NUR 2051 Module 1
A nurse is caring for a client who is on bed rest following admission to the hospital two days ago with a diagnosis of new onset heart failure. While evaluating the client's progress, what assessment findings would indicate to the nurse that treatment has been effective? 1. CVP 6 mmHg 2. 3.8 kg weight loss in 24 hours 3. Pink, frothy sputum 4. S3 heart sound 5. Urinary output 320 mL/8 hrs 6. Dyspnea on exertion
1, 2, & 5 Correct: These are all signs that the client is getting better. This is a normal CVP value, which would indicate the client is improving. A weight loss of 3.8 kg in 24 hours is a good thing. Excess fluid is being removed from the body. A urinary output of 320 mL in 8 hours is good. That averages out to 40 mL/hr.
A client has been admitted with advanced Cirrhosis. The nurse's assessment of the abdominal girth verifies an increase in 5 inches (12.7 cm) and an increase in 6 lbs. (2.72 kg) since yesterday's measurements. The client reports a decreased desire to eat due to gastric reflux and is having steatorrhea. Which interventions would the nurse expect to see in this client's plan of care? 1. Administer pantoprazole 40 mg by mouth every morning. 2. Prepare client for thorocentesis. 3. Infuse Albumin, human 25% 50 mL over 1 hour. 4. Provide a diet of 1500 calories per day. 5. Administer Vitamins A, D, and E in water-soluble form.
1, 3, & 5 Correct: Pantoprazole is a proton pump inhibitor that decreases the amount of acid produced in the stomach. In acute liver failure, Albumin (Human) 25% solution helps to stabilize vascular circulation by moving fluid into the vascular space. Clients who have have fatty stools (steatorrhea) are losing fat-soluble vitamins. They need to receive water-soluble forms of fat-soluble vitamins A, D, and E.
A client is being treated for fluid volume deficit with D5W, oral hydration, and management of viral symptoms. Which client data would indicate to the nurse that further treatment is needed? 1. BP 120/70 lying; 98/68 standing 2. Bounding pulses 3. One day weight gain of 5 kg 4. Urine specific gravity of 1.010 5. Serum sodium 145 mEq (145 mmol/L)
1. BP 120/70 lying; 98/68 standing 2. Bounding pulses 3. One day weight gain of 5 kg FVE!
A nurse arrives at the scene of a home fire along with local emergency medical services (EMS) to find a client lying in the front yard. Burns are noted to the face, neck and chest. In what order should the nurse care for this client at the scene?
1. Establish airway patency 2. Assess breathing 3. Administer 100% humidified oxygen 4. Soak burned area with cool water 5. Remove restrictive objects
The community health nurse has been educating a group of college students living in a dormitory about receiving an immune globulin (IG) injection for hepatitis A virus (HAV). Which statement made by the students would indicate to the nurse that further teaching is necessary? 1. Immune globulin contains antibiotics that destroy the HAV, preventing infection. 2. Immune globulin protection is temporary. 3. Common side effects of Immune globulin include soreness and swelling around the injection site. 4. It is important to take IG within four weeks of any exposure to hepatitis A. 5. Crowded living environments such as dormitories place people at risk for HAV.
1. Immune globulin contains antibiotics that destroy the HAV, preventing infection. 4. It is important to take IG within four weeks of any exposure to hepatitis A.
Based on the results of the arterial blood gases (ABGs), what imbalance does the nurse understand the client to be exhibiting? 1. Respiratory acidosis compensated 2. Respiratory acidosis partially compensated 3. Metabolic acidosis compensated 4. Metabolic acidosis partially compensated
1. Respiratory acidosis compensated
A client weighing 155 pounds (70 kg) is admitted to the burn unit with second and third degree burns covering 50% total body surface area. Normal Saline IV fluid resuscitation is ordered at 4 mL/kg per percentage of total body surface area burned over the first 24 hours. How much fluid does the nurse calculate the client will receive in 24 hours? Provide your answer using numbers and decimal points only.
14,000 mL
What should the nurse assess when examining a client who has had a fasciotomy of the forearm? 1. Brachial pulse 2. Capillary refill 3. Color 4. Presence of thrill 5. Skin turgur
2 & 3 Correct: Fasciotomy is a surgical procedure that cuts away the fascia to relieve tension or pressure. So after the procedure, the nurse wants to make certain that pressure has been relieved and circulation distally is good. The nurse will thus need to monitor skin color, capillary refill, distal pulses, and sensation. Since this is a surgical procedure, bleeding will also need to be monitored.
A client's arterial blood gas report has arrived at the nurses' station. Based on the results what interventions are required by the nurse? 1. Start oxygen at 2 liters/min 2. Instruct client on taking slow deep breaths 3. Monitor serium sodium level 4. Initiate safety precautions 5. Administer sodium bicarbonate 1 ampule IVP
2 & 4 Correct: This client is in respiratory alkalosis and it's acute because the kidneys have not kicked in. Fix the problem by slowing the respirations and rebreathing the CO2. The hyperventilating client is either in a panic or hysterical so calm them and give an anxiolytic if necessary. Safety precautions are needed because dizziness and faintness can occur with respiratory alkalosis.
A client is admitted for treatment of fluid volume deficit. The nurse reviews the admitting lab work and the primary healthcare provider's prescriptions. Which prescription would be of concern to the nurse? 1. Diet 2. Furosemide 3. IV infusion 4. Potassium Chloride (KCL)
2 Correct: The client is in a fluid volume deficit. Furosemide is a loop diuretic which can be prescribed to get rid of excess fluid in the vascular space. Giving this medication will worsen the fluid volume deficit.
What is the nurse's priority when treating a client admitted with a full thickness thermal burn over 30% of the body? 1. Insert a urinary catheter 2. Establish IV access of Normal Saline 3. Administer fentanyl (1 mcg/kg) IV 4. Apply antibiotic ointment and dressing to burns
2. Establish IV access of Normal Saline (Fluid resuscitation)
An elderly, bed-bound client receiving G-tube feedings at home is admitted to the unit after onset of behavioral changes and hallucinations. Which nursing actions should the nurse initiate? 1. Administer furosemide 20 mg IVP 2. Frequent mouth care 3. Provide 250 mL water via G-tube every 6 hours 4. Seizure precautions 5. Start IV of 0.9% Normal Saline
2. Frequent mouth care 3. Provide 250 mL water via G-tube every 6 hours 4. Seizure precautions
A nurse is caring for a client who had a cholecystectomy 4 hours ago. What interpretation should the nurse make based on the results of the client's arterial blood gases (ABGs)? pH: 7.31, HCO3: 22, PaCO2: 49 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated
2. Respiratory acidosis 5. Uncompensated
Which signs and symptoms would concern the nurse if assessed in a client post radical neck surgery? 1. Decreased deep tendon reflexes 2. Flaccid muscle tone 3. Laryngeal stridor 4. Muscle cramps 5. Negative Trousseau's sign
3 & 4 Correct: Laryngeal stridor and muscle cramps are signs indicating that muscles are rigid and tight due to a low calcium level. Some of the parathyroids could have been removed resulting in hypocalcemia.
What clinical manifestation does the nurse expect to see in a client suspected of having hypercalcemia? 1. Tachycardia 2. Positive Chvostek 3. Lethargy 4. Tachypnea 5. Decreased deep tendon reflexes
3 & 5 Correct: Hypercalcemia is a condition in which the calcium level in blood is above normal. Too much calcium in blood can weaken bones, create kidney stones, and interfere with heart and brain function. Hypercalcemia is usually a result of overactive parathyroid glands. Other causes include cancer, some medications, and taking too much of calcium and vitamin D supplements. Signs and symptoms of hypercalcemia range from nonexistent to severe. Lethargy and decreased deep tendon reflexes are two manifestations of hypercalcemia.
A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? 1. Metabolic acidosis 2. Respiratory alkalosis 3. Metabolic alkalosis 4. Respiratory acidosis 5. Uncompensated 6. Partially compensated 7. Fully compensated
3 & 6 Correct: Partially compensated metabolic alkalosis is indicated by these ABGs.
The nurse is reviewing morning laboratory results for multiple clients. Which client laboratory results should the nurse immediately report to the Healthcare provider? 1. Client with chronic obstructive pulmonary disease (COPD) and a PCO2 of 50 mm Hg. 2. Diabetic client with fasting blood sugar of 145 mg/dL (8.0 mmol/L). 3. Cardiac client on furosemide with potassium of 3.1mEq/L (3.1 mmol/L). 4. Client with sepsis and total white blood cell count of 16,000 mm3. 5. Client following a thyroidectomy with calcium level of 8.0 mg/dL (2 mmol/L).
3. Cardiac client on furosemide with potassium of 3.1mEq/L (3.1 mmol/L). 5. Client following a thyroidectomy with calcium level of 8.0 mg/dL (2 mmol/L).
The charge nurse is evaluating a new nurse who is performing a linear wound dressing change on a surgical client. Which action by the new nurse requires intervention by the charge nurse? 1. Hand hygiene is done prior to the dressing change. 2. Dressing tape is removed in the direction of the hair growth. 3. The soiled dressing is discarded in a biomedical waste bag. 4. Clean gloves are donned in order to clean the wound. 5. The wound area farthest from the nurse is cleaned first, then the center of the wound, followed by the area closest to the nurse. 6. New sterile dressing is applied to the wound.
4 & 5 Correct: Most dressing changes following surgery are sterile and require that the nurse use standard precautions and wear sterile gloves to clean the incision and apply sterile dressings. Clean gloves can be used to remove the old dressing. Dressings are never touched by ungloved hands. Remember, clean to dirty. The wound center is considered the cleanest area, so that is cleaned first. The area beside the wound farthest from the nurse is considered the next cleanest area. The area closes to the nurse is considered the most contaminated and is cleaned last. The new nurse performed this step correctly.
How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated
4 & 5 Correct: The blood gases confirm respiratory alkalosis. The HCO3 is normal. This means that the client is in uncompensated respiratory alkalosis.
The home health nurse is visiting a client who had a stoke a several months ago. At today's visit, the client reports nausea, vomiting and anorexia for the last few days. During the assessment, the client becomes unresponsive, without a pulse. What action should the nurse take first? 1. Defibrillate at 200 joules 2. Administer amiodarone IV 150 mg over 10 minutes 3. Infuse 500 mL NS with 40 mEq at 100 mL/hour 4. Begin cardiopulmonary resuscitation
4 Correct: The nurse is in the client's home when the client becomes unresponsive without a pulse. The client has no IV and there is no defibrillator. So what should the nurse do? Start CPR and have someone activate EMS.
A client arrives in the emergency department in a postictal state after having a seizure for the first time. The nurse notes peripheral edema to the lower extremities. BP 100/68, Resp 18, HR 86. Family reports client has taken "a lot of antacids for indigestion over the past 48 hours. Current health history includes chronic renal failure. What acid/base imbalance does the nurse anticipate for this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
4 Correct: This client condition indicate metabolic alkalosis.
An elderly, confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the unlicensed assistive personnel? 1. Perform a physical assessment. 2. Start an IV of NS with KCL 20 mEq at 50 mL/hr. 3. Insert a urinary Catheter. 4. Weigh the client
4. Correct: The UAP can weigh clients.
The Emergency department nurse is caring for a client who has sustained a high-voltage electrical injury. Which intervention should the nurse initiate? 1. Initiate continuous cardiac monitoring. 2. Identify entrance and exit wounds. 3. Give analgesic by mouth as needed. 4. Keep burned limbs below the level of the heart. 5. Cover burned areas with clean sheets.
1, 2, & 5 Correct: These are correct interventions for the nurse to initiate when caring for a client who has sustained a high-voltage electrical injury. Remember, electricity kills vessels, nerves, and organs. Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. Electrical burns have two wounds: an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. In the emergent phase of care, the nurse needs to protect the wound from contaminants. Cover burned areas with dry dressings or a clean sheet.
Based on the results of the arterial blood gases (ABGs), what imbalance does the nurse understand the client to be exhibiting? pH: 7.36, PaCO2: 55, HCO3: 32 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated
2. Respiratory acidosis 7. Fully compensated
A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education was successful when a nurse selects which set of ABGs as compensated respiratory alkalosis? 1. pH - 7.46, PaCO2 - 30, HCO3 - 26 2. pH - 7.45, PaCO2 - 35, HCO3 - 25 3. pH - 7.36, PaCO2 - 43, HCO3 - 24 4. pH - 7.43, PaCO2 - 31, HCO3 - 20
4 Correct: This set of ABGs indicates compensated respiratory alkalosis.
