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N-CLEX > Critical Care > Flashcards

Critical Care Flashcards

1
Q

The nurse is reviewing lab results and notes that a client’s serum sodium level is 150mEq/L (150mmol/L). The nurse report the serum sodium level to the HCP and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply.

  1. Peas
  2. Nuts
  3. Cheese
  4. Cauliflower
  5. Process oat cereals
A
  1. peas
  2. nuts
  3. cauliflower
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2
Q

The nurse review the electrolyte results of an assigned client and notes that the potassium level is 5.7 mmol/L. Which patterns would the nurse watch for on the cardiac monitor as a result of the lab values. Select all that apply.

  1. ST depression
  2. Prominent U wave
  3. Tall peaked T waves
  4. Prolonged ST segment
  5. Widened QRS complexes
A
  1. tall peaked t waves

5. widened QRS complexes

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3
Q

Which client is at risk for the development of a sodium level of 130 mmol/L?

  1. The client taking diuretics
  2. The client with hyperaldosteronism
  3. The client with Cushing’s syndrome
  4. The client who is taking corticosteroids.
A
  1. The client taking diuretics.
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4
Q

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished DTR’s. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

  1. Muscle Twitches
  2. Decreased urinary output
  3. Hyperactive bowel sounds
  4. Increased specific gravity of the urine
A
  1. Hyperactive Bowel Sounds
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5
Q

The nurse reviews a client’s lab report and notes that the client’s serum phosphorus level is 1.8mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level?

  1. malnutrition
  2. renal insufficiency
  3. hypoparathryoidism
  4. tumor lysis syndrome
A
  1. malnutrition
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6
Q

The nurse is assigned to care for a group of clients. On review of the client’s medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

  1. A client with an ileostomy
  2. A client with heart failure
  3. A client on long-term corticosteroids
  4. A client receiving frequent wound irrigations
A
  1. A client with an ileostomy
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7
Q

A client with Atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio of 3.5. On the basis of these lab values, the nurse anticipates which prescription?

  1. Adding a dose of heparin sodium
  2. Holding the next dose of warfarin
  3. Increasing the next dose of warfarin
  4. Administering the next dose of warfarin
A
  1. Holding the next dose of warfarin
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8
Q

The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel. Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?

  1. Taking a rectal temp for a client who has undergone nasal surgery.
  2. Taking an oral temp for a client with a cough and nasal congestion.
  3. Taking an axillary temp for a client who has just consumed hot coffee.
  4. Taking a temporal temp on the neck behind the ear for a client who is diaphoretic.
A
  1. Taking an oral temp for a client with a cough and nasal congestion.
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9
Q

A client is receiving continuous IV infusion of heparin sodium to treat DVT. The client’s aPTT is 65 seconds. The nurse anticipates that which action is needed?

  1. Discontinuing the heparin infusion
  2. Increasing the rate of the heparin infusion
  3. Decreasing the rate of the heparin infusion
  4. Leaving the rate of the heparin infusion as is
A
  1. Leaving the rate of the heparin infusion as is
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10
Q

Several lab tests are prescribed for a client, and the nurse review the results of the tests. Which lab results should the nurse report? Select all that apply.

  1. Platelets 35,000 mm
  2. Sodium 150 mmol/L
  3. Potassium 5.0mmol/L
  4. Segmented neutrophils 40% (0.40)
  5. Serum creatinine 1mg/dL (88.3 umol/L)
  6. WBC 3000mm
A
  1. Platelets 35,000 mm
  2. Sodium 150 mmol/L
  3. Segmented neutrophils 40% (0.40)
  4. WBC 3000mm
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11
Q

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering info on the client’s medication history, and determines it is necessary to contact the HCP if the client is also taking which meds? Select all that apply.

  1. Warfarin
  2. Glimepiride
  3. Amlodipine
  4. Simvastatin
  5. Hydrochlorothiazide
A
  1. Warfarin
  2. Glimepiride
  3. Amlodipine
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12
Q

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphine via a PCA pump for pain control. The nurse enters the client’s room and finds the client drowsy and records the following VS: temp 36.2*C orally, pulse 52 BPM, BP 101/58mmHg, resp rate 11 breaths per min, and SpO2 of 93% on 3L of oxygen via NC. Which action should the nurse take next?

  1. Document the findings.
  2. Attempt to arouse the client
  3. Contact the HCP immediately.
  4. Check the medication administration history of the PCA pump.
A
  1. Attempt to arouse the client
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13
Q

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands the dietary modifications if the client selects which items from the dietary menu?

  1. Cream of wheat, blueberries, coffee
  2. Sausage and eggs, banana, orange juice
  3. Bacon, cantaloupe melon, tomato juice
  4. Cured pork, grits, strawberries, orange juice
A
  1. Cream of wheat, blueberries, coffee
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14
Q

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?

  1. Vit A
  2. Vit B12
  3. Vit C
  4. Vit E
A
  1. Vit B12
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15
Q

Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsions (lipids) to infuse at 50 mL/hour?

  1. Ensure that the client does not have diabetes
  2. Determine whether the client has an allergy to eggs
  3. Add regular insulin to the fat emulsion, using aseptic technique
  4. Contact the HCP to have a central line inserted for fat emulsion infusion.
A
  1. Determine whether the client has an allergy to eggs.
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16
Q

The nurse, caring for a group of adult clients on an acute care med-surg nursing unit, determines that which clients would be the most likely candidates for parenteral nutrition? Select all that apply.

  1. A client with extensive burns
  2. A client with cancer who is septic
  3. A client who has had an open cholecystectomy
  4. A client with severe exacerbation of Crohn’s disease
  5. A client with persistent nausea and vomiting from chemotherapy
A
  1. A client with extensive burns
  2. A client with cancer who is septic
  3. A client with severe exacerbation of Crohn’s disease
  4. A client with persistent nausea and vomiting from chemotherapy
17
Q

The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition bag of an assigned client is empty. Which solution should the nurse hang until another PN solution is mixed and delivered to the nursing unit?

  1. 5% dextrose in water
  2. 10% dextrose in water
  3. 5% dextrose in Ringer’s lactate
  4. 5% dextrose in 0.9% sodium chloride
A
  1. 10% dextrose in water
18
Q

The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition. The nurse should plan to ensure that which action is taken to present the client from sustaining injury?

  1. Calculate daily intake and output
  2. Monitor the temperature once daily
  3. Secure all connections in the PN system
  4. Monitor BG levels every 12 hours
A
  1. Secure all connections in the PN system
19
Q

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply.

  1. Pain and erythema
  2. Pallor and coolness
  3. Numbness and pain
  4. Edema and blanched skin
  5. Formation of a red streak and purulent drainage
A
  1. Pallor and coolness
  2. Numbness and pain
  3. Edema and blanched skin
20
Q

IV fluids have been infusing at 100mL/hr via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the clients BP. Upon entering the client’s room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data?

  1. Excessive bleeding
  2. Crackles in the lungs
  3. Incompatibility of the infusion
  4. Chest pain radiating to the left arm
A
  1. Crackles in the lungs
21
Q

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells. Select all that apply.

  1. Checks the expiration date
  2. Inspects for the presence of clots
  3. Checks the blood group and type
  4. Checks the blood ID number
  5. Hangs the blood within the specified time frame per agency policy.
A
  1. Checks the expiration date

5. Hangs the blood within the specified time frame per agency policy.

22
Q

The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client’s VS, which include temp of 36.2*C, pulse 108 bpm, BP of 152/76mmHg, resps of 24 breaths per min, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take?

  1. Collect a urine sample for analysis
  2. Place the client in an upright position
  3. Compare current data to baseline data
  4. Slow the rate of the blood transfusion
A
  1. Compare current data to baseline data
23
Q

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) moni- tor displays tachycardia, with a heart rate of 120 beats/ minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

  1. A decreased pH and an increased PaCO2
  2. An increased pH and a decreased PaCO2
  3. A decreased pH and a decreased HCO3
  4. An increased pH and an increased HCO3
A
  1. An increased pH and an increased HCO3
24
Q

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse mon- itors the client for manifestations of which disorder that the client is at risk for?

  1. Metabolic acidosis
  2. Metabolic alkalosis
  3. Respiratory acidosis
  4. Respiratory alkalosis
A
  1. Metabolic alkalosis
25
Q

The nurse notes that a client’s arterial blood gas (ABG) results reveal a pH of 7.50 and a PaCO2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

  1. Nausea
  2. Confusion
  3. Bradypnea
  4. Tachycardia
  5. Hyperkalemia
  6. Lightheadedness
A
  1. Nausea
  2. Confusion
  3. Tachycardia
  4. Lightheadedness
26
Q

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?
1. Respiratory acidosis from inadequate ventilation
2. Respiratory alkalosis from anxiety and
hyperventilation
3. Metabolic acidosis from calcium loss due to
broken bones
4. Metabolic alkalosis from taking analgesics con-
taining base products

A
  1. Respiratory acidosis from inadequate ventilation

N-CLEX (3 decks)

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