Quizzes
A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about A. anticoagulant therapy. B. permanent pacemakers. C. electrical cardioversion. D. IV adenosine (Adenocard).
Answer Key:A Feedback:Rationale Anticoagulation therapy reduces the risk of systemic embolization from clots. These may form in the heart chambers secondary to atrial fibrillation.
A child is brought to the emergency department late one evening and is diagnosed with croup. The child was noted to have a shrill, harsh respiratory sound when breathing in. This symptom is referred to as: A. stridor. B. hoarseness. C. barking cough. D. wheezing.
Answer Key:A Feedback:Rationale: In the child with croup syndrome, inspiratory stridor (shrill, harsh respiratory sound) is often noted.
A P wave on an ECG represents an impulse arising at the A. SA node with repolarizing of the atria B. SA node with depolarizing of the atria C. AV node and depolarizing of the atria D. AV node and spreading to the bundle of his
Answer Key:B Feedback:Rationale: The P wave begins with the firing of the SA node and represents depolarization of the atria.
A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find: A. hypotension. B. thick, coarse skin. C. deposits of adipose tissue in the trunk and dorsocervical area. D. weight gain in arms and legs.
Answer Key:C Feedback:Rationale: Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moon face), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.
The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis? A. pH 7.87, PaCO2 38, HCO3 28 B. pH 7.47, PaCO2 28, HCO3 30 C. pH 7.49, PaCO2 34, HCO3 25 D. pH 7.25, PaCO2 48, HCO3 24
Answer Key:D Feedback:Rationale: pH less than 7.35, PaCO2 48, HCO3 24 indicate respiratory acidosis; pH 7.87, PaCO2 38, HCO3 28 indicate metabolic alkalosis; pH 7.47, PaCO2 28, HCO3 30 indicate respiratory alkalosis; and pH 7.49, PaCO2 34, HCO3 25 indicate respiratory alkalosis.
The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? A. Administer recombinant human activated protein C (rhAPC) as prescribed. B. Begin a continuous IV infusion of insulin per protocol. C. Initiate enteral feedings as prescribed. D. Administer norepinephrine (Levophed) as prescribed.
Answer Key:D Feedback:Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine (Levophed) centrally administered is the initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.
A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's A. blood glucose. B. urine osmolality. C. serum creatinine. D. serum potassium.
Answer Key:C Feedback:C. When a patient at risk for chronic kidney disease (CKD) receives a potentially nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in assessing for the adverse effects of the gentamicin.
A patient's cardiac rhythm is sinus bradycardia with a heart rate of 34 beats/minute. If the bradycardia is symptomatic, the nurse would expect the patient to exhibit A. Palpitations B. Hypertension C. Warm, flushed skin. D. Shortness of breath
Answer Key:D Feedback:Rationale: Signs of symptomatic bradycardia include pale, cool skin; hypotension; weakness; angina; dizziness or syncope; confusion or disorientation; and shortness of breath. Incorrect Feedback: Rationale: Signs of symptomatic bradycardia include pale, cool skin; hypotension; weakness; angina; dizziness or syncope; confusion or disorientation; and shortness of breath.
A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? A. The client will be unable to use a wheelchair. B. The client will be unable to swallow food. C. The client will be continent of urine, but incontinent of bowel. D. The client will require full assistance for all aspects of elimination.
Answer Key:D Feedback:Clients with a lesion at C4 are fully dependent for elimination. The client is dependent for feeding, but is able to swallow. The client will be capable of using an electric wheelchair.
A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? A. Insert urethral catheter. B. Obtain renal ultrasound. C. Draw a complete blood count. D. Infuse normal saline at 50 mL/hour.
Answer Key:A Feedback:A. The patient's elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions also are appropriate, but should be implemented after the retention catheter.
The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? A. Fluid restriction B. Transfusion of platelets C. Transfusion of fresh frozen plasma (FFP) D. Electrolyte restriction
Answer Key:A Feedback:Rationale: The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary.
The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? A. Crackles in the lung bases B. Low-pitched rhonchi during expiration C. Pleural friction rub D. Sibilant wheezes
Answer Key:A Feedback:Rationale: When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.
The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident. In addition to normal saline, which crystalloid fluid should the nurse prepare to administer? A. Lactated Ringer's B. Albumin C. Dextran D. 3% NaCl
Answer Key:A Feedback:Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringer's and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. 3% NaCl is a hypertonic solution and is not isotonic.
Two risk factors for coronary artery disease that increase the workload of the heart and increase myocardial oxygen demand are A. Obesity and smokeless tobacco use. B. Hypertension and cigarette smoking. C. Elevated serum lipids and diabetes mellitus. D. Physical inactivity and elevated homocysteine levels.
Answer Key:B Feedback:Rationale: An elevated blood pressure and cigarette smoking (causes vasoconstriction) increase the rate of atherosclerosis. Atherosclerosis increases the workload of the heart and increases myocardial oxygen demand.
A patient complains of leg cramps during hemodialysis. The nurse should first A. massage the patient's legs. B. reposition the patient supine. C. give acetaminophen (Tylenol). D. infuse a bolus of normal saline.
Answer Key:D Feedback:D. Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.
After receiving change-of-shift report, which patient should the nurse assess first? A. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange B. Patient with stage 4 chronic kidney disease who has an elevated phosphate level C. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L D. Patient who has just returned from having hemodialysis and has a heart rate of 124/min
Answer Key:D Feedback:D. The patient who is tachycardic after hemodialysis may be bleeding or excessively hypovolemic and should be assessed immediately for these complications. The other patients also need assessments or interventions but are not at risk for life-threatening complications.
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify? A. Absence of infarcts or emboli B. Reduced stroke volume and cardiac output C. Absence of pulmonary and peripheral edema D. Maintenance of adequate mean arterial pressure
Answer Key:D Feedback:Vasoactive medications can be given in all forms of shock to improve the client's hemodynamic stability when fluid therapy alone cannot maintain adequate MAP (> 65). Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.
The most significant factor in long-term survival of a patient with sudden cardiac death is A. Absence of underlying heart disease. B. Rapid institution of emergency services and procedures. C. Performance of perfect technique in resuscitation procedures. D. Maintenance of 50% of normal cardiac output during resuscitation efforts
Answer Key:B Feedback:Rationale: Rapid cardiopulmonary resuscitation and prompt defibrillation (with an automated external defibrillator) and early advanced cardiac life support can produce high long-term survival rates for a witnessed arrest.
Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock? A. Septic B. Anaphylactic C. Neurogenic D. Cardiogenic
Answer Key:C Feedback:The client in neurogenic shock experiences hypotension, bradycardia, and dry, warm skin. A client experiencing septic shock would exhibit tachycardia. A client in anaphylactic shock would experience respiratory distress. A client in cardiogenic shock would exhibit cardiac dysrhythmias and adventitious lung sounds.
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as A. atrial flutter. B. sinus tachycardia. C. ventricular fibrillation. D. ventricular tachycardia.
Answer Key:D Feedback:Rationale Ventricular rate is 150 to 250 beats/minute. • Rhythm may be regular or irregular. • AV dissociation may be present, with P waves occurring independently of the QRS complex. • The atria may be depolarized by the ventricles in a retrograde fashion. • The P wave is usually buried in the QRS complex, and the P-R interval is not measurable. • The QRS complex is distorted in appearance and wide (greater than 0.12 second in duration). • The T wave is in the opposite direction of the QRS complex.
A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response? A. "You could have gotten it by using I.V. drugs." B. "You must have received an infected blood transfusion." C. "You probably got it by engaging in unprotected sex." D. "You may have eaten contaminated restaurant food."
Answer Key:D Feedback:Rationale: Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn't transmitted by the I.V. route, blood transfusions, or term-13unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.
To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should A. listen for a rumbling, low-pitched, systolic murmur over the left anterior chest. B. auscultate by placing the diaphragm of the stethoscope on the lower left sternal border. C. ask the patient to cough during auscultation to distinguish the sound from a pleural friction rub. D. feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction.
Answer Key:B Feedback:Rationale: The pericardial friction rub is a scratching, grating, high pitched sound believed to result from friction between the roughened pericardial and epicardial surfaces. It is best heard with the stethoscope placed at the lower left sternal border of the chest with the patient leaning forward.
A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely? A. Negative Kernig's sign B. Positive Brudzinski's sign C. Increased intake D. Hyper-alertness
Answer Key:B Feedback:A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced. A positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses, not increased intake or hyper-alertness.
A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? A. "Monitor urine output every hour." B. "Infuse I.V. fluids at 83 ml/hour." C. "Administer oxygen by nasal cannula at 3 L/minute." D. "Draw samples for hemoglobin and hematocrit every 6 hours."
Answer Key:B Feedback:Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement (30 ml/kg) to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client.
A nurse is caring for a client who has suffered an unstable thoracolumbar fracture. What goal should the nurse prioritize during nursing care? A. Preventing skin breakdown B. Maintaining spinal alignment C. Maximizing function D. Preventing increased intracranial pressure
Answer Key:B Feedback:Clients with an unstable fracture must have their spine in alignment at all times in order to prevent neurologic damage. This is a greater threat, and higher priority, than promoting function and preventing skin breakdown, even though these are both valid considerations. Increased ICP is not a high risk.
A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action? A. Decreasing anxiety B. Maintaining an open airway C. Providing pain relief measures D. Encouraging activity
Answer Key:B Feedback:The priority action at this time is maintaining an open airway because the client is experiencing a severe allergic reaction that is compromising the airway and ability to inhale. There is no indication that the client's difficulty breathing is causing pain. Anxiety and activity are important, but the priority is the client's airway.
A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)? A. Suction the airway every hour and as needed. B. Elevate the head of the bed 15 to 30 degrees. C. Turn the client and change his position every 2 hours. D. Maintain a well-lit room.
Answer Key:B Feedback:To facilitate venous drainage and avoid jugular compression, the nurse should elevate the head of the bed 15 to 30 degrees. Clients with increased ICP poorly tolerate suctioning and shouldn't be suctioned on a regular basis. Turning the client from side to side increases the risk of jugular compression and rises in ICP, so turning and changing positions should be avoided. The room should be kept quiet and dimly lit.
Which statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? A. "I need to get most of my protein from low-fat dairy products." B. "I will increase my intake of fruits and vegetables to 5 per day." C. "I will measure my urinary output each day to help calculate the amount I can drink." D. "I need to take erythropoietin to boost my immune system and help prevent infection."
Answer Key:C Feedback:C. The patient with end-stage kidney disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? A. Turning the client every 2 hours B. Elevating the head of the bed 30 degrees C. Encouraging increased fluid intake D. Maintaining a cool room temperature
Answer Key:C Feedback:Rationale: Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.
A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the client has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this client is what? A. IV administration of immune globulins B. Transfusion of packed red blood cells and fresh-frozen plasma (FFP) C. Liver transplantation D. Lobectomy
Answer Key:C Feedback:Rationale: Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery.
What should the nurse suspect when hourly assessment of urine output on a client postcraniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? A. Cushing syndrome B. Syndrome of inappropriate antidiuretic hormone (SIADH) C. Adrenal crisis D. Diabetes insipidus
Answer Key:D Feedback:Rationale: Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the client becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.
The nurse has assessed a 6-year-old child as having respiratory distress due to swelling of the epiglottis and surrounding structures. Which signs and symptoms would support this assessment? A. The child is pale and has vomited. B. The child has pale, elevated patches on the skin. C. The child is irritable and tachycardiac. D. The child is in tripod position.
Answer Key:D Feedback:Rationale: Inflammation and swelling of the epiglottis and surrounding structures are common in children ages 2 to 7 years. The child will attempt to improve his/her airway by sitting forward and extending the neck forward with the jaw up, in a "sniffing position" (tripod position). Being pale, vomiting, and having elevated patches on the skin are not associated with epiglottis. Stridor, tachycardia, and the rapid onset are classical signs of epiglottitis.
The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED? A. Controlling hemorrhage. B. Establishing an airway. C. Obtaining consent for treatment. D. Restoring cardiac output.
Answer Key:B Feedback:The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. The first priority is always to establish a patent airway.
TTC - GI & Endocrine
ENDOCRINE -DI -SIADH -Cushings -DKA -HHS GI/LIVER -hepatitis -cirrhosis
A group of nurses have attended an in-service on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A. Disposing of sharps appropriately and not recapping needles B. Performing meticulous hand hygiene at the appropriate moments in care C. Adhering to the recommended schedule of immunizations D. Wearing an N95 mask when providing care for clients on airborne precautions
Answer Key:A Feedback:Rationale: HCV is bloodborne. Consequently, prevention of needlestick injuries is paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV.
The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider? A. Heart rate B. Urine output C. Creatinine clearance D. Blood urea nitrogen (BUN) level
Answer Key:B Feedback:B. Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.
A client is transported to the emergency department for a femur fracture following a motor vehicle crash. What action by the nurse is the highest priority? A. Assess vital signs and level of consciousness. B. Administer pain medication per orders. C. Assess pedal pulses. D. Assess the diameter of the thigh every 15 minutes.
Answer Key:A Feedback:Femur fractures can lead to hypovolemic shock due to blood loss in the tissue. By assessing the vital signs and level of consciousness, the nurse can assess for shock. Assessing the pedal pulses and measuring the diameter of the thigh are appropriate interventions for someone with a femur fracture, but assessing for hypovolemic shock would be a priority. Pain medication should be safely administered per orders to help control pain. Many pain medications lower blood pressure (BP). If the client is in shock, BP may be too low to administer the pain medication safely.
Which of the following is a common complication of an electrical burn injury? A. Localized edema B. Absent bowl sounds C. Loss of mobility D. Cardiac dysrhythmias
Answer Key:D Feedback:Cardiac dysrhythmias and central nervous system complications are common among victims of electrical burns; localized edema, absent bowel sounds, and loss of mobility are not.
At an outpatient clinic, K.L.'s 78-year-old grandma is found to have a Hgb of 8.7 g/dL (87 g/L) and a Hct of 35%. Based on the most common cause of these findings in the older adult, the nurse collects information regarding A. a history of jaundice and black tarry stools. B. a 3-day diet recall of the foods the patient has eaten. C. any drugs that have depressed the function of the bone marrow. D. a history of any chronic diseases such as cancer or renal disease.
Answer Key:D Feedback:Rationale: Anemia in the older adult population is commonly caused by co-morbid conditions such as cancer or renal disease.
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? A. Intubate the client and control breathing with mechanical ventilation B. Increase oxygen administration C. Administer a large dose of furosemide (Lasix) IVP stat D. Schedule the client for pulmonary surgery
Answer Key:A Feedback:Rationale: A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? A. pH 7.28, PaO2 50 mm Hg B. pH 7.46, PaO2 80 mm Hg C. pH 7.36, PaCO2 32 mm Hg D. pH 7.35, PaCO2 48 mm Hg
Answer Key:A Feedback:Rationale: ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.
The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? A. Rapid onset of severe dyspnea B. Inspiratory crackles C. Bilateral wheezing D. Cyanosis
Answer Key:A Feedback:Rationale: The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.
A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? A. The creatinine level is 3.0 mg/dL. B. Urine output over an 8-hour period is 2500 mL. C. The blood urea nitrogen (BUN) level is 67 mg/dL. D. The glomerular filtration rate is <30 mL/min/1.73m2.
Answer Key:B Feedback:B. The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.
A patient is admitted to the coronary care unit following a cardiac arrest and successful cardiopulmonary resuscitation. When reviewing the health care provider's admission orders, which order should the nurse question? A. Oxygen at 4 L/min per nasal cannula B. Morphine sulfate 2 mg IV every 10 minutes until the pain is relieved C. Tissue plasminogen activator (t-PA) 100 mg IV infused over 3 hours D. IV nitroglycerin at 5 mcg/minute and increase 5 mcg/minute every 3 to 5 minutes
Answer Key:C Feedback:Rationale: Traumatic or prolonged (>10 minutes) cardiopulmonary resuscitation is a relative contraindication for the administration of fibrinolytic therapy.
The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately? A. The client feels restless and hungry. B. The client exhibits an increased urinary output. C. The client's heart rate is greater than 100 beats per minute. D. The client's respiratory rate is less than 20 breaths per minute.
Answer Key:C Feedback:A heart rate greater than 100 beats per minute or a respiratory rate greater than 20 breaths per minute could indicate that sepsis has occurred. Sepsis does not increase the client's appetite or affect the client's urinary output.
The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? A. Glycerin B. Isosorbide C. Mannitol D. Urea
Answer Key:C Feedback:If signs and symptoms of increased ICP occur, efforts to decrease the ICP are initiated: alignment of the head in a neutral position without flexion to promote venous drainage, elevation of the head of the bed to 30 degrees (when prescribed), administration of mannitol (an osmotic diuretic), and possible administration of pharmacologic paralyzing agents.
An older adult client with type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A. Administration of antihypertensive medications B. Administering sodium bicarbonate intravenously C. Reversing acidosis by administering insulin D. Fluid and electrolyte replacement
Answer Key:D Feedback:Rationale: The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not given to clients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).
A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? A. Pain B. Fluid balance C. Anxiety and fear D. Airway management
Answer Key:D Feedback:Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early post-burn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? A. Encouraging oral fluid intake B. Suctioning the client once each shift C. Elevating the head of the bed 90 degrees D. Administering a stool softener as ordered
Answer Key:D Feedback:To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.
A client is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which assessment finding indicates that the client may be experiencing neurogenic shock? A. HR, 48 bpm; BP, 90/60 mm Hg B. Cool, moist skin C. HR, 120 bpm; BP, 88/58 mm Hg D. Shortness of breath
Answer Key:A Feedback:The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock. The other signs and symptoms are associated with hypovolemic shock.
The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is A. Change in level of consciousness B. Widening pulse pressure C. Slowing of heart rate D. Elevation of systolic blood pressure
Answer Key:A Feedback:The earliest sign of increasing ICP is a change in level of consciousness. Other early indicators are slowing of speech and delay in response to verbal suggestions. The other three choices are all parts of a clinical phenomenon known as the Cushing's response, which is a late sign of increasing ICP.
A nurse is assigned to care for a patient with ascites, secondary to cirrhosis. The nurse understands that the fluid accumulation in the peritoneal cavity results from a combination of factors including an alteration in oncotic pressure gradients and increased capillary permeability. Therefore, the nurse monitors the serum level of the plasma protein responsible for maintaining oncotic pressure, which is: A. Albumin. B. Globulin. C. Fibrinogen. D. Prothrombin.
Answer Key:A Feedback:Rationale: Albumin, only produced in the liver, is essential for maintaining oncotic pressure in the vascular system. A decrease in oncotic pressure due to low albumin causes fluid to leak into the peritoneal cavity.
A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system? A. Maintain the client in a semi-Fowler's position. B. Administer enteral or parenteral nutrition. C. Carry out wound care as prescribed. D. Withhold oral feedings.
Answer Key:A Feedback:Rationale: The nurse maintains the client in the semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. Respiratory distress and hypoxia are common, and the client may develop diffuse pulmonary infiltrates, dyspnea, tachypnea, and abnormal blood gas values. The client who has undergone surgery may have multiple drains or an open surgical incision and is at risk for skin breakdown and infection. Oral food or fluid intake is not permitted; therefore, enteral or parenteral feedings may be prescribed.
After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent dysrhythmias? A. Serum potassium level B. Serum calcium level C. Serum sodium level D. Serum chloride level
Answer Key:A Feedback:Rationale: The nurse should monitor the client's potassium level because during periods of acidosis, potassium leaves the cell, causing hyperkalemia. As blood glucose levels normalize with treatment, potassium reenters the cell, causing hypokalemia if levels aren't monitored closely. Hypokalemia places the client at risk for cardiac arrhythmias such as ventricular tachycardia. DKA has a lesser affect on serum calcium, sodium, and chloride levels. Changes in these levels don't typically cause cardiac arrhythmias.
A client was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the client tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? A. Prepare the client for opening or bivalving of the cast. B. Obtain a prescription for a different analgesic. C. Encourage the client to wiggle and move the fingers. D. Petal the edges of the client's cast.
Answer Key:A Feedback:Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur. Removing or bivalving the cast is necessary to relieve pressure. Prescribing different analgesics does not address the underlying problem. Encouraging the client to move the fingers or perform range-of-motion exercises will not treat or prevent compartment syndrome. Petaling the edges of a cast with tape prevents abrasions and skin breakdown, not compartment syndrome.
The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem? A. Delirium B. Pain C. Anxiety D. Fever
Answer Key:A Feedback:Delirium is a confused state that has a sudden onset and can last hours to days or weeks; it is characterized by hyperactivity and has the potential to be reversible. The client who quickly becomes confused and agitated while attempting to pull out IV lines and get out of bed is experiencing delirium. The nurse caring for this client should anticipate the need to provide close monitoring to prevent injury. Although clients can experience a high level of stress with both pain and anxiety, which often accompany one another, these problems do not cause confusion and disorientation. Nursing interventions would be aimed at reducing pain and anxiety with the use of medications and other non-pharmacological interventions that enhance client comfort. Although fever can accompany delirium, it does not produce confusion and disorientation on its own.
The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? A. Diagnostic and laboratory testing B. Assessment of peripheral pulses C. Establishing a patent airway D. Undressing the client
Answer Key:A Feedback:Diagnostic and laboratory testing is completed during the secondary survey, along with a complete health history, a head-to-toe assessment, insertion or application of monitoring devices, splinting of suspected fractures, cleansing, closure, and dressing of wounds, and performance of other necessary interventions based on the client's condition. The other interventions are completed during the primary survey.
The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities effectively in a client experiencing a trauma. Which action is completed by the nurse when implementing the "D" element of this method? A. Assessing the client's Glasgow Coma Scale score B. Managing hypothermia C. Providing cervical spine protection D. Undressing the client quickly
Answer Key:A Feedback:The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. While implementing the D element, the nurse determines neurologic disability by assessing neurologic function using the Glasgow Coma Scale and performing a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic: A, alert: is the client alert and responsive? V, verbal: does the client respond to verbal stimuli? P, pain: does the client respond only to painful stimuli? U, unresponsive: is the client unresponsive to all stimuli, including pain? The other interventions are not included in this element of the primary survey.
The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? A. "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." B. "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state." C. "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing." D. "The sudden, severe headache increases muscle tone and can cause further nerve damage."
Answer Key:A Feedback:The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to increased ICP. Autonomic dysreflexia does not directly cause nerve damage.
A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which order for the patient will the nurse question? A. NPO for 6 hours before procedure B. Ibuprofen (Advil) 400 mg PO PRN for pain C. Dulcolax suppository 4 hours before procedure D. Normal saline 500 mL IV infused before procedure
Answer Key:B Feedback:B. The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided. The suppository and NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure.
A 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider? A. Serum creatinine level 2.1 mg/dL B. Serum potassium level 6.5 mEq/L C. White blood cell count 11,500/µL D. Blood urea nitrogen (BUN) 56 mg/dL
Answer Key:B Feedback:B. The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately. The nurse also will report the other laboratory values, but abnormalities in these are not immediately life threatening.
When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of A. persistent skin tenting B. rapid, deep respirations C. bounding peripheral pulses. D. hot, flushed face and neck.
Answer Key:B Feedback:Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.
A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal? A. Controlling bleeding B. Maintaining the airway C. Maintaining fluid volume D. Relieving the client's anxiety
Answer Key:B Feedback:Rationale: Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway can be compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.
A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client? Excess fluid volume A. Acute pain B. Ineffective breathing pattern C. Activity intolerance
Answer Key:B Feedback:Rationale: Ineffective breathing pattern takes priority for a client with a pulmonary contusion with a pulmonary embolism. The objective of immediate management is to restore and maintain cardiopulmonary function. After an adequate airway is ensured and ventilation is established, examination for shock and intrathoracic and intra-abdominal injuries is necessary. Fluid volume, pain, and activity intolerance are not priority concerns.
A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response? A. Ensure that the client's sodium intake does not exceed recommended levels. B. Report this finding to the primary provider due to the possibility of hepatic encephalopathy. C. Inform the primary provider that the client should be assessed for alcoholic hepatitis. D. Implement interventions aimed at ensuring a calm and therapeutic care environment.
Answer Key:B Feedback:Rationale: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the client's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the client's physiologic deterioration.
A client is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the client's oxygenation status at the bedside? A. Obtain serial ABG samples B. Monitor pulse oximetry readings C. Perform chest auscultation D. Monitor incentive spirometry volumes
Answer Key:B Feedback:Rationale: The nurse assesses the client with pulmonary emboli frequently for signs of hypoxemia and monitors the pulse oximetry values to evaluate the effectiveness of the oxygen therapy. ABGs are accurate indicators of oxygenation status, but are not analyzed at the bedside. PFTs and incentive spirometry volumes do not accurately reveal oxygenation status.
The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate? A. Do you have a history of a heart attack? B. Is there a family history of endocarditis? C. Have you had any recent immunizations? D. Have you had dental work done recently?
Answer Key:D Feedback:Rationale: Target Groups for Prophylactic Antibiotics People with the following heart conditions should have prophylactic antibiotics when they have the conditions or procedures listed below. • Prosthetic heart valve or prosthetic material used to repair heart valve • Previous history of infectious endocarditis • Congenital heart disease (CHD)* o Unrepaired cyanotic CHD (including palliative shunts and conduits) o Repaired congenital heart defect with prosthetic material or device for 6 months after the procedure o Repaired CHD with residual defects at the site or adjacent to the site of prosthetic patch or prosthetic device • Cardiac transplantation recipients who develop heart valve disease Conditions or Procedures Needing Antibiotic Prophylaxis When the above risk groups have the following conditions or procedures, they need prophylactic antibiotics. • Dental manipulation involving the gums or roots of the teeth • Dental manipulation involving puncture of the oral mucosa • Dental extractions/dental implants • Prophylactic teeth cleaning with expected bleeding