Exam 2 Flashcards
If a patient with heart failure who is taking both Furosemide and Digoxin develops
muscle cramps, nausea, vomiting, and anxiety. What order would the nurse expect to
receive from the HCP?
Give supplemental K+
A patient is 24-hours post right leg injury caused by a shark attack.
Vitals at 0700 were: BP: 102/72, HR: 88, T: 98.2, RR: 12, and O2 96% on 2L
Vitals at 1200 were BP: 86/58, P: 126, T: 98.0, RR: 20, O2 90% on 2L.
The patient is also restless, agitated, and has cold/pale skin. Which interventions are
appropriate for the nurse do? SATA
Give 2 Units RBC
0.9% Normal Saline Bolus
A Patient is diagnosed with a UTI, which medication will be ordered?
Bactrim (sulfamexazole)
A diabetic patient comes into the office with a Hemoglobin A1C of 8. Their last A1C
was 5.5. Which question should you ask them related to their A1C increase?
“Can you demonstrate drawing up your insulin dose for me?”
Which lab value would you report for risk of disseminated intravascular coagulopathy
(DIC)?
Fibrinogen = 85
A client comes into the ED with chest pain. The
monitor shows this rhythm. Which intervention should the nurse take? (Strip Shows VTACH)
Evaluate the patient
An EKG strip shows multiple PVCs Which intervention should the nurse take?
Check Potassium Levels
A patient in end-stage renal disease has thirst, confusion, and dry, flushed skin. Which
intervention should the nurse do?
Give fluids
Restrict sodium intake
Which EKG findings suggest an MI? SATA
ST-Elevation
Abnormal Q wave
T-wave inversion
A Patient has left-sided heart failure. Which is the most appropriate assessment?
Lung Sounds
When teaching a patient about their new hypertension diagnosis, which things would
you include? SATA
Keep a diary of BP readings
Instruct patient to bake, roast, or boil food
Avoid OTC medications
With a uric acid kidney stone, which foods should be avoided? SATA
Scallops
Pork
Liver
A Patient with known cardiac disease receives a prescription for Isosorbide
mononitrate for angina. He has a history of traumatic brain injury due to dizziness.
Which intervention would the nurse do first?
Perform orthostatic BP
A patient has CKD. Which findings would you expect?
Decreased GFR
Azotemia
Increased BUN
Oliguria
A child is diagnosed with glomerulonephritis. Which statement made by the parent is
associated with this diagnosis?
The child’s urine has been the color of cola
Which vital sign would be vital to assess for a patient on a PCA pump?
RR of 6
Which condition correlates to the following ABG results?
pH: 7.48 O2: 98% CO2: 28 HC03: 22
Anxiety-induced Hyperventilation
A patient is on 15 different medications. What is the nurse’s priority?
Look for duplicates
Which lab value is the most important for the nurse to report?
Increased troponin
Which of these should the nurse include in a teaching plan for someone prescribed
Hydrochlorothiazide?
Take this medication at the same time everyday
Which acid-base imbalance could Lasix (Furosemide) cause?
Metabolic Alkalosis
A 78 year old patient appears restless, agitated, has mild decrease in LOC, which
intervention would the nurse recommend?
UA culture and sensitivity
A pediatric patient is admitted with suspected Rheumatic Fever. Which question
should the nurse ask during the admission assessment?
Has the child had a sore throat recently?
Which statement made by the patient shows that they understand their Bone Marrow
Transplant procedure?
I will have to lay on my side for 60 minutes post-procedure
Which assessment data indicated there is a complication associated with a patient’s
chronic pain treatment?
Decreased appetite, thirst, and oral intake
Which lab should be monitored if a patient is taking Simvastatin?
Liver enzymes
Which statement by the patient shows that the teaching of their medication Captopril
was effective?
I should take this medication 20-60 minutes before a meal
A patient with hypertension has been diagnosed with Atrial Fibrillation. Which
medication should be prescribed to prevent complications?
Warfarin
A patient is in the Oliguric stage of AKD. Urine output has been 350 mL for 18 hours.
What is the next action the nurse should take?
Continue to monitor patient
A nurse is evaluating a client who is being treated for dehydration. Which assessment result
should the nurse complete with a therapeutic response to the treatment plan?
Decreased orthostatic light headedness and dizziness
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which
assessment will be of most concern to the nurse?
Blood pressure is 90/40 mm Hg.
A patient has a history of kidney disease due to diabetes mellitus. The patient is on
peritoneal dialysis. After placing 1200 mL dialysate, only 400 mL drained. What should
the nurse do next? SATA
Reposition client on their side
Check for obstruction
Call HCP for orders
bag below the patient
Which ABG result represents COPD?
pH: 7.32, O2: 85%, CO2: 57, HCO3: 26
An infant is placed on diuretic therapy. Which method would you use to assess urine
output?
Weigh wet diapers
A patient who had surgery yesterday had the following vital sign changes from
yesterday to 1000 this morning. Which change is the most important to assess?
Blood pressure decreased from 135/88 to 102/66
Magnesium is given via IV. Which S/S would indicate the Magnesium level is too high?
Diminished deep tendon reflexes
A patients lab values are taken once: BP: 114/64, HR: 110, RR: 14, Temp: 101.2, O2 92% 2L
The patient becomes restless, and the labs are taken again:
BP: 90/58, HR: 124, RR: 22,
Temp: 101.4, O2 90% on 2L.
Which lab value is the nurse most concerned with?
WBC = 30,000
Which lab value is most concerning?
Platelet 128,000
A patient has suspected anemia. Which lab value would confirm this?
Hgb 10
A patient is post parathyroidectomy ( 2 days ago). The patient is irritable, has tingling and numbness in face and ears, potassium is 3.2, sodium is 138, calcium was normal. Which of these would be an appropriate lunch tray?
Grilled cheese sandwich, collard greens, yogurt
A patient is semi-conscious, has a dry swollen tongue, temp
99.3 , and urine specific gravity 1.020. What would you expect the patient’s
sodium level to be
165
A patient with a history of renal impairment is given a medication that is excreted
through the kidneys. How would you assess for an adverse reaction?
BUN & Creatinine
A patient with diabetes mellitus has the following acid-base imbalance. Which
manifestation would you see?
pH: 7.36
PaO2: 98%
PaCO2: 33
HCO3-: 18
Increase in RR and depthx
A patient is in the Oliguric stage of AKD. Urine output has been 350 mL for 18 hours.
What is the next action the nurse should take?
Continue to monitor patient/hourly output
The nurse cares for a client admitted with pericarditis. Which symptoms should the nurse
communicate to the healthcare provider immediately?
Jugular venous distention.
During a home visit to an 88-year-old client who is taking digoxin 0.25 mg/day to treat heart
failure and atrial fibrillation, the nurse obtains this assessment information. Which finding is most
important to communicate to the health care provider?
Vision that is becoming “fuzzy”
The nurse is providing care for several patients who are at risk for acid-base imbalance. Which
patient is most at risk for respiratory acidosis?
A 68-year-old patient with chronic emphysema
Biopsy instruct client too..
lie on their right side for a minimum of 2 hours to splint the puncture site.
Stage 1 HTN education SATA
diet, exercise, low sodium, no 2 cups coffee in AM, 4/5
veggies daily
the client is developing dig toxicity if which of the following is noticed on visit?
anorexia, nausea, yellow vision
The nurse reviews a client’s electrolyte laboratory report and notes that the potassium level
is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram
(ECG) as a result of the laboratory value? Select all that apply.
U waves
Inverted T waves
Depressed ST segment
The nurse reviews the electrolyte results of a client with chronic kidney disease and notes
that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for
on the cardiac monitor as a result of the laboratory value? Select all that apply.
Tall peaked T waves
Widened QRS complexes
38-Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?
The client who has sustained a traumatic burn
An adult female client has a hemoglobin level of 10.8 g/ dL (108mmol/L). The nurse interprets
that this result is most likely caused by which condition noted in the client’s history?
Iron deficiency anemia
When vfib on occurs in a CCU ,
the first person reaching the client should
Defibrillate the client
What do you monitor in a patient with celiac disease?
Magnesium, Give IV mag if low
How do you know a Brudzinski’s sign is positive?
Flexes hip and knee in response to neck flexion
What might positive brudzinski sign mean?
may be developing menengitis
Patient is confused and suspected UTI, what orders are anticipated?
UA culture and sensitivity
Patient just had a cholecystectomy T-Tub, what is the proper diet for this client?
Take fat soluble vitamins
Small low fat meals
Avoid gassy foods such as beans, broccoli, cauliflower, cabbage
What s/s should you report of a client who just underwent a parathyroidectomy?
Tetany and Paresthesia
What is the 15-15 rule of hypoglycemia?
when sugar drops give 15g of simple carbs and recheck in 15 minutes
What is the greatest risk for post op illeostomy?
Electrolyte imbalance
Which ostomy is at highest risk for skin breakdown?
Ileostomy
What is the nurse’s role during a bedside GI endoscopy?
Ensure equipment is readily available
What should be done when a patient is having EMG done?
ask about OTC herbal use
evaluate muscle weakness
d/c muscle relaxants
What is priority of a Guillain Barre Syndrome?
Respiratory management
have intubation tray ready and EKG
What assessment should be done for a client with a CVA?
NIH and NIHSS
What are priority post craniotomy interventions?
measure head circumference
apply nail bed pressure if unconscious
What are two early signs of increased ICP?
Decreased LOC and vomiting
What is a late sign of increased ICP?
Bradycardia
What are normal ammonia levels?
10-80
How do you lower ammonia levels?
Give lactulose
What is a early sign of high ammonia levels?
Increased confusion, if confusion is getting better lactulose therapy is effective
What are s/s of a bone metastasis emergency?
Facial edema
calcium of 12
numbness and tingling
What is calcitonin for?
given for high calcium levels
What is an adverse reaction of carbamazepine?
WBC 3000
What is isosorbide mononitrate for?
Chest pain
Headache is a sign the med is working
take first thing in the am
side effects are dizziness, flushing, nausea
