Final Flashcards
1
Q
The nurse is developing a care plan for a patient who is taking an anticholinergic drug. ___________ is the nursing diagnosis that would be appropriate for this patient?
A
Urinary Retention
Rationale: Patients receiving anticholinergic drugs are at risk for urinary retention and constipation, not diarrhea
2
Q
A patient has sustained a major head injury and the nurse is assessing the patient’s neurologic status every two hours. What early sign of increased ICP does the nurse monitor for?
A
Early signs and symptoms include: changes in mental status, such as disorientation, restlessness, and mental confusion. purposeless movements. increased respiratory effort.
3
Q
A nurse is teaching a patient with premature ectopic beats. Which education would the nurse include in the patient’s teaching? Select all that apply.
A
Mnemonic: Social Security Accepted
Smoking Cessation
Stress Reduction and Management
Adverse Effects of Medications( Beta blockers)
Avoid Caffeine
Rationale: A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.
4
Q
The nurse contacts the health care provider with data collected from a patient admitted for a stroke. Which information indicates the patient may be experiencing central herniation? Select all that apply
A
Mnemonic: PIC-B
Positive Babinski
Increased Systolic BP
Coma
Bradycardia
GCS <7
5
Q
The nurse is completing discharge teaching with an 80 year old male patient who underwent right total hip replacement.The nurse identifies the need for further instruction if the patient states the need to.
A
Maintain hip in adduction and internal rotation
Rationale: The patient should not force hip into adduction, beyond 90 degree angle sitting down or force hip into internal rotation as these movements could displace the hip replacement. Avoiding crossing the legs, using a toilet elevator on toilet seat, high chair and notifying future caregivers about the prosthesis indicate understanding of discharge teaching
6
Q
Which is a preventative measure for diverticular disease?
A
Taking bulk agents such as psyllium hydrophilic mucilloid (Metamucil)
No seeds, no corn. High Fiber foods decrease the risk of Diverticulitis. Foods such fresh fruits and vegetables soften waste material and help it pass more quickly through the colon. Drinking plenty of fluids.Diverticulitis Tx: flagyl and cipro. During acute phase pt is NPO and will receive abx IV. After Acute phase, push large fiberr to get ride of everything in the colon . May take bulk laxative agent to clean out everything.
7
Q
The nurse correlates which data in a patient’s medical history as risk factors for acute kidney injury? Select all that apply.
A
HTN
Dehydration
Kidney stones
Hypovolemia
Being Hospitalized especially for a serious condition that requires intensive care
Advanced age
Blockages in blood vessels in your arms or legs (peripheral artery disease)
Diabetes
High BP
Heart Failure
Kidney Disease
Liver Disease
Certain cancers and their treatements
Rationale: Acute kidney failure (also called Acute Renal Failure) occurs when your kidney suddenly becomes unable to filter waste products from your blood. Dangerous levels of wastes may accumulate and your blood’s chemical get out of balance
8
Q
Which discharge instructions are appropriate for a patient diagnosed with hepatitis A?
A
Hep A is inflammation of the liver caused by the Hep A Virus (HAV) Mostly spread through contaminated food.
Discharge/Preventitive Instructions
Wash your hands
Cover a sneeze or cough
Stay away from others while you are sick
Ask about vaccines you may need (flu and pneumonia)
9
Q
The nurse is assessing a patient with Huntington disease and observes jerky movements of the face, limbs and trunk. How does the nurse document this assessment finding?
A
Chorea
10
Q
The nurse monitoring a patient for therapeutic response to oral antidiabetic drugs will look for.
A
Hemoglobin A1C levels of less than 7%.
11
Q
The nurse is interviewing a patient who is newly admitted to a unit with a diagnosis of anemia.Which assessment findings is the nurse expect? Select all that apply.
A
Mnemonic: CHIP-DO
Club like appearance of the nails
Headache
Intolerance to cold temps
Pallor of the ears
Dyspnea on exertion
Orthostatic hypotension
12
Q
A patient reports “excruciating sharp shooting, unilateral” facial pain which which lasts from seconds to minutes, and describes the reluctance to smile, eat or talk because of fear of precipitating an attack. The patient’s description of symptoms is consistent with which.the symptoms of which disorder?
A
Trigeminal Neuralgia
13
Q
The patient with chronic kidney disease (CKD) and severe anemia, refuses blood transfusion. The health care provider prescribes epoetin alfa. Which action should the nurse explain to the patient about the medication therapeutic response?
A
Stimulates erythropoiesis in the bone marrow to increase circulating erythrcytes
Rationale: Epoetin alfa is a biological response modifier that is used to stimulate the formation of red blood cells
14
Q
The nurse is caring for the patient with acute appendicitis, which interventions will the nurse perform? Select all that apply.
A
Mnemonic: I-AM
If tolerated, maintain the patient in a semi-fowler’s position
Maintain the patient on NPO status
Administer IV fluids as prescribed
15
Q
The patient is admitted for acute MI, but the nurse notes that the traditional manifestation of ST Elevation MI (STEMI) is not occurring. What other evidence for acute MI does the nurse expect to find in the patient? Select all that apply.
A
Positive Troponin markers
Non ST-elevation MI (non STEMI)
16
Q
The nurse cares for a patient who presents with bradycardia secondary to hypothyroidism.Which medication is best for the nurse to prepare to administer to the patient?
A. Propranolol (Inderal)
B. Epinephrine (Adrenalin)
C. Levothyroxine sodium (Synthroid)
D. Atropine sulfate
A
Levothyroxine sodium (Synthroid)
The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using levothyroxine sodium. If the heart rate were so slow that it became an emergency, then atropine or epinephrine might be an option for the short term management. Propranolol is a beta blocker and would be contraindicated for a patient with bradycardia
17
Q
A patient reports urinary retention, nausea, flank pain rated 10 on a 10 point scale.Which obstruction uropathy does this suggest?
A
Renal calculi
Rationale: Urinary retention, nausea, and flank pain rated 10 on a 10-point scale indicate the presence of renal calculi.
18
Q
Which data in an older adult history does the nurse correlate as risk factors for developing acute kidney injury (AKI)? .Select all that apply.
A
- Dehydration
- Renal calculi
- Hypertension
Risk factors include trauma, nephrotic syndrome, and atrial fibrillation.
19
Q
A patient experiences impaired swallowing after a stroke and has worked with speech language pathology on eating.What nursing assessment best indicates that a priority goal for this problem has been met?
A
Has clear lung sounds on auscultation
Rationale: Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.
20
Q
A patient is diagnosed with chronic kidney disease (CKD).What is the most ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema?
A
Maintaining a balanced intake and output
Rationale: With an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Other ideal goals are oxygen saturations greater than 92%, no auscultated crackles or wheezes, and no demonstrated shortness of breath.
21
Q
A patient had a nephrostomy and a nephrostomy tube is in place.What is included in post operative care of this client?
A
Assess the amount of drainage in the collection bag
Ensure nephrostomy is secure at all times with drain fixation dressing (and secondary film dressing if required) Check drainage tubing is patent and not kinked/twisted. If urine output is <30ml/hour, inform member of medical team. Apply drainage bag at insertion.
Empty the drainage bag before it is completely full or every 2 to 3 hours. Do not swim or take baths while you have a nephrostomy tube. You can shower after wrapping the end of the nephrostomy tube with plastic wrap. Change the dressing around the nephrostomy tube about every 3 days or when it gets wet or dirty.
22
Q
The nurse is providing care to a confused patient with hepatic encephalopathy who refuses to stay in bed and is at risk for falling. Which intervention will the nurse implement to keep the patient safe?
A
Provide a low bed with the wheels locked
23
Q
The nurse is caring for a patient who had hypovolemic shock secondary to trauma 2 days ago. Based on the pathophysiology of hypovolemia and prerenal azotemia, what does the nurse assess every hour?
A
Urinary output
24
Q
What does Sinemet do?
A
SINEMET is most helpful in improving slow movement and muscle stiffness. It is also frequently helpful in treating shaking, difficulty in swallowing and drooling. The symptoms of Parkinson’s disease are caused by a lack of dopamine, a naturally occurring chemical produced by certain brain cells.
25
After cholecystectomy, a patient is returned to the unit with a nasal gastric tube connected to low intermittent suction, an IV of D5W, a T-tube in place, and a Penrose drain .The nurse understands that the purpose of the Penrose drain includes which of the following.
Remove accumulated bile and blood after surgery
26
The patient with GBS describes a chronological progression of motor weakness that started in the legs and then spread to the arms and upper body. Which type of GBS do these symptoms indicate?
Ascending
27
While performing cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur.The nurse documents the finding and describes the sound as which?
A blowing or swooshing noise/ Turbulent blood flow
Rationale: A heart murmur is an abnormal heart sound and is described as a faint or loud blowing, swooshing sound with a high, medium or low pitch.
Rationale: A murmur is auscultated as a swishing sound that is associated with the
blood turbulence created by the heart or valvular defect
28
During the nurse's assessment of a patient with Parkinson's disease, the nurse notes that the patient has masked like faces. What functional assessment is now a priority?
Ability to chew and swallow
29
When monitoring the laboratory values of a patient who is taking antithyroid drugs, the nurse knows to watch for:
Increased blood urea nitrogen level
Decreased platelet counts
30
The nurse is teaching a patient with cirrhosis about lactulose therapy.What statement by the nurse indicates the teaching has been effective?
This therapy will promote the removal of ammonia in my stool.
31
A patient has received thrombolytic therapy for treatment of acute MI. What are the nursing post administrative responsibilities for this treatment?Select all that apply.
Mnemonic: M2 DOT
Document the patient's neurologic status.
Observe all IV sites for bleeding and patency.
Monitor clotting studies.
Monitor hemoglobin and hematocrit.
Test stools, urine, and emesis for occult blood.
32
Which substances predispose a patient to peptic ulcer disease and gastrointestinal (GI) bleeding?Select all that apply.
NSAIDs
Anticoagulant
Aspirin
Caffiene
33
The nurse is assessing a patient with glomerulonephritis and notes crackles in the lung fields and neck vein distension.The patient reports mild shortness of breath. Based on these findings, what does the nurse do next?
Assess for additional signs of fluid overload. Can cause pulmonary edema.
34
A patient questions the new diagnosis of chronic myelogenous leukemia (CML) because he has no symptoms.Which response by the nurse is appropriate?
"It's very common for patients with CML to have no symptoms initially."
Rationale: In CML, patients are typically free of symptoms in the early stages of the disease.
35
Patient with gastritis asks the nurse about the bodily process behind the diagnosis.The nurse explains that which physiologic event is responsible for the patients symptoms?
Disruption of the stomach mucosa
Rationale: Gastritis may be caused by hydrochloric acid and pepsin diffusing into the mucosa, resulting in tissue edema, disruption of capillary walls with loss of plasma into the gastric lumen, and possible hemorrhage.
36
During therapy with a beta blocker, the patient notices that she has swollen feet, has gained 3 pounds within 2 days, has short of breath even when walking around the house and has been dizzy.
The nurse suspects that which of these is occurring?
The patient may be developing heart failure.
Rationale: Even though some beta blockers may be used for the treatment of some types of heart failure, the patient needs to be assessed often for the development of heart failure, a potential adverse effect of the drugs. These symptoms do not indicate expected adverse effects, an allergic reaction, or a therapeutic response.
37
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? Select all that apply.
Accompanied by shortness of breath
Feelings of fear or anxiety (impending doom)
No relief from taking nitroglycerin
Pain occurs without known cause
Rationale: The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion
38
The patient with acute gastritis is receiving treatment to block and buffer gastric acid secretions to release pain. Which drug does the nurse identify as an antisecretory agent (Proton pump inhibitor)?
Omeprazole (Prilosec)
39
A client who is in hypovolemic shock has a hematocrit value of 25%. The nurse anticipates that the primary health care provider will prescribe:
Blood replacement
40
A 79-year-old woman sees her physician with complaints of muscle weakness, lethargy, dry skin, constipation, and depression. The most accurate preliminary hypothesis is that:
Decreased thyroid function and/or age may be causative factors
41
The major difference between HHNC and DKA is that:
ketosis does not occur with HHNC
42
A client with Crohn's disease is admitted to the hospital with abdominal pain, fever, poor skin turgor, and diarrhea, with 10 stools in the past 24 hours. Which signs are evidence that the client probably is dehydrated? (Select all that apply.)
sunken eyes and dry mucous membrane
43
A client with a traumatic brain injury is demonstrating signs of increasing intracranial pressure, which may exert pressure on the medulla. What should the nurse assess to determine involvement of the medulla? (Select all that apply.)
breathing (bradypnea), blood pressure (hypertension- widen pulse pressure with increase in systolic rate) , heart rate (bradycardia)
44
Which condition is associated with Diabetic Ketoacidosis (DKA)?
Severe insulin deficiency
45
Which electrolyte is closely monitored in patients with syndrome of inappropriate secretion of antidiuretic hormone (SIADH)?
Sodium
46
A patient with Graves' disease has shortness of breath, fever of 103º F orally, heart rate 160 beats/min, blood pressure 160/80 mm Hg, and distended neck veins. These signs are suggestive of:
thyroid storm- medical emergency
47
The nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group?
constriction of the peripheral vessels the flow of force
Rationale: Constriction of the peripheral blood vessels and the resulting increase in blood pressure impairs circulation and limits the amount of oxygen being delivered to body cells, particularly in the extremities. Nicotine constricts all peripheral vessels, not just superficial ones. Its primary action is vasoconstriction; it will not dilate deep vessels. Nicotine constricts rather than dilates peripheral vessels.
48
The nurse is caring for a patient receiving Gentamycin. Because this drug has potential for nephrotoxicity, which laboratory results does the nurse monitor? (Select all that Apply)
BUN, Creatitine, Drug peak and trough level- trough is drawn immediately before the next dose is due. 1 hr after administering abx you should draw for the peak level
49
A nurse provides a list of suggested food choices to a client who has peptic ulcer disease. What foods should be included on the list?
applesauce, cream of wheat, and milk
50
Long-term glycemic control in patients with diabetes mellitus is best achieved by monitoring glycosylated hemoglobin, which reflects the:
Average blood glucose level over a period of ti
51
Urinary Tract obstruction may constitute a medical emergency because it can:
destroy kidney tissue
52
A patient with Hyperglycemic, Hyperosmolar, Nonketotic coma (HHNC) is at increased risk for which complication?
dehydration
53
In patients with exophthalmos, the eyes:
are pushed forward by pressure and appear protruded
54
A woman with type 1 Diabetes has an elevated hemoglobin A1c level. the nurse can conclude that the patient:
has had elevated glucose levels over the past 3 months
55
A nurse is assessing a client with Crohn's disease who is to have an upper gastrointestinal series. Which condition necessitates the cancellation of the upper gastrointestinal series?
Colon perforation
56
Which assessment finding is associated with renal calculi?
flank pain
57
After surgery to repair a retinal detachment, an older adult client is transferred to the postanesthesia care unit with the affected eye patched. During the first four hours after surgery, the nurse should plan to notify the health care provider if the client:
complains of sharp pain in eye
58
A client is admitted with post traumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document?
3 ,, ranges from 3 to 15
59
A patient with sickle cell anemia is admitted to the unit in vaso- occlusive crisis (VOC). After the patient has been given the prescribed analgesic, which intervention is the priority to minimize the effects of the crisis?
Intravenous fluid
During a VOC bedrest is preferred, with the only exercise being passive range of motion. Because the kidneys of children with sickle cell anemia do not concentrate urine as well as do healthy kidneys, it is important to maintain adequate hydration. Hydration with IV fluids supplementing oral fluids can minimize the occurrence of a crisis because hemodilution helps prevent sickling.
60
The nurse is providing preoperative teaching for a client who is to have cataract surgery. Which is appropriate for the nurse to include concerning what the client should do after surgery? (Select all that apply.)
avoid bending from waist. Do not blow nose
Rationale:
The client needs to avoid activities that cause a sudden rise in intraocular pressure, such as bending from the waist, blowing the nose, sneezing, and coughing. It is not necessary to remain flat in bed for three hours after surgery, and the diet is not restricted.
61
The nurse is teaching a client about preventing intraocular pressure increase after cataract surgery. Which health teaching would the nurse include? (Select all that apply.)
“Avoid blowing your nose or sneezing.”
“Don’t bend down from the waist.”
“Don’t strain to have a bowel movement.”
“Avoid having sexual intercourse.”
“Don’t wear tight shirt or blouse collars.”
62
When treating Graves' disease, the drug methimazole (Tapazole) is used to:
thyroid storm
63
A nurse is reviewing a list of current medications with an 80-year- old client who has developed gastrointestinal bleeding. Which medication prescription should the nurse discuss with the health care provider because it is contraindicated for a person who is experiencing gastrointestinal bleeding?
Ibuprofen (advil), Naproxen
64
A family member of a client with a hemorrhagic stroke asks about anticoagulant therapy. The nurse explains that anticoagulant therapy for the client:
is contradicted because it will increase bleeding
Rationale: Administration of an anticoagulant to a client who is bleeding will interfere with clotting and increase bleeding. Anticoagulants are not used in the is situation because they will increase bleeding, they may be used for a client with a cerebral thrombosis
65
Initially after a brain attack (stroke), a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing?
increasing intracranial pressure
Rationale: Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure.
66
The ED Nurse is caring for a patient with severe chest pain and EKG changes gives supplemental oxygen to the patient as ordered. Which other medications does the nurse anticipate giving to the patient (Select all That Apply)
Iv nitroglycerin
Beta blocker
Iv morphine
Oral aspirin
67
Which situation should the nurse give highest priority for obtaining a blood pressure? A patient diagnosed with:
intracranial pressure
68
A client with a fractured head of the right femur and osteoporosis is placed in Buck's extension before surgical repair. What should the nurse do when caring for this client until surgery is perfromed?
Assess the circulation of the affected leg every 2 hours to ensure adequate tissue perfusion
69
A nurse is providing discharge instructions for a client with a diagnosis of gastroesophageal reflux disease (GERD). What should the nurse advise the client to do to limit symptoms of GERD? (Select all that apply.)
Ans: avoid heavy lifting
Avoid drinking alcohol Eat small frequent meals
Rationale: Heavy lifting increases intra-abdominal pressure allowing gastric contents to move up through the lower esophageal sphincter causing heartburn. Alcohol, in addition to peppermints, caffeine and chocolate decreases lower esophageal sphincter pressure (regurgitation), which permits gastric contents to move from the stomach into the esophagus. Eating small frequent meals limits the amount of food in the stomach which limits gastroesophageal reflux. Lying down after eating promotes reflux and should be avoided. Increasing fluids with meals increases gastric volume, causing distention and reflux. Constrictive garments, such as belt, binders and girdles increase intra abdominal pressure and may lead to reflux.
70
Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease. The nurse monitors the client for which side effects of the medication? (Select all that apply.)
Vomiting
Anorexia
Changes in mood
71
A nurse is eliciting a health history from a client with ulcerative colitis. What factor does the nurse consider to be most likely associated with the client's colitis?
Genetic predisposition
Rationale: Studies indicate that inflammatory bowel diseases, which include ulcerative colitis and Crohn disease, are familial, which suggests that they are hereditary. Although food allergy and infectious agent may be causative factors, they are not the most common factors. No specific dietary component has been identified.
72
Given the structure of the endocrine feedback loop, which event should occur in response to a low serum calcium level?
Parathyroid gland released parathyroid hormone
73
A client with a seizure disorder is receiving phenytoin (Dilantin) and phenobarbital (Barbital). What client statement indicates that the instructions regarding the medications are understood?
stopping the drugs can cause continuous seizures and I may die
74
A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. What reason should the nurse consider for the increased incidence of dysrhythmias after an MI?
myocardial hypoxia
75
Which is a classic clinical manifestation of diabetes insipidus.
Massive urine output
76
Which is the most common cause of pyelonephritis?
Ecoli
77
Which clinical findings are consistent with the diagnosis of acute pyelonephritis?
leukocytosis (in the urine), flank pain
78
Which is a serious complication of hypocalcemia after thyroidectomy?
Tetany
79
The most important laboratory value for monitoring parathyroid function is the serum:
Calcium
80
Which symptoms does the nurse expect to see in the patient with Intrarenal AKI ? (Select all that Apply)
Oliguria/anuria
Shortness of breath
Jugular vein distention
Crackles
Nausea and anorexia
81
A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurological examination. What should the nurse document in the client's medical record?
exhibits a positive Babinski sign
82
A client has a history of hypothyroidism. Which skin condition should the nurse expect when performing a physical assessment?
dry
83
A Foley catheter was placed with a urimeter for an 85-year-old client with a history of congestive heart failure. The output is 45 mL/hour, cloudy, and has sediment. These findings indicate:
Cloudy urine may be indicative of infection
84
A standard laboratory test important to the evaluation of patients with suspected endocrine pathology is:
serum electrolyte
85
A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. What health care provider prescription should the nurse question?
Teach Isometric exercise
Rationale: The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure.
86
The nurse will prevent and/or detect which complication when caring for the patient with peritonitis?
distended abdomen
87
Which statement regarding type 1 diabetes mellitus is true? The disease is:
caused by insulin deficiency
88
Which is a major side effect of radioactive iodine treatment for hyperthyroidism?
Hypothyroidism
89
A nurse is assessing two clients. One client has ulcerative colitis and the other client has Crohn's disease. Which is more likely to be identified in the client with ulcerative colitis than the client with Crohn's disease?
involvement starting distally with rectal bleeding that spreads contionously up the colon
90
Evidence that a dehydrated patient is compensating by secreting antidiuretic hormone includes:
reduced urine output
91
The nurse performs which activity before initiating prescribed antibiotic therapy for a patient with a UTI?
obtain a urine sample for culture
92
A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life- threatening complication should the nurse assess the client?
Electrolyte imbalance
Rationale: An ileostomy directs liquid feces out of the body, bypassing the large intestine where fluid and electrolytes normally are reabsorbed. The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance
93
After cataract surgery, a client reports feeling nauseated. How can the nurse help to relieve the nausea?
Administer the prescribed antiemetic drug
94
A client with gastroesophageal reflux disease (GERD) receives a prescription for an H2 receptor antagonist. Which medications are within the classification of an H2 receptor antagonist? (Select all that apply)
Nizatidine, raniditine, famotidine
95
The patient with polycystic kidney disease needs to be taught:
to recognize signs of infection or bleeding
96
The cardiac monitor of a 50-year-old patient admitted for cocaine ingestion shows ventricular tachycardia (VT) converting to ventricular fibrillation (VF). What priority action should the nurse implement?
Defibrillate at 200 joules.
After confirming(assessing pt 1st) ventricular fibrillation, rapid defibrillation is critical in re-establishing cardiac output and preserving vital organ function
97
The nurse administers dopamine IV Infusion at 3mcg/kg/min to a critically ill, hypotensive patient. What is the intended effect this treatment? To increase
urine output to 55 ml/hr.
The expected outcome of this treatment is an increase in urine output due to increased renal perfusion Dopamine, a catecholamine provides renal and mesenteric vasodilation at a low dosage level, such as the 3 mcg/kg/minute infusion that was prescribed for this client.
98
A patient has undergone a kidney biopsy. In the immediate postprocedural period, the nurse notifies the health care provider about which findings? (Select all that Apply)
Hematuria with blood clots
Decreasing urine output
Flank pain
Decreasing blood pressure
99
When teaching a patient about taking a newly prescribed antiepileptic drug at home, the nurse will include which instruction?
"Regular, consistent dosing is important for successful treatment."
Rationale: Consistent dosing, taken regularly at the same time of day, at the recommended dose, and with meals to reduce the common gastrointestinal adverse effects, is the key to successful management of seizures when taking AEDs. Noncompliance is the factor most likely to lead to treatment failure
100
Which finding if present, is consistent with a diagnosis of unstable angina?
Increased frequency and intensity of chest pain
Rationale: Unstable angina is chest pain that is new in onset, occurs at rest, or has a worsening pattern. Sense of impending doom, or trouble breathing.
101
Which patient statement would cause the nurse to suspect peripheral artery disease (PAD)?
"I will exercise to increase my endurance, which will help relieve my leg pain."
Regular exercise to increase endurance and relieve leg pain is an appropriate goal for a patient with PAD. Other goals include adequate tissue perfusion; intact, healthy skin on the extremities; and increased knowledge of disease and treatment plan.
102
The nurse is caring for a paliont admitted for an interior wall Mi The patient develops hoart block with bradycardia. Because the patient's pulse rate is low and the blood pressure is unstable, which procedure is the nurse prepared to assist with?
Temporary pacemaker
103
Traditionally, what medications will most likely be ordered for a patiunt with atrial fibiliation? (Select all That Apply)
Heparin
Digoxin
Warfarin
Diltiazem; Cardizem
Amiodarone
104
Which nursing action is appropriate for a client in sickle cell crisis?
Administer O2
Administer prescribed narcotics
Force fluids
Exchange transfusions - to reduce the number of sickle cells
105
A bone marrow biopsy reveals which characteristic finding is associated with Acute Myelogenous Leukemia (AML)?
Immature Myloblast
106
Which of the following peripheral nerve disorder is being investigated for an association for occurence after a vaccination, surgical procedure, or stressful event?’
Guillian Barre syndrome
107
The nurse assesses a client who has Guillain-Barre syndrome? Which clinical manifestation does the nurse expect to find in this client?
Progressive ascending weakness and parathesia
108
The nurse is assessing a client with trigeminal neuralgia. Which clinical manifestation does the nurse expect to observe?
Excruciating pain
Rationale: Signs of trigeminal neuralgia are excruciating pain and uncontrollable facial twitching which causes the client to avoid talking, smiling, eating, or attending to hygienic needs. Sensory and mobility deficits are not associated with trigeminal neuralgia.
109
The nurse administers carbidopa, levodopa (Sinemet) client with Parkinson’s disease. Which therapeutic effect does the nurse expect the medication to produce?
replacement of a neurotransmitter in the brain
used because levodopa is the precursor of dopamine. it is converted to dopamine in the brain cells, where it is stored until needed by axon terminals; it functions as a neurotransmitter
110
The most significant observations to be recorded when monitoring a patient with increased ICP are:
Increased Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP.
111
What should the following test does the nurse anticipate will be ordered for a patient to confirm a suspected diagnosis of epilepsy?
EEG, CT
112
A 39-year-old patient who was hospitalized for repair of a fractured tibia and fibula, reports shortness of breath. Which complication related to the injury might the patient be experiencing?
Fat embolism
113
A nurse is reviewing orders for a patient who was admitted for 24-hour observation of a leg fracture. Cast is in place: which order does the nurse question?
Perform neurovascular assessments ("circ checks") every 8 hours.
114
A patient with ulcerative colitis is admitted to the acute medical unit. Which medication would the nurse question?
Ibuprofen (Motrin), Naproxen
115
Your client has a fracture and is being treated with skeletal traction. Which assessment causes the nurse to take immediate action?
The traction weights are resting on the floor.
Rationale: The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. Slight oozing of clear fluid is normal as is the capillary refill time. The client's blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture.
116
The patient's chart indicates a sensorineural hearing loss. Which assessment question does the nurse ask to determine the possible cause?
"Have you been exposed to loud noises?"
Rationale: Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions relate to conductive hearing loss.
117
Which signs and symptoms should a patient who has had cataract surgery report to the health care provider? Select all that apply.
Sharp sudden pain in the surgical eye
Green or yellow discharge from the surgical eye
Eyelid swelling of the surgical eye
Decreased vision in the surgical eye
Blindness in the surgical eye
Flashes or floaters seen in the surgical eye
118
The patient had recently been placed on corticosteroids as treatment for ulcerative colitis. The nurse should monitor the patient's laboratory results for evidence of which condition?
Hyperglycemia
Can make you get Cushing’s
Rationale: Long-term adverse effects that commonly occur with steroid therapy include hyperglycemia, osteoporosis, peptic ulcer disease, and increased risk for infection. Pt should be tapered off of of corticosteroids or pt can get Addison’s becaus eof decrease cortisol.
119
A client who first experienced symptoms related to a confirmed thrombolytic stroke two hours ago is brought to the intensive care unit. Which prescribed medication. Does the nurse prepare to administer?
TPA Tissue Plasminogen Activator
Rationale: The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery occlusion and re-establish blood flow. Clients must meet eligibility criteria for administration of this therapy. The other medications do not assist in the re-establishment of blood flow for a client with a confirmed thrombotic stroke.
120
The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications?
watch closely and monitor neurologic status every 1 to 2 hours
121
Following the ED provider’s assessment of an acute stroke patient. The Ed nurse continues to assess the patient every 15 minutes. The patient’s son is sitting by the bedside while the nurse assesses the patient. Which assessment findings warrant immediate intervention by the nurse? Select all that apply.
GCS changes from 12 to 9
positive Babinski's reflex bilaterally
unable to verbalize response to questions
122
Retinal detachment
Medical Emergeny
Onset is painless
Sx: scleral buckling
123
An older adult patient has skin traction in place for a hip fracture. Which outcome statement reflects that the goal of the therapy is successful?
Patient reports a decrease in painful muscle spasms
124
A patient with a fractured pelvis is initially treated with bed rest with no turning from side-to-side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals:
petechiae of the neck and anterior chest wall (late sign)
restlessness and confusion
125
For a patient diagnosed with Hepatitis A what are the recommendations for her family members?
Immune Globulin
Immune globulins is recommended for household members of people with hepatitis A
126
A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication?
Aspirin
127
A patient with a history of angina is admitted for surgery. The patient reports nausea, pressure in the chest radiating to the left arm, appears anxious, skin is cool and clammy, blood pressure is 150/90 mm Hg, pulse 100, and respiratory rate is 32. What are the priorities of nursing care for this patient? (SATA)
Improve coronary perfusion
Improve coronary oxygenation
Relieve chest pain
128
An older patient diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse should monitor the patient for what priority assessment?
Dehydration
Rationale: In older adults, dehydration occurs with viral and bacterial gastroenteritis and may require hospitalization. Electrolyte imbalances are also common, especially hypokalemia and hypernatremia. The aging skin is also at risk of compromise from frequent exposure to enzymes in the stool.
129
Which conditions would put a patient at risk for hypovolemic shock? (Select all That Apply)
Excessive hemorrhaging,
Prolonged vomiting and diarrhea
Rationale:
Excessive hemorrhaging A patient who is losing large amounts of blood will be at risk for hypovolemic shock. Prolonged vomiting and diarrhea A patient with large volumes of fluid loss from prolonged nausea, vomiting, and diarrhea will be at risk for hypovolemic shock.
130
A client sustains a fractured femur and pelvic fractures in a motor vehicle crash. For which signs and symptoms, indicative of hypovolemic shock, does the nurse monitor the client closely? (select all that apply)
Oliguria
Tachycardia
Hypotension
Rationale: Clients who sustain fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed as well as open fractures. Signs of hypovolemic shock include tachycardia, hypotension, and diminished urine output. Fever and bradypnea are not associated with hypovolemic shock.
131
What is the system in the kidneys that is an important control and compensation mechanism, initiated by a decrease in renal blood flow?
Renin-angiotensin-aldosterone system
132
What does a decrease in renal blood flow stimulate the release of? What in turn does this stimulate?
Renin ; Activates angiotensin (vasoconstrictor) and aldosterone secretion
133
The nurse is caring for several patients on an orthopedic trauma unit. Which conditions have a high risk for development of acute compartment syndrome? Select all that apply.
Lower legs caught between the bumpers of two cars
Massive infiltration of IV fluid into forearm
Multiple insect bites to lower legs
Severe burns to the upper extremities
134
A patient comes to the ED with Crush syndrome from a crush injury to the right upper extremity and right lower extremity when heavy equipment fell on him at a construction site. The patient has signs and symptoms of hypovolemia, hyperkalemia and compartment syndrome. Management of care for the patient will focus on preventing which complications? Select all that apply.
Cardiac dysrhythmias
Acute kidney failure
Acute tubular necrosis
135
The nurse is caring for a patient with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome? Select all that apply.
Severe pain not relieved by analgesics
Tingling of extremity
Inability to move extremity
Rationale: Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the extremity less than 3 seconds are expected findings.
136
A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse's first intervention?
Assess pedal pulses
Rationale: The symptoms represent early warning of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible.
137
Which is a potentially fatal complication of acute compartment syndrome? (Select all that Apply)
Myoglobinuric renal failure
Sepsis from Gangrene
138
The neurologic assessment of a client who had a craniotomy includes the Glasgow Coma Scale. What does the nurse evaluate to assess the client’s score on the Glasgow Coma Scale? Select all that apply
Degree of purposeful movement by the client
Appropriateness of clients verbal responses
Stimulus necessary to cause the clients eyes to open
139
The nurse is assessing a patient with Parkinson’s disease. Which Cardinal findings does the nurse expect to observe? Select all that apply.
Tremors, Rigidity, Postural instability, Slow movements
140
The nurse is caring for a client with myasthenia gravis. The nurse expects which test to be ordered to differentiate a myasthenic crisis from a cholinergic crisis?
tensilon
141
A patient received rtPA for the treatment of ischemic stroke and the physician ordered an IV sodium heparin infusion. In relation to the drug therapy, what does the nurse monitor for?
Bleeding gums or bruising
142
Which is the most common type of facial paralysis?
BELLS PALSY
143
A client has been prescribed an antibiotic for otitis media asks the nurse “why did the doctor tell me not to discontinue this medication until the pills are gone?” Which response by the nurse is appropriate?
"Completing the medication ensures that the infection will be resolved."
144
Which of the following statements are accurate regarding glaucoma? Select all that apply.
The main physiological mechanism of glaucoma is due to increased intraocular pressure.
Glaucoma can arise from an overproduction of aqueous humor.
Glaucoma can arise from decreased drainage from the canal of Schlemm.
145
Which desired effect of medical therapy should the nurse explain to the client who has primary angle-closure glaucoma?
Controlling intraocular pressure
Rationale: Glaucoma is a disease in which there is increased intraocular pressure resulting from narrowing of the aqueous outflow channel (canal of Schlemm). This can lead to blindness, caused by compression of the nutritive blood vessels supplying the rods and cones. Pupil dilation increases intraocular pressure because it narrows the canal of Schlemm. Intraocular pressure is not affected by activity of the eye. Although secondary infections are not desirable, the priority is to maintain vision by controlling the pressure.
146
Healthcare provider is educating a 65 year old patient on a new diagnosis of primary open-angle glaucoma (poag). Which assessment by the patient shows an understanding of the discussion?
"I will need to follow my treatment plan to prevent damage to the optic nerve."
Rationale: Once diagnosed, the priority for glaucoma is to keep the intraoptic pressure (IOP) low in order to prevent optic nerve damage.
147
A nurse is caring for a patient who reports a loss of peripheral vision that developed over time. _________ would be the diagnostic tests ordered by the physician to reach a diagnosis.
Tonometry. The patient presents with a sign of glaucoma, which results from increased intraocular pressure. Tonometry, or measurement of intraocular pressure, is important to diagnosing glaucoma.
148
Which statements about Intra Ocular Pressure (IOP) are true? (Select all that Apply)
If the IOP is too low, the eyeball can collapse. (can happen in end stage glaucoma)
High IOP can cause glaucoma.
149
Which patient history factor is considered causative for acute glomerulonephritis?
Strep throat 3 weeks ago
150
Patients can often prevent chronic urinary tract infections (UTIs) by:
increasing their daily fluid intake to 3 to 4 liters
151
A patient with a markedly distended bladder is just diagnosed with hydronephrosis and left hydroureter after an IV pyelogram.The nurse catheterize the patient and obtains a residual urine value of 1650mL.This finding supports which pathophysiological cause for the patient's urinary tract obstruction?
Obstruction at the urinary bladder neck.
Rationale: Hydroureter (dilation of the renal pelvis) vesicoureteral reflux (backward movement of urine from the lower to upper urinary tracts) and hydronephrosis (dilation or enlargement of the renal pelvis and calyces) result from post-renal obstruction which can consequently result in chronic pyelonephritis and renal atrophy
152
A patient reports increased fatigue, malaise, bleeding gums, and frequent "chills" to the nurse. What is the priority nursing intervention?
Review laboratory analysis for signs and symptoms of bone marrow suppression.
The nurse should initially review the patient's laboratory analysis for collective signs of pancytopenia related to the patient's reports of fatigue (anemia), bleeding gums (thrombocytopenia), and chills (neutropenia). Laboratory data are needed before informing the physician and deciding whether to administer an antibiotic. Obtaining blood cultures prior to antibiotic administration is an important intervention. Antipyretic medications may be prescribed to treat the patient's symptoms ("chills").
153
The nurse is caring for a patient immobilized by a fractured hip. Which complication should the nurse monitor related to the patient's immobilization status?
Venous stasis leading to thrombi or emboli formation
Rationale: The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate decreases with immobilization. Loss of joint mobility leads to contractures. Bone demineralization with osteoporosis and hypercalcemia occur with immobilization.
154
A patient is admitted to the intensive care unit because of low urine output, increased body weight, lethargy and confusion. Serum sodium level is below 120 mEq/L.What should the nurse do first?
Administer 3% sodium chloride intravenously at a slow rate.
Rationale: A small amount of a hypertonic saline solution is indicted to help correct the hyponatremia, but it must be administered at a slow rate to prevent permanent damage to the nerve cells in the brain
155
A patient is receiving scheduled and PRN narcotics for severe pain related to a musculoskeletal Injury. The nurse finds that the patient's abdomen is distended and bowel sounds are hypoactive. Because the nurse suspects that the patient is having a medication side effect, which does the nurse ask the patient?
"When was your last bowel movement?"
156
A patient questions the new diagnosis of chronic myelogenous leukemia (CML) because he has no symptoms.Which response by the nurse is appropriate?
"It's very common for patients with CLL to have no symptoms initially."
In CML, patients are typically free of symptoms in the early stages of the disease.
157
Which are the two priority nursing diagnoses for the person undergoing chemotherapy for leukemia?
Risk for infection/ risk for injury
158
Anya becomes ill and presents to the ED dehydrated. After a blood work-up, Anya is diagnosed as being in a state of Ketoacidosis and is admitted to the hospital. Which assessment findings are consistent with this diagnosis?
Nausea, fruity breath, ketonuria
159
A nurse is developing a dietary plan for a patient with Diabetes Mellitus and new-onset microalbuminuria. ______________are the most important components of the patient's diet for the nurse to decrease.
Proteins
Rationale: Restriction of dietary protein to 0.8 g/kg of body weight per day is recommended for clients with
microalbuminuria to delay progression to renal failure. The clients diet does not need to be decreased in carbohydrates, fats, or total calories.
160
The nurse case manager is making a home visit to assist an older patient with a hip fracture. During the home visit, the nurse reviews home environment safety. Which observation indicates a need for additional teaching?
Floors are clean and shiny and covered with throw rugs.
161
The nurse has provided teaching about oral corticosteroid therapy to a patient, which statement by the patient shows a need for more teaching?
I can stop medication if I have severe adverse effects
162
Which patient statement would cause the nurse to suspect peripheral artery disease (PAD)?
"My feet have been pale in the mornings, but by the end of the day are bright red. I have been experiencing hair loss on my legs."
In PAD, skin becomes thin, shiny, and taut, and hair loss occurs on the lower legs. Pallor (blanching of the foot) develops in response to leg elevation (elevation pallor). Conversely, reactive hyperemia (redness of the foot) develops when the limb is in a dependent position (dependent rubor).
163
The student nurse is caring for a patient with cirrhosis. Which action by the student nurse causes the supervising nurse to intervene?
Uses a straight-edge razor to shave the patient
164
A 44-year-old female patient with Cushing Syndrome is admitted for adrenalectomy. Which intervention by the nurse will be most helpful for the patient problem of disturbed body image related to changes in appearance?
emind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery
Rationale: The most reassuring communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. Reassurance that the physical changes are expected or that they are more serious physiological change are caused by the high hormone levels, not by the patient's diet or exercise choices.
165
A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?
check for pulse
166
The nurse is administering a stat dose of epinephrine. Epinephrine is appropriate for which situation.
Cardiac Arrest
Rationale:Treatment of cardiac arrest is an indication for the use of epinephrine. The other options are not indications for epinephrine
167
An older adult patient is on a cardiac monitoring after an myocardial infarction. The patient shows infrequent dysrhythmias. What action by the nurse is most appropriate?
Assess for hemodynamic effects of the rhythm
Rationale: Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.
168
What is the primary significance of ventricular tachycardia (VT) in a cardiac patient?
It is commonly the initial rhythm before deterioration into VFIB.
169
A client is scheduled for an electrophysiology study (EPS) because of persistent ventricular tachycardia. Before the procedure the client is placed on a beta blocker. The clients response during the procedure that best indicates that the beta blocker is working effectively would be:
Sinus bradycardia
170
Which hormones are released in response to decreased mean arterial pressure (MAP)? (Select all that apply.)
Renin
Antidiuretic hormone (ADH)
Epinephrine
Aldosterone
171
The nurse is caring for an older adult who sustained a closed head injury and notes that the patient has not urinated in the past four hours despite drinking 500 mL of fluid and receiving IV fluids at a rate of 150 mL/hr. Which condition should the nurse suspect for this patient?
SIADH
SIADH occurs more frequently in older adults and can be caused by a head injury. The manifestations include fluid retention and low fluid output, as well as thirst, which would correlate with drinking 500 mL of fluid and receiving IV fluids but not urinating.
172
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?
1630 (4:30 PM)
173
An 81-year-old Patient who is a resident of a nursing home presents to the ED with altered mental status Temp 39.4 C, hypotensive with a widened pulse pressure, tachycardia, with warm extremities What type of shock does this case represent?
Septic Shock
174
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which findings would the nurse anticipate when auscultating the client's breath sounds?
Crackles
Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum.
175
Locate the Apex of the heart
176
Name this Strip
Normal Sinus Rhythm
177
Name this Strip
Sinus Tachycardia
178
Name this Strip
Atrial Fibrilation
179
Name this Strip
Sinus Bradycardia
180
Name this Strip
Atrial Flutter
181
Name this Strip
Supraventricular Tachycardia
182
Name this Strip
Ventricular Fibrilation
183
Name this Strip
Asystole
184
Name this Strip
Ventricular Tachycardia
185
Location of Appendicitis and Diverticulitis
Appendicitis: RLQ
Diverticulitis: LLQ
