenosis has been on a Salem Sump tube and low continuous suction ever since being admitted 72 hours ago. Upon reviewing the latest blood work, the nurse notices that the client's potassium is below reference range, placing the client at risk for what imbalance?
Metabolic alkalosis
Vomiting results in which of the following acid-base imbalances?
Metabolic alkalosis
An older adult has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the client's most recent laboratory tests, the nurse should prioritize which of the following?
Potassium level
The nurse is caring for a client with burns over 55% of total body surface area. Which information is essential for the nurse to document to guide the care of this client? Select all that apply.
Pre-burn body weight Current list of medications Last tetanus immunization Current body temperature
An inpatient client with acute kidney injury (AKI) has moderate edema to both legs. What resulting skin conditions would increase the client's likelihood of skin breakdown? Select all that apply.
Pruritus Excoriation
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?
Respiratory alkalosis
A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency department (ED). The triage nurse notes upon assessment that the patient has been experiencing rapid, deep respirations since before arriving at the ED 20 minutes ago. This observation suggests that the patient is at risk for developing which form(s) of acid-base imbalance? Select all that apply.
Respiratory alkalosis
Which assessment finding requires immediate attention?
T 38.6°C (101.4°F) cloudy urine foul-smelling urine
The nurse in the ICU is admitting a 57-year-old with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary conclusion?
The client is in the compensatory stage of shock.
The nurse recognizes what conditions cause elevated prostate-specific antigen (PSA) levels in the absence of prostate cancer. Select all that apply.
acute urinary retention acute prostatitis benign prostatic hyperplasia (BPH) transurethral resection of the prostate (TURP)
A client reports experiencing nocturia. The nurse obtains a thorough history including current signs and symptoms. What would the client likely include when describing the symptoms?
decrease in the force of urinary stream
A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area?
escharotomy
A client is brought into the ED with extensive traumatic injuries. The paramedic reports that the client has "shock." What are the etiologies of shock? Select all that apply.
heart fails as effective pump blood volume decreases peripheral vascular dilation
A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply.
kidney failure disseminated intravascular coagulation acute respiratory distress syndrome
To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply.
pH PaCO2 HCO3
Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30 mm Hg; and HCO3, 21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state?
Compensated respiratory alkalosis
An older client with foul-smelling urine has a temperature of 100.4°F (38°C). Which assessment findings will the nurse use to determine if the client has a urinary tract infection? Select all that apply.
Confusion Warm, flushed skin Heart rate of 102 beats/minute Respiratory rate of 26 breaths/minute
The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?
Cool, clammy skin
A client with end-stage kidney disease is scheduled to begin hemodialysis. The nurse is working with the client to adapt the client's diet to maximize the therapeutic effect and minimize the risks of complications. The client's diet should include which of the following modifications? Select all that apply.
Decreased protein intake Decreased sodium intake Fluid restriction
Which of the following should be included when teaching a client about the management of benign prostatic hyperplasia (BPH)? Select all that apply.
Do not delay the urge to void. Schedule digital rectal exams.
In a client with benign prostatic hyperplasia (BPH), which assessment finding provides the best indication of urinary retention?
Frequency
When a client's ventilation is impaired, the body retains which substance?
Carbon dioxide
Which of the following is a common complication of an electrical burn injury?
Cardiac dysrhythmias
A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition?
dehydration
The nurse visits the home of a client recovering from a thyroidectomy. Which finding(s) indicates to the nurse that the client is developing hypocalcemia? Select all that apply.
New onset of dysphagia Report of stiff hands and feet Numbness and tingling of the hands
A client is being prepared for the creation of an arteriovenous fistula. Which education will the nurse provide in the preoperative phase? Select all that apply.
The purpose of the fistula is accommodating the dialysis needles. Taking a BP reading on the affected arm can occlude the fistula. Hemodialysis begins approximately 6 months after the fistula is created. The fistula is created to enlarge the involved artery.
