NRS 222 Final questions
What fluid/electrolyte concerns do we have for patients with burns?
- hyponatremia - hyperkalemia - third spacing (fluid in interstitial space) - Protein loss - Fluid loss
The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? A. Assess the blood pressure by Doppler B. Estimate the systolic pressure as 60 mmHg C. Obtain an electric blood pressure monitor D. Record the blood pressure as "not assessable"
A. Assess the blood pressure by Doppler
What should the nurse identify as symptoms of hypovolemic shock in a patient? Select all that apply. A. Capillary refill time greater than 3 seconds B. Restlessness C. Temperature of 97.6F D. Decrease in blood pressure of 20 mmHg when the patient sits up E. Sinus bradycardia of 55 bpm
A. Capillary refill time greater than 3 seconds B. Restlessness D. Decrease in blood pressure of 20 mmHg when the patient sits up
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention? A. Daily weight B. intake and output C. serum sodium D. serum potassium
A. Daily weight
A nurse is caring for a child who has electrical burns on the lower arms and hands. Which of the following findings indicate the child is experiencing a complication of the injury? A. Dark urine B. 2+ radial pulses C. Respiratory rate of 20/min D. Minimal pain
A. Dark urine may indicate myoglobinuria--which will lead to renal failure
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take? A. Discontinue the medication infusion B. Prepare for an emergency c-section C. Assess maternal blood glucose D. Place the client in the Trendelenburg position
A. Discontinue the medication infusion
A nurse is planning care for a client who has cirrhosis. Which of the following actions should the nurse take? Select all that apply. A. Give furosemide B. Administer Warfarin C. Implement a low-sodium diet D. Measure the client's abdominal girth E. Encouraging weight lifting
A. Give furosemide D. Measure the client's abdominal girth
A community health nurse is performing client triage while participating in a disaster drill. The nurse should recommend that which of the following client injuries receives treatment first? A. Hemothorax B. Open humeral fracture C. Multiple deep abrasions on the arms and face D. Superficial partial-thickness burns on both legs
A. Hemothorax
A nurse is planning care for a client who has deep partial-thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? A. Initiate range-of-motion exercises B. Use clean technique to provide wound care C. Place the client on a low-protein diet D. Maintain the client on bed rest
A. Initiate range-of-motion exercises acute phase is 36-48 hr after. The nurse should initiate range of motion to maintain mobility and prevent contractures
A nurse is planning care for a client who sustained severe burn injuries. Which of the following intervention should the nurse include in the plan of care? Select all that apply. A. Limit visitors in the client's room B. Encourage fresh vegetables in the diet C. Increase protein intake D. Instruct the client to consume 2000 cal/day. E. Restrict fresh flowers in the room
A. Limit visitors in the client's room C. Increase protein intake E. Restrict fresh flowers in the room
A nurse is caring for a postpartum client who saturates a perineal pad in 10 min. Which of the following actions should the nurse take first? A. Massage the client's fundus B. Assess the client's blood pressure C. Assess for bladder distention
A. Massage the client's fundus
A nurse is planning care for an intubated client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan of care? A. Place in a prone position B. Offer high-protein and high-carbohydrate foods frequently C. Administer low-flow oxygen continuously via nasal cannula D. Encourage oral intake of at least 3.000 ml of fluids a day
A. Place in a prone position
A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? A. Practice effective hand hygiene B. Avoid serving raw foods C. Wear a bearer during sexual contact D. Avoid eating at fast food
A. Practice effective hand hygiene
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia? A. Provide oral hygiene at least every 12 hours and as needed B. Place the client in the supine position C. Reposition every 4 hr D. Provide humidity by maintaining moisture within the ventilator tubing
A. Provide oral hygiene at least every 12 hours and as needed
A patient is brought to the emergency department with manifestations of anaphylactic shock. What should the nurse assess as possible causes for this disorder? Select all that apply. A. Recent diagnostic imaging tests B. Recent bee sting C. History of latex allergy D. Recent MI E. Ingestion of drugs
A. Recent diagnostic imaging tests B. Recent bee sting C. History of latex allergy E. Ingestion of drugs
A nurse is providing dietary teaching to a client who has chronic kidney disease. The nurse should instruct the client to limit which of the following nutrients? Select all that apply. A. Sodium B. Phosphorus C. Calcium D. Protein E. Magnesium
A. Sodium B. Phosphorus D. Protein
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of the highest priority? A. Suction saliva from the client's mouth B. Perform passive range of motion on each extremity C. Monitor the client's electrolyte levels D. Record the client's intake and output
A. Suction saliva from the client's mouth
A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? A. Superficial thickness B. Superficial partial thickness C. Deep partial thickness D. Full thickness
A. Superficial thickness
A nurse is assessing a client who sustained deep partial thickness and full thickness burns over 40% of the body 24 hours ago. Which of the following are findings common during this phase? Select all that apply. A. Temperature 36.1°C/97°F B. Bradycardia C. Hyperkalemia D. Hyponatremia E. Decreased hematocrit
A. Temperature 36.1°C/97°F C. Hyperkalemia D. Hyponatremia Decrease temperature can occur in the first few hours following a burn. Hematocrit increases during the initial phase of burn due to hemoconcentration.
A nurse is assessing an infant who develops respiratory distress, absence of breath sounds on one side, and deviation of the trachea away from the affected side. Based on these manifestations, which of the following conditions is the infant experiencing? A. Tension pneumothorax B. Flail chest C. Pulmonary contusion D. Fractured rib
A. Tension pneumothorax
A nurse is caring for a client following his first hemodialysis treatment. The client reports headache, nausea, and restlessness. The nurse identifies these findings as indicators of which of the following complications? A. dialysis disequilibrium B. air embolism C. peritonitis D. septicemia
A. dialysis disequilibrium
A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? A. dry the skin B. test vitamin k C. putting an identification armband on D. eye prophylaxis
A. dry the skin temperature regulation!!
The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment finding indicates that the patient is developing neurogenic shock? Select all that apply. A. warm, dry skin B. palpitations C. hypotension D. abdominal cramps E. bradycardia
A. warm, dry skin C. hypotension E. bradycardia
Which finding should the nurse expect while assessing a client with sepsis? (Select all that apply.) A.Leukocytosis B.Hypertension C.Tachypnea D.Bradycardia E.Confusion
A.Leukocytosis C.Tachypnea E.Confusion
A nurse is teaching a newly licensed nurse about the purpose pf a CA125 test. Which of the following statements would the nurse include in the teaching? A. A CA 125 is used to confirm a diagnosis of cancer B. A CA 125 is used to monitor the client's progress during treatment C. A CA 125 is used to identify the cell differentiation D. A CA 125 is used to measure the amount of cancer
B. A CA 125 is used to monitor the client's progress during treatment
A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take? A. Keg-gal's B. Assist the client to the bathroom to void C. Move to the left lateral position D. Ask the client to rate their pain
B. Assist the client to the bathroom to void
A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on the chest and arms D. Flushed, dry skin E. Abdominal distension
B. Bleeding at the venipuncture site C. Petechiae on the chest and arms E. Abdominal distension The formation of large amounts of microemboli in the circulation depletes the body's platelets and clotting factors. As a result, uncontrollable bleeding can occur, as manifested by bleeding at the venipuncture site, petechiae on the chest and arms, and bleeding in the abdominal cavity resulting in abdominal distension due to internal bleeding.
A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill. The nurse suspects the patient is experiencing which type of shock? A. Hypovolemic B. Cardiogenic C. Anaphylactic D. Obstructive
B. Cardiogenic
A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? A. Estimation of burn injury B. Characteristics of the cough and sputum C. Extent of peripheral edema D. Amount of urine output
B. Characteristics of the cough and sputum
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? A. Notify the client's provider B. Document the findings and continue to monitor the client C. Increase the frequency of fundal massage D. Encourage the client to empty their bladder
B. Document the findings and continue to monitor the client When the fundus is displaced to the right, that's when the bladder may be full and may need emptied
A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? A. Blood glucose 110 mg/dL B. Increased serum amylase C. WBC 9,000/mm3 D. Decreased bilirubin
B. Increased serum amylase
13. A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take? A. Place the newborn under a radiant warmer B. Obtain blood glucose by heel stick C. Monitor the newborn's blood pressure D. Initiate phototherapy
B. Obtain blood glucose by heel stick
A nurse is caring for a 4-year-old child who has superficial partial-thickness burns over 50% of his body. To meet the nutritional needs of the child, which of the following actions should the nurse plan to take? A. Administer pancrelipase to the child prior to each meal B. Supplement the child's feedings with enteral feedings C. Provide the child with a low-protein meal D. Perform dressing changes 10 min prior to the child's meals
B. Supplement the child's feedings with enteral feedings
A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? A. The client states having a severe headache. B. The client's bladder becomes distended. C. The client's blood pressure becomes elevated. D. The client states having nasal congestion.
B. The client's bladder becomes distended.
A nurse is caring for a client who has end-stage kidney disease (ESKD) and reports having shortness of breath and swelling in his lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and elevated blood pressure. The nurse should suspect which of the following based on the client's manifestations? A. hyperkalemia B. hypervolemia C. hyponatremia D. hypocalcemia
B. hypervolemia
A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care? A. hypocalcemia B. hypoglycemia C. hypomagnesemia D. hyperbilirubinemia
B. hypoglycemia
A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids did not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see? A. decreased WBC B. increased serum amylase C. increased serum lipase D. increased serum calcium
B. increased serum amylase
A nurse is caring for a client receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis? A. hyperactive bowel sounds B. nausea and vomiting C. bradycardia D. increased urinary output
B. nausea and vomiting
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure? A. hypotension B. restlessness C. tachycardia D. amnesia
B. restlessness
A nurse in the ED is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? (select all that apply) A. heart rate 60/min B. seizure activity C. respiratory rate 42/min D. increased urine output E. weak, thready pulse
B. seizure activity C. respiratory rate 42/min E. weak, thready pulse
A nurse in the emergency department is admitting a child who has full-thickness burns over 45% of his body. Which of the following actions should the nurse take first? A. Administer IV morphine B. Administer topical antimicrobials C. Administer IV fluid replacement D. Administer tetanus prophylaxis
C. Administer IV fluid replacement
A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has A. Kussmaul breathing. B. apneustic breathing. C. Cheyne-Stokes respirations (CSR). D. stridor.
C. Cheyne-Stokes respirations (CSR).
A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching? A. Consume 40-50 g of protein daily B. Avoid salting of foods during cooking C. Drink 48-64 ounces of water daily D. Limit intake of whole grains, raw fruits, and vegetables
C. Drink 48-64 ounces of water daily
A nurse is caring for a newborn immediately after birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? A. Adjust the temperature in the room to 75ºF B. Place the baby under a biliary lamp C. Drying the newborn's skin thoroughly D. Rinsing the newborn with luke warm water
C. Drying the newborn's skin thoroughly
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take? A. Teach controlled coughing and deep breathing. B. Provide a brightly lit environment. C. Elevate the head of the bed 20°. D. Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day.
C. Elevate the head of the bed 20°.
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? A. Cleanse the perineum from back to front. B. Obtain a prescription for an indwelling urinary catheter. C. Encourage fluid intake at and between meals. D. Offer the client the bedpan every 2 hr.
C. Encourage fluid intake at and between meals.
A nurse is teaching a group of male adolescents about testicular self-examination. Which of the following information should the nurse include? A. Perform testicular self-examination twice per year. B. Pinch the testicles to feel for abnormalities C. Examine the testicles after a bath or shower D. Expect a moderate amount of swelling
C. Examine the testicles after a bath or shower
A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? A. BUN 18 mg/dL B. Capillary refill 1.5 sec C. Hct 55% D. Urine specific gravity 1.001
C. Hct 55%
A nurse is caring for a client who has sustained burns over 35% of the total body surface area. The client's voice has become horse, brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning
C. Inhalation injury
A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness and Full thickness burns over 60% of the body 24 hours ago. The nurse should plan to use which of the following routes to administer the medication? A. Subcutaneous B. Oral C. Intravenous D. Transdermal
C. Intravenous
A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include? A. A family history increases your risk for acquiring hepatitis A. B. Hepatitis A infects the kidneys. C. Manifestations of the virus are similar to flu-like symptoms. D. The incubation of the virus is 5 days
C. Manifestations of the virus are similar to flu-like symptoms.
A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? A. Question the client's coworkers about the mechanism of injury B. Check the client's pupils for equality and reaction to light C. Measure the client's alertness using the Glasgow Coma Scale D. Immobilize the client's cervical spine
C. Measure the client's alertness using the Glasgow Coma Scale
A nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions is the top priority? A. Monitor intake and output. B. Administer antibiotics. C. Monitor respiratory status. D. Encourage fluid and food intake.
C. Monitor respiratory status.
A nurse in the PACU is assessing a client who has an endotracheal tube in place and observed the absence of the left-side chest wall expansion upon respiration. Which of the following complications should the nurse suspect? A. Blockage of the ET tube by the tongue B. Passage of the ET tube in the esophagus C. Movement of the ET tube into the right main bronchus
C. Movement of the ET tube into the right main bronchus
A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow coma scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response
C. Oxygen saturation
A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? A. Administer a nitrate antihypertensive. B. Assess the client for bladder distention. C. Place the client in a high Fowler's position. D. Obtain the client's heart rate.
C. Place the client in a high Fowler's position.
A nurse is planning care for a client who has viral hepatitis. Which of the following actions should the nurse include in the plan of care? A. Administer Tylenol B. Eat three large meals a day C. Provide a high in carbohydrate diet D. Include high protein snacks
C. Provide a high in carbohydrate diet
A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level? A. Administer diuretics B. Restrict the client's intake of fluids C. Reduce the client's intake of protein D. Administer vitamin K
C. Reduce the client's intake of protein protein breaks down as ammonia
A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer? A. lactulose B. phosphorus binder C. Sodium polystyrene (kayexalate) D. neupgoen
C. Sodium polystyrene (kayexalate)
A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? A. Warm, dry skin B. Increased urinary output C. Tachycardia D. Bradypnea
C. Tachycardia
A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication? A. The leukocyte count B. The platelet count C. The hematocrit (Hct) D. The erythrocyte sedimentation rate (ESR
C. The hematocrit (Hct)
A postpartum nurse is caring for a client who has developed hemorrhagic shock. Which of the following manifestations should the nurse expect? A. Urinary output of 40 mL/hr B. Deep abdominal breathing C. Weak and irregular pulse D. Warm, dry hands with prompt capillary refill
C. Weak and irregular pulse hypovolemic shock
A nurse is caring for a client experiencing menopausal symptoms. The client asks the nurse about menopausal hormone therapy. The nurse should inform the client that hormone therapy is not recommended due to the following findings in the client's medical history? A. dermatitis B. COPD C. history of breasts cancer D. gerd
C. history of breasts cancer
A nurse is teaching a client who has pre-dialysis end-stage kidney disease about diet. Which of the following instructions should the nurse include? A. increase phosphorus B. eliminate food with protein C. reduce the intake of foods high in potassium D. increased intake of sodium
C. reduce the intake of foods high in potassium
A nurse is caring for a client who is scheduled for a blood sampling for a serum creatinine level. The client asks the nurse, "What is the purpose for this test?" Which of the following responses should the nurse give? A. you'll have to ask your doctor B. we'll find out if any medications such as steroids are interfering with your kidney function C. the test will tell the doctor how your kidneys are functioning D. the test will tell you if you have severe renal impairment or disease
C. the test will tell the doctor how your kidneys are functioning
A nurse is planning to administer fluids to a client who has 25% total body surface area burns. The client has no prior medical history. Which of the following intravenous fluids is contraindicated for this client? A. Whole blood B. Lactated Ringer's C. Dextran 40 in 0.9% sodium chloride D. 0.45% sodium chloride
D. 0.45% sodium chloride because it is a hypotonic solution and will worsen third spacing
A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride
D. 0.9% sodium chloride
A nurse is caring for a group of clients. Which of the following clients is at risk for obstructive shock? A. A client who is having occasional PVCs on the ECG monitor B. A client who has been experiencing vomiting and diarrhea for several days C. A client who has a gram-negative bacterial infection D. A client who has a pulmonary arterial stenosis
D. A client who has a pulmonary arterial stenosis obstructive shock results from decreased function by a non-cardiac cause such as with pulmonary arterial stenosis or hypertension, or a thoracic tumor
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? A. Assess for indications of pulmonary embolism. B. Prepare for mechanical ventilation. C. Prepare to administer a sedative. D. Administer oxygen via face mask.
D. Administer oxygen via face mask.
A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification? A. Assess deep tendon reflexes every hour B. Obtain a daily weight C. Continuous fetal monitoring D. Ambulate twice daily
D. Ambulate twice daily
A nurse is reviewing the bun and creatinine levels of an older adult client who has chronic kidney disease. The nurse should expect which of the following findings? A. BUN 25 mg/dL and creatinine 1.1 mg/dL B. BUN 8 mg/dL and creatinine 1.0mg/dL C. BUN 10 mg/dL and creatinine 0.8 mg/dL D. BUN 45 mg/dl and creatinine 8 mg/dl
D. BUN 45 mg/dl and creatinine 8 mg/dl
A nurse is teaching a client who has chronic kidney disease about the process of continuous ambulatory peritoneal dialysis (CAPD). Which of the following information should the nurse include in the teaching? A. CAPD requires the use of a dialyzer B. CAPD is the treatment of choice for those who have had abdominal surgery C. CAPD had Rigid schedule of exchange times D. CAPD's advantages include fewer dietary and fluid restrictions as compared to hemodialysis
D. CAPD's advantages include fewer dietary and fluid restrictions as compared to hemodialysis
A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first? A. Cover the child's wounds with a clean, dry cloth B. Establish IV access with a large-bore catheter C. Provide reassurance to the child's parents D. Determine the child's breathing pattern
D. Determine the child's breathing pattern
A nurse is assessing a client who has a urine output of 250 mL in a 24-hr period. Which of the following descriptive terms should the nurse place in the client's electronic record? A. Enuresis B. Anuria C. Nocturia D. Oliguria
D. Oliguria
A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching? A. Take Acetaminophen every 4 hr as needed for discomfort B. Consume a high-protein diet C. You may donate blood 6 months after completing the medication regimen D. Rest frequently throughout the day
D. Rest frequently throughout the day
A nurse is caring for a client who is postoperative following a right-sided mastectomy and has a drain connected to a portable drainage evacuator. Which of the following actions should the nurse take? A. Dangle the operative limb for 5 min every hour. B. Place the head of the client's bed at a 15° angle C. Keep the wound drain evacuator fully expanded at all times. D. Take blood pressure on the client's non-affected arm.
D. Take blood pressure on the client's non-affected arm.
A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1°C (102.4°F)
D. Temperature of 39.1°C (102.4°F) indicates infection
A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1°C (102.4°F)
D. Temperature of 39.1°C (102.4°F) infection is the concern
A nurse is caring for a client who has suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis? A. Severe nausea and vomiting B. Large amount of vaginal bleeding C. Uterine enlargement greater than expected D. Unilateral, abdominal pain
D. Unilateral, abdominal pain
A nurse is prioritizing client care after receiving a change of shift report. Which of the following clients should the nurse plan to see first? A. a client who is going for abdominal surgery and is awaiting transport B. a client who has a prescription for discharge C.a client who received oral pain medication 30 min ago D. a client who told an assistive personal he is short of breath
D. a client who told an assistive personal he is short of breath
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. range of motion exercise B. suction equipment at the bedside C. administer expectorant D. encourage use of incentive spirometer
D. encourage use of incentive spirometer
The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. to evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to asses? A. breath sounds and capillary refill B. blood pressure and oral temperature C. oral temperature and capillary refill D. right atrial pressure and urine output
D. right atrial pressure and urine output
A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy 6L via nasal cannula. Which of the following actions should the nurse take? A. remove the nasal cannula while they eat B. secure the oxygen tubing to the bedsheet C. apply petroleum jelly D. use a humidifier
D. use a humidifier
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? a. Test the drainage for glucose b. Suction the nostril c. Notify the physician D. Ask the client to blow his nose
a. Test the drainage for glucose
A nurse is caring for a client who has a prescription for an after-load-reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? a. cardiogenic b. obstructive c. hypovolemic d. distributive
a. cardiogenic
A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching? a. urine output is less than 400 mL per 24 hr b. the glomerular filtration rate (GFR) recovers c. renal ruction is reestablished d. BUN and creatinine levels decrease
a. urine output is less than 400 mL per 24 hr
A nurse is caring for a client who has a new arteriovenous graft in his left forearm. which of the following techniques should the nurse use to assess the patency of this graft?
auscultate the site for the bruit
A nurse is planning care for a client with septic shock. Which of the following actions is the priority for the nurse to take? a. Maintain adequate fluid volume with IV infusions b. Administer antibiotic therapy c. Monitor hemodynamic status d. Administer vasopressor medication
b. Administer antibiotic therapy
A nurse in the ED is caring for a client who had an allergic reaction related to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? a. Methylprednisolone IV bolus b. Diphenhydramine subq c. Epinephrine IV d. Albuterol inhaler
c. Epinephrine IV
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? a. Furosemide b. Dexamethasone c. Heparin d. Atropine
c. Heparin
If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances? a. Hyperkalemia and hyponatremia b. Hyperkalemia and hypernatremia c. Hypokalemia and hyponatremia d. Hypokalemia and hypernatremia
c. Hypokalemia and hyponatremia
The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? a. Antibiotics to treat the underlying infection. b. Corticosteroids to reduce inflammation. c. IV fluids to increase intravascular volume. d. Vasopressors to increase blood pressure.
c. IV fluids to increase intravascular volume. Rationale: Circulation and perfusion are addressed first so IV fluids will be started immediately. After blood cultures are obtained, broad-spectrum antibiotics should be administered without delay. Vasopressors are administered if the patient is not responding to the fluid challenge. Corticosteroids may be considered to address the inflammatory-induced vasodilation and capillary leakage.
A patient who has pericarditis related to radiation therapy, becomes dyspneic, and has a rapid, weak pulse. Heart sounds are muffled, and a 12 mmHg drop in blood pressure is noted on inspiration. The healthcare provider's interventions are aimed at preventing which type of shock? a. Distributive b. Neurogenic c. Obstructive d. Cardiogenic
c. Obstructive Rationale: Obstructive shock can be caused by anything that impedes the heart's ability to contract and pump blood around the body, as with cardiac tamponade.
A nurse is caring for a client in shock. Which of the following signs is a priority for the progressive stage? A. decreased oxygen saturation B. tachycardia C. cold and clammy skin
c. cold and clammy skin this is an early sign that the body is not compensating and getting worse
A client is admitted to the rehabilitation unit following a spinal cord injury that resulted in paraplegia. after a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. which of the following actions should the nurse take first? a. inform the client that privileges are related to participation in therapy b. limit visiting hours until the client begins to participate in therapy c. allow the client to control the timing and frequency of therapy d. establish a plan of care with the client with mutually set attainable goals
d. establish a plan of care with the client with mutually set attainable goals
What is the fluid of choice for burn patients?
lactated ringers
A nurse in the ED is caring for a client with T5 vertebral trauma. The client's respiratory rate is 26, his heart rate 50 bpm, and his skin is warm and dry to the touch. What should the nurse be concerned for?
neurogenic shock
A nurse is preparing to administer an osmotic diuretic to a client with increased intracranial pressure which of the following should the nurse identify as the purpose of the medication?
reduce brain volume/fluid in brain tissue
A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity?
vancomycin
