Review

The healthcare provider has ordered a hypotonic IV solution to be administered. Which IV bad will the nurse prepare? 0.45% sodium chloride 0.9% sodium chloride Lactated ringers Dextrose 5% in lactated ringers

0.45% sodium chloride

A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic iv therapy. Which iv will the nurse prepare. 0.225% sodium chloride 0.45% sodium chloride 0.9% sodium chloride 3% sodium chloride

0.9% sodium chloride

The nurse is performing moist-to-dry dressings. The nurse has prepared the supplies, solution and removed the old dressing. In which order will the nurse implement the steps 1. Apply sterile gloves 2 cover and secure topper dressing 3 assess wound and surrounding skin 4 moisten gauze with prescribed solution 5 gently wring out excess solution and unfold 6 loosely pack until all wound surfaces are in contact with gauze

1,3,4,5,6,2

The nurse is caring for a group of patients. Which patient will the nurse see first. A patient with D5W hanging with blood A patient with type a blood receiving type O blood A patient with intravenous potassium chloride that is diluted A patient with a right mastectomy and an iv site in the left arm

A patient with D5W hanging with blood

A nurse is caring for patients with dysphagia. Which patient has neurogenic dysphagia A patient with benign peptic stricture A patient with muscular dystrophy A patient with myasthenia Gracie A patient with a stroke

A patient with a stroke

A nurse is caring for a patient whose ECG presents with changes characteristics of hypokalemia. Which assessment finding will the nurse expect? Dry mucous membranes Abdominal distention Distended neck veins Flushed skin

Abdominal distention

Which process requires energy to maintain the unique composition of extracellular and intracellular compartments? Diffusion Osmosis Filtration Active transport

Active transport

A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check? Vitamin E Potassium Albumin Sodium

Albumin

A patient has a deep wound on the right hip, with tunneling at 8 o clock position extending 5 cm. The wound is draining large amounts of serisanguineous fluid and contains 100% red beefy tissue in the wound bed. Which would be an appropriate dressing choice? Alginate dressing Dry gauze dressing Hydrogel Hydrocolloid dressing

Alginate dressing

Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? An infant with temperature of 102.2 and diarrhea for 3 days A teenager with a sprained ankle and excessive edema A middle aged adult with abdominal pain who is morning and holding her stomach An older adult with nausea and vomiting for 3 days with a blood pressure of 112/60

An infant with a temp of 102.2 and diarrhea

A patients blood group is B. From which donor groups can this patient receive blood? SATA A B O AB

B O

A client who follows a vegan eating plan is experiencing numbness and tingling of the fingers and toes. Which supplement should the nurse recommend to this client? C B12 Zinc Magnesium

B12

A patient who was prescribed furosemide is deficient in potassium. Therefore the patient should be instructed to increase his intake of which foods? Bananas, peaches molasses and potatoes Eggs, baking soda, and baking powder Wheat bran, chocolate, eggs and sardines Egg yolks, nuts and sardines

Bananas, peaches, molasses, and potatoes

The nurse receives the patients most recent blood work results Which laboratory value is the greatest concern? Sodium 145 Calcium 15.5 Potassium 3.5 Chloride 100

Calcium 15.5

The nurse is completing a skin assessment on a medical surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? SATA Can you easily change your position? Do you have sensitive to heat or cold? How often do you need to use the toilet? What medications do you take? Is movement painful? Have you ever fallen?

Can you easily change positions Do you have sensitivity to hear or cold? How often do you need to use the toilet? Is movement painful

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? GI Neuro Respiratory Cardiac

Cardiac

For a patient with Risk for imbalanced nutrition: less then body requirements related to impaired swallowing which nursing intervention is appropriate SATA Check inside the mouth for pocketing of food Provide a full liquid diet that is easy to swallow Remind the patient to raise the chin slightly to prepare for swallowing Keep the head of the bed elevated Provide a straw for drinking

Check inside the mouth for pocketing of food Keep the head of the bed elevated for 30 to 45 minutes

Pressure ulcers are directly caused by which condition at the site? Compromised blood flow Edema Shearing forces Inadequate venous return

Compromised blood flow

The nurse is working on a medical surgical unit that has been participating in a research project associate with pressure ulcers. which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development Decreased level of consciousness Adequate dietary intake Shortness of breath Muscular pain

Decreased level of consciousness

What is common characteristic of aging skin? Increases permeability to moisture Diminished sweat gland activity Reduced oxygen free radicals Overproduction of elastin

Diminished sweat gland activity

What intervention would be most appropriate for a wound with a beefy red wound bed? Mechanical debridement Autolyctic debridement Dressing to keep the wound moist and clean Removal of devitalized tissue and a sterile dressing

Dressing to keep the wound moist and clean

Which instruction should the nurse give to the patient experiencing constipation! SATA Drink at least 8 glasses of water or noncaffeinated fluid per day Include a minimum of four servings of meat per day Consume a high fiber diet Exercise as you feel necessary Eat meals in a regular schedule

Drink at least 8 glasses of water Consume a high fiber diet Eat meals in a regular schedule

A patient has a stage 1 pressure injury on the left heel. What is the initial treatment for this pressure ulcer? Antibiotic therapy for 2 weeks Normal saline irrigation of the ulcer daily Debridement to the left heel Elevation of the left heel off the bed

Elevation of the left heel off the bed

A patient has an area of nonblanchable erythema on his coccyx. What would be the most important treatment for this patients stage 1 pressure injury? Transparent film dressing Sheet hydrogel Frequent turn schedule Enzymatic debridement

Frequent turn schedule

The nurse administers an IV hypertonic solution to a patient. In which direction will the fluid shift? From intracellular to extracellular From extracellular to intracellular From intravascular to intracellular From intravascular to interstitial

From intracellular to extracellular

A patient in respiratory distress has the following ABGs pH= 7.30; PCO2 40, HCO3= 19, PO2 80. After treatment pH 7.38, PCO2 32, HCO3 19 what should the nurse conclude from this information Respiratory acidosis. The treatment plan is ineffective Metabolic alkalosis. The treatment plan is effective Partial compensation the treatment plan is ineffective. Full compensation; the treatment plan is effective

Full compensation; the treatment plan is effective

The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing? Eschar Slough Granulation Purulent drainage

Granulation

The nurse notes that a client has had significant diarrhea Over the past several days. Which level in the clients arterial blood gas results will be most affected? pH pO2 PCO2 HCO3

HCO3

When performing a central venous catheter dressing change, which step is correct? Wear sterile gloves while removing and discarding the soiled dressing Apply pressure on the catheter-hub junction when removing the soiled dressing Place a sterile transparent dressing over the site and the catheter-hub junction Have the patient wear a mask or turn his head away from the site.

Have the patient wear a mask or turn his head away from the site

Before giving the patient an intermittent tube feeding, the nurse should a. Make sure that the tube is secured to the gown with a safety pin. b. Have the tube feeding at room tempera-ture. c. Inject air into the stomach via the tube and auscultate. d. Place the patient in a supine position.

Have the tube feeding at room temperature

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing and healthy tissue is observed. How should the nurse document this ulcer in the patients medical record? Stage I pressure ulcer Healing stage II pressure ulcer Healing stage III pressure ulcer Stage III pressure ulcer

Healing stage III pressure ulcer

In a healthy adult which regulates body fluids SATA Hormone levels Fluid intake Oxygen saturation Kidney function Neurological function

Hormone levels Fluid intake Kidney function

A patient has a stage 2 pressure injury that is covered with dry,yellow slough that tightly adheres right the wound. What is the best treatment the nurse could recommend for treating this wound? Dry gauze changed twice daily Nonadherent dressjfn changed as needed Hydrocolloid dressings changed as needed Wet to dry dressings changed three times daily

Hydrocolloid dressings changed as needed

The nurse observes edema in a patient who has venous congestion from right heart failure. Which type of pressure facilitated the formation of the patients edema? Osmotic Oncotic Hydrostatic Concentration

Hydrostatic

The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? SATA Vision Hypermedia Induration Blanching Temperature of skin

Hyperemia Induration Blanching Temperature of skin

The nurse examines the electrocardiograph tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect Hypokalemia Hypophosphatemia Hyperkalemia Hypercalcemia

Hyperkalemia

A patient's 2:1 parenteral nutrition container infuses before the pharmacy prepares the next container. This places the patient at risk for which complication? Sepsis Pneumothorax Hypoglycemia Thrombophlebitis

Hypoglycemia

A patient's arterial blood gas (ABG) results include pH 7.30, PaCO2 40mm Hg, PaO2 80 mm Hg, and HCO3 19 mEq/L. What would be an appropriate nursing diagnosis for the patient? Impaired gas exchange Metabolic acidosis Risk for impaired gas exchange Risk for acid-base imbalance

Impaired gas exchange

What impact does hypertensive medication have on skin integrity and wound healing? Causes cellular toxicity Increases the risk of ischemia Delays wound healing Predisposes to hematoma formation

Increases risk of ischemia

The nurse collects the following assessment data; right heel with reddened area that does not blanch. Which diagnosis will the nurse assign Imbalanced nutrition: less than body requirements Ineffective peripheral tissue perfusion Risk for infection Acute pain

Ineffective peripheral tissue perfusion

Three days after abdominal surgery, the nurse notes 4 cm Periwound erythema and swelling at the distal ended if the clients incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Heart rate is 96 beats and oral temp is 100.8. What kind of complication should the nurse suspect this client is experiencing? Infection Dehiscence Hematoma under the skin Formation of granulation tissue

Infection at the incision site

The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consume 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? Intake 255, output 375 Intake 285,output 375 Intake 505,output 125 Intake 535,output 125

Intake 255; output 375 Remember ice chips are only 1/2

Which body fluid lies in the spaces between the body cells? Interstitial Intracellular Intravascular Trans cellular

Interstitial

A patient is dehydrated. While planning care the nurse considers that the majority of the patients total water volume exists in with compartment? Intracellular Extracellular Intravascular Transcellular

Intracellular

A patient has multiple open wounds that require treatment. What should the nurse do when performing dressing changes? Remove all of the soiled dressings before beginning wound treatment Cleanse wounds from most contaminated to least Treat wounds on your the patients side first, then the front and back of the patient Irrigate wounds from least contaminated to most contaminated

Irrigate from least contaminated to most

Which laboratory result should alert the nurse to a potential problem? Na 137 K 5.2 Ca 9.2 Mg 1.8

K 5.2 Hyperkalemia

The nurse working in the ED is preparing heat therapy for one of the patients on the unit. Which one is it most likely to be? Actively bleeding Swollen, tender insect bites Sprained ankle Lower back pain

Lower back pain

Which is the most appropriate goal for a patient with a nursing diagnosis of deficient fluid volume? Electrolyte balance restored as evidence by improved levels of alertness and cognitive orientation Electrolyte balance restored, as evidence by sodium returning to normal range Patient demonstrates effective coughing and deep breathing techniques Maintained fluid balance as evidence by moist mucous membranes and urinating every 4 hours

Maintain fluid balance as evidenced by moist mucous membranes and urinating every four hours

A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene? a. Custard b. Frozen yogurt c. Pureed vegetables d. Mashed potatoes and gravy

Mashed potatoes

A client is admitted to the emergency department in respiratory distress. The result of his abgs are 7.30, PCO2 40, HCO3 19 PO2 80. How should the nurse interpret these results. Respiratory acidosis with normal oxygen levels Respiratory alkalosis with hypoxia Metabolic acidosis with normal oxygen levels Metabolic alkalosis with hypoxia

Metabolic acidosis with normal oxygen levels

A patient admitted for a bowel obstruction and has had a NG tube set to low intermittent suction for the last 3 day's. Which arterial blood gas values will the nurse expect to observe Respiratory alkalosis Metabolic alkalosis Metabolic acidosis Respiratory acidosis

Metabolic alkalosis

Which is an appropriate intervention for a patient with hypovolemia? SATA Teach deep breathing techniques Monitor I&O daily Encourage fluid intake Monitor electrolyte balance Measure daily weights

Monitor I&O daily Encourage fluid intake Monitor electrolyte balance Measure daily weights

The nurse records a patient's hourly urine output from an indwelling catheter as follows: 0700: 36 ml 0800: 45 ml 0900: 85 ml 1000: 62 ml 1100: 50 ml 1200: 48 ml 1300: 94 ml 1400: 78 ml 1500: 60 ml The nurse can conclude that the patient's urine output should be described as which of the following? Low Normal High Inconclusive

Normal

The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which is the nurse describing? Osmosis Filtration Diffusion Active transport

Osmosis

A patient with quadriplegia has an ischial wound that extends through the epidermis into the dermis. How should the nurse document the depth of this wound? Partial thickness wound Penetrating wound Superficial wound Full thickness wound

Partial thickness wound

A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching? Milk and cheese Potatoes and fresh fruit Canned soups and vegetables Whole grains and dark green leafy vegetables

Potatoes and fresh fruit

The nurse is caring for a patient who was involved in an automobile accident two weeks ago. Patient sustained a head injury and is unconscious. Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer? Resistance Pressure Weight Stress

Pressure

What is the function of the stratum Corneum Provides insulation for temperature regulation Provides strength and elasticity to the skin Protects the body against the entry of pathogens Continually produces new skin cells

Protects the body against the entry of pathogens

what represents the sum of all ventricular muscle cell depolarization? PR interval QRS complex QT interval p wave

QRS complex

A nurse is caring for a postoperative patient. Which funding will alert the nurse to a potential wound dehiscence? Protrusion of visceral organs through a wound opening Chronic drainage if fluid through the incision site Report by patient that something has given way Drainage that is odorous and purulent

Report by patient that something has given to way

A 2 year old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? Respiratory alkalosis Respiratory acidosis Metabolic acidosis Metabolic alkalosis

Respiratory acidosis

What is the mechanism that controls acid-base balance? SATA Respiratory mechanisms Active transport mechanism Renal mechanism Buffer system Peripheral vascular system

Respiratory mechanism Renal mechanisms Buffer system

When a patient has metabolic acidosis, which body system influences the acid-base imbalance to produce the compensatory changes in the arterial blood gases? Respiratory system Renal system Vascular system Neurological system

Respiratory system

The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following prescriptions are written in the clients electronic health record. Which one should the nurse question? Administer an IVnid D5W at 125 ml/hr Strict I&O monitoring Restrict oral intake to 900 mL every 24 hr Monitor serum electrolytes every 4 hr

Restrict oral intake to 900 mL every 24 hr

Which nutritional goal is appropriate for a patient newly diagnosed with hypertension Limit protein intake Avoid food with gluten Restrict sodium Limit potassium

Restrict sodium

A client requires sedation intubation and mechanical ventilation for two weeks. What would be an appropriate nursing diagnosis for the clients? Risk for infection related to subcutaneous injuries Risk for impaired skin integrity related to immobility Impaired tissue integrity related to renovator dependency Impaired skin integrity related to ventilator dependency

Risk for impaired skin integrity related to immobility

In providing diet education for a patient on a low fat diet which information. Is important for the nurse to share? Polyunsaturated fats should be less than 7% of the total calories Trans fat should be less than 7% of the total calories Unsaturated fats are found mostly in animal sources Saturated fats are found mostly in animal sources

Saturated fats are found mostly in animal sources

A patient is recovering from surgery for a ruptured appendix. Because the surgeon did not surgically close the wound, what wound healing process will occur? Primary intention Secondary intention Tertiary intention Approximation

Secondary intention

The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider planning care for this patient? Partial thickness repair Secondary intention Tertiary intention Primary intention

Secondary intention

The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? SATA The patients expectations are not being met Skin is intact with no redness or swelling Nonblanchable erythema is absent No injuries to the skin and tissues are evident Granulation tissue is present

Skin is intact with no redness or swelling Non-blanchable erythema is absent No injuries to the skin and tissues are evident Granulation tissue is present

The patient has just started on enteral feedings, and the patient is reporting abdominal cramping. Which actions will the nurse take next Slow the rate of tube feeding Instill cold formula to numb the stomach Change the tube feeding TI a high fat formula Consult with the health care provider about pro kinetic medication

Slow the rate of the tube feeding

A patient with leg cramps is irritable and febrile and has dry mucous membranes. Based on these findings, the patient most likely has excess levels of which mineral Sodium Potassium Phosphorus Magnesium

Sodium

The nurse is reviewing lab results. Which cation will the nurse observe is the most abundant in the blood Sodium Chloride Potassium Magnesium

Sodium

Which electrolyte is the primary regulator of fluid volume? Potassium Calcium Sodium Magnesium

Sodium

In determining malnourishment in a patient, which assessment finding is consistent with this disorder? a. Moist lips b. Pink conjunctivae c. Spoon-shaped nails d. Not easily plucked hair

Spoon shaped nails

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? Stage 1 Stage 11 Stage III Stage IV

Stage II

A client developed a stage four pressure injury to the sacrum six weeks ago and now the ulcer appears to be a shallow crater involving only partial skin loss. How should the nurse now classify this pressure injury? Stage one pressure injury healing Stage two pressure injury healing Stage III pressure injury healing stage four pressure injury healing

Stage four pressure injury healing

The nurse learns that a patients wound will be sutured closed after additional healing occurs. Which type of healing is occurring Primary intention Regenerative healing Tertiary intention Secondary intention

Tertiary intention

Which nursing observation will indicate the patient is at risk for pressure ulcer formation The patient has fecal incontinence The patient ate two thirds of breakfast The patient has a raised red rash on the right shin The patients capillary refill is less than 2 seconds

The patient has fecal incontinence

What is the primary goal that the nurse should establish for a patient with an open wound? The wound will remain free of infection throughout the healing process Client completes antibiotic treatment as ordered The wound will remain free of scar tissue at healing Client increases caloric intake throughout the healing process

The wound will remain free of infection throughout the healing process

A patient develops a food borne disease from escherichia Coli. When taking a health history which food item will the nurse most likely find the patient ingested? Improperly home-canned food Undercooked ground beef Soft cheese Custard

Undercooked ground beef

A patient has a pressure injury on the coccyx measuring 5cm by 3 cm that's is covered with eschar. How should the nurse classify this wound? Stage 2 pressure injury Stage 3 pressure injury Stage 4 pressure injury Unstageable pressure injury

Unstageable pressure injury

A patient with underlying cardiac disease and a draining wound requires careful monitoring of fluid balance. Which method for evaluating wound drainage would be most appropriate for assessing fluid loss? Draw a circle around the area of drainage on a dressing Classify drainage as less or more than the previous drainage Weigh the patient at the same time each day on the same scale Weigh dressings before they are applied and after they are removed

Weigh dressings before they are applied and after they are removed

The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? Assess the patients for edema in extremities Ask the patients to record their intake and output Weigh the patients every morning before breakfast Measure the patients blood pressures every 4 hours

Weigh the patients every morning before breakfast

I'm general when a patients energy requirements are completely met by kilocalorie intake in food, which assessment finding will the nurse observe? Weight increases Weight decreases Weight does not change Weight fluctuates daily

Weight does not change

The pericardium is: the outer muscular layer of the heart the innermost layer of the heart chambers a membranous sac that encloses the heart the hearts fibrous skeleton

a membranous sac that encloses the heart

Diffusion of respiratory gases takes place at the: alveolocapillary membrane visceral pleurae parietal pleura respiratory center

alveolocapillary membrane

what structure conducts action potentials down the atrioventricular septum? bachmann bundle bundle of his sinoatrial node atrioventricular node

bundle of Hiss

A nurse observes a cardiologist multiplying the heart rate by stroke volume. What is the cardiologist measuring? vascular resistance preload cardiac output ejection fraction

cardiac output

Baroreceptors are located in the: renal artery superior vena cava carotid artery circle of willis

carotid artery

The cardiac electrical impulse normally begins spontaneously in the sionatrial node because it has a superior location to the right atrium is the only area of the heart capable of spontaneous depolarization depolarizes more rapidly than other automatic cells of the heart

depolarizes more rapidly than other automatic cells of the heart

The internal lining of the cardiovascular system is formed by what tissue? tunica adventita connective mesothelium endothelium

endothelium

one of the functions of the pulmonary system is the: expelling of bacteria exhange of gases between environment and blood movement of blood into and out of capillarires principal mechanism for cooling the heart

exchange of gases between the environment and blood

The nurse is describing the slit-shaped space between true vocal cords. What term should the nurse use? glottis epiglottis larynx carina

glottis

The nasopharynx is lined with a ciliated mucosal membrane with a highly vascular blood supply. One function of this membrane is to: absorb air humidify air cool air exchange gases

humidify air

During inspiration, muscular contraction of the diaphragm causes air to move into the lung. The mechanism that drives air movement during inspiration results in: decrease in intra-alveolar pressure and shortening the rib cage decrease the size of the thorax and alveolar expansion increase in the size of the thorax and decrease in intrapleural pressure increase in atmospheric pressure and intrapleural pressure

increase in the size of the thorax and decrease in intrapleural pressure

a 13 year old took a weight loss drug that activated the sympathetic nervous system. Which of the following assessment findings would the nurse expect? decreased myocardial contraction decreased heart rate increased cardiac conduction increased intranodal conduction time

increased cardiac conduction

A nurse is evaluating stroke volume. Which of the following factors affect stroke volume. SATA preload peripheral vascular resistance afterload ejection fraction contractility

preload afterload contractility

function of pericardium provide a barrier against extracardial infections improve blood flow through the heart play a role in cardiac conduction assist in cardiac contraction

provide a barrier

As a result of blockage in the pulmonary artery, blood would first back up into the: aorta left ventricle pulmonary veins right ventricle

right ventricle