Review Flashcards
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 should the nurse make?
A. Fluid overload
B. Intracardiac shunt
C. Hypovolemia
D. Left ventricular failure
C. Hypovolemia
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. Perform pre-oxygenation prior to suctioning.
C. Suction the client less frequently.
D. Administer an antidysrhythmic medication.
B. Perform pre-oxygenation prior to suctioning.
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
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 respiratory secretions.
B. Induce sedation
C. Suppress respiratory effort
D. Decrease chest wall compliance
C. Suppress respiratory effort
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
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 caused by abnormal coagulation involving fibrinogen.”
C. “DIC is a genetic disorder involving a vitamin K deficiency.”
D. “DIC is characterized by an elevated platelet count.”
B. “DIC is caused by abnormal coagulation involving fibrinogen.”
A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
a. Bradypnea
b. Hypertension
c. Oliguria
d. Flushing of the skin
c. Oliguria
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.
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 the 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.
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. Metabolic alkalosis.
B. Respiratory acidosis.
C. Metabolic acidosis.
D. Respiratory alkalosis.
B. Respiratory acidosis.
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. Sinus bradycardia
B. Sinus tachycardia
C. Atrial fibrillation
D. First-degree AV block
C. Atrial fibrillation
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. Hypotension
B. Muscle pain
C. Ototoxicity
D. Hyperthermia
A. Hypotension
A nurse in a provider’s office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?
A. Narrowed pulse pressure
B. Night sweats
C. Bradycardia
D. Confusion
D. Confusion
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. Obtain a sputum culture.
B. Position head of bed at 10 degrees.
C. Cough and deep breathe every 8 hr.
D. Encourage fluid intake of 1500 mL/day.
A. Obtain a sputum culture.
A nurse is caring for a client who has 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 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. Jerking movements of the extremities
B. Extremities that turned blue when exposed to cold
C. Spasms of the extremities
D. Tingling feeling in the extremities
D. Tingling feeling in the extremities
A nurse is caring for a client who has HIV.
Which of the following laboratory values is the nurse’s priority?
A. WBC 5,000/mm³.
B. Platelets 150,000/mm³.
C. O Positive Western blot test.
D. CD4-T-cell count 180 cells/mm.
D. CD4-T-cell count 180 cells/mm.
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
Anion gap >31
Na +127 mEq/L
K+ 3.5 mEq/L
Creatinine 1.8 mg/dL
After the patient’s airway and ventilation have been established, the next priority for this
patient is:
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. IV push administration of 1 amp of
sodium bicarbonate.
a. administration of a 1-L normal saline fluid
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 advanced Alzheimer’s disease who recently developed influenza
d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer’s disease who recently developed influenza
A patient 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. 12-lead electrocardiogram
b. Cardiac catheterization
c. Echocardiogram
d. Electrophysiology study
c. Echocardiogram
An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first?
a. Obtain the blood pressure.
b. Obtain blood for laboratory testing.
c. Assess for the presence of an abdominal bruit.
d. Determine any family history of kidney disease.
a. Obtain the blood pressure.
Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
A. Monitor the quality and presence of the pedal pulses
B. Teach the patient the sign 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
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. Eliciting the gag reflex
B. Testing visual acuity
C. Observing for facial symmetry
D. Checking the pupillary response to light
D. Checking the pupillary response to light
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.
Open the airway using a jaw-thrust maneuver.
Determine effectiveness of ventilator efforts.
Establish IV access.
Perform a Glasgow Coma Scale assessment.
Remove clothing for a thorough assessment.
A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
A. Perform passive range of motion on each extremity.
B. Record the client’s intake and output.
C. Suction saliva from the client’s mouth.
D. Monitor the client’s electrolyte levels.
C. Suction saliva from the client’s mouth.
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. Limit the client’s ambulation to once a day.
B. Place the client in protective isolation.
C. Minimize environmental stimuli.
D. Elevate the head of the client’s bed 45 degrees.
C. Minimize environmental stimuli.
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.
A nurse is caring for a client who had an evacuation of a subdural hematoma. Immediately after the evacuation, which of the following nursing actions is a priority?
A. observe for CSF leaks from the evacuation site
B. assess for an increase in temperature
C. check the pulse oximeter
D. monitor for signs of increasing ICP
C. check the pulse oximeter
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. Which of the following ethical principles was demonstrated?
A. Veracity.
B. Autonomy.
C. Nonmaleficence.
D. Fidelity.
C. Nonmaleficence.
A nurse is caring for a client who is admitted to the emergency department for fatigue. Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply).
A. Assessment of lower extremities
B. Sodium level
C. Lung sounds
D. Creatinine level
E. Assessment of Incision site
F. Bowel sounds
G. Blood pressure.
A. Assessment of lower extremities
D. Creatinine level
E. Assessment of Incision site
G. Blood pressure.
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. Bring the child to the office for a rapid infusion of deferoxamine.
B. Give the child syrup of ipecac.
C. Contact the poison control center.
D. Provide a high-carbohydrate meal.
C. Contact the poison control center.
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 suspect which of the following?
A. Carbon monoxide poisoning
B. Meniere’s disease
C. Migraine
D. Benign paroxysmal positional vertigo.
A. Carbon monoxide poisoning
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. Administer N-acetylcysteine.
B. Initiate chelation therapy with deferoxamine.
C. Perform gastric lavage with activated charcoal.
D. Induce vomiting with syrup of ipecac.
C. Perform gastric lavage with activated charcoal.
A nurse on a medical surgical unit is admitting a client from a provider’s office. 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. The client’s oxygen saturation, cardiac sounds, and hyperactive bowel sounds do not need to be reported to the provider. The oxygen saturation and cardiac sounds are within the expected reference ranges. The client does have hyperactive bowl sounds, which is outside of the expected reference range; however, this is an expected finding for a client who has food poisoning and is not a change in the client’s condition; therefore, it does not need to be reported to the provider.
- increased temperature and heart rate, and decreased blood pressure
- headache, dizziness, and dry mucous
- abdominal cramping, lethargy, projectile vomiting, and voiding dark
A nurse is performing 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 closed upper extremity fracture
C. A client who has fill thickness burns over 80% of his body
D. A client who has agonal respirations
A. A client experiencing a tension pneumothorax
A nurse is caring for a client who has meningitis, 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. Shivering.
C. Seizures.
D. Burns.
B. Shivering.
A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? Select all.
A. Hypotension
B. Bradycardia
C. Clubbing of the nail beds
D. Weak pulses
E. Murmur
A. Hypotension
D. Weak pulses
E. Murmur
A nurse is caring for a 73-year-old client in the emergency department (ED).
Exhibits
It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.
A. Insert a nasogastric (NG) tube.
B. Measure lactate level.
C. Obtain a wound culture.
D. Administer broad-spectrum antibiotics.
E. Obtain blood cultures.
F. Type and cross-match for 2 units of packed RBCs.
G. Rapidly administer 30 mL/kg of normal saline.
H. Obtain a urine specimen.
B. Measure lactate level.
D. Administer broad-spectrum antibiotics.
E. Obtain blood cultures.
G. Rapidly administer 30 mL/kg of normal saline.
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. Do not have a microwave oven in the home.
B. Request to be scanned with a handheld metal detector when in the airport.
C. Count your pulse for 1 min each morning.
D. Do not wear tight clothing over the insertion area.
E. Resume activities that can cause jolting, such as horseback riding, after 4 weeks.
C. Count your pulse for 1 min each morning.
D. Do not wear tight clothing over the insertion area.
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. Use log rolling to reposition the client.
B. Place a warming blanket on the client.
C. Instruct the client to cough and deep breathe.
D. Place the client in a supine position.
A. Use log rolling to reposition the client.
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 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 patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of
400/μL. Which factor is most important for the nurse to determine before the initiation of
antiretroviral therapy (ART) for this patient?
a. CD4+
cell count trajectory
b. HIV genotype and phenotype
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
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 (Lipitor).
d. The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).
d. The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).
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 a large-bore IV line.
d. Start normal saline fluid infusion with a large-bore IV line.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should
a. obtain a complete set of vital signs.
b. obtain a Glasgow Coma Scale score.
c. ask about chronic medical conditions.
d. attach a cardiac electrocardiogram monitor
b. obtain a Glasgow Coma Scale score.
A 22-year-old patient who experienced a near 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. Auscultate heart sounds.
b. Palpate peripheral pulses.
c. Auscultate breath sounds.
d. Check pupil reaction to light.
c. Auscultate breath sounds.
Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first?
a. Insert a large-bore orogastric tube.
b. Assist with intubation of the patient.
c. Prepare a 60-mL syringe with saline.
d. Give first dose of activated charcoal.
b. Assist with intubation of the patient.
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. What action should the nurse plan to take?
A. Give acetaminophen (Tylenol) rectal suppository.
B. Provide O2 at 2 L/min with a nasal cannula.
C. Apply wet sheets and a fan to the patient
D. Start lactated Ringer’s solution at 1000 mL/hr
C. Apply wet sheets and a fan to the patient
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient’s oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take?
a. Suction the patient’s oropharynx.
b. Increase the prescribed O2 flow rate.
c. Instruct the patient to cough and deep breathe.
d. Help the patient to sit in a more upright position.
b.Increase the prescribed O2 flow rate.
A nurse is caring for a client on the medical- surgical unit. 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.
BOWTIE
Dx: ventricular tachycardia
action: 12-lead ECG and prepare the client for cardioversion
monitor: client’s cardiac rhythm and serum potassium
A nurse is caring for a client in the emergency department (ED).
Nurses’ Notes
1500:
Client presents to the ED and reports dyspnea, chest pain, and tachycardia. Client returned home from a vacation out of the country 24 hr ago.
1515:
The client has become diaphoretic, increasingly dyspneic, and states that their chest pain is sharp and increasing. The client states, “I feel like I’m going to die.” Crackles auscultated in bilateral lower lobes, S3 and 54 heart sounds noted. Petechiae noted on the client’s chest. Pulmonary embolism protocol initiated.
Vital Signs
1500:
Temperature: 38.1° C (100.6° F)
Heart rate: 110/min
Respiratory rate: 24/min
BP: 138/52 mm Hg
Oxygen saturation: 92% oxygen at 2 L/min via nasal cannula
1515:
Temperature: 38.1° C (100.6° F)
Heart rate: 135/min
Respiratory rate: 32/min
BP: 120/50 mm Hg
Oxygen saturation: 90% on 4 L/min via nasal cannula
The nurse should first __________ followed by ______________
place the client in high-Fowler’s position
obtaining IV access
The nurse obtains a rhythm strip on a patient 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, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient’s cardiac rhythm as
a. atrial flutter.
c. ventricular fibrillation.
b. sinus tachycardia.
d. ventricular tachycardia.
d. ventricular tachycardia.
A patient 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 should the nurse take next?
a. Immediately notify the health care provider.
b. Document the rhythm and continue to monitor the patient.
c. Prepare for synchronized cardioversion per agency protocol.
d. Prepare to give IV amiodarone per agency dysrhythmia protocol.
d. Prepare to give IV amiodarone per agency dysrhythmia protocol.
The nurse evaluates that discharge teaching about the management of a new permanent pacemaker has been effective when the patient states
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 airlines when I make a reservation that I have a pacemaker.”
d. “I won’t lift the arm on the pacemaker side until I see the health care provider.”
d. “I won’t lift the arm on the pacemaker side until I see the health care provider.”
The nurse is caring for a patient suspected of having ketoacidosis. What early manifestation(s) may be noted with this condition? (Select all that apply.)
a. Fruity breath
b.Polyuria
c.Nausea
d.Thirst
e.Sunken eyes
a. Fruity breath
b.Polyuria
c.Nausea
A nurse is admitting a client who has type 1 diabetes mellitus. Select the 7 findings that require immediate attention.
ECG findings
Sodium level
Client’s self-monitoring of blood glucose Bicarbonate level
Blood pressure results
Glasgow Coma Scale score
IV access
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.Lung cancer
B.Osteoarthritis
C.Dyspepsia
D.Liver cirrhosis
A.Lung cancer
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.Check urine specific gravity.
C.Administer a diuretic
D.Initiate fluid restrictions
B.Check urine specific gravity.
Which finding indicates to the nurse that demeclocycline is effective for a patient with a syndrome of inappropriate antidiuretic hormone (SIADH)?
A.Urine-specific gravity is increased.
B.Patient’s weight is increased.
C.Peripheral edema is decreased.
D.Patient’s urinary output is increased.
A.Urine-specific gravity is increased.
Which patient statement indicates to the nurse that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH)?
a. “I should weigh myself daily and report sudden weight loss or gain.”
b. “I need to stop 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 stop for foods low in sodium and avoid adding salt to food.”
Which problem should the nurse anticipate for a patient admitted to the hospital with diabetes insipidus?
a. Generalized edema
b. Fluid volume overload
c. Disturbed sleep pattern
d. Decreased gas exchange
c. Disturbed sleep pattern
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. Pulmonary embolism
B. Bradycardia
C. Peripheral vascular disease
D. Hypertension.
A. Pulmonary embolism
The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider?
A. Red-brown drainage from nasogastric tube
B. Blood urea nitrogen (BUN) level 32 mg/dL
C. Scattered coarse crackles heard throughout lungs
D. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68
A. Red-brown drainage from nasogastric tube
A patient with acute respiratory distress syndrome (ARDS) 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 (FIO2).
c. Perform endotracheal suctioning more frequently.
d. Lower the positive end-expiratory pressure (PEEP).
d. Lower the positive end-expiratory pressure (PEEP).
A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this patient problem?
a. Encourage use of the incentive spirometer.
b. Offer the patient fluids at frequent intervals.
c. Teach the patient the importance of ambulation.
d. Titrate oxygen level to keep O2 saturation above 93%.
b. Offer the patient fluids at frequent intervals.
A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone positioning is used, which information obtained by the nurse indicates that the positioning is effective?
a. The patient’s PaO2 is 89 mm Hg, and the SaO2 is 91%.
b.Endotracheal suctioning results in clear mucous return.
c.Sputum and blood cultures show no growth after 48 hours.
d.The skin on the patient’s back is intact and without redness
a. The patient’s PaO2 is 89 mm Hg, and the SaO2 is 91%.
A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?
a. Oral temperature
b. Peripheral pulses
c. Extremity movement
d. Pupil reaction to light
c. Extremity movement
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take?
a. Notify the health care provider.
b. Monitor the pulses every 2 hours.
c. Elevate both legs above heart level with pillows.
d. Encourage the patient to flex and extend the toes on both feet.
a. Notify the health care provider.
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 action will the nurse anticipate taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion.
c. Increase the rate of the ordered IV solution.
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
A nurse is assisting in performing triage on several clients following a mass casualty event. The nurse should assign a red tag to which of the following clients? Sata
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 the upper torso and extremities.
C. A client who has sustained a partial amputation of the right leg.
E. A client who has sustained a major burn to the upper torso and extremities.
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 heart failure and peripheral edema.
B. A client who has cirrhosis of the liver and bruising on their arms.
C. A client who reports urinary burning and a temperature of 39.2° C (102.5° F).
D. A client who has a new onset of atrial fibrillation and a heart rate of 152/min.
D. A client who has a new onset of atrial fibrillation and a heart rate of 152/min.
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. A conscious adult client who has a dislocated right shoulder, respiratory rate of 18/min, and capillary refill of <2 seconds
C. An unconscious adult client who has a sucking chest wound, respirations of 38/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
C. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of <2 seconds
A nurse assisting with field triage following a motor vehicle crash involving a bus with multiple victims. The nurse assess 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
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
B. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically
C. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around
D. 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 client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site
External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to 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 every bowel movement.
d. Inspect the mouth and throat daily for the appearance of thrush.
c. Clean the perianal area carefully after every bowel movement.
The nurse should suggest which food choice 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
A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?
a. Teach the patient about the medications available for treatment.
b. Inform the patient how to protect sexual and needle-sharing partners.
c. Remind the patient about the need to return for retesting to verify the results.
d. Ask the patient to notify individuals who have had risky contact with the patient.
c. Remind the patient about the need to return for retesting to verify the results.
A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?
Sensitivity to light
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. Instruct the client to wiggle his toes.
C. Palpate the femoral pulse.
D. Monitor the client’s calf for edema.
B. Instruct the client to wiggle his toes.
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 Your injury What percentage of body surface area should the nurse estimate the client has burned?
54%
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. Restlessness
C. Hypotension
D. Amnesia
B. Restlessness
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
A. Dehydration.
B. Bradycardia.
C. Polyphagia.
D. Hyperglycemia.
A. Dehydration.
The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
A. Heart rate
B. Blood pressure
C. Weight
D. Urine output
A. Heart rate
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 tear PRN.
c. Obtain vital signs every 2 hr.
d. Perform mouth care every hour.
e. Administer oxygen 2L/min via nasal cannula.
a. Provide skin care with a moisture barrier cream.
b. Administer artificial tear PRN.
d. Perform mouth care every hour.
e. Administer oxygen 2L/min via nasal cannula.
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.Eliciting the gag reflex
B.Testing visual acuity
C.Observing for facial symmetry
D.Checking the pupillary response to light
D.Checking the pupillary response to light
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 highest priority to address?
a. “We don’t have air conditioning”
b. “We usually have just two meals a day.”
c. “We only buy the prescription we can afford.”
d. “We cannot afford new batteries for his hearing aid.”
c. “We only buy the prescription we can afford.”
A client who has metastatic bone cancer tells the nurse, “I want to go home to die.” The client’s family is concerned about meeting the client’s care needs at home. Which of the following actions should the nurse take?
A. Discuss a referral to home health and hospice care with the client and family.
B. Contact the social worker to assist with nursing home placement.
C. Talk with the provider about extending the client’s hospital stay.
D. Instruct the family about meeting the client’s palliative care needs at home.
A. Discuss a referral to home health and hospice care with the client and family.
A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements should the nurse identify as an indication that the client understands and accepts his prognosis?
A. I am thinking of getting a second opinion.
B. This is not working, and I plan to stop treatment.
C. I am hoping this will help relieve my discomfort.
D. This is making me stronger every day.
C. I am hoping this will help relieve my discomfort.
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 has an electrical burn, which caused coagulation of some tissues
B. He is doing well, although he might be in the hospital for some time.
C. He does not appear to have much damage and should be fine soon
D. He has an electrical burn. He is stable, and we will update you with any changes.
D. He has an electrical burn. He is stable, and we will update you with any changes.
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.
A nurse is caring for a client who experienced severe head trauma. The client’s partner asks the nurse why they are concerned about the mean arterial pressure (MAP). The nurse should explain that MAP determines which of the following?
a. regulation of blood pressure
b. resorption of cerebrospinal fluid
c. cerebral blood flow
d. the client’s intake and output needs
c. cerebral blood flow
A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock?
A. The client who has chronic kidney disease
B. The client experiencing an asthma attack
C. The client who has Guillain-Barré syndrome
D. The client who has a severe burn injury
C. The client who has Guillain-Barré syndrome
A nurse is providing care to a client who has spent several weeks in the intensive care unit because of complications related to shock. What adverse psychological outcomes should the nurse educate the client about prior to transfer to the medical unit?
A. Hypoxia and acidosis
B. Hearing deficits and increased risk of glaucoma
C. Bipolar behaviors and schizotypal behaviors
D. Disorientation and depression
D. Disorientation and depression
A nurse is providing care for a client who was involved in a motor-vehicle crash. Complete the following sentence.by using the list of options.
The nurse should first address the client’s ______ followed by the client’s ______.
dropdown: Level of Consciousness
Dropdown: Oxygen saturation
A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?
A. Hemodynamic status
B. Spinal cord perfusion
C. Renal function
D. Intracranial pressure
A. Hemodynamic status
A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the following findings as an indication of hypovolemic shock?
A. Widening pulse pressure
B. Increased heart rate
C. Increased deep tendon reflexes
D. Pulse oximetry 96%
B. Increased heart rate
A nurse is assisting with the care of 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. Pink mucous membranes
C. Heart rate 110/min
D. Restlessness
B. Pink mucous membranes
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. Offer high-protein and high-carbohydrate foods frequently.
C. Place in a prone position.
D. Encourage oral intake of at least 3,000 mL of fluids per day.
C. Place in a prone position.
A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take?
A. Assist the client to the orthopneic position.
B. Instruct the client to remain as still as possible during the recording.
C. Attach a blood pressure cuff to the client’s upper arm.
D. Tell the client to expect a mild stinging sensation during the test.
B. Instruct the client to remain as still as possible during the recording.
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication?
a. Bowel sounds
b. Stool frequency
c. Abdominal distention
d. Stools for occult blood
d. Stools for occult blood
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 into a fetal position
a. The shoulders droop
b. The facial muscles relax
d. The pulse is within the expected range
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
A. Decreased level of consciousness
B. Increased respiratory rate
C. Hypotension
D. Anuria
B. Increased respiratory rate
