Final Exam Flashcards
A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses. Which of the following information should the nurse include?
A. The nurse caring for the client at the time of death requests organ donation.
B. Donation costs are the responsibility of the donor’s family and estate.
C. The nurse may serve as a witness to informed consent for organ donation.
D. Clients are placed on artificial life support before organ and tissue donation can occur.
C. The nurse may serve as a witness to informed consent for organ donation.
Rationale: Nurses may witness the consent for organ donation after a specially trained professional
requests consent.
A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?
A. “He is doing well, although he might be in the hospital for some time.”
B. “He has an electrical burn. He is stable, and we will update you with any changes.”
C. “He has an electrical burn, which caused coagulation of some tissues.”
D. “He does not appear to have much damage and should be fine soon.”
B. “He has an electrical burn. He is stable, and we will update you with any changes.”
Rationale: This response provides concrete information without medical jargon, and offers ongoing support.
A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment?
A. “I am thinking of getting a second opinion.”
B. “I am hoping this will limit my discomfort.”
C. “This treatment should help me live a little longer.”
D. “This is not working and I plan to stop treatment.”
B. “I am hoping this will limit my discomfort.”
Rationale: Clients receiving palliative care are aware that the outcome is to prevent suffering and provide
the best possible quality of life.
A nurse is caring for a client who has metastatic bone cancer. The client states, “I want to go home to die.” The family is concerned about meeting the client’s care needs at home. Which of the following actions should the nurse take?
A. Discuss initiating hospice care with the client and family.
B. Write a referral to place the client in a nursing home.
C. Talk with the provider about extending the client’s hospital stay.
D. Inform the client’s family that they are responsible for providing palliative care.
A. Discuss initiating hospice care with the client and family.
The nurse should discuss the availability of resources that can assist with the care of the client.
Home health and hospice care are both resources that can provide support for the care of a
client at home.
A nurse suspects that a family caregiver is neglecting an older adult client. Which of the following statements by the caregiver should the nurse identify as the priority to address?
A. “We only have enough money for two meals a day.”
B. “We sit outside every afternoon.”
C. “We buy the prescriptions we can afford.”
D. “We cannot afford new batteries for his hearing aid.”
C. “We buy the prescriptions we can afford.”
The greatest risk to this client is injury from not receiving the medications the provider has prescribed; therefore, the priority intervention is to determine which medications the client is receiving and which prescriptions the caregiver is not filling. A referral to social services can
assist the client and family with purchasing prescriptions. In addition, the nurse should educate the client and family about the importance of correct medication administration.
A nurse is assessing a client’s cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?
A. Ask the client to read a Snellen chart.
B. Listen to the client’s speech.
C. Ask the client to identify scented aromas.
D. Ask the client to clench his teeth.
A. Ask the client to read a Snellen chart.
Rationale: Cranial nerve II controls central and peripheral vision. visual acuity and dysfunction of cranial nerve II (optic).
A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect? (Select all that apply.)
A. Provide skin care with a moisture barrier cream.
B. Administer artificial tears PRN.
C. Obtain vital signs every 2 hr.
D. Perform mouth care every hour.
E. Administer oxygen 2 L/min via nasal cannula.
A. Provide skin care with a moisture barrier cream.
B. Administer artificial tears PRN.
D. Perform mouth care every hour.
E. Administer oxygen 2 L/min via nasal cannula.
A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (Select all that apply.)
A. The shoulders droop.
B. The facial muscles relax.
C. The respiratory rate increases.
D. The pulse is within the expected range.
E. The client draws his legs up into a fetal position.
A. The shoulders droop.
B. The facial muscles relax.
D. The pulse is within the expected range.
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
A. Blood pressure
B. Heart rate
C. Urine output
D. Weight
B. Heart rate
Rationale: When a client’s circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
A. Dehydration
B. Polyphagia
C. Hyperglycemia
D. Bradycardia
A. Dehydration
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
A. Tachycardia
B. Amnesia
C. Hypotension
D. Restlessness
D. Restlessness
A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine
the total body surface area of the burn injury. What percentage of body surface area should the nurse estimate the
client has burned?
Answer: 54%
First, determine the burned areas:
1) Entire right and left leg
2) Entire rear torso
Next, refer to the Rule of Nines for estimating body surface area
Rule of Nines
Head: 9%
Torso: 36% total (front 18% & back 18%)
Arm 9% each
Leg 18% each
Perineum 1%
Apply the Rule of Nines to this client:
Left leg = 18%
Right leg = 18%
Rear torso = 18%
Then total all the burned areas:
18 x 3 = 54%
A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following
techniques should the nurse use when performing an assessment of the client’s neurovascular status?
A. Measure the circumference of the thigh.
B. Palpate the femoral pulse.
C. Monitor the client’s calf for edema.
D. Instruct the client to wiggle his toes.
D. Instruct the client to wiggle his toes.
A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?
A. Loss of consciousness lasting 30 to 60 min
B. Glasgow Coma Scale score of 11
C. Nuchal rigidity
D. Sensitivity to light
D. Sensitivity to light
.A patient informed of a positive rapid screening test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. Which action by the nurse is most important?
A. Inform the patient about the available treatments.
B. Teach the patient how to manage a possible drug regimen.
C. Remind the patient to return for retesting to verify the results.
D. Ask the patient to identify those persons who had intimate contact.
C. Remind the patient to return for retesting to verify the results.
Which food choice would the nurse suggest for a patient scheduled to receive external-beam radiation for abdominal cancer?
A. Fruit salad
B. Baked chicken
C. Creamed broccoli
D. Toasted wheat bread
B. Baked chicken
Rationale: Protein is needed for wound healing. To minimize the diarrhea that is associated with bowel
radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. A
temporary lactose intolerance may develop secondary to radiation, so dairy products should
External-beam radiation is planned for a patient with cervical cancer. What instructions would the nurse give the
patient to prevent complications from the effects of the radiation?
A. Test all stools for the presence of blood.
B. Maintain a high-residue, high-fiber diet.
C. Clean the perianal area carefully after each bowel movement.
D. Inspect the mouth and throat daily for the appearance of thrush.
C. Clean the perianal area carefully after each bowel movement.
Rationale: Radiation to the abdomen affects organs in the radiation path, such as the bowel, and causes frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection.
A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a
local factory. Which of the following clients should the nurse tag to be the priority for care?
A. A client who has severe head injuries, respiratory rate 6/min, and is unresponsive
as the priority for care.
B. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically
C. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site
D. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around
C. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site
Rationale: A client who has air leaking from a chest wound requires immediate intervention for survival; therefore, when using the survival approach to client care, the nurse should recommend this client as the priority for care.
A is nurse assisting with field triage following a motor-vehicle crash involving a bus with multiple victims. The nurse
assesses a child who has an open fracture of the femur. Which of the following actions should the nurse take?
A. Locate the child’s parents to obtain consent for treatment.
B. Place a yellow triage tag on the child.
C. Notify the emergency department of the child’s imminent arrival.
D. Perform a complete head-to-toe assessment.
B. Place a yellow triage tag on the child.
Rationale: The child’s Condition indicates the need for treatment within 30 min to 2 hr. Therefore, the
nurse should triage the child with a yellow tag.
A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?
A. A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of < 2 seconds
B. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of < 2 seconds
C. A conscious adult client who has a dislocated right shoulder, respiratory rate of 18/min, and capillary refill of < 2 seconds
D. An unconscious adult client who has no respirations, capillary refill is > 2 seconds, and paramedics have already tried to reposition airway without results
B. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of < 2 seconds
Rationale: Any adult who has a respiratory rate of over 30/min requires immediate attention. Additionally, this patient is unconscious, which constitutes altered mental status. This client is the client he nurse should care for first.
A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first?
A. A client who has cirrhosis of the liver and bruising on their arms.
B. A client who has a new onset of atrial fibrillation and a heart rate of 152/min.
C. A client who reports urinary burning and a temperature of 39.2° C (102.5° F).
D. A client who has heart failure and peripheral edema.
B. A client who has a new onset of atrial fibrillation and a heart rate of 152/min.
A nurse is performing triage on several clients following a mass casualty event. The nurse should assign a red tag to which of the following clients?
A. A client who has a sprained left ankle
B. A client who has an open traumatic brain injury and agonal breaths
C. A client who has sustained a partial amputation of the right leg
D. A client who is deceased
E. A client who has sustained a major burn to their upper torso and extremities
F. A client who has a fractured left fibula and tibia
C. A client who has sustained a partial amputation of the right leg
E. A client who has sustained a major burn to their upper torso and extremities
An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
A. Pulse
B. Heart rhythm
C. Breath sounds
D. Body temperature
A. Pulse
Rationale: The priority assessment in an unresponsive patient relates to CAB (circulation, airway, breathing) so a pulse check should be performed first. While assessing the pulse, the nurse should look for signs of breathing. The other data will also be collected rapidly but are not as essential as determining if there is a pulse.
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which prescribed action would be the nurse’s priority?
A. Monitoring urine output
B. Scheduling additional laboratory tests
C. Increasing the rate of the ordered IV solution.
D. Typing and crossmatching for a blood transfusion
C. Increasing the rate of the ordered IV solution.
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and reports numbness in the toes. Which action would the nurse take first?
A. Monitor the pulses every hour.
B. Notify the health care provider.
C. Encourage the patient to flex and extend the toes.
D. Elevate both legs above heart level with pillows.
B. Notify the health care provider.
Rationale: The decrease in pulse and numbness in a patient with circumferential burns shows decreased circulation to the legs and the likely need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe
movement will not improve the patient’s circulation.
Esomeprazole is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug?
A. Bowel sounds
B. Stool frequency
C. Stool occult blood
D. Abdominal distention
C. Stool occult blood
A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. Which assessment is the priority?
A. Oral temperature
B. Peripheral pulses
C. Extremity movement
D. Pupil reaction to light
C. Extremity movement
Rationale: All patients with electrical burns would be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data. The other assessment data are necessary but not as essential as determining the cervical spine status.
Prone positioning is being used for a client with acute respiratory distress syndrome. Which information obtained
by the nurse indicates the the positioning is effective?
A. Client’s PaO2 is 89 mm Hg and SaO2 is 91%
B. Endotracheal suctioning results in clear mucous return.
C. Sputum and blood cultures show no growth after 48 hours.
D. Skin on the client’s back is intact and without redness.
A. Client’s PaO2 is 89 mm Hg and SaO2 is 91%
A client admitted with acute respiratory failure is unable to clear thick secretions from the airway. Which nursing
intervention would specifically address this client problem?
A. Encourage the use of incentive spirometer.
B. Offer the client fluids at frequent intervals.
C. Teach the client the importance of ambulation.
D. Titrate oxygen to keep O2 saturation above 93%.
B. Offer the client fluids at frequent intervals.
A client with acute respiratory distress syndrome who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next?
A. Increase the tidal volume and respiratory rate.
B. Decrease the fraction of inspired oxygen.
C. Perform endotracheal sucitoning more frequently.
D. Lower the positive end-expiratory pressure.
D. Lower the positive end-expiratory pressure.
The nurse is caring for a client who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome. Which finding is most important to report to the health care provider?
A. Red-brown drainage from nasogastric tube
B. Blood urea nitrogen level of 32 mg/dL
C. Scattered coarse crackles throughout lungs
D. pH 7.31, PaCO2 50 mm Hg, PaO2 68 mm Hg
A. Red-brown drainage from nasogastric tube
Rationale: The NG drainage indicates possible GI bleeding or stress ulcer and should be reported.
A nurse is preparing to perform a 12-lead electrocardiogram. Which of the following instructions should the nurse provide to the client?
A. “I will be placing electrodes on your breasts.”
B. “Try to hold your breath until this procedure is complete.”
C. “Try to remain still once I have attached the gel pads.”
D. “I will lower the head of your bed so you can lie flat.”
C. “Try to remain still once I have attached the gel pads.”
A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor for which of the following complications?
A. Bradycardia
B. Pulmonary embolism
C. Peripheral vascular disease
D. Hypertension
B. Pulmonary embolism
Rationale: Altered atrial contractions can cause blood pooling and thrombus formation. The client is at risk for developing a pulmonary embolism or embolic stroke. The client should monitor and report immediately manifestations, such as shortness of breath, or neurological changes.
Which problem would the nurse anticipate for a client admitted to the hospital with diabetes insipidus?
A. Generalized edema
B. Respiratory distress
C. Fluid volume overload
D. Disturbed sleep pattern
D. Disturbed sleep pattern
Rationale: Nocturia occurs because of polyuria caused by diabetes insipidus.
Which client statement indicates to the nurse that further instruction is needed about chronic syndrome of inappropriate antiduretic hormone?
A. “I should weigh myself daily and report sudden weight loss or gain.”
B. “I need to shop for foods low in sodium and avoid adding salt to food.”
C. “I need to limit my fluid intake to no more than 1 quart of liquids a day.”
D. “I should eat foods high in potassium because diuretics cause potassium loss.”
B. “I need to shop for foods low in sodium and avoid adding salt to food.”
Rationale: Clients with SIADH are at risk for hyponatremia and a sodium supplement may be prescribed.
Which finding indicates to the nurse the demeclocycline has been effective for a client with syndrome of inappropriate antiduretic hormone?
A. Weight has increased
B. Urinary output has increased
C. Peripheral edema has increased
D. Urine specific gravity has increased
B. Urinary output has increased
.A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following
interventions should the nurse include in the plan of care?
A. Measure blood glucose levels every 4 hr.
B. Administer a diuretic.
C. Initiate fluid restrictions.
D. Check urine specific gravity.
D. Check urine specific gravity.
A nurse is collecting the medical history from a client who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if he has a history of which of the following conditions that can cause SIADH?
A. Osteoarthritis
B. Lung cancer
C. Liver cirrhosis
D. Dyspepsia
B. Lung cancer
Rationale: The nurse should ask the client if he has a history of lung cancer because some of the
treatment options for small cell lung cancer can cause secretion of antidiuretic hormone. This
results in the body retaining water and can cause the syndrome of inappropriate antidiuretic
hormone (SIADH).
Add 5% dextrose to IV fluid when glucose is below 300 mg/dL is correct.
Rationale: Once the blood glucose is below 300 mg/dL 5% dextrose should be added to the IV fluid to prevent hypoglycemia. The goal is to decrease the blood glucose by 50 to 100 mg/dL/hr and maintain the levels between 120 to 140 mg/dL.
Infuse bolus of 1,400 mL of IV fluid 0.9% NaCL over 1 hr is correct.
Rationale: Rapid replacement of fluids with an isotonic solution is necessary to prevent hypovolemic shock. The nurse’s notes reflect
manifestations of severe dehydration which is commonly seen in DKA and this child, had a history of fever, vomiting and diarrhea for 3 days. Replacing the initial loss of fluid must be done quickly and should be replaced at 20 mL/kg over 1 hour.
Bicarbonate level is correct.
Rationale: The client’s bicarbonate level (HCO3-) is above the expected
reference range. Although this is an expected finding of diabetic ketoacidosis, the provider should
be aware of this finding.
Sodium level is correct.
Rationale: The client has manifestations of diabetic ketoacidosis, which can alter electrolyte levels. The sodium might be below, within, or above the expected reference range.
Blood pressure results is correct.
Rationale: The nurse should identify that the client is experiencing orthostatic hypotension and should implement measures to ensure client safety by implementing fall precautions. The nurse should continue to monitor the client’s blood pressure and notify the provider if hypotension does not resolve with the administration of IV fluid therapy.
Client self-monitoring of blood glucose is correct.
Rationale: The nurse should plan to further assess the client’s self-management of diabetes, including the client and care partner’s ability to monitor blood glucose levels. Measuring glucose twice daily when taking insulin is likely not effective for the client since their glycosylated hemoglobin indicates poor diabetic control.
IV access is correct.
Rationale: The presence of edema at the IV insertion site and cool temperature indicate
that the client’s IV access has infiltrated and should be discontinued and replaced.
Glasgow coma scale score is correct.
Rationale: The nurse should recognize that a change from 14 to 12 in the Glasgow coma scale indicates a decline in the client’s neurologic function and report this finding to the provider.
ECG findings is correct.
Rationale: The client’s potassium level is above the expected reference range of 3.5 to 5 mEq/L, indicating hyperkalemia. Hyperkalemia can cause cardiac arrythmias as well as a prolonged PR interval, widened QRS, and peaked T wave.
.A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse
expect?
A. Malignant hypertension
B. Acetone odor to breath
C. Cheyne-Stokes breathing
D. Blood glucose level below 40 mg/dL
B. Acetone odor to breath
.Which client statement indicates that discharge teaching about the management of a new permanent pacemaker
was effective?
A. “It will be several weeks before I can return to my usual activities.”
B. “I will avoid cooking with a microwave oven or being near one in use.”
C. “I will notify the airline that I have a pacemaker when I make a reservation.”
D. “I won’t lift my arm on the incision side until I see the health care provider.”
D. “I won’t lift my arm on the incision side until I see the health care provider.”
A client who was admitted with a myocardial infarction has a 45-second episode of ventricular tachycardia then
converts to sinus rhythm with a heart rate of 98 beats/min. Which action would the nurse take next?
A. Notify the health care provider immediately.
B. Document the rhythm and continue to monitor client.
C. Prepare for synchronized cardioversion.
D. Prepare to give IV amiodarone per protocol
D. Prepare to give IV amiodarone per protocol
The nurse obtains a rhythm strip on a client who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, ORS complex wide and distorted, and QRS duration of 0.18 second. How would the nurse interpret this cardiac rhythm?
A. Atrial flutter
B. Sinus tachycardia
C. Ventricular fibrillation
D. Ventricular tachycardia
D. Ventricular tachycardia
Dropdown 1Place the client in high-Fowler’s position is correct. When using the airway
breathing and circulation approach to client care, the nurse should first place the client in
high-Fowler’s position to promote gas exchange. Obtain a doppler ultrasound, administer an
anticoagulant, and obtain ABGs are incorrect. The nurse might obtain a doppler ultrasound at
some point to detect presence of a venous thromboembolism; however, there is another the action
the nurse should take first. The nurse might need to administer an anticoagulant at some point, but
at this time there is another action that the nurse should take first. The nurse might need to obtain
ABGs at some point: however, there is another action that the nurse should take first. Dropdown 2
Obtaining IV access is correct. After placing the client in high-Fowler’s position, the nurse should
then obtain vascular access to maintain circulation. The nurse should also administer required
medications. Placing the client on telemetry, initiating bleeding precautions, and obtaining
vital signs are incorrect. The nurse should place the client on continuous cardiac monitoring due
to the risk of dysrhythmias; however, there is another action that the nurse should take first. The
nurse might need to initiate bleeding precautions if the client receives an anticoagulant; however,
there is another action the nurse should take first. The nurse should plan to monitor vital signs
frequently; however, a set has just been obtained and there is another action that the nurse should
complete prior to this action.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client’s progress.
Answers cannot be displayed for this alternate item format.
A client was admitted with pulmonary embolism has a change in oxygen saturation from 94% to 88%. Which action would the nurse take?
A. Suction the client’s oropharynx.
B. Increase the prescribed oxygen flow rate.
C. Teach the client to cough and deep breathe.
D. Help the client to sit in an upright position.
B. Increase the prescribed oxygen flow rate.
An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The
patient’s core temperature is 105.4°F (40.8°C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. Which action would the nurse plan to take?
A. Apply wet sheets and a fan to the patient.
B. Provide O2 at 2 L/min with a nasal cannula.
C. Start lactated Ringer’s solution at 1000 mL/hr.
D. Give acetaminophen rectal suppository.
A. Apply wet sheets and a fan to the patient.
Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been
admitted to the emergency department (ED) after ingesting 30 lorazepam tablets. Which prescribed action would
the nurse plan to take first?
A. Insert a large-bore orogastric tube.
B. Assist with endotracheal intubation.
C. Prepare a 60-mL syringe with saline.
D. Give first dose of activated charcoal.
B. Assist with endotracheal intubation.
Rationale: In an unresponsive patient, endotracheal intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.
A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
A. Assess heart sounds.
B. Palpate peripheral pulses.
C. Check mental orientation
D. Auscultate breath sounds.
D. Auscultate breath sounds.
Rationale: Because pulmonary edema is a common complication after drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is
not as pertinent to the patient’s risks for complications.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. Which action would the nurse complete during the primary survey of the patient?
A. Obtain a complete set of vital signs.
B. Check a Glasgow Coma Scale score.
C. Attach an electrocardiogram monitor.
D. Ask about chronic medical conditions.
B. Check a Glasgow Coma Scale score.
Rationale: The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?
A. Send blood to the lab for a complete blood count.
B. Assess further for a cause of the decreased circulation.
C. Finish the airway, breathing, circulation, disability survey.
D. Start normal saline fluid infusion with two large-bore IV lines.
C. Finish the airway, breathing, circulation, disability survey.
Rationale: The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although sending off blood for a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.
The nurse is caring for a patient who is living with human immunodeficiency virus (HIV) and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?
A. The patient reports feeling “constantly tired.”
B. The patient reports having no side effects from the medications.
C. The patient is unable to explain the effects of atorvastatin.
D. The patient reports missing doses of tenofovir AF/emtricitabine.
D. The patient reports missing doses of tenofovir AF/emtricitabine.
Because missing doses of ART can lead to drug resistance, this patient statement indicates the
need for interventions such as teaching or changes in the drug scheduling. Fatigue is a
common side effect of ART. The nurse should discuss medication actions and side effects with the patient, but this is not as important as addressing the skipped doses of Descovy.
A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/mL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?
A. CD4+ cell count
B. How the patient obtained HIV
C. Patient’s tolerance for potential medication side effects
D. Patient’s ability to follow a complex medication regimen
D. Patient’s ability to follow a complex medication regimen
Rationale: Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.
A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting?
A. “My wife tries to get me to go to the grocery store, but I don’t like to go out much.”
B. “I am using the modified feeding utensils at every meal. I still spill, but I’m getting better.”
C. “My greatest pleasure each day is having a few beers every day.”
D. “I have all the equipment to take a shower, but I prefer a bed bath, because it is easier.”
B. “I am using the modified feeding utensils at every meal. I still spill, but I’m getting better.”
.A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should
indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)
A. Headache
B. Neck pain and stiffness
C. Slurred speech
D. Pupillary changes
E. Disorientation
A. Headache
C. Slurred speech
D. Pupillary changes
E. Disorientation
A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?
A. Instruct the client to cough and deep breathe.
B. Place the client in a supine position.
C. Place a warming blanket on the client.
D. Use log rolling to reposition the client.
D. Use log rolling to reposition the client.
.A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the
following instructions should the nurse include? (Select all that apply.)
A. Count your pulse for 1 min each morning.
B. Resume activities that can cause jolting, such as horseback riding, after 4 weeks.
C. Do not wear tight clothing over the insertion area.
D. Request to be scanned with a handheld metal detector when in the airport.
E. Do not have a microwave oven in the home.
A. Count your pulse for 1 min each morning.
C. Do not wear tight clothing over the insertion area.
Select The 4 actions that the nurse should complete
Measure lactate level is correct.
— Interventions for sepsis include identifying the problem early, correcting the cause, and preventing complications. A sepsis resuscitation bundle is used to prevent complications. Measuring lactate level within the first hour after client presentation or onset of sepsis manifestations is included in the resuscitative bundle to identify severity.
Rapid administration of 30 mL/kg of normal saline is correct.
— Interventions for sepsis include identifying the problem early, correcting the cause, and preventing complications. A sepsis resuscitation bundle is used to prevent complications and includes rapid administration of crystalloid within the first hour after client presentation or onset of sepsis manifestations such as hypotension or a lactate level greater than or equal to 4 mmol/L.
Obtain blood cultures is correct.
— Interventions for sepsis include identifying the problem early, correcting the cause, and preventing complications. A sepsis resuscitation bundle is used to prevent complications and includes obtaining blood cultures within the first hour after client presentation or onset of sepsis manifestations. Blood cultures should be obtained before administering antibiotics to identify the specific microorganism.
Administer broad-spectrum antibiotics is correct.
—Interventions for sepsis include identifying the problem early, correcting the cause, and preventing complications. A sepsis resuscitation bundle is used to prevent complications and includes administration of broad-spectrum antibiotics after obtaining prescribed cultures, but within the first hour after client presentation or onset of sepsis manifestations. Administration of broad-spectrum antibiotics within the first hour after client presentation or onset of sepsis manifestation assists in eliminating the micro-organism until the specific organism is identified.
A nurse is assessing a client who has aortic stenosis. Which of the following findings should the nurse expect?
(Select all that apply.)
A. Hypotension
B. Bradycardia
C. Clubbing of the nail beds
D. Weak pulses
F. Murmur
A. Hypotension
D. Weak pulses
F. Murmur
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?
A. Dehydration
B. Seizures
C. Burns
D. Shivering
D. Shivering
Rationale: The hypothermia blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the
metabolic rate by two to five times and in doing so greatly raise oxygen consumption.
A nurse is performing triage for a group of clients following a mass casualty incident (MCI). Which of the following
clients should the nurse plan to care for first?
A. A client experiencing a tension pneumothorax
B. A client who has a closed upper extremity fracture
C. A client who has full-thickness burns over 80% of his body
D. A client who has agonal respirations
A. A client experiencing a tension pneumothorax
Click to highlight the information in the Nurse’s Notes and Vital Signs that should be reported to the provider.
Changes in the client’s condition such as increased temperature and heart rate, and
decreased blood pressure should be reported to the provider. These changes might be an
indication the client is experiencing fluid volume deficit.
The client’s report of headache, dizziness, and dry mucous membranes should be provided to the provider. These reports indicate changes in the client’s condition that may be an indication the client is experiencing fluid volume deficit.
The nurse’s assessment of the client’s abdominal cramping, lethargy, projectile vomiting, and voiding dark and concentrated urine should be reported to the provider. These are changes in the client’s condition that might be an indication the client is experiencing fluid volume deficit.
A nurse is planning care for a client who ingested a large amount of acetylsalicylic acid. Which of the following actions should the nurse take?
A. Induce vomiting with syrup of ipecac.
B. Administer N-acetylcysteine.
C. Initiate chelation therapy with deferoxamine.
D. Perform gastric lavage with activated charcoal.
D. Perform gastric lavage with activated charcoal.
A nurse is caring for a client who reports that he has a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions?
A. Carbon monoxide poisoning
B. Heat stroke
C. Hypersensitivity reaction
D. Oxygen toxicity
A. Carbon monoxide poisoning
A nurse at a pediatrician’s office is contacted by a parent whose child just ingested half a bottle of vitamins with added ferrous sulfate. Which of the following instructions should the nurse provide to the parent?
A. Provide a high-carbohydrate meal.
B. Give the child syrup of ipecac.
C. Contact the poison control center.
D. Bring the child to the office for a rapid infusion of deferoxamine.
C. Contact the poison control center.
Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply).
Rationale: Blood pressure is correct.
— The client’s blood pressure is above the defined limits and increased blood pressure is an indication of renal transplant rejection.
Assessment of the incision site is correct.
— Tenderness at the incision site can indicate an enlarged or tender kidney, which indicates
renal transplant rejection.
Creatinine level is correct.
— The client’s creatinine level is increased, which can be an indication of renal transplant rejection.
Assessment of lower extremities is correct.
— The assessment of the client’s lower extremities indicate edema, which is an indication of fluid retention caused by renal transplant rejection.
A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication.
After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles?
A. Veracity
B. Autonomy
C. Fidelity
D. Nonmaleficence
D. Nonmaleficence
.A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?
A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
B. Assess for an increase in temperature.
C. Check the pulse oximeter.
D. Monitor for manifestations for increased intracranial pressure.
C. Check the pulse oximeter.
The priority action the nurse should take when using the airway, breathing, circulation (ABC)
approach to client care is to maintain a patent airway. Checking the oximeter is the first
indicator of poor oxygen exchange which can cause cerebral edema.
A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?
A. Reduce edema of the brain.
B. Provide fluid hydration.
C. Increase cell size in the brain.
D. Expand extracellular fluid volume.
A. Reduce edema of the brain.
Rationale: An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles into the bloodstream.
A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the
following interventions should the nurse take?
A. Place the client in protective isolation.
B. Minimize environmental stimuli.
C. Elevate the head of the client’s bed 45°.
D. Limit the client’s ambulation to once a day.
B. Minimize environmental stimuli.
A client who has a cerebral aneurysm is at risk for rupture and should avoid any stimulation
that could cause anxiety, such as noise or bright lights.
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?
A. Perform passive range of motion on each extremity.
B. Monitor the client’s electrolyte levels.
C. Suction saliva from the client’s mouth.
D. Record the client’s intake and output.
C. Suction saliva from the client’s mouth.
The unconscious client is unable to independently maintain a clear airway and is at risk for ineffective airway clearance. According to the safety and risk reduction priority setting
framework, maintaining the client’s airway, breathing, and circulation is the highest priority.
A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)
C. Open the airway using a jaw-thrust maneuver.
D. Determine effectiveness of ventilator efforts.
B. Establish IV access.
A. Perform a Glasgow Coma Scale assessment.
E. Remove clothing for a thorough assessment.
A nurse is assessing a client’s cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?
A. Testing visual acuity
B. Observing for facial symmetry
C. Eliciting the gag reflex
D. Checking the pupillary response to light
D. Checking the pupillary response to light
Rationale: Cranial nerve III is the oculomotor nerve and is responsible, along with cranial nerves IV (trochlear) and VI (abducens), for eye movement and pupillary response to light. If the cranial nerve is functioning properly, the expected reaction is pupil constriction in response to light.
Which intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously could
the nurse delegate to assistive personnel (AP)?
A. Monitor the quality and presence of the pedal pulses.
B. Teach the patient the signs of possible wound infection.
C. Check the lower extremities for strength and movement.
D. Help the patient to use a pillow to splint while coughing.
D. Help the patient to use a pillow to splint while coughing.
Rationale: Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement would be done by RNs.
An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action would the nurse take first?
A. Check the patient’s blood pressure.
B. Assess the patient for an abdominal bruit.
C. Determine any family history of heart disease.
D. Draw blood for laboratory testing.
A. Check the patient’s blood pressure.
Rationale: Because the patient appears to be experiencing aortic dissection, the nurse’s first action should be to determine the hemodynamic status by assessing blood pressure. The other actions may also be done, but they will not provide information to determine what interventions are needed immediately.
A patient with coronary artery disease is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers?
A. Echocardiogram
B. 12-lead electrocardiogram
C. Cardiac catheterization
D. Elelctrophysiology study
A. Echocardiogram
Rationale: Echocardiography is a noninvasive, acoustic imaging procedure and involves the use of ultrasound to visualize the cardiac structures and the motion and function of cardiac valves and chambers.
Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?
A. An 18-year-old college student with type 1 diabetes who exercises excessively
B. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning
C. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections
D. An 83-year-old, long-term care resident with type 2 diabetes and Alzheimer’s disease who recently developed influenza
D. An 83-year-old, long-term care resident with type 2 diabetes and Alzheimer’s disease who recently developed influenza
Rationale: Hyperosmolar hyperglycemic syndrome is more common in type 2 diabetes; influenza is a stressor that would result in further increases in blood sugar. Some individuals with advanced Alzheimer’s disease cannot communicate thirst needs and may be incontinent, making hypertonic fluid loss more difficult to estimate.
A 20-year-old female with a history of type 1diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose 648 mg/dL, pH 6.88, PaCO2 20 mm Hg,
PaO2 95 mm Hg, HCO3- undetectable, Na+127 mEq/L, K+ 3.5 mEq/L, and creatinine1.8 mg/dL. After the patient’s airway and ventilation have been established, which of the following is the next priority for this client?
A. Administration of a 1-L normal saline fluid bolus
B. Administration of 0.1 unit of regular insulin IV push followed by an insulin infusion
C. Administration of 20 mEq KCl in 100 mL
D. Intravenous push administration of 1 amp of sodium bicarbonate
A. Administration of a 1-L normal saline fluid bolus
Rationale: After airway is established, the next priority in management of DKA is fluid resuscitation with 1 liter of normal saline over 1 hour. The fluid resuscitation should begin prior to administration of insulin. Potassium may be added to fluid replacement bags after the first liter of normal saline has infused, provided that the serum potassium is greater than 3.3 mEq/L. Although
bicarbonate replacement is indicated in this clinical situation, the bicarbonate is administered by infusion, not by IV push, until the pH exceeds 7.0.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse’s priority?
A. Positive Western blot test
B. CD4-T-cell count 180 cells/mm3
C. Platelets 150,000/mm3
D. WBC 5,000/mm3
B. CD4-T-cell count 180 cells/mm3
Rationale: A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely
immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider.
A nurse is caring for a client who has chemotherapy- induced peripheral neuropathy. The nurse should expect the
client to report having experienced which of the following symptoms?
A. Extremities that turned blue when exposed to cold
B. Tingling feeling in the extremities
C. Jerking movements of the extremities
D. Spasms of the extremities
B. Tingling feeling in the extremities
Rationale: Peripheral neuropathy is a neurological disorder resulting from damage to the peripheral nerves. It may be caused by diseases of the nerves, systemic illnesses, or it may be a side-effect from chemotherapy. If a sensory nerve is damaged, the client is likely to experience pain, numbness, tingling, burning, or a loss of feeling in the extremities.
A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for
which of the following manifestations of this condition? (Select all that apply.)
A. Severe dyspnea
B. Nausea
C. Decreased level of consciousness
D. Headache
E. Hypotension
A. Severe dyspnea
C. Decreased level of consciousness
D. Headache
E. Hypotension
A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take?
A. Encourage fluid intake of 1500 mL/day.
B. Position head of bed at 10 degrees.
C. Cough and deep breathe every 8 hr.
D. Obtain a sputum culture.
D. Obtain a sputum culture.
Rationale: The nurse should obtain a sputum culture to determine which antibiotic is needed for the organism that is causing the pneumonia.
.A nurse in the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect?
A. Unequal pupils
B. Hypertension
C. Tympany upon chest percussion
D. Confusion
D. Confusion
Rationale: Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.
A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?
A. Hyperthermia
B. Hypotension
C. Ototoxicity
D. Muscle pain
B. Hypotension
Rationale: Verapamil, a calcium channel blocker, can be used to control supraventricular tachyarrhythmias. It also decreases blood pressure and acts as a coronary vasodilator and antianginal agent. A major adverse effect of verapamil is hypotension; therefore, blood
pressure and pulse must be monitored before and during parenteral administration.
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?
A. First-degree AV block
B. Atrial fibrillation
C. Sinus bradycardia
D. Sinus tachycardia
B. Atrial fibrillation
Rationale: Atrial fibrillation causes a disorganized twitching of the atrial muscles. The rate is irregular with no visible P waves. The ventricular response is irregular which results in an irregular pulse and a pulse deficit.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base
excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L
A. Respiratory acidosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
A. Respiratory acidosis
Rationale: Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid
administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 – 7.45) and a CO2 level that is higher than the normal reference range (35 – 45 mm Hg).
A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client’s recovery?
A. It decreases the client’s level of anxiety.
B. It facilitates the client’s deep breathing.
C. It enhances the client’s ability to sleep.
D. It reduces the client’s blood pressure.
B. It facilitates the client’s deep breathing.
Rationale: When using the airway, breathing, circulation approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids aside from pain relief. Following thoracic type surgeries, the client’s has increased pain with moving, deep breathing and coughing. Opioid medications help minimize the discomfort experienced with deep breathing and coughing which prevents the development of postoperative pneumonia. The nurse should also encourage the client to splint his incision to help minimize pain.
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?
A. Decrease in the respiratory rate from 20 to 16/min.
B. Decrease in the urinary output from 50 mL to 30 mL per hour.
C. Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F).
D. Increase in the heart rate from 88 to 110/min.
D. Increase in the heart rate from 88 to 110/min.
Rationale: Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of blood loss or inadequate blood volume. In an effort to compensate for this, the heart rate increases steadily. In the first stage of shock (compensatory), the heart rate is > 100/min. As shock progresses, the heart rate continues to accelerate to more than 150/min. In the final (irreversible or refractory) stage, the heart rate becomes very erratic and may develop asystole.
A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
A. Hypertension
B. Flushing of the skin
C. Oliguria
D. Bradypnea
C. Oliguria
Rationale: Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys.
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
A. “DIC is controllable with lifelong heparin usage.”
B. “DIC is characterized by an elevated platelet count.”
C. “DIC is caused by abnormal coagulation involving fibrinogen.”
D. “DIC is a genetic disorder involving a vitamin K deficiency.”
C. “DIC is caused by abnormal coagulation involving fibrinogen.”
Rationale: DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage.
A nurse is reviewing a client’s laboratory report of arterial blood gas (ABG) findings: pH 7.28, HCO3- 18 mEq/L, and PaCO2 36 mm Hg. Which of the following conditions should the nurse anticipate when interpreting these findings?
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
A. Metabolic acidosis
Rationale: After analysis of the client’s ABG findings, the nurse should anticipate that the client has metabolic acidosis. Manifestations of metabolic acidosis include diarrhea, circulatory shock, decreased level of consciousness, abdominal pain, cardiac dysrhythmia, and increased depth and rate of respirations.
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?
A. Administer low-flow oxygen continuously via nasal cannula.
B. Encourage oral intake of at least 3,000 mL of fluids per day.
C. Offer high-protein and high-carbohydrate foods frequently.
D. Place in a prone position.
D. Place in a prone position.
Rationale: Oxygenation in clients who have ARDS is improved when placed in the prone position. Frequent and consistent turning of the client is also beneficial and can be accomplished by the use of specialty beds.
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
A. Decrease chest wall compliance
B. Suppress respiratory effort
C. Induce sedation
D. Decrease respiratory secretions
B. Suppress respiratory effort
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress the client’s respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over the work of breathing for the client. This therapy is especially helpful for a client who has ARDS and poor lung compliance.
A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?
A. Bradypnea
B. Somnolence
C. Pallor
D. Tachycardia
D. Tachycardia
Rationale: The nurse should expect the client who has hypoxia to manifest tachycardia.
A nurse is caring for a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective?
A. Respiratory rate 28/min
B. Heart rate 110/min
C. Pink mucous membranes
D. Restlessness
C. Pink mucous membranes
Rationale: Pink mucous membranes, capillary refill less than 2 sec, intact mental status, and increased oxygen saturation indicate the intervention was effective.
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client’s heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?
A. Obtain a cardiology consult.
B. Suction the client less frequently.
C. Administer an antidysrhythmic medication.
D. Perform pre-oxygenation prior to suctioning.
D. Perform pre-oxygenation prior to suctioning.
Rationale: Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. . In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen.
A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?
A. Fluid overload
B. Left ventricular failure
C. Intracardiac shunt
D. Hypovolemia
D. Hypovolemia
Rationale: A low CVP indicates reduced right ventricular preload, which can be seen in clients who are experiencing hypovolemia, excessive blood loss, or overdiuresis.
