Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood? You answered this question Correctly 1. Pancakes with whipped butter, syrup, bacon, apple juice
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Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood? You answered this question Correctly 1. Pancakes with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit, whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea - ANSWER Rationale
2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection is too high in sodium and fats. 3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine. 4. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine.
Following a total hip replacement, the nurse provides discharge teaching to the client. The nurse knows that teaching was effective when the client states which activities are safe to perform? You answered this question Correctly 1. Using an abduction pillow while sleeping 2. Crossing the legs 3. Using a toilet extender 4. Showering rather than taking a bath 5. Tying shoes - ANSWER RationaleStrategies 1., 3., & 4. Correct: The client should use an abduction pillow to keep hip in proper alignment and prevent hip dislocation. A toilet extender keeps the hip in proper alignment and prevents hip dislocation. Showering rather than sitting in a tub will prevent flexion of the hip. 2. Incorrect: Crossing the leg can pop the hip out of place and prevent total healing and success with the replacement. 5. Incorrect: To tie shoes, the client has to bend over which can pop the hip out of place. The client would need to have shoes that do not require tying or have someone do it for them.
What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? You answered this question Correctly 1. Fat distribution greater in abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome. - ANSWER RationaleStrategies 1., & 5. Correct: If the body stores fat primarily in the abdomen, risk of type 2 diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with polycystic ovary syndrome have increased risk of diabetes. 2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes. The more fatty tissue, the more resistant cells become to insulin. 3. Incorrect: A type 1 diabetic will remain a type 1 diabetic. 4. Incorrect: African Americans, Hispanics, American Indians, and Asian Americans are more likely to develop type 2 diabetes than Caucasians are.
The nurse is caring for a client following spinal surgery. The client is placed on methylprednisolone. What additional drug therapy would the nurse expect to be prescribed with methylprednisolone? You answered this question Correctly 1. Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acid - ANSWER RationaleStrategies 1. Correct: A potential side effect of methylprednisolone is a peptic ulcer. The primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this side effect. 2. Incorrect: Phenytoin is an anticonvulsant. Seizures are not a side effect of methylprednisolone. 3. Incorrect: Imipramine HCI is an antidepressant which is not routinely given with methylprednisolone (Although mood changes can occur with steroid administration, anti-depressants are not routinely given). 4. Incorrect: Aminocaproic acid is given when clients are bleeding. Bleeding is not a side effect of methylprednisolone.
In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last. You answered this question CorrectlyThe Correct Order Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad. Your Selected Order Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad. - ANSWER RationaleStrategies First, apply clean gloves. Second, remove soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4's. Sixth, clean around Penrose drain using circular pattern inside to outside. Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain. Eighth, apply abdominal dressing pad.
A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer? You answered this question Incorrectly 1. Lorazepam 2. Atropine 3. Benztropine 4. Chlorpromazine - ANSWER RationaleStrategies 3. Correct: These signs and symptoms are reflective of pseudoparkinsonism, a form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic agent maybe used for treatment. This is an anticholinergic agent that may be used for extrapyramidal side effects. 1. Incorrect: This is a sedative/hypnotic or antianxiety agent. It is not used for treatment of extrapyramidal side effects. 2. Incorrect: This is an anticholinergic agent, but not one commonly used to treat pseudoparkinsonism, a form of extrapyramidal side effects. It is commonly used to treat arrhythmias and preoperatively to decrease secretions. 4. Incorrect: This is another antipsychotic medication.
A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. What interventions should the nurse initiate? You answered this question Correctly 1. Wear an N95 respirator when caring for client. 2. Restrict fluid intake to 500 mL per day. 3. Position client in semi-Fowler's position. 4. Place client in a negative pressure airflow room. 5. Do not allow visitors for 48 hours. - ANSWER RationaleStrategies 1., 3. & 4. Correct: The nurse should suspect that the client is suffering from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases, nonspecific symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease advances, cough, sputum production, and hemoptysis may appear. This client has the classic symptoms of TB and should be placed on airborne precautions. N95 respirator ensures that the nurse does not inhale the TB organism. Placing in a semi-Fowler's position reduces the work of breathing. 2. Incorrect: Unless contraindicated, 3-4 liters of fluid is needed per day to liquefy secretions. 5. Incorrect: Visitors are allowed if standard and airborne precautions are followed.
Which task should the nurse perform first? You answered this question Correctly 1. Suctioning the tracheostomy. 2. Changing a colostomy bag that is leaking. 3. Performing an admission assessment on a client. 4. Administering pain medication to a postoperative client. - ANSWER RationaleStrategies 1. Correct: The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning the tracheostomy should take priority. Remember, airway first. 2. Incorrect: The client may be uncomfortable from the colostomy bag leaking. This task can be delegated. The suctioning of the client does not have priority over airway. 3. Incorrect: Important, but not priority over airway. There is no indication from the question that the new client is in distress. The priority intervention is to maintain the airway. 4. Incorrect: Important, but it does not take priority over airway.
A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important nursing measure to include in the nursing care plan for this client? You answered this question Correctly 1. Observation and support of ventilation 2. Insertion of indwelling urinary catheter 3. Nasogastric suctioning 4. Frequent assessments of level of consciousness - ANSWER RationaleStrategies 1. Correct: Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis. 2. Incorrect: Insertion of an indwelling urinary catheter may in fact be necessary but does not prioritize higher than support of ventilation. 3. Incorrect: Nasogastric suctioning is not a need identified with Guillain-Barre syndrome. Guillain-Barre does not affect the LOC. 4. Incorrect: The client's cognitive function remains intact, and there is no data in the stem of the question that indicates otherwise; therefore, ventilation is the priority.
The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which assessment findings? You answered this question Correctly 1. Continued lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP 114/78 5. Increased thirst - ANSWER RationaleStrategies 3. & 4. Correct: Urinary output should increase with decreasing shortness of breath as hydration is corrected, and BP should be normal. 1. Incorrect: Level of consciousness (LOC) should improve with perfusion to the brain. 2. Incorrect: Heart rate should decrease if hydration is corrected. 5. Incorrect: Thirst level should be decreased if hydration is corrected.
The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum client should the nurse see first? You answered this question Correctly 1. A primipara 6 hours postpartum saturating one peripad every two hours 2. A multigravida 1 hour postpartum and reporting intense perineal pain 3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4. A multigravida 72 hours postpartum with a brownish pink lochia discharge. - ANSWER RationaleStrategies 2. Correct: Intense perineal pain is a symptom of a perineal hematoma which is a medical emergency. 1. Incorrect: Expected findings for the postpartum period are described here. This is a normal peripad saturation and does not indicate a problem. 3. Incorrect: Expected findings for the postpartum period are described here. This is the proper position of the fundus 12 hours postpartum. 4. Incorrect: Expected findings for the postpartum period are described here also. A client postpartal 72 hours should have a brownish pink lochia discharge.
The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? You answered this question Incorrectly 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions." - ANSWER RationaleStrategies 4. Correct: Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration. 1. Incorrect: The client has a right to be told the reason the drug is given. This is a nontherapeutic communication response. The nurse should not refuse the client's desire to understand their medications. 2. Incorrect: Glycopyrrolate blocks the secretions in the mouth, throat, airway and stomach. The medication does not prevent the client having a seizure. The ECT will induce a seizure, which is the desire. 3. Incorrect: This is not the drug's purpose so this would be incorrect information to give to the client.
The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue? You answered this question Correctly 1. Cumulative Index for Nursing and Allied Health Literature (CINAHL) 2. Cochrane Library 3. Health and Wellness Resource Center 4. MEDLINE - ANSWER RationaleStrategies 1. Correct: The Cumulative Index for Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing and allied health information. It is also located in other healthcare data bases. 2. Incorrect: Cochrane Library includes evidence based medicine databases. 3. Incorrect: The Health and Wellness Resource Center provides access to a variety of journal articles, magazines, and pamphlets. 4. Incorrect: MEDLINE is one of the major sources for biomedical information.
A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client? You answered this question Correctly 1. "Do you take metronidazole on an empty stomach?" 2. "Are you using any products that contain alcohol?" 3. "How long have you had these symptoms?" 4. "What other medications are you currently taking?" - ANSWER RationaleStrategies 2. Correct: Flushing, nausea and vomiting, palpitations, tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol (cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole. 1. Incorrect: Although it is preferable to take metronidazole on an empty stomach, this is not the most important question to ask at this time. 3. Incorrect: How long the client has had these symptoms is not as important as whether the client is using any alcohol containing products. 4. Incorrect: Although the nurse needs to know what other medications the client is taking, it is not as important as knowing if the client is using any alcohol containing products.
A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client? You answered this question Correctly 1. Dinner plate food guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip eating utensils 6. Button closures on clothes - ANSWER RationaleStrategies 1., 2., 3., 4., & 5. Correct: The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The dinner plate food guard will prevent food from being pushed off the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled shoe horn allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip. 6. Incorrect: It is hard for someone with hemiplegia to use buttons. Velcro fasteners are best.
The nurse is caring for a Native American client who has returned to the surgical floor following abdominal surgery. The nurse is concerned about the level of discomfort that the client is experiencing. Which comment is the nurse likely to hear upon assessment? You answered this question Correctly 1. "The pain is getting worse. I can't stand it." 2. "I need something for pain as soon as possible." 3. "I hope that the pain will go away soon." 4. "I am doing okay. The pain is not bad." - ANSWER RationaleStrategies 4. Correct: The Native American client is likely to be quiet and less expressive of pain. Native Americans tend to tolerate high levels of pain. 1. Incorrect: This comment is likely to come from the dominant American culture where pain is considered something to be treated. 2. Incorrect: Native Americans tend to tolerate high levels of pain. Abdominal surgery usually results in sensations of pain for most people. 3. Incorrect: The Native American client is likely to be very quiet about the pain being experienced.
The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should the charge nurse assign to the medical-surgical nurse? You answered this question Correctly 1. Total abdominal hysterectomy 2. Breast reduction 3. Vaginal delivery with fetal demise 4. 32 week gestation with lymphoma 5. Post-partal with HELLP syndrome - ANSWER RationaleStrategies 1., & 2. Correct: Though the clients are females, their postoperative care has similarities to the standard postoperative clients. 3. Incorrect: This client needs specialized care. This postpartum client had a vaginal delivery. A nurse who has experience caring for a client who delivered a stillborn should be assigned to this client. 4. Incorrect: This client needs specialized care. The client is at 32 weeks gestation. A nurse with obstetrical experience, should be assigned to this client. 5. Incorrect: No, the monitoring is too specific for the medical-surgical nurse. Hemolysis Elevated Liver enzymes Low Platelet count (HELLP) syndrome is a form of preeclampsia with severe liver damage. The medical-surgical nurse should not be assigned to this client.
Which nursing task would be appropriate to delegate to an LPN/VN? You answered this question Incorrectly 1. Obtain a wound culture from a client. 2. Administer regular insulin IV to a client in diabetic ketoacidosis. 3. Monitor a client's closed drainage unit (CDU) for tidaling. 4. Assess a client for tactile fremitus. - ANSWER RationaleStrategies 1. Correct: The LPN/VN has the knowledge and skill to obtain a wound culture. This is within the scope of practice for the LPN/VN. 2. Incorrect: The LPN/VN cannot administer IV medications to an unstable client. This client needs the RN for close monitoring. 3. Incorrect: The LPN/VN can monitor a chest tube and closed drainage unit, however we don't know whether the client is unstable or not. The LPN can definitely obtain a wound culture. 4. Incorrect: Assessment is the task of an RN. LPN/VN's can collect data, observe, and monitor the client.
The nurse is caring for a client taking spironolactone. Which dietary change should the nurse teach the client to make when starting treatment with this medication? You answered this question Correctly 1. Eat extra helpings of bananas. 2. Increase intake of water. 3. Avoid salt substitutes. 4. Increase intake of green leafy vegetables. - ANSWER RationaleStrategies 3. Correct: Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided. 1. Incorrect: Bananas have potassium and should be avoided to prevent hyperkalemia and life-threatening arrhythmias. 2. Incorrect: Water intake does not affect the use of spironolactone and is not the best answer to the question. 4. Incorrect: Green leafy vegetables contain vitamin K and are not contraindicated. This is a distractor to the answer that could cause the most harm to the client if not chosen.
A long-term care nurse is planning care for a newly admitted client diagnosed with Alzheimer's disease. What should the nurse include in the plan of care? You answered this question Correctly 1. Assess client's ability to perform activities of daily living. 2. Perform activities of daily living for the client. 3. Place a clock and calendar in client's room. 4. Encourage family to visit client often. 5. Have nursing staff spend time talking and listening to client. - ANSWER RationaleStrategies 1., 3., 4., & 5. Correct: All of these should be included in this client's plan of care. Assess the client's ability to perform activities of daily living and allow client to perform alone if capable. Maintain stimuli such as a clock, newspaper, calendar, and/or weather status. Encourage family to visit to maintain socialization. Plan for staff to spend some time talking and listening to the client. 2. Incorrect: Teach staff to facilitate client's independence in all activities for as long as they are able. Encouraging self-care and allowing the client to be involved in activity of daily living (ADL) is a basic right and core principle of planning client-centered care.
Which nursing intervention should receive priority after a client has returned from having had eye surgery? You answered this question Correctly 1. Administer pain medication around the clock. 2. Maintain head of bed at 35°. 3. Apply warm compresses. 4. Instruct on importance of turning, coughing, and deep breathing. - ANSWER RationaleStrategies 2. Correct: Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures, including the retina and optic nerve, with resulting loss of vision, may result. 1. Incorrect: Although pain management is important, it is not the priority here. The priority intervention of maintaining the bed at 35° is to reduce the risk of increased intraocular pressure. Unless the pain becomes out of proportion or suddenly worsens, it is an expected finding and would not be cause for alarm or require "priority" attention. 3. Incorrect: Warm and hot compresses could possibly increase intraocular pressure and cause damage to the eye structures. 4. Incorrect: Coughing will increase intraocular pressure and could result in damage to the surgical site and/or the structure within the eye. Loss of vision could result if pressure becomes too great. Coughing is a type of valsalva movement which results in an increase in the intraocular pressure.
Which electrolyte imbalance would be the nurse's priority concern in the burn client? You answered this question Incorrectly 1. Hypernatremia 2. Hyperkalemia 3. Hypoalbuminemia 4. Hypermagnesemia - ANSWER RationaleStrategies 2. Correct: Good job. When the cells lyse they release potassium, and then the serum potassium goes up. And if the kidneys stop, we are in real trouble. 1. Incorrect: Well this one does occur when the client becomes very dehydrated, but it's not as dangerous as the potassium one. 3. Incorrect: Low albumin can cause problems keeping fluid in the vascular space, but albumin is not an electrolyte. 4. Incorrect: No, the magnesium doesn't go up unless the kidneys shut down.
Which assessment findings would be of concern to the nurse who is caring for a client who has an arterial line to the radial artery? You answered this question Incorrectly 1. Capillary refill: Left hand-2 seconds; Right hand- 4 seconds. 2. Blue tinged color to finger tips of right hand. 3. Warm skin to right and left hand. 4. Left radial pulse-88/min; Right radial pulse-82/min 5. Blanching to right hand. - ANSWER RationaleStrategies 1., 2., 4., & 5. Correct: These are all signs of poor circulation to the right hand. The arterial line could be occluding circulation and needs to be removed. 3. Incorrect: This is a good sign. We would worry with cool skin/extremity.
The nurse is assigned to care for a client who has developed intestinal obstruction and has had an NG tube inserted to low suction. Blood gases are pH 7.54, pCO2 52, HCO3 35. Assessment of the client by the nurse reveals that the client is weak, shaky, and reporting tingling of the fingers. The nurse determines that this client is in which acid/base imbalance? You answered this question Correctly 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis - ANSWER RationaleStrategies 4. Correct: Metabolic alkalosis occurs from gastric losses via vomiting, NG tubes to suction, or lavage, and potent diuretics. Signs and symptoms include n/v, sensorium changes, tremors, convulsions. pH > 7.45, pCO2 > 45, HCO3 > 27. 1. Incorrect: Not a respiratory related acid/base imbalance. 2. Incorrect: Not a respiratory related acid/base imbalance. 3. Incorrect: Not acidosis. There is loss of gastric acid.
The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse? You answered this question Correctly 1. Leave the client alone and remove clients from the dayroom. 2. Call for personnel to escort the client out of the day room. 3. Restrain the client, and notify the primary healthcare provider. 4. Tell the client that there is no way that a person can fly. - ANSWER RationaleStrategies 2. Correct: The first priority is the safety of the client. If the client jumps off the table, this action may cause an injury to the client. The nurse may need extra help in case the client becomes violent. 1. Incorrect: The client may cause self injury by jumping from a table. The other clients are not in danger. 3. Incorrect: The primary healthcare provider does not need to be notified at this time. Restraints should be used as a last resort. 4. Incorrect: Presenting a client with reality is a therapeutic communication technique. The safety of the client at this time is the priority intervention.
The nurse is planning health promotion strategies for an older client on a limited, fixed income who is trying to increase activity. The client has been cleared for moderate physical activity by the primary healthcare provider. Which strategies would be appropriate for this client? You answered this question Correctly 1. Suggest that the client join a local gym for access to equipment and support. 2. Suggest contacting a neighbor so that they can walk each day in the neighborhood. 3. Encourage client to get up and walk around the house during each TV commercial break. 4. Suggest the client go to the community senior center for daily strengthening exercises. 5. Encourage client to use one-pound soup cans for muscle toning. - ANSWER RationaleStrategies 2., 3., 4. & 5. Correct: The neighborhood buddy is accessible and can be a source of emotional support too, which increases the likelihood of continuing the plan. This activity is easily accessible and burns calories during the day or evening. Senior centers usually do not cost any money for the client, and other seniors may help motivate the client to increase activity level. The use of ordinary items does not further strain a fixed income. 1. Incorrect: Joining a gym will require monthly fees, thus impacting financial resources in a negative way. Additionally, transportation to and from the gym could impact finances in a negative way.
A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect? You answered this question Correctly 1. Stop taking the medication and call the primary healthcare provider. 2. Drink plenty of water with the medication. 3. Take the medication before bedtime. 4. Take antacids when taking the medication. - ANSWER RationaleStrategies 2. Correct: Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet. 1. Incorrect: Slight heartburn does not warrant primary healthcare provider report. Extreme pain or difficulty swallowing should be reported, as should heartburn that increases despite suggestions listed above. 3. Incorrect: The client should take in the morning, thus preventing prolonged contact with the esophagus. 4. Incorrect: The absorption of the medication is decreased when it is taken with calcium, iron, and magnesium, or antacids containing calcium, aluminum, or magnesium. Thirty minutes should elapse before taking the antacid following administration of the alendronate.
A client with heart failure and pulmonary edema is given furosemide intravenously. Which assessment indicates that the furosemide has achieved the desired effect? You answered this question Incorrectly 1. Weight has decreased 2 pounds. 2. Systolic blood pressure has decreased. 3. Urinary output has increased. 4. Lungs have fewer rales on auscultation. - ANSWER RationaleStrategies 4. Correct: The goal for diuretic therapy in this client is to prevent/relieve fluid accumulation in the lungs. This answer addresses the most life-threatening sequelae with HF. The number one thing to worry about in clients with HF is pulmonary edema, because this is what can kill the client. 1. Incorrect: Weight loss is a good assessment of fluid loss or gain, especially acute weight changes. The stem of the question, however, asks which is the desired effect? The desired effect is to decrease fluid in the lungs and weight loss alone does not ensure that the lungs are clearing. 2. Incorrect: Lowered blood pressure is an expected finding, but treatment of pulmonary edema is the primary goal. 3. Incorrect: Increased urinary output is an expected finding, but treatment of pulmonary edema is the primary goal.
A 72 year old client admitted with a diagnosis of bleeding ulcers has been prescribed ranitidine 50 mg IVPB every 8 hours and omeprazole 10 mg po every morning. Based on this data what intervention should the nurse take first? Exhibit You answered this question Incorrectly 1. Stop the infusion of ranitidine. 2. Send the client for a CT scan of the head. 3. Provide oxygen at 2L/NC. 4. Notify the primary healthcare provider.
exhibit: 0900 Client alert and oriented. Denies abdominal pain, discomfort, or nausea and vomiting. Active bowel sounds in all quadrants. Abdomen soft, non-tender to palpation. Ranitidine 50 mg IVPB hung to IV line of NS at 100 mL per hour. No redness or edema noted at IV site. 0930 Client confused to place and time. Oxygen sat 95%. Lungs clear bilaterally. Denies pain. BP 118/78, HR 84/min, RR - 20/min, Temp. - 97.8 F (36.55 C). - ANSWER RationaleStrategies 1. Correct: Ranitidine can cause confusion in the elderly as well as agitation. Stop the infusion, then notify the primary healthcare provider. 2. Incorrect: Confusion is a side effect of ranitidine, so the medication should be stopped and then the healthcare provider notified. 3. Incorrect: The oxygen saturation is not low at 95%. Providing oxygen will not correct the confusion. 4. Incorrect: The primary healthcare provider should be notified after stopping the ranitidine.
An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority? You answered this question Correctly 1. Alert client who fell on the side walk. Skin warm and dry to the touch, with a three inch laceration on the right knee continuously oozing dark red liquid. 2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds. 3. A client who "passed out" but regained consciousness when feet were elevated. Awake and confused, with warm and dry skin. 4. An alert, responsive client who reports severe abdominal and shoulder pain that began two hours after eating at a local fast food restaurant. Skin is warm and dry. - ANSWER RationaleStrategies 2. Correct: This client is responding to verbal stimuli by moaning and has an open airway; but any client with an altered level of consciousness is at risk for airway obstruction. The skin assessment indicates a circulation problem. 1. Incorrect: This client demonstrates no signs of life threatening problems. The client is stable. 3. Incorrect: This client has an open airway and the skin findings do not suggest a circulation problem. This client is confused but alert, so lower priority. 4. Incorrect: The client is alert and talking so the airway is open. The client's skin findings do not suggest a circulation problem. This client has no immediate life-threatening problems.
The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment goals have not been met? You answered this question Correctly 1. Diuresis 2. Dyspnea on exertion 3. Persistent cough 4. Warm, dry skin 5. Heart rate irregular at 118/min 6. Alert and oriented - ANSWER RationaleStrategies 2., 3. & 5. Correct: When the cardiac output decreases, renal perfusion decreases, which leads to decreased urine output and fluid retention. This leads to difficulty breathing. Tachycardiac and rhythm irregularity are signs of fluid volume excess (FVE) and decreased output. Persistent cough, wheezing, and pink blood tinged sputum are all signs that the client is still sick. 1. Incorrect: No, that is what we want, but there is not enough blood to the kidneys, and the renin angiotensin (aldosterone) mechanism has activated. 4. Incorrect: Indication of improved cardiac output. 6. Incorrect: Indication of improved cardiac output.
Family members have been asking triage nurses if lov
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