Module 1-5 Qs

The nurse is caring for a patient who arrived in the ED with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? A. The patients PaO2 is 45 mm Hg B. The patients respiratory rate is 32 breaths/min C. The patients respirations are shallow D. The patient's PaCO2 is 33 mm Hg

A. The patients PaO2 is 45 mm Hg Module 2 quiz

A nurse is assessing a client reports severe headache and a stiff neck. The nurses assessment reveals positive Kernig and Brudzinskis signs. Which of the following action should the nurse perform first? A. Administer antibiotics B Implement Droplet precautions C. Initiate IV access D. Decrease bright lights

B Implement Droplet precautions

The nurse is caring for a client who just had a PICC insertion. Which of the following actions tells a nurse that a student nurse understands the care of the client with a PICC line? A. Able to shower at home without restrictions B. May perform blood pressure monitoring of affected arm C. Covered insertion site with 4 x 4 gauze to prevent bleeding D. Use 10 ml normal saline to flush the line

D. Use 10 ml normal saline to flush the line Module 1 Quiz

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? a. hyperglycemia b. hyponatremia c. hypervolemia d. oliguria

b. hyponatremia Mannito is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances such as hyponatremia

Patients with a tracheostomy or endotracheal tube need suctioning as needed to keep the airway patent. Which nursing actions demonstrate proper suctioning technique? Select all that apply. A. Preoxygenate the patient for at least 30 seconds before suctioning B. Quickly insert the suction catheter until resistance is met C. Suction the patient for at least 30 seconds to remove secretions D. Repeat suctioning as needed for four to five total suction passes E. Apply suction when withdrawing the suction catheter

A. Preoxygenate the patient for at least 30 seconds before suctioning B. Quickly insert the suction catheter until resistance is met E. Apply suction when withdrawing the suction catheter

patient has an endotracheal tube and mechanical ventilator for acute respiratory failure. Which nursing actions are appropriate to reduce the risk for ventilator-associated pneumonia (VAP)? Select all that apply. A. Provide oral care with chlorhexidine (0.12%) solution. B. Administer pantoprazole 40mg IV push daily. C. Maintain strict hand hygiene. D. Elevate the head of the bed to at least 30 degrees. E. Obtain arterial blood gases daily.

A. Provide oral care with chlorhexidine (0.12%) solution. B. Administer pantoprazole 40mg IV push daily. C. Maintain strict hand hygiene. D. Elevate the head of the bed to at least 30 degrees.

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse plan to take if an allergic transfusion reaction is suspected? SATA A. Stop the transfusion B. Monitor for hypertension C. Maintain an IV infusion with 0.9% sodium chloride D. Position the client in an upright position with the feet lower than the heart E. Administer diphenhydramine

A. Stop the transfusion C. Maintain an IV infusion with 0.9% sodium chloride E. Administer diphenhydramine You would stop the transfusion, monitor for HYPOtension, maintain IV infusion w/ 0.9% sodium chloride, position the client w/ feet elevated and the head flat or elevated no more than 30 degrees to prevent or treat hypotension associated with allergic reaction and administer antihistamine. ATI Medsurg pg 263

A nurse is up to the plan of care for a client who is to receive total parenteral nutrition (TPN). Which of the following actions should the nursing include in the plan? Select all that apply. A. Weigh the client daily B. Obtain a serum blood glucose every 4 hours C. Apply a new dressing to the clients IV site every 5 days D. Change the IV tubing every 24 hours E. Infuse the TPN in through a peripheral IV line

A. Weigh the client daily B. Obtain a serum blood glucose every 4 hours D. Change the IV tubing every 24 hours module 1 emailed quiz The nurse should weigh the client daily while receiving TPN. Clients who are receiving TPN are typically malnourished, therefore, the clients weight needs to be monitored closely. Fluid retention can also be an indication that the client is not digesting the TPN, and the rate of the transfusion might need to be decreased. The nurse should also obtain a client serum blood glucose, insulin can be given if needed. Finally the nurse should change the clients IV tubing every 24 hours to prevent bacteria from developing in the clients tubing. The nurse should apply a new dressing to the clients IV site every 48 to 72 hours as per facility protocol to maintain the IV site and inspect the clients skin for irritation and infection. The nurse should infuse the TPN through the client's central line. Partial parenteral nutrition can be given through a peripheral line.

A nurse is providing teaching for a client who is scheduled for a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates an understanding of the teaching? A. " This test will be performed while I am laying flat on my back." B. "I will need to stay in bed for an hour after the test." C. "This test will determine which antibiotic I should take for treatment." D. "I will receive general anesthesia for the test."

B. "I will need to stay in bed for an hour after the test." Client needs to be on bed rest 30-60 min after the test, positioned prone or side lying, and local anesthesia will be used. Culture and sensitivity test will be used to determine antibiotic. CH 39 ATI MEDSURG pg 258

The nurse is caring for a patient with a pulmonary embolism. The patient is awake, follows commands, and is receiving oxygen via Nonrebreather at 15 L/min. Based on this assessment, an arterial blood gas is drawn: pH= 7.45, CO2=38, O2=59, HCO3=21. What is the priority nursing action? A. Notify the provider, prepare for BiPAP B. Administer oxygen via high flow nasal cannula 30L and 60% FiO2 C. Administer normal saline (0.9%) 1 L IV bolus D. Notify provider and prepare for endotracheal intubation

B. Administer oxygen via high flow nasal cannula 30L and 60% FiO2 ABG is pretty normal but O2 indicating hypoxemia. They don't need BiPAP because not in resp acidosis, don't need fluids or intubation

A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion? A. Obtain consent from the client for the transfusion B. Assess for an acute hemolytic reaction C. Explain the transfusion procedure to the client D. Obtain blood culture to send to the lab

B. Assess for an acute hemolytic reaction You would assess and stay with client at the beginning of the infusion to monitor for reactions. A and C would be done before the transfusion and D would only be done if bacterial reaction is suspected. ATI pg 262 Medsurg

A client is admitted with severe headache, fever, vomiting, photophobia, drowsiness and stiff neck associated with viral meningitis. What is the priority action? A. Encourage client to breath slowly B. Dim the lights in the room C. Place a large, soft pillow under the head D. Offer sips of warm liquids

B. Dim the lights in the room

An older adult patient arrives in the emergency department after falling off a roof. The nurse observes "sucking inward" of the loose chest area during inspiration and a "puffing out" of the same area during expiration. Arterial blood gases (ABG) results show severe hypoxemia and hypercarbia. Which procedure does the nurse prepare for? A. Chest tube insertion B. Endotracheal intubation C. Needle thoracotomy D. Tracheostomy

B. Endotracheal intubation Patient has flail chest (noted by that sucking inward during inspiration and the puffing out during expiration which refers to paradoxical movement and is the most telling sign of flail chest). They also have high PaCO2 we can assume this due to severe hypoxemia and hybercarbia, therefore due to this they are breathing very slow and their airway is not protected so they will need ET tube first.... Trach would be later for long term. There is no indication for a chest tube since there are no s/s of a pneumothorax.

A nurse is caring for a client who is receiving warfarin for anticoagulation therapy, Which of the following lab test results indicate to the nurse the client needs an increase in the dosage? A. APTT 38 sec B. INR 1.1 C. PT 22 sec D. D-dimer negative

B. INR 1.1 INR of 1.1 is within expected reference range for a client who is not receiving warfarin therapy. Expect the client to receive and increased dosage of warfarin until INR is 2-3. Pg 256 ATI ch 39 MEDSURG

The RN in the ICU is caring for a patient who is in acute respiratory failure. What nursing action can the registered nurse delegate to the licensed practical nurse (LPN)? A. Place patient in prone position B. Insert indwelling urinary catheter C. Assess breath sounds every hour D. Obtain arterial blood gases

B. Insert indwelling catheter Module 2 quiz

The nurse is caring for a patient with a right sided chest tube in place. At 0800, the chest tube drainage was 30 mL and serous. At 0900, the chest tube drainage was 110 mL and sanguineous. What is the nurse's best action? A. Check the chest tube for leaks B. Notify the provider immediately C. Instruct the patient to cough and deep breathe D. Gently "milk" the tubing to remove clots

B. Notify the provider immediately Module 2 quiz

The nurse is on a Med-SURG unit and receives hand off report on 4 patients. Which patient is the priority to assess first? A. Pt with rib fractures, resp rate 23 breaths/min, heart rate 106 bpm, O2 sat 96% on high flow nasal cannula, complaining of chest discomfort B. Pt who is 1 day post op femur repair and suddenly complains of shortness of breath, HR 125 bpm, O2 sat 71% on nasal cannula 6 L/min. C. Pt with sepsis, resp rat 22 breaths/min, HR 112 bpm, blood pressure 112/79 (90), O2 sat 88% nasal cannula 2 L/min D. Pt who is recovering from opioid overdose, resp rate 14 breaths/min, HR 90 bpm, O2 sat 96% on nasal cannula 2 L/min

B. Pt who is 1 day post op femur repair and suddenly complains of shortness of breath, HR 125 bpm, O2 sat 71% on nasal cannula 6 L/min. Lowest O2 sat, post op, tachycardia and shortness of breath... could indicate a pulmonary embolism making this patient the priority

The graduate nurse is caring for a patient with a tracheostomy tube. What is the safest nursing action to prevent accidental decannulation of a tracheostomy tube? A. Obtain an order for continuous upper extremity restraints B. Secure the tube in place using ties or fabric fasteners C. Allow some flexibility in the motion of the tube while coughing D. Instruct the patient to hold the tube with a tissue while coughing

B. Secure the tube in place using ties or fabric fasteners

A client presents to the emergency department with a 3-day history of nausea, headache and stiff neck. Nursing assessment reveals a rash on the client's lower extremities. Vital signs: Blood pressure 142/88, temperature 102.2 F, heart rate 100 and respirations 22. What is the priority nursing action? A. Apply ointment to the client's rash B. Place the client in a darked room to decrease stimuli C. Place the client on droplet precautions D. Administer prescribed pain medication

C. Place the client on droplet precautions

The nurse is caring for a patient admitted for pneumothorax. The patient has a chest tube, does not follow commands, and is becoming more agitated and confused despite having oxygen via Nonrebreather at 15 L/min. Based on this assessment, an arterial blood gas is drawn: pH= 7.21, CO2= 58, HCO3=19. What is the priority nursing action? A. Notify provider, prepare for BiPAP B. Administer oxygen via Nonrebreather at 25 L/min C. Administer normal saline (0.9%) 1L IV bolus D. Notify healthcare provider, prepare for intubation

D. Notify healthcare provider, prepare for intubation BiPAP can't be done because they are confused, Nonrebreather can't be done at 25, and fluids aren't indicated

The nurse is caring for a patient with a left sided chest tube in place for pneumothorax and hemothorax. At 0700, the drainage from the chest tube was 65 mL and serosanguinous. At 0800, the drainage from the chest tube was at 150 mL and sanguineous. What is the priority nursing action? A. Gently "strip" the tubing to remove clots B. Check the chest tube for leaks C. Instruct the patient to cough and deep breathe D. Notify the provider immediately

D. Notify the provider immediately They go from serosanguinous (pinky colored some blood in it) to sanguineous (darker fresher blood) that increases to 150 mL. We suspect it could be bleeding so provider is notified immediately. Nurses do not strip tubing. No indication for chest tube leaks and pulmonary hygiene will not help in this case and is used for prevention

A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Inserts an 18 gauge IV catheter in the client B. Verifies blood compatibility and expiration date of the blood with an assistive personnel C. Administer dextrose 5% and 0.9% sodium chloride IV with the transfusion. D. Obtain vital signs every 15 min throughout the procedure

D. Obtain vital signs every 15 min throughout the procedure Check the older adult clients vital signs every 15 minutes throughout the transfusion to allow for early detection of fluid overload or other transfusion reactions. Use no larger than a 19 gauge needle in the older adult client. Verify the clients identity and blood compatibility and expiration date of the blood with another nurse. This task is beyond the scope of practice for an assistive personnel. Administer blood products with 0.9% sodium chloride. IV solutions containing dextrose cannot be used. Ati medsurg pg 263

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? A. Using half-strength peroxide for cleansing B. Holding the device securely when changing ties C. Suctioning the patient first if secretions are present D. Tying a square knot at the back of the neck

D. Tying a square knot at the back of the neck Module 2 quiz

During change of shift report, the nurse learns that a patient with aspiration pneumonia has become increasingly agitated. Which actions should the nurse take first? A. Offer reassurance and reorient the patient B. Notify the provider about the patients status C. Give the prescribed PRN sedative drug D. Use pulse oximetry to check the oxygen saturation

D. Use pulse oximetry to check the oxygen saturation Module 2 quiz

After starting IV access, what is the best for the nurse to document immediately after the procedure? A. The types catheter used in the number of venipuncture attempts B. type, amount, and flow rate of IV fluid, condition of IV site C. The type of IV fluid hung and equipment used D. the date, time, venipuncture site, type, the gauge of the catheter and the IV fluid hung

D. the date, time, venipuncture site, type, the gauge of the catheter and the IV fluid hung Module 1 Quiz

Which nursing action is most important for the nurse to implement to prevent nausea and vomiting in a client who is prescribed intravenous (IV) chemotherapy? a. Administer antiemetic drugs before administering chemotherapy b. Ensure that the chemotherapy is infused over a 4-to-6-hour period c. Keep the client NPO while the chemotherapy is infusing d. Assess the client for manifestations of dehydration hourly during the infusion period

a. Administer antiemetic drugs before administering chemotherapy

A nurse is collecting data from a client who has fluid-volume excess. Which of the following findings should the nurse expect? a. Crackles in the lung field. b. Flat neck veins c. Postural hypotension d. Dark yellow urine

a. Crackles in the lung field. manifestations of fluid-volume excess include crackles in the lungs, dependent edema, full neck veins when the client is upright, increased blood pressure, and sudden weight gain. module 1 emailed quiz

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? SATA a. Encourage the client to cough and deep breathe b. Check for continuous bubbling in the suction chamber c. Strip the drainage tubing every 4 hr d. Clamp the tube once a day e. Obtain a chest x-ray

a. Encourage the client to cough and deep breathe b. Check for continuous bubbling in the suction chamber e. Obtain a chest x-ray Coughing and deep breathing will help the pt with lung expansion and should be encouraged. The nurse should check for continuous bubbling in the suction chamber to verify that suction is being maintained at an appropriate level. A chest xray is obtained to verify placement. Nurse should not milk or strip tubing to check for kinks or clamp tubing unless indicated by provider, it can cause tension pnx.

A client who is receiving chemotherapy develops stomatitis. Which of the following actions is appropriate for the nurse to incorporate into the plan of care? a. Encourage the client to use a soft-bristled toothbrush after each meal b. Avoid using dental floss until the client's stomatitis is resolved c. Rinse the client's mouth with full-strength hydrogen peroxide every 4 hours d. Provide hot tea with honey to soothe the client's painful oral mucosa

a. Encourage the client to use a soft-bristled toothbrush after each meal

A nurse is caring for a client who is receiving vecuronium during mechanical ventilation. Which of the following medications should the nurse anticipate with this medication? SATA a. Fentanyl b. Furosemide c. Midazolam d. Famotidine e. Dexamethasone

a. Fentanyl c. Midazolam Fentanyl is a pain med and midazolam a sedative that are administered with neuromuscular blocking agents such as vecuronium.The other meds are not indicated.

The nurse is caring for an oncologic client. The nurse recognizes the following as possible manifestations of tumor lysis syndrome. Select all that apply: a. Hyperuricemia b. Hyperphosphatemia c. Renal calculi d. Cardiac dysrhythmia e. Hypokalemia f. Acute renal failure

a. Hyperuricemia b. Hyperphosphatemia c. Renal calculi d. Cardiac dysrhythmia f. Acute renal failure

The registered nurse (RN) in the intensive care unit is caring for a patient with a myocardial infarction. What nursing action can the registered nurse delegate to the unlicensed assistive personnel (UAP)? a. Obtain vital signs. b. Assess chest pain. c. Apply oxygen via nasal cannula. d. Administer sublingual nitroglycerin.

a. Obtain vital signs. Module 3 quiz

A nurse is preparing to care for a client following a chest tube placement. Which of the following items should be available in the client's room? SATA a. Oxygen b. Sterile water c. Enclosed hemostat clamps d. Indwelling urinary catheter e. Occlusive dressing

a. Oxygen b. Sterile water c. Enclosed hemostat clamps e. Occlusive dressing If chest tubing becomes disconnected the nurse would put the end of tubing in sterile water to restore the water seal and would immediately place an occlusive dressing on the site. The hemostat clamps are used to check air leaks and oxygen should be readily available. Indwelling urinary catheter is not indicated.

A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? SATA a. Tachypnea b. Deviation of the trachea c. Bradycardia d. Decreased use of accessory muscles e. Pleuritic pain

a. Tachypnea b. Deviation of the trachea e. Pleuritic pain Also would have tachycardia, and it would increase the use of accessory muscles

Which discharge instructions would the nurse include for a patient with a new permanent pacemaker? Select all that apply. a. Until your incision is healed, do not submerge your pacemaker in water. b. Report any pulse rates lower than your pacemaker settings. c. Have your pacemaker turned off before having magnetic resonance imaging (MRI). d. Do not lift the arm above the level of your shoulder for 4 weeks. e. If you feel weak, apply pressure over your generator.

a. Until your incision is healed, do not submerge your pacemaker in water. b. Report any pulse rates lower than your pacemaker settings. d. Do not lift the arm above the level of your shoulder for 4 weeks. module 3 quiz

A nurse is assisting with developing the plan of care for an older adult client who is to receive a unit of packed red blood cells (RBCs). Which of the following actions should the nurse recommend? a. Verify the information on the packed RBCs with another nurse b. Administer the packed RBCs through an 18-gauge IV catheter c. Infuse the packed RBCs over 2 hours d. Allow the packed RBCs to warm at room temperature for 1 hr before starting the transfusion.

a. Verify the information on the packed RBCs with another nurse (the nurse should verify the information on the label of the packed RBCs with another nurse. The nurse should also verify the information on the label with the provider's order, the blood administration form from the blood bank, and the client armband and blood bracelet.) module 1 emailed quiz

A nurse is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the nurse indicates an understanding of PSV? a. "It keeps the alveoli open and prevents atelectasis." b. "It allows preset pressure delivered during spontaneous ventilation." c. "It guarantees minimal minute ventilator." d. "It delivers a preset ventilatory rate and tidal volume to the client."

b. "It allows preset pressure delivered during spontaneous ventilation." Pressure support ventilation (PSV) allows preset pressure delivered during spontaneous ventilation to decrease the work of breathing. PEEP maintains pressure in the lungs to keep alveoli open. PSV does not guarantee minimal minute ventilation because no ventilator breaths are delivered. Assist-control (AC) mode delivers a preset ventilatory rate and tidal volume to the pt.

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the new nurse indicates understanding of the teaching? a. "This med is given to treat infection." b. "This med is given to facilitate ventilation." c. "This med is given to decrease inflammation." d. "This med is given to reduce anxiety."

b. "This med is given to facilitate ventilation." Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and to decrease oxygen consumption

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? a. Obtain a chest x-ray b. Apply sterile gauze to the insertion site c. Place tape around the insertion site d. Assess respiratory status

b. Apply sterile gauze to the insertion site Using ABC framework, application of the sterile gauze to the site should be the 1st action for the nurse to take. This allows air to escape and reduces the risk for development of a tension pneumothorax.

A patient on the telemetry unit develops atrial fibrillation, rate 150, with associated dyspnea and chest pain, oxygen saturation 88%. What is the priority nursing action? a. Obtain a 12-lead electrocardiogram (ECG). b. Apply supplemental O2 at 4 L/min via nasal cannula. c. Notify the health care provider of the change in rhythm. d. Assess the patient's blood pressure and discomfort level.

b. Apply supplemental O2 at 4 L/min via nasal cannula. module 3 quiz

A nurse in the ED is assessing a client who has sustained multiple rib fractures and has a flail chest. Which of the following findings should the nurse expect? SATA a. Bradycardia b. Cyanosis c. Hypotension d. Dyspnea e. Paradoxical chest movement

b. Cyanosis c. Hypotension d. Dyspnea e. Paradoxical chest movement would have tachycardia instead

A client who has been diagnosed with lung cancer complains of increasing shortness of breath and difficulty swallowing. The client has facial swelling and jugular venous distention (JVD). What is the priority nursing action? a. Prepare the client for a swallow evaluation b. Ensure the client has a patent airway c. Encourage the client to cough and deep breathe d. Assist the client to a tripod position

b. Ensure the client has a patent airway

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (SATA) a. Continuous bubbling in the water seal chamber b. Gentle constant bubbling in the suction control chamber c. Rise and fall in the level of water in the water seal chamber with inspiration and expiration d. Exposed sutures without dressing e. Drainage system upright at chest level

b. Gentle constant bubbling in the suction control chamber c. Rise and fall in the level of water in the water seal chamber with inspiration and expiration Continuous bubbling in water seal chamber indicates an air leak. The nurse should cover the sutures at the insertion site with an airtight dressing. Drainage system should be upright but BELOW chest level.

A nurse is assisting the provider to care for a client who has developed a spontaneous pneumothorax. Which of following actions should the nurse perform first? a. Assess the client's pain b. Obtain a large bore IV needle for decompression c. Administer lorazepam d. Prepare for chest tube insertion

b. Obtain a large bore IV needle for decompression

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? SATA a. Confusion b. Pale skin c. Bradycardia d. Hypotension e. Elevated blood pressure

b. Pale skin e. Elevated blood pressure Pale skin and elevated blood pressure are early signs of hypoxemia. The rest are all late signs.

A nurse is monitoring a client who is receiving lactated Ringer's 500 mL infused over 4 hours. The drop factor of the manual IV tubing is 15 gtt/mL. the nurse should make sure the manual IV infusion is delivering how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.) a. 30 b. 32 c. 31 d. 33

c. 31 module 1 emailed quiz Follow these steps to calculate the infusion rate using the ratio and proportion and "desired over have" methods: Step 1 - what is the unit of measurement the nurse should calculate? Gtt/min Step 2 - what is the volume the nurse should infuse? 500 mL Step 3 - what is the total infusion time? 4 hours Step 4 - should the nurse convert the units of measurement? Yes (hr does not equal min) 1 hr/60 min = 4 hr/X min X = 240 min Step 5 - set up an equation and solve for X Volume (mL)/Time (min) x drop factor (gtt/min) =X 500 mL/240 min x 15 gtt/mL = Xgtt/min X = 31.2499 Step 6 - round if necessary. 31.2499 = 31 Step 7 - determine if the amount to administer makes sense. If the prescription is for lactated Ringer's 500 mL IV infused over 4 hours, the nurse should check that the manual IV infusion is delivering lactated Ringer's IV at 31 gtt/min.

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states, "I am anxious and unable to get enough air." Vital signs are HR 117 bpm, RR 38/min, temp 38.4 c(101.2 F), and BP 100/54. Which of the following is the nurse's priority action? a. Notify provider b. Administer heparin via IV infusion c. Administer oxygen therapy d. Obtain CT scan

c. Administer oxygen therapy ABCs

A nurse in the ED is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in left lower lobe w/ dyspnea, BP 118/68, HR 124 bpm, RR 38/min, temp 38.6C(101.4F), and SaO2 92% on RA. Which of the following actions should the nurse take first? a. Obtain a chest xray b. Prepare for chest tube insertion c. Administer oxygen via a high flow mask d. Initiate IV access

c. Administer oxygen via a high flow mask ABCs

A nurse cares for a patient who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate? a. Avoid strenuous exercise such as running. b. Make certain that your bath water is warm. c. Avoid straining while having a bowel movement. d. Limit your intake of caffeinated drinks to one a day.

c. Avoid straining while having a bowel movement. module 3 quiz

A client with cancer who is receiving radiation therapy develops thrombocytopenia. The priority nursing goal is to prevent which of the following? a. Pain related to spontaneous bleeding episodes b. Skin breakdown related to decreased tissue perfusion c. Bleeding related to the decreased platelet count d. Altered nutrition related to anemia

c. Bleeding related to the decreased platelet count

The nurse is taking a history and vital signs on a patient who has come to the clinic for a routine checkup. The patient has a pulse rate of 50 beats/min and denies any distress. What action does the nurse do next? a. Complete the health history. b. Give supplemental oxygen. c. Check the blood pressure. d. Establish IV access.

c. Check the blood pressure. module 3 quiz

A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next? a. Perform synchronized cardioversion. b. Give atropine per agency dysrhythmia protocol. c. Start cardiopulmonary resuscitation (CPR). d. Apply supplemental O2 via non-rebreather mask.

c. Start cardiopulmonary resuscitation (CPR). module 3 quiz

A nurse is collecting data from a client who has cancer and is receiving chemotherapy by peripheral IV infusion. The client reports pain at the insertion site, and the nurse notes fluid leaking around the catheter. Which of the following actions should the nurse take first? a. Take a photograph of the peripheral IV site b. Obtain and record the client's vital signs c. Stop the infusion d. Identify all medications administered through the IV site for the past 24 hours.

c. Stop the infusion

A nurse is caring for a client receiving chemotherapy. The client's most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for the client? WBC 1,400/mm3 RBC 4.3 x 10¹² /L Hgb 12.1 g/dL Hct 36.5% Platelets 170,000/mm3 a. The client has an increased risk for anemia b. The client has an increased risk for bleeding c. The client has an increased risk of infection d. The client has an increased risk for hyponatremia

c. The client has an increased risk of infection

The nurse completed health promotion teaching about skin cancer protection. What statement by the client indicates the teaching was effective? a. "As long as I wear sunscreen, I will not develop skin cancer." b. "Since I have dark-colored skin, I do not need to worry about developing skin cancer." c. "Indoor tanning booths are safer than being in the sun." d. "I need to let my doctor know if I develop a spot on my skin that has different colors."

d. "I need to let my doctor know if I develop a spot on my skin that has different colors."

Which of these statements made by a client receiving external radiation therapy indicates a need for further teaching? a. "I must leave the ink or dye markings on my skin." b. "I will notify the provider if I have difficulty swallowing." c. "I can use prescribed lotions on the radiated area." d. "I will expose the radiated area to sunlight to help the skin heal."

d. "I will expose the radiated area to sunlight to help the skin heal."

Which of these clients should be seen immediately after hand-off shift report? a. A client with a temperature of 99.0 F and heart rate 88 beats/minute b. A client complaining of nausea and vomiting following chemotherapy c. A client complaining of feeling fatigued following chemotherapy d. A client complaining of discomfort at the IV insertion site during chemotherapy

d. A client complaining of discomfort at the IV insertion site during chemotherapy

A 19-year-old student comes to the student health center at the end of the semester stating, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next? a. Start supplemental O2 at 2 to 3 L/min via nasal cannula. b. Insert an IV catheter for emergency use. c. Have the patient taken to the nearest emergency department (ED). d. Ask the patient about current stress level and caffeine use.

d. Ask the patient about current stress level and caffeine use. Module 3 quiz

A nurse is caring for a client who is receiving mechanical ventilation. via endotracheal tube. Which of the following actions should the nurse take? a. Apply a vest restraint if self extubation is attempted b. Monitor ventilator settings every 8 hr c. Document tube placement in centimeters at the angle of jaw d. Assess breath sounds every 4 hr

d. Assess breath sounds every 4 hr Soft wrist restraints would be applied not a vest, monitor ventilator settings should be HOURLY, and the nurse documents tube placement from the lips/teeth.

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? a. Apply sterile gloves prior to opening the dressing package. b. Clean the incision from top to bottom c. Remove the tape by pulling away from the wound. d. Clean the drain site from the center outward.

d. Clean the drain site from the center outward. module 1 emailed quiz

A nurse prepares to defibrillate a patient who is in ventricular fibrillation. Which priority intervention would the nurse perform prior to defibrillating this patient? a. Administer epinephrine 1 mg intravenous. b. Test the equipment by delivering a smaller shock at 100 J. c. Set the defibrillator to the synchronous mode. d. Ensure that everyone is clear of contact with the patient and the bed.

d. Ensure that everyone is clear of contact with the patient and the bed. module 3 quiz

A patient is found pulseless, and the cardiac monitor shows a rhythm that has no recognizable deflections, but instead has coarse "waves" of varying amplitudes. What is the priority intervention for this rhythm? a. Noninvasive temporary pacing. b. Endotracheal intubation. c. Administer epinephrine IV push. d. Immediate defibrillation.

d. Immediate defibrillation. module 3 quiz

A nurse is collecting data from a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction? a. Bradycardia b. Paresthesia c. Hypertension d. Low back pain

d. Low back pain the nurse should identify that low back pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include headaches, chest pain, tachypnea, tachycardia and dark urine. module 1 emailed quiz

A nurse is assisting a provider with the removal of a chest tube. Which of the following actions should the nurse take? a. Instruct the client to lie prone with arms by the sides b. Complete a surgical checklist on the client c. Remind the client that there is minimal discomfort during the removal process d. Place on occlusive dressing over the site once the tube is removed

d. Place on occlusive dressing over the site once the tube is removed The nurse should place an occlusive dressing over the site once the tube is removed and observe the site for drainage. The position of the client should assume during the removal of a chest tube depends upon the location of insertion site. The client would need to ensure the arm is not covering the ribs on the side insertion site.

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications? a. Skeletal muscle relaxants b. Beta-adrenergic blockers c. Broad-spectrum anti-infectives d. Plasma volume expanders

d. Plasma volume expanders (dextran and albumin are plasma volume expanders. They help correct hypovolemia in emergency situations such as hemorrhage or burns.) module 1 emailed quiz

A nurse is caring for a client who is receiving an IV infusion of 5% dextrose in lactated Ringer's. the nurse notices that the area around the catheter insertion site is edematous and cooler than the surrounding skin on the forearm. Which of the following actions should the nurse take? a. Switch the fluid to 0.9% sodium chloride b. Place the arm in a dependent position c. Prepare to administer a diuretic d. Stop the infusion

d. Stop the infusion Coolness and swelling at the insertion site indicate an infiltration. The nurse should stop the infusion, remove the catheter, and report the situation to the charge nurse and the provider. module 1 emailed quiz

A patient is admitted with superior vena cava syndrome. What action by the nurse is most appropriate? A. Administer a dose of allopurinol B. Assess the patient serum potassium level C. Gently inquire about advance directives D. Prepare the patient for cardiac catheterization

C. Gently inquire about advance directives Late sign of later stage of cancer and it compromises airway so the nurse know next steps the staff will take. A & B are interventions for tumor lysis syndrome not superior vena cava syndrome.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? A. Bradycardia B. Large amounts of very dilute urine C. Restlessness and confusion D. Widened pulse pressure

Correct Answer: C. Restlessness and confusion The earliest symptom of elevated ICP is a change in mental status. Following the neurological exam closely is very important. Usually, there is an altered mental status and development of a fixed and dilated pupil. Patients presenting with findings suggestive of cerebral insult should undergo computed tomography (CT) scan of the brain; this can show the edema, which is visible as areas of low density and loss of gray/white matter differentiation, on an unenhanced image.

A nurse in a clinic is caring for a client who has suspected anemia. Which of the following lab test results should the nurse expect? A. Iron 90 mcg/dL B. RBC 6.5 million/uL C. WBC 4,800 mm3 D. Hgb 10 g/dL

D. Hgb 10 g/dL This is below the expected rang and is an expected finding of anemia ATI MED SURG pg 256 chapter 39

Which condition, sign, or symptom does the nurse consider most relevant in assessing a client suspected to have ARDS? Select all that apply A. Dyspnea B. ECG shows ST elevation C. Intercostal retractions D. PaO2 84% on oxygen at 6 L/min E. Substernal pain or rubbing F. Wheezing on exhalation

A. Dyspnea C. Intercostal retractions D. PaO2 84% on oxygen at 6 L/min

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

ANS: A, C, D Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

The nurses is caring for an older client who exhibits confusion as a result of dehydration. Which intervention by the nurse is best? A. Measure intake and output every 4 hours B. Assess the client further for fall risk C. Place the client and high fowlers position D. Increase an IV flow rate of 250 mL per hour

B. Assess the client further for fall risk Module 1 Quiz

A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? SATA a. Bradypnea b. Pleural friction rub c. Hypertension d. Petechiae e. Tachycardia

b. Pleural friction rub d. Petechiae e. Tachycardia Tachypnea and hypotension are also manifestations of PE

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 and HR 54/min. Which of the following action should the nurse take first? a. Examine skin for irritation or pressure b. Sit the client upright in bed c. Check the urinary catheter for blockage d. Administer antihypertensive medication

b. Sit the client upright in bed This client has a SCI and is at risk for a stroke secondary to elevated blood pressure due to autonomic dysreflexia. The very first action is to elevate the HOB until the client is in an upright position, which will help lower the blood pressure.

A nurse is caring for a client who is receiving chemotherapy and has mucositis. Which of the following actions should the nurse take? a. Use a glycerin-soaked swab to clean the client's teeth b. Encourage increased intake of citrus fruit juices c. Obtain a culture of the lesions d. Provide an alcohol based mouthwash for oral hygiene

c. Obtain a culture of the lesions All other answers would irritate mucositis

A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem? a. Assisting the client to pre-plan for this event b. Reassuring the client that alopecia is temporary c. Teaching the client ways to protect the scalp d. Telling the client that there are worse side effects

A ~ Alopecia does not occur for all clients who have cancer, but when it does, it can be devastating. The best action by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for this event. Not all clients will have the same reaction, but some possible actions the client can take are buying a wig ahead of time, buying attractive hats and scarves, and having a hairdresser modify a wig to look like the clients own hair. Teaching about scalp protection is important but does not address the psychosocial impact. Reassuring the client that hair loss is temporary and telling him or her that there are worse side effects are both patronizing and do not give the client tools to manage this condition.

The nurse delegates care for a client with Parkinson's disease to an unlicensed assistant personnel. Which statement would the nurse include when delegating this clients care? A. "Allow the client to be as independent as possible with activities." B. "Assist the client with frequent and meticulous oral care." C. "Assess the client's ability to eat and swallow for each meal." D. "Schedule appointments early in the morning to ensure rest in the afternoon."

A. "Allow the client to be as independent as possible with activities." B would be for oncology pts C&D: UAPs cannot assess or educate

A patient who has a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would leave the nurse provide for the education on home care? A. "I know I can take care of all the needs by myself" B. "I need to seek counseling because I am very angry" C. "Hopefully things will improve gradually overtime" D. "With respite care and support, I think I can do this"

A. "I know I can take care of all the needs by myself" These caregivers need a lot of support. A severe TBI pt has a lot of needs and the caregiver needs to have support and shouldn't be putting it all on themselves.

A client with prostate cancer is receiving external beam radiation for treatment. What teaching will the nurse provide following the radiation treatment? A. After the treatment, there is no radiation hazards to others B. Do not share a bathroom with your spouse for two days C. Visitors should be limited to 30 minutes to avoid prolonged radiation exposure D. Report temperature of 99.1 F to the healthcare provider

A. After the treatment, there is no radiation hazards to others B & C are internal radiation precautions, 100.4 F would be reported to provider

A patient's family members are concerned that telling the patient about a new findings of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be cut from the patient. What actions by the nurse are most appropriate? Select all that apply. A. Ask the family to describe their concerns more fully B. Consult with a social worker, chaplain, or ethics committee C. Explain the patient's right to know and ask for their assistance D. Have the unit manager take over the care of this patient and Family E. Tell the family that the secret will be kept from the patient

A. Ask the family to describe their concerns more fully B. Consult with a social worker, chaplain, or ethics committee C. Explain the patient's right to know and ask for their assistance The nurse cannot ethically keep this from the patient or advocate responsibility to unit manager

A patient is receiving chemotherapy through a peripheral IV line. What action by the nurse's most important? A. Assessing the IV site every hour B. Educating the patient on side effects C. Monitoring the patient for nausea D. Providing warm packs for comfort

A. Assessing the IV site every hour IV chemotherapy can cause local tissue destruction due to extravasation, more common with peripheral vs central

Admission vital signs for a patient who has a traumatic brain injury are blood pressure of 128/68, pulse of 110 BPM, and respirations 26 breaths/minute,. Which set of vital signs, if taken one hour later, will be of most concern to the nurse? A. Blood pressure 154/68, pulse 56 BPM, respirations 12 breaths/min B. Blood pressure 134/72, pulse 90 BPM, respirations 32 breaths/min C. Blood pressure 110/70, pulse 120 BPM, respirations 30 breaths/min D. Blood pressure 148/79, pulse 112 BPM, respirations 28 breaths/min

A. Blood pressure 154/68, pulse 56 BPM, respirations 12 breaths/min Biggest changes/most abnormal from baseline could indicate cushings triad-widened BP, drop in pulse and rr

Which symptom are changing assessment of a client with four broken ribs on the right side indicates to the nurse the possibility of tension pneumothorax? A. Distended neck veins B. Mediastinal shift towards the left side C. Right sided pain on deep inhalation D. Right side of the chest is more prominent than the left

A. Distended neck veins Severe deviation of the trachea away from the midline and side of injury would be a better answer than B Iggy pg 608

A 70 yr old woman with neutropenia secondary to metastic breast cancer is admitted to the medical intensive care unit. The nurse notes the patient is lethargic and confused with the following vital signs: 101.3°F (38.5°C), BP 94/52 MAP (66), HR. 105 bpm, RR 40 breaths/min w/ shallowing breathing, SpO2 83% on 2L NC. Which priority nursing action(s) does the nurse anticipate? Select all that apply A. Draw two peripheral blood cultures B. Administer normal saline 1L IV bolus C. Administer narrow spectrum IV antibiotics D. Administer 1 unit of packed red blood cells E. Apply Nonrebreather with 100% oxygen

A. Draw two peripheral blood cultures B. Administer normal saline 1L IV bolus E. Apply Nonrebreather with 100% oxygen Fever indicates need for two blood cultures to rule out infection, fluids for low blood pressure, c is wrong because you want BROAD not narrow antibiotics, no indication of anemia or Pancytopenia for PRBCs, and Nonrebreather is the next option or a bag valve mask or intubate

A patient with respiratory failure has a respiratory rate of six breaths per minute and an oxygen saturation SPO2 of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? A. Endotracheal intubation and positive pressure ventilation B. Administration of 100% O2 by nonrebreather mask C. Initiation of continuous positive pressure ventilation (CPAP) D. Insertion of mini tracheostomy with frequent suctioning

A. Endotracheal intubation and positive pressure ventilation Module 2 quiz

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away painful stimulus. How should the nurse record the patient's Glasgow coma scale (GCS) score? A. GCS 11 B. GCS 15 C. GCS 13 D. GCS 9

A. GCS 11 He opens his eyes to speech=3, curses when stimulated-inappropriate words=3, moves to localized pain=5

A nurse assesses a patient who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations would the nurse correlate with neurogenic shock? Select all that apply A. Heart rate of 34 beats/min B. Blood pressure of 185/65 C. Urine output less than 30 mL/hr D. Decreased level of consciousness E. Increase oxygen saturation

A. Heart rate of 34 beats/min C. Urine output less than 30 mL/hr D. Decreased level of consciousness Neurogenic shock is a vasodilation issue, so the patient has a decreased HR, hypotension, decreased LOC, hypoxic and decreased urine output

The nurse is assessing a client who had a coronary artery bypass graft yesterday. Which assessment findings indicate the client is at risk for decreased perfusion? A. Heart rate of 50 beats/min B. Potassium level of 4.2 mEq/L C. Systolic blood pressure of 120 D. 50 ml of bloody drainage in chest over 4 hours

A. Heart rate of 50 beats/min

The nurse is caring for a patient who suddenly presents with the following cardiac rhythm, What nursing action(s) does the nurse anticipate being implemented? SATA A. Monitor airway, breathing, circulation. B. Administer epinephrine 1 mg IV push. C. Obtain full set of vital signs. D. Administer adenosine 6 mg IV push. E.Prepare for transcutaneous pacing.

A. Monitor airway, breathing, circulation. C. Obtain full set of vital signs. D. Administer adenosine 6 mg IV push. module 3 quiz

The nurse is preparing to teach a client who has been prescribed levodopa carbidopa preparation for Parkinson disease. What health Teaching will the nurse include for the client and the family? Select all that apply. A. Move slowly when changing positions from sitting to standing B. Take your medication after meals to help prevent nausea C. Report any hallucinations that the client may have D. Note any changes in mental or emotional status E. Pay attention to whether you're tremors improve or worsen

A. Move slowly when changing positions from sitting to standing C. Report any hallucinations that the client may have D. Note any changes in mental or emotional status E. Pay attention to whether you're tremors improve or worsen

A nurse is caring for four patients and the neurological intensive care unit. After receiving the handoff report, which patient does the nurse see first? A. Patient with a Glasgow Coma Scale score that was 10 and is now 8 B. Patient with a Glasgow Como Scale score that was 9 and is now 12 C. Patient with a moderate brain injury who is amnesic from the event D. Patient who is requesting pain medication for a headache seven out of 10

A. Patient with a Glasgow Coma Scale score that was 10 and is now 8 8 means the patient needs to be intubated and this patient should be the priority. B is getting better, C is common with TBI and D is not the priority to intubation/airway problems

What are skip the handoff report on for oncology patients. Which patient with a nurse assess first? A. Patient with blood pressure change of 128/74 to 110/88 B. Patient with oxygen saturation unchanged at 94% C. Patient with a heart rate change of 100 to 88 beats/min D. Patient with a urine output of 40 ml/hr for the last hour

A. Patient with blood pressure change of 128/74 to 110/88 This patient is assessed first because the blood pressure is going down, so we need to assess further to see if this pt is having s/s of infection, septic shock, bleeding, N/V All the other patients are stable and WNL

A nurse is caring for a client who has cervical cancer and is scheduled for a braky therapy. Which of the following actions should the nurse take? Select all to apply A. Permit visitors to stay with the client 30 minutes at of time B. Warn pregnant individuals to visit the room only once daily C. Where a dosimeter went in the clients room D. Place soiled dressings in a biohazard bag before discarding in the regular trash E. Dispose soiled linens in a hamper outside the client's room

A. Permit visitors to stay with the client 30 minutes at of time B. Warn pregnant individuals to visit the room only once daily C. Where a dosimeter went in the clients room

The nurse is responsible for teaching the immunocompromised patient and the family about health promoting activities. Which information is the best to provide? A. Wash hands thoroughly with antimicrobial soap B. Do not drink water, milk, juice, or other cold liquids C. Boil dishes or use disposables whenever possible D. Don a mask before entering the patient's personal space

A. Wash hands thoroughly with antimicrobial soap HAND HYGIENE, HAND HYGIENE, HAND HYGIENE is the #1 way to prevent infection

The nurse started the transfusion of 1 unit of PRBC's. Which clinical findings indicate a complication of an allergic reaction? select all that apply A. urticaria B. chills C. lower back pain D. pruritus E. wheezing

A. urticaria D. pruritus E. wheezing Module 1 Quiz

A client receiving radiation for head and neck cancer reports that the skin in the radiation field is itching and painful. Which nursing education will the nurse provide? Select all that apply A. "This is likely from medication, not the radiation treatment." B. "Cover the area with soft clothing." C. "Be sure to wash your hands before touching this area." D. "Sunlight to the radiated area can help the skin heal." E. "Use a wash cloth to thoroughly clean the area with soap and water." E. "Do not remove the ink marks on the skin."

B. "Cover the area with soft clothing." C. "Be sure to wash your hands before touching this area." E. "Do not remove the ink marks on the skin." Patient is experiencing radiation dermatitis. Gently cleaning only with mild soap and sunlight is contraindicated.

The nurse is teaching about infection prevention to a client with cancer who is NEUTROPENIC. Which client statement indicates a need for additional teaching? A. "I will call the provider if I get a temp of 100.4 or greater" B. "I will wash my hands after attending church" C. "I will wear a conform when having intercourse." D. "I will not drink anything that has been at room temp for more than one hour"

B. "I will wash my hands after attending church" Should be avoiding crowds

A client who is three days postop underwent extensive abdominal surgery for cancer reports having a a difficult time "catching her breath" and feeling very scared. After assessing the client, what is the nurses best action or response to prevent harm? A. Ask the client about possible drug allergies B. Apply oxygen and initiate the rapid response team C. Determine when she last received an opioid dose D. Check the oxygen saturation and encourage her to cough

B. Apply oxygen and initiate the rapid response team Showing Signs of a PE

A patient who is involved in a high-speed motor vehicle accident sustained multiple injuries. He is transported to the ED by emergency medical services with immobilization devices in place. There is a high probability of cervical spine fracture, the patient has a altered mental status and flaccid extremities. What is the priority assessment for this patient? A. Check the mental status using the Glasgow coma scale (GCS) B. Assess the respiratory pattern and ensure patent airway C. Observe for intra-bdominal bleeding and hemorrhage D. Assessed for loss of motor function and sensation

B. Assess the respiratory pattern and ensure patent airway ABCDs... + probability of cervical spine fracture C would be next then A then D

A client who is 24 hours postop after a right lower lobe to my has two chest tubes in place. They report intense burning in the lower chest. On assessment, the nurse notes there is no bubbling in the water seal chamber. What action will the nurse perform FIRST? A. Immediately notify either rapid response team or surgical resident B. Assist the client into a side lying position and reassess the water seal chamber C. Administer the prescribed opioid analgesic immediately then assess the chest tube system D. No action is needed because these responses are normal for the first postop day after lobectomy

B. Assist the client into a side lying position and reassess the water seal chamber Water seal chamber should be gently bubbling on exhalation, forceful cough or changing positions. You would notify the provider if if was continuously bubbling. Iggy pg 560-561

A nurse is caring for a client who is post procedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following action should the nurse take? Select all that apply. A. Use the Glasgow coma scale when assessing the client B. Assist the client to a supine position C. Administer an opioid medication D. Encourage the client to increase fluid intake E. Instruct the client to perform deep breathing and coughing exercises

B. Assist the client to a supine position C. Administer an opioid medication D. Encourage the client to increase fluid intake LOC doesn't need assessed right now, supine position can relieve a headache following a lumbar puncture. Opioids can be administered for the clients headache pain. The nurse should encourage an increase fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture. Coughing can increase ICP which can result in an increase of a clients headache.

The nurse is caring for an older adult who is receiving multiple packed red blood cell transfusions. Which assessment findings indicate possible transfusion circulatory overload? Select all that apply A. Bradycardia B. Bilateral lung crackles C. Dyspnea D. Bounding pulse E. Hypertension F. Depression

B. Bilateral lung crackles C. Dyspnea D. Bounding pulse E. Hypertension Module 1 Quiz

Which conditions or changes indicate to the nurse that a client with a tracheostomy requires suctioning? Select all that apply A. The client has a fever B. Crackles and wheezes heard on auscultation C. The client requests that suctioning be performed D. Suction was last performed more than 3 hours ago. E. The tracheostomy dressing has a moderate amount of serosanguinous draining F. The skin around the tracheostomy is puffy and makes a crunching sound when touched

B. Crackles and wheezes heard on auscultation C. The client requests that suctioning be performed

The nurse in the medical surgical unit is caring for a patient with suspected meningitis. What are the priority nursing actions? Select all that apply. A. Prepare patient for head MRI and continue droplet precautions B. Decrease environmental stimuli and place patient in private room C. Draw peripheral blood cultures after administering antibiotics D. Assess neurological status and vital signs at least every 4 hours E. Educate patient's family members to obtain vaccination

B. Decrease environmental stimuli and place patient in private room D. Assess neurological status and vital signs at least every 4 hours E. Educate patient's family members to obtain vaccination Patient would not be getting a head MRI they would be getting a lumbar puncture, even though droplet precautions is correct. You draw blood before antibiotic administration.

Which statements about blood transfusion capabilities are correct? A. Donor type B can donate to recipient blood type O B. Donor type O can donate to anyone C. Donor type A can donate to recipient blood type AB D. Donor type AB can donate to anyone

B. Donor type O can donate to anyone Type O is the universal donor Module 1 Quiz

A nurse is planning care for a client who is undergoing chemotherapy and is on neutropenic precautions. Which of the following interventions should be included in the plan of care? Select all that apply A. Encourage a high fiber diet B. Eliminate standing water in the room C. Have the client wear a mask when leaving the room D. Have a client specific equipment remain in the room E. Eliminate raw foods from the clients diet

B. Eliminate standing water in the room C. Have the client wear a mask when leaving the room D. Have a client specific equipment remain in the room E. Eliminate raw foods from the clients diet No benefit for a client to have a high fiber for a client on NEUTROPENIC precautions

A client with a spinal cord injury is being prepared for discharge. Because of the risk for autonomic dysreflexia, the nurse should instruct the client and family to report which symptoms to the healthcare provider? A. Pallor and itching of the face and neck B. Headache and facial flushing C. Dizziness and tachypnea D. Circumoral pallor and lightheadedness

B. Headache and facial flushing

A patient has a platelet count of 9800/mm3. What action by the nurse is most appropriate? A. Assess the patient for calf pain, warmth, and redness B. Instruct the patient to call for help to get out of bed C. Obtain cultures as per the facility standing policy D. Place the patient on protective isolation precautions

B. Instruct the patient to call for help to get out of bed Pt with low PLT is at high risk for bleeding episodes so should instruct the pt to help them get out of bed A would be for a pt with a clotting risk, C and D for a pt with low WBC count

The nurse is assessing a client with as suspected diagnosis of multiple sclerosis. Which your assessment findings will the nurse expect? Select all the apply a. Resting tremors B. Memory loss C. Muscle spasticity D. Fatigue E. Diplopia F. Dysarthria

B. Memory loss C. Muscle spasticity D. Fatigue E. Diplopia F. Dysarthria Resting tremors is parkinson, MS is tremors when doing something

The nurse is assessing a client with Parkinson's Disease. Which finding(s) should the nurse report to provider immediately? SATA A. Active bowel sounds B. New onset of drooling during meals C. Oxygen saturation 91% on room air D. Stooped posture when standing E. Acute confusion

B. New onset of drooling during meals C. Oxygen saturation 91% on room air E. Acute confusion New onset of drooling indicates dysphagia, decreased O2, and acute confusion should all be reasons to notify the provider immediately. Active bowel sounds are a positive finding. Stooped posture or postural instability is an expected finding in PD.

The nurse is caring for an oncology patient with sepsis secondary to a central line bloodstream infection (CLABSI). After receiving 2 L of normal saline intravenously, the patient's blood pressure is 82/40 (MAP 54). What medication should the nurse anticipate to administer? A. Nitroprusside B. Norepinephrine C. Nitroglycerin D. Naproxen

B. Norepinephrine Norepinephrine is a high alert med that is administered through a central that vasoconstrict (vasopressor) would be used to help raise the blood pressure. Only given in the ICU and it is titrate IV (always on IV pump). We go up an down based on what that MAP goal is (typically >65) Nitroprusside is used to treats hypertension & it vasodilates which would lower blood pressure, Nitroglycerin treats angina, Naproxen is a NSAID

A patient vegan mitted with suspected meningitis has a temperature of 102. 5°F (39°C) and a severe headache. Which order should the nurse implement first? A. Give acetaminophen 650 mg PO B. Obtain 2 sets of peripheral blood cultures C. Administer ceftizoxime 1 g IV D. Use a cooling blanket to lower temperature

B. Obtain 2 sets of peripheral blood cultures Blood culture -> antibiotics -> acetaminophen-> cooling blanket

The nurse receives handoff report on four patients. Which patient is a priority to assess first? A. Patient with meningitis who complains of a headache rated 8/10 B. Patient with Parkinson's disease who is coughing while eating food C. Patient with multiple sclerosis who is waiting to be discharged home D. A patient with traumatic brain injury who has a change in GCS from 13 to 14

B. Patient with Parkinson's disease who is coughing while eating food Risk for aspiration->airway problem. Severe headache is an expected finding of meningitis. Discharge isn't a priority and the TBI pt is actually doing better.

The nurse asses a patient with ovarian cancer and notes that she has petechiae on chest and legs, crackles heard bilaterally in lung bases, and no redness or swelling at central line IV site. Her vitals are Temp 100°F (37.8°C), Pulse 102 bpm, RR 26/min, BP 110/60, O2 sat 93% on 2L NC. Her labs are BUN 34 mg/dL, Hct 30%, PLT 50,000. Which information is the most important to report to health care provider? A. Oxygen saturation and breath sounds B. Platelet count and presence of petechiae C. Temperature and IV site appearance D. Blood pressure, pulse rate, respiratory rate

B. Platelet count and presence of petechiae Concerned about bleeding -> DIC, you would increase the NC before calling the provider

Ir is planning care for a client who has bacterial meningitis which of the following action should the nursing include in the plan of care? select all that apply A. Monitor for Bradycardia B. Provided emesis basin at the bedside C. Administer anti-pyretic medication D. Perform a skin assessment E. Keep the head of bed flat

B. Provided emesis basin at the bedside C. Administer anti-pyretic medication D. Perform a skin assessment Tachycardia is what you monitor for and you keep HOB elevated

The nurse is observing the assistive personnel (AP) provide care to a client who is a NEUTROPENIC. Which action by the AP requires a nurse to intervene? A. Performing a bed bath because the client is too tired to get in the shower B. Using the unit mobile blood pressure machine to assess the clients vitals C. Using alcohol-based hand phone before touching the client D. Cleaning the clients bathroom with a disinfectant

B. Using the unit mobile blood pressure machine to assess the clients vitals This client is NEUTROPENIC and should have their own designated equipment

The nurse receives change of shift report on the oncology unit. Which patient should the nurse assess first? A. A 35-year-old patient who has dermatitis associated with abdominal radiation B. A 42-year-old patient who is sobbing after receiving a new diagnosis of ovarian cancer C. A 24-year-old patient who received neck radiation and has blood oozing from the neck D. A 56-year-old patient who developed a new pericardial friction rub after chest radiation

C. A 24-year-old patient who received neck radiation and has blood oozing from the neck Neck is close to airway and the bleeding is oozing. AIRWAY. Pericardial friction rub would be next.

A patient with stage IV breast cancer has a blood pressure of 70/46, heart rate of 136 BPM, respirations of 32 breast/min, temperature of 104°F, and a blood glucose of 246 mg/dL. Which intervention ordered by the healthcare provider should the nurse implement first? A. Administer acetaminophen 650 mg rectally B. Start norepinephrine to keep blood pressure above 90 mmHg C. Administer normal saline IV 500 mL bolus D. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL

C. Administer normal saline IV 500 mL bolus This patient is hypotensive, tachycardia, tachypnea, febrile and hyperglycemic indicating sepsis. You need to address this with fluids first. There is not an airway or breathing issue so you address circulation first. B is wrong because the goal with norepinephrine is to keep MAP >65, Instead of an insulin drip, you would want to sliding scale insulin SubQ instead of drip, Antibiotics are a better option to treat the fever for sepsis than acetaminophen.

The nurse is caring for a patient with increased intracranial pressure. Which action can the nurse delegate to the unlicensed assistive personnel who regularly works in the intensive care unit? A. Document intracranial pressure every hour B. Monitor cerebrospinal fluid color and volume hourly C. Assist the client with the urinal and bedpan when needed D. Check capillary blood glucose level every 6 hours

C. Assist the client with the urinal and bedpan when needed

A patient started on total parenteral nutrition (TPN) is complaining of thirst and states he has urinated 4 times over the past hour which action by the nurse is priority? A. Notify the provider B. Immediately stop the TPN infusion and notify the provider C. Check capillary glucose levels D. Obtain urine specimen for culture and sensitivity

C. Check capillary glucose levels Signs of hyperglycemia-polyuria therefore check glucose. You never want to immediately stop TPN. Module 1 Quiz

The SPO2 of a client receiving oxygen therapy by nasal cannula at 6 L/min has a drop from 94% an hour ago to 90%. Which action does the nurse perform first to improve the gas exchange before reporting the change to the primary healthcare provider? A. Tighten the straps on the nasal cannula B. Increase the oxygen flow rate to 8 L/min C. Check the tubing for kinks, leaks, or obstructions. D. Check to determine whether the oxygen delivery system is adequately humidified

C. Check the tubing for kinks, leaks, or obstructions.

Which patient problems should the nurse identify as of highest priority for a patient who has Parkinson's disease and is unable to move the facial muscles? A impaired physical mobility B. Activity intolerance C. Inadequate nutrition D. Disturbed body image

C. Inadequate nutrition Goes with unable to move facial muscles, which will effect diet. They will have thickened/puréed food or drinks.

Upon entering the clients room, the nurse finds the client unresponsive. And what order will the nurse provide care? (put in order) A. Begin chest compressions B. Check carotid pulse C. Notify the rapid response team D. Get the crash cart/AED E. Provide rescue breaths

C. Notify the rapid response team D. Get the crash cart/AED B. Check carotid pulse A. Begin chest compressions E. Provide rescue breaths Iggy pg 660

The nurse is caring for an older patient who was hospitalized 2 days earlier with community acquired pneumonia. Which assessment information is the most important to communicate to the healthcare provider? A. Persistent cough of blood tinged sputum B. Temperature 101.5 F (38.6 C) after 2 days of IV antibiotics C. Oxygen saturation 90% on 100% O2 by nonrebreather mask D. Scattered crackles and posterior lung bases

C. Oxygen saturation 90% on 100% O2 by nonrebreather mask Module 2 quiz

A client who's sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed. The client's blood pressure is 190/110. What is the nurses priority action out this time? A. Perform a bladder assessment B. Insert an indwelling urinary catheter C. Place the client in a sitting position D. Turn on a fan to cool the patient

C. Place the client in a sitting position

The graduate nurse is caring for a patient with a cervical spinal cord injury. What action by the graduate nurse requires a charge nurse to intervene? A. Maintaining head of bed elevated at least 30° B. Ensuring the cervical collar has a proper fit C. Removing the cervical collar to allow neck flexion D. Monitoring for airway and breathing problems

C. Removing the cervical collar to allow neck flexion RNs do not remove cervical collars. You want to avoid neck flexion with a cervical spinal cord injury. Cervical spinal injuries can have HOB elevated and lumbar and thoracic should not.

A client with multiple sclerosis tells the unlicensed assistive personnel (UAP) that she is too tired and fatigued to take a bath, after completing physical therapy. What is the priority nursing concern at this time? A. Risk for seizures B. Risk for infection C. Risk for falls D. Risk for aspiration

C. Risk for falls

And older at all is having frequent and severe chemotherapy induced nausea and vomiting that seems to be anticipatory and acute. Which assessment is the most important to make? A. Fears and feelings associated with chemotherapy B. Patient's self-management of distressing symptoms C. Signs of dehydration or electrolyte imbalance D. Willingness to try complementary or alternative therapies

C. Signs of dehydration or electrolyte imbalance

An older adult is having frequent and severe chemotherapy-induced nausea and vomiting that seems to be anticipatory and acute. Which assessment is the most important to make? A. Fears and feelings associated with chemotherapy B. Patient's self-management of distressing symptoms C. Signs of dehydration or electrolyte imbalance D. Willingness to try complementary or alternative therapies

C. Signs of dehydration or electrolyte imbalance They are older with nausea and vomiting so they are at high risk for dehydration/electrolyte imbalance so this is the most important assessment out of the answers.

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? A. The patient received a regular diet tray B. The bed rails on both sides of the bed are elevated C. Staff have entered the patient's room without a mask D. Staff turned off the lights in the patient's room

C. Staff have entered the patient's room without a mask This is a bacterial meningitis so they are on droplet precautions which requires a mask, gown, gloves and in a private room

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? A. Administer the chemotherapy through a small bore catheter B. Infuse the medication over a short period of time C. Stop the infusion of swelling observed at the site D. Hold medication unless a central venous line is available

C. Stop the infusion of swelling observed at the site Indicates extravasation Chemo drugs CAN be given in peripheral but central is preferred ****

The nurse is caring for a patient who has a head injury and a fractured right arm. Which assessment information requires rapid action by the nurse? A. The apical pulse is slightly irregular B. The blood pressure increases to 140/62 C. The patient is more difficult to arouse D. The patient complains of a headache

C. The patient is more difficult to arouse This could mean their neurological status is decreasing... they need abc assessment, vitals and neuro status to see if ICP is increasing etc

A client who is 5'11 tall and 176 pounds, has been mechanically ventilated at a tidal volume of 400 ml at a respiratory rate of 12 breaths/min for the past 24 hours. The most recent atrial blood gas (ABG) results for this client are pH =7.32, PaO2=84, PaCO2=56. What is the nurses interpretation of these results? A. Ventilation adequate to maintain oxygenation B. Ventilation excessive, respiratory alkalosis present. C. Ventilation inadequate, respiratory acidosis present. D. Ventilation status cannot be determined from information presented

C. Ventilation inadequate, respiratory acidosis present. Look at the ABG and see that respiratory acidosis is present which means Hypoventilation = inadequate ventilation ROME

The nurse is assessing a client who has advanced bone cancer. Which client assessment finding causes the nurse to suspect spinal cord compression? Select all that apply A. Reports of a headache for the past 7 hours B. Decrease breath sounds in the left lung C. Worsening mid thoracic back pain D. Tingling in the right lower extremity E. Unsteady gait when ambulating to the bathroom F. Reports of difficult sleeping

C. Worsening mid thoracic back pain D. Tingling in the right lower extremity E. Unsteady gait when ambulating to the bathroom

A nurse is providing pre-operative teaching for a client who request autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? A. You should make an appointment to donate blood 8 weeks prior to the surgery B. If you need an autologous transfusion the blood that your brother donates can be used C. You can donate blood each week if your hemoglobin is stable D. Any unused blood that is donated can be used for other clients

C. You can donate blood each week if your hemoglobin is stable Beginning 6 weeks (not 8 weeks) prior to the surgery, the client can donate blood each week for autologous transfusion if their Hgb and Hct remains stable. Autologous donation refers to the clients donation of blood for their own personal use that is only used by them not donated to others. ATI pg 263 medsurg

Which of the following medical treatments should the nurse anticipate administering to a client with increased intracranial pressure due to brain hemorrhage, except? A. acetaminophen (Tylenol) B. dexamethasone (Decadron) C. mannitol (Osmitrol) D. phenytoin (Dilantin) E. nitroglycerin (Nitrostat)

Correct Correct Answer: E. nitroglycerin (Nitrostat) Decreasing blood pressure is essential to prevent exacerbation of intracerebral bleeding. However, BP medication such as nitroglycerin is avoided due to its vasodilating effects that increase cerebral blood volume and thus increases intracranial pressure. Option A: Acetaminophen, an antipyretic, prevents increased temperature. A decrease in temperature reduces metabolism, cerebral blood flow, thus decreasing intracranial pressure. It also relieve headache. Option B: Dexamethasone, a corticosteroids, decreases intracranial pressure by stabilizing the cell membrane and decreases the leakiness in the blood-brain-barrier. Option C: Mannitol, an osmotic diuretic, lowers intracranial pressure by increasing intravascular pressure to draw fluid from the interstitial spaces and from the brain cells. Option D: Phenytoin, an anticonvulsant, is given as prophylaxis to prevent seizures. Seizures increase metabolic rate and cerebral blood flow, and volume that may result in increased intracranial pressure.

A client is having frequent premature ventricular contractions. A nurse would place a priority on the assessment of which of the following items? A. Blood pressure and peripheral perfusion. B. Sensation of palpitations. C. Causative factors such as caffeine. D. Precipitating factors such as infection.

Correct Answer: A. Blood pressure and peripheral perfusion. Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. Physical examination findings would reveal an irregular heart rhythm upon auscultation if the patient is experiencing PVCs during the examination. In some patients, cannon A waves may cause chest or neck discomfort. Otherwise, there would not be any direct physical examination findings. A prolonged run of PVCs can result in hypotension.

A client has developed atrial fibrillation, which has a ventricular rate of 150 beats per minute. A nurse assesses the client for: A. Hypotension and dizziness B. Nausea and vomiting C. Hypertension and headache D. Flat neck veins

Correct Answer: A. Hypotension and dizziness The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. A physical exam should always begin with the assessment of airway breathing and circulation as it is going to affect the decision making regarding management. On general physical examination, patients may have tachycardia with an irregularly irregular pulse.

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases. B. Pupils are 8 mm and nonreactive. C. Systolic blood pressure remains at 150 mm Hg. D. BUN and creatinine levels return to normal.

Correct Answer: A. Urine output increases. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. The mannitol causes the cells in the brain to dehydrate mildly. The water inside the brain cells (intracellular water) leaves the cells and enters the bloodstream as the mannitol draws it out of the cells and into the bloodstream. Once in the bloodstream, the extra water is whisked out of the skull. When the mannitol gets to the kidneys, the kidneys filter the mannitol into the urine. The mannitol again draws the water with it, and diuresis (increased urination) ensues.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

Correct Answer: B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise. Cushing triad is a clinical syndrome consisting of hypertension, bradycardia and irregular respiration and is a sign of impending brain herniation. This occurs when the ICP is too high the elevation of blood pressure is a reflex mechanism to maintain CPP.

A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead, there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be: A. Ventricular tachycardia B. Ventricular fibrillation C. Atrial fibrillation D. Asystole

Correct Answer: B. Ventricular fibrillation Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles. VF is a WCT caused by irregular electrical activity and characterized by a ventricular rate of usually greater than 300 with discrete QRS complexes on the electrocardiogram (ECG). QRS morphology in VF varies in shape, amplitude, and duration with a prominent irregular rhythm.

A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following? A. Immediately defibrillate. B. Prepare for pacemaker insertion. C. Administer amiodarone (Cordarone) intravenously. D. Administer epinephrine (Adrenaline) intravenously.

Correct Answer: C. Administer amiodarone (Cordarone) intravenously. First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of antidysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Procainamide will terminate between 50% and 80% of ventricular tachycardias, and it will slow the conduction of those that it does not terminate. Amiodarone will convert about 30% of patients to sinus rhythm but is very effective in reducing the reversion rate of refractory SMVT.

A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client's blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take? A. Loosen tight clothing or accessories B. Assess for any bladder distention C. Raise the head of the bed D. Administer antihypertensive

Correct Answer: C. Raise the head of the bed The client is experiencing an autonomic dysreflexia, a life-threatening medical emergency that affects individuals with spinal injuries. Usually an individual with SCI has a blood pressure reading of 20 mm to 40 mm Hg above baseline. If this condition is suspected, the priority nursing action is to raise the head of bed or place the client in high Fowler's position. This promotes adequate ventilation and prevents the occurrence of hypertensive stroke.

The nurse is assessing a client with Parkinson's disease who was prescribed Carbidopa-levodopa. What is the highest priority assessment question? A. "Are you experiencing fewer tremors in your hands?" B. "Are you having less stiffness and rigidity?" C. "Have you had any difficulty with urination?" D. "Are you having any side effects of the medication?"

D. "Are you having any side effects of the medication?"

After receiving change of shift report on a medical unit, which patient should the nurse assess first? A. A patient with emphysema who has an oxygen saturation of 90% to 92% B. Apatient with pneumonia who has crackles bilaterally in the lung bases C. A patient with cystic fibrosis who has thick green colored sputum D. A patient with sepsis who has intercostal and suprasternal retractions

D. A patient with sepsis who has intercostal and suprasternal retractions Module 2 quiz

A client with a spinal cord injury (SCI) at level C3-4 is being triaged by the nurse in the emergency department. What is the priority nursing assessment? A. Determine Glasgow coma scale (GCS) score B. Assess motor function, sensory function, and deep tendon reflexes C. Obtain blood pressure, heart rate, and temperature D. Assess respiratory effort, rate, and oxygen saturation level

D. Assess respiratory effort, rate, and oxygen saturation level

The nurse is caring for a client who has experienced occasional premature ventricular contractions. What assessment data are most concerning to the nurse? A. Potassium 4.8 mEq/L B. Magnesium 2 mEq/L C. Heart rate 90 D. History of smoking

D. History of smoking

Which action is a nurse used to prevent harm by loss of tracheal tissue integrity in a client with a tracheostomy? A. Providing meticulous oral care every 8 hours B. Deflating the cuff for 15 minutes every 2 hours C. Feeding the client liquids rather than solid foods D. Maintaining cuff inflation pressure less than 25 cm h2o

D. Maintaining cuff inflation pressure less than 25 cm h2o To reduce tracheal damage keep the cuff pressure between 14-20 mmHg or 20-30 cm H2O (ideally 25 or less) Iggy pg 508

A patient has been receiving chemotherapy for several weeks has been admitted with dehydration and hypotension after having vomiting and diarrhea for four days. Which finding is most important for the nurse to report to the healthcare provider? A. Pale, cool, and dry extremities B. Heart rate 112 beats/min C. Decreased bowel sounds D. New onset of confusion

D. New onset of confusion Indicates neuro decline could be due to hypoxia.

A patient in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the patient breathing irregularly with one pupil is fixed and dilated. What action by the nurse is best? A. Ensure that informed consent is on the chart B. Document these findings and the patient's record C. Give the prescribe pre-procedure sedation D. Notify the providers of the findings immediately

D. Notify the providers of the findings immediately Signs of increased ICP-> pupil changes and irregular breathing.... Manage ICP first is the priority

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) a. "Chemo" gloves b. Face mask c. Impervious gown d. N95 respirator e. Shoe covers f. Eye protection

a. "Chemo" gloves b. Face mask c. Impervious gown f. Eye protection The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or "chemo" gloves), eye protection, a face mask, and a gown. An N95 respirator and shoe covers are not required.

The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information? a. "I will be careful if I need enemas for constipation." b. "I will use an electric shaver instead of a razor." c. "I should only eat soft food that is either cool or warm." d. "I won't be able to play sports with my grandkids."

a. "I will be careful if I need enemas for constipation." The thrombocytopenic client is at high risk for bleeding even from minor trauma. Due to the risk of injuring rectal and anal tissue, the client should not use enemas or rectal thermometers. This statement would indicate the client needs more information. The other statements are appropriate for the thrombocytopenic client.

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement would the nurse include in this client's teaching? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience d. "Take amiodarone daily to prevent PACs."

a. "Minimize or abstain from caffeine." PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse would explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first would try lifestyle changes to control them.

A nurse teaches a client with a new permanent pacemaker. Which instructions would the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." e. "Do not lift your left arm above the level of your shoulder for 8 weeks." The client would not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client would be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client would be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client would never apply pressure over the generator and would avoid tight clothing. The client would never have MRI because, whether turned on or off, the pacemaker contains metal. The client would be advised to inform all health care providers that he or she has a pacemaker.

A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) a. A sore that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing d. Near-daily abdominal pain e. Obvious change in a mole f. Frequent indigestion

a. A sore that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing e. Obvious change in a mole f. Frequent indigestion The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign.

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering antiulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule f. Turning and positioning the client at least every 2 hours

a. Adherence to proper hand hygiene b. Administering antiulcer medication c. Elevating the head of the bed d. Providing oral care per protocol f. Turning and positioning the client at least every 2 hours The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving antiulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, turning and positioning, and providing pulmonary hygiene measures. Suctioning is done AS NEEDED.

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication would the nurse being most beneficial? a. Alteplase b. Enoxaparin c. Unfractionated heparin d. Warfarin sodium

a. Alteplase Alteplase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows that this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting

A client receiving radiation therapy reports severe skin itching and irritation. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.) a. Apply approved moisturizers to dry skin. b. Apply steroid creams to the skin. c. Bathe the client using mild soap. d. Help the client pat skin dry after a bath. e. Teach the client to avoid sunlight. f. Make sure no clothing is rubbing the site.

a. Apply approved moisturizers to dry skin. c. Bathe the client using mild soap. d. Help the client pat skin dry after a bath. f. Make sure no clothing is rubbing the site e. Teach the client to avoid sunlight. The nurse can delegate applying moisturizer approved by the radiation oncologist using mild soap for bathing, and helping the client pat wet skin dry after bathing. Any clothing worn over the site should be soft and not create friction. Steroid creams are not used for this condition. Hot water will worsen the irritation. Client teaching is a nursing function.

A nurse is planning care for a client who has a PLT count of 10,000 mm. Which of the following interventions should the nurse include in the plan of care? a. Apply prolonged pressure to puncture site after blood sampling b. Administer epoetin alfa as prescribed c. Place the client in a private room d. Have the client use an oral topical anesthetic before meals

a. Apply prolonged pressure to puncture site after blood sampling Bleeding precautions, b is for anemia, c is neutropenic, d is for mucositis

A client has thrombocytopenia. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.) a. Apply the client's shoes before getting the client out of bed. b. Assist the client with ambulation. c. Shave the client with a safety razor only. d. Use a lift sheet to move the client up in bed. e. Use a water pressure device be set on low for oral care.

a. Apply the client's shoes before getting the client out of bed. b. Assist the client with ambulation. d. Use a lift sheet to move the client up in bed. Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the AP to put the client's shoes on before getting the client out of bed, assist with ambulation, shave the client with an electric razor, use a lift sheet when needed to reposition the client, and use a soft-bristled toothbrush for oral care. All of these measures help prevent client injury.

A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

a. Applying suction while inserting the catheter Suction would only be applied while withdrawing the catheter. The other actions are appropriate.

A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (select all that apply) a. Areas of paresthesia b. Involuntary eye movements c. Alopecia d. Increased salivation e. Ataxia

a. Areas of paresthesia b. Involuntary eye movements e. Ataxia

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown (pic): What action would the nurse take first? a. Assess airway, breathing, and circulation. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

a. Assess airway, breathing, and circulation. Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a potentially lethal dysrhythmia. The nurse would first assess if the client is alert, breathing, and has a pulse. If this client is pulseless, then the nurse would call a Code Blue and begin CPR. The treatment of choice for pulseless ventricular tachycardia is defibrillation. If the client has a pulse, then cardioversion would be indicated. Amiodarone is an appropriate antidysrhythmic, but it is not the first action.

A client receiving chemotherapy has a white blood cell count of 1000/mm3 (1 × 109/L). What actions by the nurse are most appropriate? (Select all that apply.) a. Assess all mucous membranes every 4 to 8 hours. b. Do not allow the client to eat meat or poultry. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance hourly. e. Take and record vital signs every 4 to 8 hours. f. Encourage activity the client can tolerate.

a. Assess all mucous membranes every 4 to 8 hours. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance hourly. e. Take and record vital signs every 4 to 8 hours. Depending on facility protocol, the nurse would assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Assisting the client with mobilization will also help prevent infection. Eating meat and poultry is allowed.

A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes that the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry, and skin turgor is poor. What action should the nurse perform next? a. Assess the 24-hour intake and output. b. Assess the client's oral cavity. c. Prepare to hang a normal saline bolus. d. Increase the infusion rate of the TPN.

a. Assess the 24-hour intake and output. This client has clinical indicators of dehydration, so the nurse calculates the patient's 24-hour intake, output, and fluid balance. This information is then reported to the health care provider. The client's oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The client's dehydration is most likely due to fluid shifts from the TPN, so increasing the infusion rate would make the problem worse, and is not done as an independent action for clients receiving TPN.

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? a. Assess the client's gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the client's job risks.

a. Assess the client's gait and balance. This client has symptoms of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is most important. Documentation would be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this would not be where the nurse starts investigating.

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? a. Assessing the IV site and blood return every hour b. Educating the client on side effects c. Monitoring the client for nausea d. Providing warm packs for comfort

a. Assessing the IV site and blood return every hour Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse would check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for some drugs, whereas for others ice is more comfortable. would monitor the site and check for blood return to prevent injury from infiltration or extravasation.

A client has mucositis. What actions by the nurse will improve the client's nutrition? (Select all that apply.) a. Assist with rinsing the mouth with saline frequently. b. Encourage the client to eat room-temperature foods. c. Give the client hot liquids to hold in the mouth. d. Provide local anesthetic medications to swish and spit. e. Remind the client to brush teeth gently after each meal. f. Offer the client fluids to drink each hour.

a. Assist with rinsing the mouth with saline frequently. b. Encourage the client to eat room-temperature foods. d. Provide local anesthetic medications to swish and spit.e. Remind the client to brush teeth gently after each meal. f. Offer the client fluids to drink each hour. Mucositis can interfere with nutrition. The nurse can help with rinsing the mouth frequently with water or saline; encouraging the client to eat cool, slightly warm, or room-temperature foods; providing swish-and-spit anesthetics; and reminding the client to keep the mouth clean by brushing gently after each meal. Drinking plenty of fluids (unless contraindicated for another condition) is another beneficial measure. Hot liquids would be painful for the client.

A nurse assesses a client and notes the client's position as indicated in the illustration (pic): How would the nurse document this finding? a. Decorticate posturing b. Decerebrate posturing c. Atypical hyperreflexia d. Spinal cord degeneration

a. Decorticate posturing The client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the client's condition has deteriorated. The primary health care provider, the charge nurse/team leader, and other health care team members would be notified immediately of this change in status. Decerebrate posturing consists of external rotation and extension of the extremities. Hyperreflexes present as increased reflex responses. Spinal cord degeneration presents frequently with pain and discomfort.

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL (61 mmol/L). The client is symptomatic but refuses blood transfusions. What medication does the nurse prepare to administer? a. Epoetin alfa b. Filgrastim c. Mesna d. Dexrazoxane

a. Epoetin alfa The client's hemoglobin is very low, so the nurse prepares to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Dexrazoxane helps protect the heart from cardiotoxicity from other agents.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient's spouse is very frustrated, stating that the patient's personality has changed and the situation is very difficult. What response by the nurse is most appropriate? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse that this is expected and he or she will have to learn to cope.

a. Explain that personality changes are common following brain injuries. Personality and behavior often change permanently after head injury. The nurse will explain this to the spouse. Asking the client about his or her behavior isn't useful because the patient probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles his or her concerns and feelings.

The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) a. Flexed trunk b. Long, extended steps c. Slow movements d. Uncontrolled drooling e. Tachycardia

a. Flexed trunk c. Slow movements d. Uncontrolled drooling Key features of Parkinson disease include a flexed trunk, slow and hesitant steps, bradykinesia, and uncontrolled drooling. Tachycardia is not a key feature of this disease.

A nurse is in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? Select all that apply a. Headache b. Dilated pupils c. Tachycardia d. Decorticate posturing e. Hypotension

a. Headache b. Dilated pupils d. Decorticate posturing C & E are wrong because you see hypertension and bradycardia with ICP

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

a. Heart rate of 34 beats/min c. Urine output less than 30 mL/hr d. Decreased level of consciousness Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke. Which evidence-based nursing actions are indicated for this client? (Select all that apply.) a. Hyperoxygenate the client before and after suctioning. b. Avoid sudden or extreme hip or neck flexion. c. Provide oxygen to maintain an SaO2 of 95% or greater. d. Maintain the client in a supine position at all times. e. Avoid clustering care nursing activities and procedures. f. Provide environmental stimulation to improve cognition.

a. Hyperoxygenate the client before and after suctioning. b. Avoid sudden or extreme hip or neck flexion. c. Provide oxygen to maintain an SaO2 of 95% or greater. e. Avoid clustering care nursing activities and procedures. These precautions help prevent further increases in ICP. Clustering nursing activities and procedures and providing stimulation can increase ICP and should be avoided.

A nurse is planning care for a client and has meningitis and an at risk for increased intracranial pressure ICP. Which of the following action should the nurse plan to take? Select all that apply a. Implement seizure precautions b. Perform neurological checks 4 times a day c. Administer morphine for the report of neck and generalized pain d. Turn off room lights and television e. Monitor for impaired extraocular movements f. Encourage the client to cough frequently

a. Implement seizure precautions d. Turn off room lights and television e. Monitor for impaired extraocular movements Neuro Checks should be at least every 2-4 hours, opioids should be avoided for clients at risk for ICP, they can mask the loc,

The nurse assesses a client who has meningitis. Which sign(s) and symptom(s) would the nurse anticipate? (Select all that apply.) a. Photophobia b. Decreased level of consciousness c. Severe headache d. Fever and chills e. Bradycardia

a. Photophobia b. Decreased level of consciousness c. Severe headache d. Fever and chills All of the choices except for bradycardia are key features of meningitis. Tachycardia is more likely than bradycardia due to the infectious process and fever.

A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week age. The client has no muscle control of the lower limbs, bowel, or bladder. Which of following should be the nurse's highest priority? a. Prevention of further damage to the spinal cord b. Prevention of contractures of the lower extremities c. Prevention of skin breakdown in areas that lack sensation d. Prevention of postural hypotension when placing the client in a wheelchair

a. Prevention of further damage to the spinal cord The greatest risk to a client during the acute phase of an SCI is further damage to the spinal cord. When planning care, the priority intervention to take is to prevent further damage by minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord

The nurse is performing an assessment of cranial nerve III. Which testing is appropriate? a. Pupil constriction b. Deep tendon reflexes c. Upper muscle strength d. Speech and language

a. Pupil constriction CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid movement.

A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern? a. Request a prescription for an antispasmodic drug such as baclofen. b. Prepare the client for deep brain stimulation surgery. c. Refer the client to a massage therapist to relax the muscles. d. Consult with the occupational therapist for self-care assistance.

a. Request a prescription for an antispasmodic drug such as baclofen. Clients who have multiple sclerosis often have muscle spasticity which may be reduced by drug therapy, such as baclofen. While massage and assistance with self-care may be helpful, these interventions are not the most effective and therefore not the most appropriate in managing muscle spasticity. If drug therapy and other interventions do not help reduce muscle spasms, some client are candidates for deep brain stimulation as a last resort.

A nurse is caring for a client admitted for Non-Hodgkin's lymphoma and chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nurse is most important? a. Request an order for serum electrolytes and uric acid. b. Increase the client's IV infusion rate. c. Instruct assistive personnel to strain all urine. d. Administer an IV antiemetic.

a. Request an order for serum electrolytes and uric acid. This client's reports are consistent with tumor lysis syndrome, for which he or she is at risk due to the diagnosis. Early symptoms of TLS stem from electrolyte imbalances and can include lethargy, nausea, vomiting, anorexia, flank pain, muscle weakness, cramps, seizures, and altered mental status. The nurse would notify the primary health care provider and request an order for serum electrolytes. Hydration is important in both preventing and managing this syndrome, but the nurse would not just increase the IV rate. Assistive personnel may need to strain the client's urine and the client may need an antiemetic, but first the nurse would assess the situation further by obtaining pertinent lab tests.

A nurse is reinforcing teaching with a client who has Parkinson's disease and has a new prescription for a dopamine receptor agonist (bromocriptine). Which of the following instructions should the nurse include? a. Rise slowly when standing b. Exprect urine to become dark colored c. Avoid foods containing tyramine d. Report any skin discoloration

a. Rise slowly when standing Orthostatic hypotension is a common side effect of a dopamine receptor agonist. Rising slowly will help decrease the risk of dizziness and lightheadedness.

A nurse is admitting a client who has suspected MI and a HX of angina. Which of the following findings will help the nurse distinguish stable angina from an MI? a. Stable angina can be relieved with rest and nitroglycerin b. The pain of an MI resolves in less than 15 min c. The type of activity that causes an MI can be identified d. Stable angina can occur for longer than 30 min

a. Stable angina can be relieved with rest and nitroglycerin Pain associated with an MI usually lasts longer than 30 min and requires opioid analgesics for relief. There is no specific type of activity that causes an MI. The pain of stable angina is usually less than 15 min.

A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) a. Unique facility identifier b. Lot number related to the donor c. Name of the client receiving blood d. ABO group and Rh type of the donor e. Blood type of the client receiving blood f. Signature line for 2-person verification

a. Unique facility identifier b. Lot number related to the donor d. ABO group and Rh type of the donor The ISBT universal bar-coding system includes four components: (1) the unique facility identifier, (2) the lot number relating to the donor, (3) the product code, and (4) the ABO group and Rh type of the donor. Positive identification by two qualified health care providers is essential although automated bar coding is acceptable in some care areas. However, a signature line is not required on the blood label

A nurse is caring for a client who asks why the provider prescribed a daily aspirin. Which of the following responses should the nurse make? a. "Aspirin relieves pain due to myocardial ischemia." b. "Aspirin reduces the formation of blood clots that could cause a heart attack." c. "Aspirin dissolves clots that are forming in your coronary arteries." d. "Aspirin relieves headaches that are caused by other medications."

b. "Aspirin reduces the formation of blood clots that could cause a heart attack." Aspirin decreases platelet aggregation that can cause a myocardial infarction

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? a. "Avoid getting salt water on the radiation site." b. "Do not expose the radiation area to direct sunlight." c. "Have a wonderful time and enjoy your vacation!" d. "Remember you should not drink alcohol for a year."

b. "Do not expose the radiation area to direct sunlight." The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse would inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate? a. "Are you getting adequate rest and sleep each day?" b. "It is normal to be fatigued even for months afterward." c. "This is not normal and I'll let the primary health care provider know." d. "Try adding more vitamins B and C to your diet."

b. "It is normal to be fatigued even for months afterward." Radiation-induced fatigue can be debilitating and may last for months after treatment has ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client (and family) understands this is normal.

A nurse is caring for a client who is 4 hr postop following coronary artery bypass grafting (CABG) surgery. The client is able to inspire 200 mL with the incentive spirometer, then declines to try to cough because of fatigue and pain. Which of the following actions should the nurse take? a. Allow the client to rest, and return in 1 hr b. Administer IV bolus analgesic, and return in 15 min c. Document the 200 mL as an appropriate inspired volume d. Tell the client coughing after incentive spirometry is required.

b. Administer IV bolus analgesic, and return in 15 min Providing adequate analgesia and returning in 15 min will reduce pain and improve coughing effectiveness. Coughing and deep breathing should be performed every 2 hours not hourly.

A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16-22 mmHg. Which of the following actions should the nurse take to decrease the potential for raising the clients ICP? Select all that apply a. Suction the endotracheal tube frequently b. Decrease the noise level in the client's room c. Elevate the client's head on two pillows d. Administer a stool softener e. Keep the client well hydrated

b. Decrease the noise level in the client's room d. Administer a stool softener Stool softener helps the client from not bearing down which can increase pressure. Suctioning increases ICP, the double pillows would cause hyperflexion in the neck-the HOB should be at least 30 instead, Overhydration can worsen ICP fluids must be closely monitored.

A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure from the emergency department. What action does the nurse take first? a. Assessing that the ventilator settings are correct b. Ensuring that 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

b. Ensuring that there is a bag-valve-mask in the room

A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury. What other assessment finding will the nurse anticipate for this client? a. Quadriplegia b. Flaccid bowel c. Spastic bladder d. Tetraparesis

b. Flaccid bowel A low-level complete spinal cord injury (SCI) is a lower motor neuron injury because the reflect arc is damaged. Therefore, the client would be expected to have paraplegia and a flaccid bowel and bladder. Quadriplegia and tetraparesis are seen in clients with cervical or high thoracic SCIs.

A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order would 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.

b. Increase the heparin rate.

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm (pic): After calling for assistance and a defibrillator, what action would the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the client's family about code status

b. Initiate cardiopulmonary resuscitation (CPR). The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse would start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status would already be known by the nurse prior to this event.

A client has a platelet count of 9800/mm3 (9800 × 109/L). What action by the nurse is most appropriate? a. Assess the client for calf pain, warmth, and redness. b. Instruct the client to call for help to get out of bed. c. Obtain cultures as per the facility's standing policy. d. Place the client on protective Isolation Precautions.

b. Instruct the client to call for help to get out of bed. A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client would be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell counts.

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? a. Fluctuations in blood pressure b. Loss of cognitive function c. Ineffective cough d. Drooping eye lids

b. Loss of cognitive function Other answers not associated with MS

A nurse assesses a patient who is recovering from a lumbar puncture (LP). Which complication of this procedure would alert the nurse to urgently contact the primary health care provider? a. Weak pedal pulses b. Nausea and vomiting c. Increased thirst d. Hives on the chest

b. Nausea and vomiting The nurse would immediately contact the provider if the client experiences a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased intracranial pressure. Weak pedal pulses, increased thirst, and hives are not complications of an LP.

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? a. Assess the client's lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs

b. Notify the Rapid Response Team. This client has signs and symptoms of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority

A nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? Select all that apply a. Decreased vision b. Pill-rolling tremor of the fingers c. Shuffling gait d. Bilateral ankle edema e. Lack of facial expression f. drooling

b. Pill-rolling tremor of the fingers c. Shuffling gait e. Lack of facial expression f. drooling tremors, altered gait, mask like face and drooling due to difficulty swallowing are all manifestations of PD

A nurse assesses a client with atrial fibrillation. Which manifestation would alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

b. Speech alterations Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

Which of these nursing actions by the LPN for a client who is in protective isolation following chemotherapy indicates a need for immediate intervention by the charge nurse? a. The LPN refuses to take in a moist potted plant to the client b. The LPN delivers a fruit tray including apples, pears and bananas to the client c. The LPN requires the UAP to practice effective hand hygiene when providing care to the client d. The LPN notifies the healthcare provider that the client's temperature is 100.8 F

b. The LPN delivers a fruit tray including apples, pears and bananas to the client

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates several times a day in the room. b. The patient's visitors bring in some fresh peaches from home. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

b. The patient's visitors bring in some fresh peaches from home. Fresh fruit can have bacteria on it and they are NEUTROPENIC therefore it is a contraindication

A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client's discharge teaching? a. "Be sure that you use a wheelchair when you go out in public." b. "Wear an undergarment brief at all times in case of incontinence." c. "Avoid overexertion, stress, and extreme temperature if possible." d. "Avoid having sexual intercourse to conserve energy."

c. "Avoid overexertion, stress, and extreme temperature if possible." Clients who have multiple sclerosis have chronic fatigue and are prone to disease exacerbation (flare-up) is they overexert, are stressed, or are exposed to extreme temperature and humidity. They should not wear briefs unless they have actual problems with continence and should not use a wheelchair if they are able to ambulate with a cane or walker. Maintaining independence and self-esteem is important, so participating in sexual activities is encouraged.

A nurse is assessing a client who is suspected of having ARDS. The nurse is confused that although the client appears dyspneic and the oxygen saturation is 88% on 6 L/min of oxygen, the client's lungs are clear. What explanation does the more senior nurse provide? a. "The client is too dehydrated for moist-sounding lungs." b. "The client hasn't started having any bronchospasm yet." c. "Lung edema is in the interstitial tissues, not the airways." d. "Clients with ARDS usually have clear lung sounds."

c. "Lung edema is in the interstitial tissues, not the airways." The clear lung sounds are due to the fact that the edema is found in the lung interstitial tissues, where it can't be auscultated, instead of in the airways. It is not related to the client being dehydrated or having bronchospasm. The statement about all clients with ARDS having clear lung sounds does not provide any information

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next? a. Initiate oxygen via a nasal cannula. b. Recheck the client's blood pressure. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker

c. Palpate the bladder for distention. The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury such as s stroke. The other actions are not appropriate for this complication.

A nurse administers prescribed adenosine to a client. Which response would the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

c. Short period of asystole Clients usually respond to adenosine with a short period of asystole, bradycardia with long pauses, nausea, or vomiting. Adenosine has no impact on intraocular pressure nor does it cause increased heart rate or hypertensive crisis.

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands changes associated with this disease? a. "His masklike face makes it difficult to communicate, so I will use a white board." b. "He should not socialize outside of the house due to uncontrollable drooling." c. "This disease is associated with anxiety causing increased perspiration." d. "He may have trouble chewing, so I will offer bite-sized portions."

d. "He may have trouble chewing, so I will offer bite-sized portions." Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client would be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the client's masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous system's response.

The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first? a. Client with amnesia for the incident b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg and on a ventilator d. Client who has a temperature of 102° F (38.9° C)

d. Client who has a temperature of 102° F (38.9° C) A fever is a poor prognostic indicator in patients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and amnesia for the incident are all either expected or positive findings.

A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment finding would be the priority for the nurse to report to the primary health care provider? a. Mild temporal headache b. Pupils equal and react to light c. Alert and oriented × 3 d. Decreasing level of consciousness

d. Decreasing level of consciousness A decreasing level of consciousness is the first sign of increasing intracranial pressure, a potentially severe and possibly fatal complication of a traumatic brain injury (TBI). A mild headache would be expected for a client having a TBI. Equal reactive pupils and being alert and oriented are normal assessment findings.

The nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

d. Evaluate respiratory status The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise due to interference with diaphragmatic innervation. The other actions would be performed after airway and breathing are assessed.

A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse? a. Teach the client to walk more quickly when ambulating b. Complete passive ROM exercises daily c. Place the client on a low protein, low calorie diet d. Give the client extra time to perform activities

d. Give the client extra time to perform activities Bradykinesia is abnormally slow movement and is seen in clients with PD. They should be given extra time and encouraged to remain active.

The nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client's plan of care? a. Restrain the client to prevent falling. b. Ensure that the client uses incentive spirometry. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater.

d. Keep the head of the bed at 30 degrees or greater. Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Pursed-lip breathing increases exhalation of carbon dioxide; incentive spirometry expands the lungs. The client should not be restrained to prevent falls. Other less restrictive interventions should be used to maintain client safety.

A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action does the nurse take first? a. Administer oxygen and reassess. b. Auscultate the client's lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.

d. Prepare to assist with intubation This client has signs and symptoms of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? a. Neurogenic shock b. Paralytic ileus c. Stress ulcer d. Respiratory compromise

d. Respiratory compromise ABCs

The nurse is collaborating with the occupational therapist to assist a client with a complete cervical spinal cord injury to transfer from the bed to the wheelchair. What ambulatory aid would be most appropriate for the client to meet this outcome? a. Rolling walker b. Quad cane c. Adjustable crutches d. Sliding board

d. Sliding board A client who has a complete cervical spinal cord injury is unable to use any extremity except for parts of the hands and possibly the lower arms. Therefore, the client would be unable to use any of these ambulatory aids except for a sliding board, also known as a slider, which provides a "bridge" between the bed and a chair. The client uses his or her arms in a locked position to support the body while moving slowly across the board.

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment would the nurse wear? (Select all that apply.) a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves

d. Surgical mask e. Gloves Meningococcal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers would wear a surgical mask when within 6 feet (1.8 m) of the client and would continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority? a. Helping clients adjust to their appearance b. Reassuring clients that this change is temporary c. Referring clients to a reputable wig shop d. Teaching measures to prevent scalp injury

d. Teaching measures to prevent scalp injury

A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate? a. Crush the medications if the client cannot swallow them. b. Give one medication at a time with a full glass of water. c. No special precautions are needed for these medications. d. Wear personal protective equipment when handling the medications.

d. Wear personal protective equipment when handling the medications. During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed.

The nurse is caring for a patient in the ER with thoracic trauma from a motor vehicle collision. The patient is restless, confused, and agitated. The patient's ABG results are the following: pH -7.30, PaCO2-66, HCO3- 28. Based on the ABG interpretation, what is the priority nursing action? A. Call the provider and prepare to intubate B. Administer oxygen 2 L/min via nasal cannula C. Obtain a full set of vital signs and assess for pain D. Administer normal saline 0.9% at 100 mL/hour

A. Call the provider and prepare to intubate Module 2 quiz

The nurse is caring for a client who sustained a spinal cord injury four days ago and now has quadriplegia. What assessments are priority in preventing pressure injuries? Select all that apply A. Complete the Braden Scale every shift B. Assess the client for constipation and urinary retention C. Auscultate the client's heart and lung sounds D. Assess bony prominences for actual or potential skin breakdown E. Assess the client's total protein, albumin, and prealbumin levels

A. Complete the Braden Scale every shift D. Assess bony prominences for actual or potential skin breakdown E. Assess the client's total protein, albumin, and prealbumin levels

The nurse is caring for a patient who was recently extubated. Upon assessment, the nurse notes the patient has difficulty coughing up secretions, dyspnea, and has a high pitched crowing sound. What are the nursing priority action(s)? Select all that apply A. Notify provider immediately B. Prepare for intubation C. Reassure the patient these are expected findings D. Administer racemic epinephrine E. Encourage the patient to cough and deep breathe

A. Notify provider immediately B. Prepare for intubation D. Administer racemic epinephrine Patient is having trouble protecting their airway and now are showing s/s of airway obstruction. Crowing sound=stridor which means reintubation will happen. Racemic epinephrine is a drug that is inhaled to help open the airway up, used for stridor or airway obstruction post extubation. These are not expected findings and pulmonary hygiene is not indicated in this scenario.

The nurse is preparing to administer of blood transfusion what action is most important? A. Put on pair of gloves B. Place the client on NPO status C. Place the client isolation D Document transfusion

A. Put on pair of gloves Module 1 Quiz

What action should the nurse take when the client is exhibiting clinical manifestation of a possible blood transfusion reaction? Select all the apply A. Stop the transfusion B. Notify provider C. Obtain a type and cross screen D. Check vital signs E. Send the blood bag and tubing to the blood bank for analysis F. Maintain an IV infusion with 0.9% sodium chloride

A. Stop the transfusion B. Notify provider D. Check vital signs E. Send the blood bag and tubing to the blood bank for analysis F. Maintain an IV infusion with 0. 9% sodium chloride Module 1 Quiz

A patient has an endotracheal tube and mechanical ventilator for pulmonary embolism. Which nursing interventions are appropriate for this patient? Select all that apply. A. Suction as needed to keep the airway patent B. Suction the airway with oral suction equipment C. Position the tubing so it does not pull on the airway D. Apply suction when withdrawing the suction catheter E. Keep a resuscitation bag at the bedside at all times

A. Suction as needed to keep the airway patent C. Position the tubing so it does not pull on the airway D. Apply suction when withdrawing the suction catheter E. Keep a resuscitation bag at the bedside at all times

The nurse on the MEDSURG unit receives hand off report on 4 patients. Based on the arterial blood gases below, which patient is the priority to assess first? A. pH= 7.21, CO2= 58, O2= 59, HCO3=19 B. pH= 7.33, CO2= 44, O2= 81, HCO3=24 C. pH= 7.59, CO2= 23, O2= 79, HCO3=20 D. pH= 7.40, CO2= 36, O2= 86, HCO3=23

A. pH= 7.21, CO2= 58, O2= 59, HCO3=19 A is uncompensated, respiratory acidosis with severe hypoxemia and metabolic acidosis

A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? A. Apply oxygen 100% B. Assess the respiratory rate C. Ensure a patent airway D. Administer 1 L of crystalloid fluid bolus

C. Ensure a patent airway ABCs! Priority for any chest trauma is ABCs! The other answers are correct but not the priority action.

A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of febrile transfusion reaction? Select all that apply. A. Temperature change from 37 C(98.6F) pre-transfusion to 37.2 C(99.0F) B. Current blood pressure 178/90 mmHG C. Heart rate change from 88/min pre-transfusion to 120/min D. Client report of itching E. Client appears flushed

C. Heart rate change from 88/min pre-transfusion to 120/min E. Client appears flushed Tachycardia and flushed appearance is an indication of a febrile transfusion reaction. You would need an increase of 1 F or 0.5 C temperature change and hypotension to indicate febrile transfusion reaction. Other s/s include chills and tachypnea, Itching is associated with allergic reaction. ATI medsurg pg 263, Iggy pg 819

The nurse is caring for a client with a traumatic brain injury. The client's intracranial pressure (ICP) has changed from 14 to 21mmHg. Which nursing interventions are appropriate to decrease increased intracranial pressure? (Select all that apply) A. Place the client in a supine position. B. Assess the client's cough and gag reflex. C. Maintain a quiet, calm, and dark environment. D. Remove the cervical collar to relieve pressure. E. Elevate the bed to semi-Fowler's position.

C. Maintain a quiet, calm, and dark environment. E. Elevate the bed to semi-Fowler's position.

The nurse receives hand off report on 4 patients who all have endotracheal intubation and mechanical ventilation. Which patient is the priority to assess first? A. Patient with head of bed at 25 degrees B. Patient with bilateral wrist restraints who is calm and cooperative C. Patient with decreased right side lung sounds D. Patient with bilateral crackles and increased oral secretions

C. Patient with decreased right side lung sounds This is a sign of pneumothorax which is a possible complication of endotracheal intubation so they would be priority, patient D would be next because they need suctioning.

A nurse is caring for a patient who is receiving mechanical ventilation via endotracheal two. Which of the following action should the nurse take? A. Apply mittens if self extubation is attempted B. Perform oral care once per shift C. Monitor ventilator settings as needed D. Document to placement in centimeters at the lips

D. Document to placement in centimeters at the lips We document the tube in cm at the teeth or lips Soft restraints not mittens should be applied if pt attempts self exhumation, oral care is performed every 2 hours, ventilator settings should be checked hourly or at least every 8 hours against the computer.

The client receiving TPN via central venous catheter (CVC) is scheduled for an IV anabiotic. The nurses first action is to: A. Check the TPN for compatibility with anabiotic B. Turn off the TPN for 30 minutes to run the antibiotic C. Flush the TPN line with normal saline then run the antibiotic D. Ensure that the client has a separate line for the antibiotic

D. Ensure that the client has a separate line for the antibiotic Module 1 Quiz

The nurse is caring for a patient who was extubated 30 minutes ago. What is an expected assessment finding for this patient? A. Stridor B. Dyspnea C. Restlessness D. Hoarseness

D. Hoarseness

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take? A. Help the patient to sit in a more upright position B. Suction the patient's oropharynx C. Teach the patient to cough and deep breathe D. Increase the oxygen flow rate

D. Increase the oxygen flow rate Module 2 quiz

The nurse in the neurology unit is admitting a young adult client with a closed head injury. The client is sleepy and arousable, oriented to person, place, time, and situation, and has clear liquid draining from the nose. What is the priority intervention? A. Encourage the client to blow their nose to remove secretions. B. Reposition the client from side to side. C. Apply packing in the nose to prevent further drainage. D. Maintain the head of bed (HOB) elevated at least 30 degrees.

D. Maintain the head of bed (HOB) elevated at least 30 degrees.

A client with a mild traumatic brain injury asks why he cannot have medication for his headache. The nurse's response is based on the understanding that analgesics could: A. Stimulate the central nervous system B. Counteract the effects of antibiotics C. Elevate the blood pressure D. Mask symptoms of increasing intracranial pressure

D. Mask symptoms of increasing intracranial pressure

A nurse is reviewing the health records of 5 clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (ARDS)? SATA a. A client who experience a near drowning incident b. A client following coronary artery bypass graft surgery c. A client who has a hemoglobin of 15.1 mg/dL d. A client who has dysphagia e. A client who experienced acute drug toxicity

a. A client who experience a near drowning incident (at risk due to lung trauma and cerebral edema) b. A client following coronary artery bypass graft surgery (at risk due to chest trauma) d. A client who has dysphagia (at risk due to aspiration risk) e. A client who experienced acute drug toxicity (at risk due to damage in central nervous system.) And a client with low Hgb is at risk

A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? (SATA) a. A client who has a BMI of 30 b. A female client who is postmenopausal c. A client who has a fractured femur d. A client who is a marathon runner e. A client who has chronic atrial fibrillation

a. A client who has a BMI of 30 c. A client who has a fractured femur e. A client who has chronic atrial fibrillation Obesity is a risk, long bone fractures increase the risk of fat emboli, chronic a fib has turbulent blood flow in the heart and increases blood clot. Estrogen increases the risk, a postmenopausal has less estrogen.