REVIEW Flashcards
Based upon Eleanor’s condition, an ABG is obtained with the following results.. 7.28/55/80/28/89%. Which acid base imbalance is she experiencing?
A metabolic acidosis
B metabolic alkalosis
C respiratory acidosis
D respiratory alkalosis
C respiratory acidosis
pH is down and CO2 is up
Partially compensated bc bicarb is slightly elevated
Which nursing diagnosis is priority in the caring for Eleanor?
A Activity Intolerance
B Ineffective Airway Clearance
C Altered nutrition
D Anxiety
B Ineffective Airway Clearance
ABCs are always the most important
What action should the nurse take prior to administering ampicillin?
A Assess the BP
B Obtain a pulse ox reading
C Obtain the sputum culture
D Monitor the intake and output
C Obtain the sputum culture
Check for infection
Based upon the ABG results and Eleanor’s manifestations, which action should the nurse implement? Select all that apply
A Increase the head of the bed
B Increase the oxygen to keep pulse ox >95%
C Bedrest
D Encourage fluids at least 3L /day
A Increase the head of the bed
C Bedrest
Which assessment is essential for the nurse to check while Eleanor is receiving Albuterol?
A temperature
B apical pulse
C weight
D intake and output
B apical pulse
Which blood level is essential that the nurse monitor when Eleanor is taking Solumedrol?
A white blood cells
B potassium level
C glucose level
D sodium level
C glucose level
Steroids increase the glucose levels
In a healthy pt, it is not as big of a deal, but Eleanor probs has type 2 diabetes so its something we want to monitor
Eleanor is receiving Albuterol and Flovent via inhalers. Which patient statement requires further teaching by the nurse? Select all that apply
A “I will wait at least 5 minutes between each puff of my Flovent”
B “I will rinse my mouth after the Albuterol”
C “I should take the Flovent at the first sign of respiratory troubles”
D “I will call the doctor if I feel any chest discomfort with the medications”
A “I will wait at least 5 minutes between each puff of my Flovent”
B “I will rinse my mouth after the Albuterol”
C “I should take the Flovent at the first sign of respiratory troubles”
Which outcome indicates to the nurse that the diagnosis of Ineffective Airway Clearance is resolving and Eleanor is improving?
A Pulse ox 95%
B Lungs clear to auscultation
C Tolerates walking down the hall
D Reports less pain when taking deep breaths
B Lungs clear to auscultation
Got to listen to know they are clear
Eleanor’s blood sugar is 340mg/dL. Which item most likely accounts for this blood sugar level?
A The slice of cake the night prior
B Developing Pneumonia
C Missing one dose of oral diabetic medication
D Lack of recent activity
B Developing Pneumonia
Illness/Stress - increases blood sugar
In addition to the serum fasting glucose level of 340mg/dL, Eleanor’s Hgb A1c is 9.1% and her urine is positive for glucose. She is wondering if her pre-diabetes is getting worse. Which response by the nurse is most appropriate?
A “You are at risk for developing type 2 diabetes within 10 years from the initial signs of pre diabetes.”
B “Your risk is higher given your increased weight, blood pressure and cholesterol levels.”
C “Since your blood sugar is impacted by the Pneumonia, you are still considered pre-diabetic.”
D “The laboratory test results are positive for type 2 diabetes which can be controlled with diet and exercise.”
D “The laboratory test results are positive for type 2 diabetes which can be controlled with diet and exercise.”
A1c should be below 6.5 for diabetic
Which condition is essential that the nurse should monitor given Eleanor’s rising blood glucose levels?
A HHNS
B DKA
C Somogyi
D Polyuria
A HHNS
The Unlicensed Assistive Personnel (UAP) assisted Eleanor back to bed after urinating in the bedside commode. The register nurse (RN) enters Eleanor’s room to find that the oxygen cannula lying on the bed and the pulse ox reading 82%. Eleanor mentions that the UAP took off the cannula since it did reach the commode. Which action should the RN take first?
A Locate the UAP and discuss the incident
B Restart the oxygen via cannula on the patient and check pulse ox
C Reassign care of Eleanor to an licensed practical nurse (LPN)
D Contact respiratory therapy to recheck the equipment and replace the cannula
B Restart the oxygen via cannula on the patient and check pulse ox
Later in the evening, Debbie calls the nurse into the room because she thinks her mother is getting worse. Upon assessment, the nurse notes, pulse ox is 75%, pulse is 120 weak and thready and BP is 79/56. In addition to initiating rapid response., which action should the nurse take next?
A Ask Debbie to leave the room and Initiate CPR
B Request the UAP gather the resuscitation cart and bring to the room
C Assess the vital signs and be prepared to administer a pericordial thump.
D Administer an albuterol treatment and recheck the pulse ox
B Request the UAP gather the resuscitation cart and bring to the room
Eleanor is transferred to the ICU and her vital signs are slowing improving but her a blood sugar is now 500mg/dL. What interventions can the nurse expect will be ordered for Eleanor? Select all that apply.
A Administer D51/2 NSS at 100 mL/hr
B IV regular Insulin in NSS
C Place on a cardiac monitor
D Administer bicarbonate
B IV regular Insulin in NSS
C Place on a cardiac monitor
A non-tunneled percutaneous central catheter is being placed in Frank. After placement, Frank inquires why this type of catheter was used instead of the one in his hand as with his last admission. Which response is most appropriate by the nurse?
A “This catheter allows for easier care when used at home after discharge.”
B “There is less risk of serious infections with this central catheter.”
C “Your condition requires urgent fluids and medications that the smaller catheter cannot provide”
D “Since your left hand was injured and the right hand is your dominant, we cannot place the catheter in these areas”
C “Your condition requires urgent fluids and medications that the smaller catheter cannot provide”
Frank has sustained multiple lacerations and fracture leg in which he has lost a significant amount of blood. Which IV solution can the nurse anticipate will be ordered for Frank given his condition?
A 5% LR
B D10 1/2 NS
C 0.45% NSS
D 0.9% NSS
D 0.9% NSS
Frank will need a blood transfusion He has type B+ blood and is scheduled to receive packed RBCs. Which donor blood type can the nurse anticipate? Select all that apply.
A Type B-
B Type A+
C Type O-
D Type AB+
A Type B-
C Type O-
After verifying the physician order, which action should the nurse take next in the administration of packed RBC to Frank?
A Ensure that the patient has a patent 22-guage IV catheter in place
B Verify that patient understands the rationale and risks/benefits
C Obtain the patient’s temperature and pain level
D Obtain the blood product from the blood bank and begin to prime the tubing
B Verify that patient understands the rationale and risks/benefits
Frank complains of back pain and feeling apprehensive after the start of the 1st packed RBC’s infusion. Which action is the most appropriate by the nurse?
A Stop the transfusion
B Administer D5W at KVO
C Assess the patient for pulmonary edema
D Sit with Frank to reduce his anxiety and continue to monitor
A Stop the transfusion
Franks received additional units of Packed RBC’s to replace the blood loss. Since packed RBC’s is lacking clotting factors, the nurse anticipated the physician may order which additional blood product?
A Granulocytes
B Platelets
C Fresh Frozen Plasma
D Whole Blood
C Fresh Frozen Plasma
During the last blood product infusion, The nurse notices that Frank is beginning to experiencing dyspnea, crackles in the lung bases and an increase in blood pressure. Which action should the nurse take next?
A Administer IV D5 ½ NSS at 100 ml/hr
B Administer Lasix IV push
C Administer IV Solumedrol
D Obtain Blood cultures
B Administer Lasix IV push
Frank is experiencing signs of fluid overload. Which tasks can be delegated to the UAP assisting the RN? Select all that apply.
A Administer oxygen via nasal canula B Increase the head of the bed C Ask Frank how he is feeling after receiving the Lasix D Take Frank's vital signs E Auscultate Frank's lungs
B Increase the head of the bed
D Take Frank’s vital signs
Frank is ordered antibiotics intravenously . Which action is appropriate regarding the administration of the antibiotic?
A Piggyback the antibiotic in the parenteral nutrition line
B Piggyback the antibiotic with the blood product
C Piggyback the antibiotic in the 0.9% NSS line
D Wait until one of the other three solutions are completed.
C Piggyback the antibiotic in the 0.9% NSS line
While assessing Franks Central line device, the nurse notices that the leur lock on one of the lumens is not tight placing Frank at highest risk for which condition?
A Catheter clot
B Blood loss
C Infection
D Air Embolism
D Air Embolism
