NURSING 2230 Advanced Care management Exam New Exam update(Graded A)

Advanced Care management Exam Chapter 08: Concepts of Emergency and Trauma Nursing 1. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when ...

Advanced Care management Exam Chapter 08: Concepts of Emergency and Trauma Nursing 1. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this clients care? Emergency medicine physician Case manager Forensic nurse examiner Psychiatric crisis nurse 2. The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. Which action should the nurse take first? Request that the clients spouse sit in the waiting room. Ask the spouse if he wishes to be present during the resuscitation. Suggest that the spouse begin to pray for the client. Refer the clients spouse to the hospitals crisis team. 3. An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first? A 30-year-old distraught mother holding her crying child A 65-year-old conscious male with a head laceration A 26-year-old male who has pale, cool, clammy skin A 48-year-old with a simple fracture of the lower leg 4. While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first? Apply oxygen via nasal cannula. Administer intravenous 0.9% saline solution. Transfer the client to a negative-pressure room. Obtain a sputum culture and sensitivity. 5. A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? A 22-year-old with a painful and swollen right wrist A 45-year-old reporting chest pain and diaphoresis A 60-year-old reporting difficulty swallowing and nausea An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F 6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? Level I Located within remote areas and provides advanced life support within resource capabilities Level II Located within community hospitals and provides care to most injured clients Level III Located in rural communities and provides only basic care to clients Level IV Located in large teaching hospitals and provides a full continuum of trauma care for all clients 7. Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? Assess that the client is breathing adequately. Insert a large-bore intravenous line. Place the client on a cardiac monitor. Assess for the best neurologic response. 8. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support? Contact the on-call orthopedic surgeon. Don personal protective equipment. Notify the Rapid Response Team. Obtain a complete history from the paramedic. 9. A nurse is triaging clients in the emergency department. Which client should be considered urgent? A 20-year-old female with a chest stab wound and tachycardia A 45-year-old homeless man with a skin rash and sore throat A 75-year-old female with a cough and a temperature of 102 F A 50-year-old male with new-onset confusion and slurred speech 10. An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? Remove all tubes and wires in preparation for the medical examiner. Limit the number of visitors to minimize the family’s trauma. Consult the bereavement committee to follow up with the grieving family. Communicate the clients death to the family in a simple and concrete manner. 11. An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide? Communicate client needs and restrictions to support staff. Prescribe low-cost antibiotics to treat community-acquired infection. Provide referrals to subsidized community-based health clinics. Offer counseling for substance abuse and mental health disorders. 12. An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust? Speak in a quiet and monotone voice. Avoid eye contact with the client. Listen to the clients concerns and needs. Ask security to store the clients belongings. 13. A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent? A 44-year-old with chest pain and diaphoresis A 50-year-old with chest trauma and absent breath sounds A 62-year-old with a simple fracture of the left arm A 79-year-old with a temperature of 104 F MULTIPLE RESPONSE 1.A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.) Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. Use two identifiers before each intervention and before mediation administration. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. Search the belongings of clients with altered mental status to gain essential medical information. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections. 2. An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) Mechanism of injury Diagnostic test results Immunizations List of home medications Isolation precautions 3. An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (Select all that apply.) Foley catheterization Needle decompression Initiating IV fluids Splinting open fractures Endotracheal intubation Removing wet clothing Laceration repair 4. The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.) Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis Forensic nurse examiner Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources Triage nurse Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs Emergency medical technician Obtains client histories, collects evidence, and offers counseling and follow- up care for victims of rape, child abuse, and domestic violence Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration 5. A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? (Select all that apply.) Provide medical supplies to the family. Consult a home health agency. Encourage participation in community activities. Screen for depression and suicide. Complete a functional assessment. Chapter 09: Care of Patients with Common Environmental Emergencies 1.On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1 F (40.1 C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? Encourage the client to drink cool water or sports drinks. Start an intravenous line and infuse 0.9% saline solution. Administer acetaminophen (Tylenol) 650 mg orally. Encourage rest and re-assess in 15 minutes. 2. While at a public park, a nurse encounters a person immediately after a bee sting. The persons lips are swollen, and wheezes are audible. Which action should the nurse take first? Elevate the site and notify the persons next of kin. Remove the stinger with tweezers and encourage rest. Administer diphenhydramine (Benadryl) and apply ice. Administer an EpiPen from the first aid kit and call 911. 3. A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first? Reposition the client into a prone position. Administer warmed intravenous fluids to the client. Wrap the clients extremities in warm blankets. Initiate extracorporeal rewarming via hemodialysis. 4. An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement? Administer dexamethasone (Decadron). Complete a minimental state examination. Prepare the client for computed tomography of the brain. Request a psychiatric consult. 5. An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first? Electrocardiogram (ECG) Wound inspection Creatinine kinase Computed tomography of head 6. A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? I can go swimming all by myself because I am a certified lifeguard. I cannot leave my toddler alone in the bathtub for even a minute. I will appoint one adult to supervise the pool at all times during a party. I will make sure that there is a phone near my pool in case of an emergency. 7. A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment? Administer intravenous morphine. Wrap the limb with a compression dressing. Massage the frostbitten areas. Assess the limb for compartment syndrome. 8. A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first? Unilateral peripheral swelling Clotting times Cardiopulmonary status Electrocardiogram rhythm 9. A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate? The facilitys neurologist The poison control center The physical therapy department A herpetologist (snake specialist) 10. While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first? Deliver rescue breaths. Wrap the client in dry blankets. Assess for signs of bleeding. Check for a carotid pulse. 11. A nurse assesses a client admitted with a brown recluse spider bite. Which priority assessment should the nurse perform to identify complications of this bite? Ask the client about pruritus at the bite site. Inspect the bite site for a bluish purple vesicle. Assess the extremity for redness and swelling. Monitor the clients temperature every 4 hours. 12. A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication? Assess temperature and for signs of fever. Check the clients creatinine kinase level. Ask about allergies to pineapple or papaya. Inspect the skin for signs of urticaria (hives). 13. A provider prescribes diazepam (Valium) to a client who was bitten by a black widow spider. The client asks, What is this medication for? How should the nurse respond? This medication is an antivenom for this type of bite. It will relieve your muscle rigidity and spasms. It prevents respiratory difficulty from excessive secretions. This medication will prevent respiratory failure. 14. After teaching a client how to prevent altitude-related illnesses, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching? If my climbing partner can’t think straight, we should descend to a lower altitude. I will ask my provider about medications to help prevent acute mountain sickness. My partner and I will plan to sleep at a higher elevation to acclimate more quickly. I will drink plenty of fluids to stay hydrated while on the mountain. MULTIPLE RESPONSE 1.A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) Wear synthetic clothing instead of cotton to keep your skin dry. Drink plenty of fluids. Brandy can be used to keep your body warm. Remove your hat when exercising to prevent the loss of heat. Wear sunglasses to protect skin and eyes from harmful rays. Know your physical limits. Come in out of the cold when limits are reached. 2. A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this clients teaching? (Select all that apply.) Consult an exterminator to control bugs in and around your home. Do not swat at insects or wasps. Wear sandals whenever you go outside. Keep your prescribed epinephrine auto-injector in a bedside drawer. Use screens in your windows and doors to prevent flying insects from entering. 3. A nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) Seek shelter inside a building or vehicle. Hide under a tall tree. Do not take a bath or shower. Turn off the television. Remove all body piercings. Put down golf clubs or gardening tools. 4. An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at higher risk for heat-related illnesses? (Select all that apply.) Homeless individuals Illicit drug users White people Hockey players Older adults 5. An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this client’s plan of care? (Select all that apply.) Administer oxygen via mask or nasal cannula. Administer ibuprofen, an antipyretic medication. Apply cooling techniques until core body temperature is less than 101 F. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. Obtain baseline serum electrolytes and cardiac enzymes. Chapter 10: Concepts of Emergency and Disaster Preparedness 1. A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? Provide water and healthy snacks for energy throughout the event. Schedule 16-hour shifts to allow for greater rest between shifts. Encourage counseling upon deactivation of the emergency response plan. Assign staff to different roles and units within the medical facility. 2. A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? Do you need something for pain right now? Please stop yelling. I brought dinner as soon as I could. I suggest that you get control of yourself. You seem upset. I have time to talk if youd like. 3. A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? Dislocated right hip and an open fracture of the right lower leg Large contusion to the forehead and a bloody nose Closed fracture of the right clavicle and arm numbness Multiple fractured ribs and shortness of breath 4. An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims. 5. The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? You are free to express your feelings; whatever is said here stays here. Let’s evaluate what went wrong and develop policies for future incidents. This session is only for nursing and medical staff, not for ancillary personnel. Let’s pass around the written policy compliance form for everyone. 6. A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, I can’t believe that my wife is gone and I am left to raise my children all by myself. How should the nurse respond? a. Please accept my sympathies for your loss. b. I can call the hospital chaplain if you wish. c. You sound anxious about being a single parent. d. At least your children still have you in their lives. 7. A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, Why are the individuals with black tags not receiving any care? How should the nurse respond? To do the greatest good for the greatest number of people, it is necessary to sacrifice some. Not everyone will survive a disaster, so it is best to identify those people early and move on. In a disaster, extensive resources are not used for one person at the expense of many others. With black tags, volunteers can identify those who are dying and can give them comfort care. 8. A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurses interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team 9. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns? Deployed DMAT providers are federal employees, so their licenses are good in all 50 states. The government has a program for quick licensure activation wherever you are deployed. During a time of crisis, licensure issues would not be the governments priority concern. If you are deployed, you will be issued a temporary license in the state in which you are working. 10. After a hospital’s emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. Which question should the nursing supervisor ask at this time? Are you sure no more victims are coming into the ED? Do all areas of the hospital have the supplies and personnel they need? Have all ED staff had the chance to eat and rest recently? Does the Chief Medical Officer agree this disaster is under control? 11. A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? Provide a calm location for the family to cope and discuss needs. Call the hospital chaplain to stay with the family and pray for the deceased. Do not allow visiting of the victims until the bodies are prepared. Provide privacy for law enforcement to interview the family. 12. An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? Organize a pizza party for each shift. Remind the staff of the facility’s sick-leave policy. Arrange for critical incident stress debriefing. Talk individually with staff members. MULTIPLE RESPONSE 1. Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) Partial-thickness burns covering both legs Open fractures of both legs with absent pedal pulses Neck injury and numbness of both legs Small pieces of shrapnel embedded in both eyes Head injury and difficult to arouse Bruising and pain in the right lower abdomen 2. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) A 35-year-old female with severe chest pain: red tag A 42-year-old male with full-thickness body burns: green tag A 55-year-old female with a scalp laceration: black tag A 60-year-old male with an open fracture with distal pulses: yellow tag An 88-year-old male with shortness of breath and chest bruises: green tag 3. A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) Older adult in the medical decision unit for evaluation of chest pain Client who had open reduction and internal fixation of a femur fracture 3 days ago Client admitted last night with community-acquired pneumonia Infant who has a fever of unknown origin Client on the medical unit for wound care 4. A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) Paramedic Decides the number, acuity, and resource needs of clients Hospital incident commander Assumes overall leadership for implementing the emergency plan Public information officer Provides advanced life support during transportation to the hospital Triage officer Rapidly evaluates each client to determine priorities for treatment Medical command physician Serves as a liaison between the health care facility and the media Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances 1. A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration? A 36-year-old who is prescribed long-term steroid therapy A 55-year-old receiving hypertonic intravenous fluids A 76-year-old who is cognitively impaired An 83-year-old with congestive heart failure 2. A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? Measure intake and output every 4 hours. Apply oxygen by mask or nasal cannula. Increase the IV flow rate to 250 mL/hr. Place the client in a high-Fowlers position. 3. After teaching a client who is being treated for dehydration, a nurse assesses the clients understanding. Which statement indicates the client correctly understood the teaching? I must drink a quart of water or other liquid each day. I will weigh myself each morning before I eat or drink. I will use a salt substitute when making and eating my meals. I will not drink liquids after 6 PM so I wont have to get up at night. 4. A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg b. Daily weight increase from 55 kg to 57 kg c. Heart rate decrease from 100 beats/min to 82 beats/min d. Respiratory rate increase from 12 breaths/min to 15 breaths/min 5. A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss? Client taking furosemide (Lasix) Anxious client who has tachypnea Client who is on fluid restrictions Client who is constipated with abdominal pain 6. A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? Increased respiratory rate from 12 breaths/min to 22 breaths/min Decreased skin turgor on the clients posterior hand and forehead Increased urine specific gravity from 1.012 to 1.030 g/mL Decreased orthostatic light-headedness and dizziness 7. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients understanding. Which food choice for lunch indicates the client correctly understood the teaching? Slices of smoked ham with potato salad Bowl of tomato soup with a grilled cheese sandwich Salami and cheese on whole wheat crackers Grilled chicken breast with glazed carrots 8. A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia? A 34-year-old on NPO status who is receiving intravenous D5W A 50-year-old with an infection who is prescribed a sulfonamide antibiotic A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin) A 73-year-old with tachycardia who is receiving digoxin (Lanoxin) 9. A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this clients teaching? Weigh yourself every morning and every night. Check your radial pulse twice a day. Read food labels to determine sodium content. Bake or grill the meat rather than frying it. 10. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first? Depth of respirations Bowel sounds Grip strength Electrocardiography 11. A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first? Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth. Provide a heart healthy, low-potassium diet. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. Prepare the client for hemodialysis treatment. 12. A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? Client with pancreatitis who has continuous nasogastric suctioning Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor Client in a motor vehicle crash who is receiving 6 units of packed red blood cells Client with uncontrolled diabetes and a serum pH level of 7.33 13. A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first? Assess the clients respiratory rate, rhythm, and depth. Measure the clients pulse and blood pressure. Document findings and monitor the client. Call the health care provider. 14. After teaching a client to increase dietary potassium intake, a nurse assesses the clients understanding. Which dietary meal selection indicates the client correctly understands the teaching? Toasted English muffin with butter and blueberry jam, and tea with sugar Two scrambled eggs, a slice of white toast, and a half cup of strawberries Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee 15. A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I cant because of my high potassium level. How should the nurse respond? Potatoes and avocados can be substituted for fruit. If you cook the fruit, the amount of potassium will be lower. Berries, cherries, apples, and peaches are low in potassium. You are correct. Fruit is very high in potassium. 16. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first? Encourage oral fluid intake. Connect the client to a cardiac monitor. Assess urinary output. Administer oral calcitonin (Calcimar). 17. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital? Ask family members to speak quietly to keep the client calm. Assess urine color, amount, and specific gravity each day. Encourage the client to drink at least 1 liter of fluids each shift. Dangle the client on the bedside before ambulating. MULTIPLE RESPONSE 1. A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.) Increased pulse rate Distended neck veins Decreased blood pressure Warm and pink skin Skeletal muscle weakness ANS: A, B, E Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness. 2. A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.) A 36-year-old who is malnourished A 42-year-old with uncontrolled diabetes A 50-year-old with hyperparathyroidism A 58-year-old with chronic renal failure A 76-year-old who is prescribed antacids 3. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.) Urine output of 25 mL/hr Serum potassium level of 5.4 mEq/L Urine specific gravity of 1.02 g/mL Serum sodium level of 128 mEq/L Blood osmolality of 250 mOsm/L 4. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.) Electrocardiogram changes Slow, shallow respirations Orthostatic hypotension Paralytic ileus Skeletal muscle weakness 5. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) Hypokalemia Flaccid paralysis with respiratory depression Hyperphosphatemia Paresthesia with sensations of tingling and numbness Hyponatremia Decreased level of consciousness Hypercalcemia Positive Trousseaus and Chvosteks signs Hypomagnesemia Bradycardia, peripheral vasodilation, and hypotension 6. After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all that apply.) Respiratory rate of 8 breaths/min Absent deep tendon reflexes Strong productive cough Active bowel sounds U waves present on the electrocardiogram (ECG) 7. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.) Encourage oral fluid intake of at least 2 L/day. Use a draw sheet to reposition the client in bed. Strain all urine output and assess for urinary stones. Provide nonslip footwear for the client to use when out of bed. Rotate the client from side to side every 2 hours. Chapter 12: Assessment and Care of Patients with Acid-Base Imbalances 1. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism? Increased rate and depth of respirations Increased urinary output Increased thirst and hunger Increased release of acids from the kidneys 2. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first? Cardiac rate and rhythm Skin and mucous membranes Musculoskeletal strength Level of orientation 3. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis 4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? Monitor daily hemoglobin and hematocrit values. Administer furosemide (Lasix) intravenously. Encourage the client to take deep breaths. Teach the client fall prevention measures. 5. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess? Agitation Kussmaul respirations Seizures Positive Chvosteks sign 6. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next? Assess clients rate, rhythm, and depth of respiration. Measure the clients pulse and blood pressure. Document the findings and continue to monitor. Notify the physician as soon as possible. 7. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values? Diabetic ketoacidosis in a person with emphysema Bronchial obstruction related to aspiration of a hot dog Anxiety-induced hyperventilation in an adolescent Diarrhea for 36 hours in an older, frail woman 8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first? Apply oxygen by mask or nasal cannula. Apply a paper bag over the clients nose and mouth. Administer 50 mL of sodium bicarbonate intravenously. Administer 50 mL of 20% glucose and 20 units of regular insulin. 9. After teaching a client who was malnourished and is being discharged, a nurse assesses the clients understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis? I will drink at least three glasses of milk each day. I will eat three well-balanced meals and a snack daily. I will not take pain medication and antihistamines together. I will avoid salting my food when cooking or during meals. 10. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results? Diarrhea and vomiting for 36 hours Anxiety-induced hyperventilation Chronic obstructive pulmonary disease (COPD) Diabetic ketoacidosis and emphysema 11. After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching? I dont drink milk because it gives me gas and diarrhea. I have been taking digoxin every day for the last 15 years. I take sodium bicarbonate after every meal to prevent heartburn. In hot weather, I sweat so much that I drink six glasses of water each day. 12. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive? Furosemide (Lasix) 40 mg intravenous push Sodium bicarbonate 100 mEq diluted in 1 L of D5W Mechanical ventilation Indwelling urinary catheter 13. A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first? Assess the airway. Administer prescribed bronchodilators. Provide oxygen. Administer prescribed mucolytics. 14. A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care? Do you take any over-the-counter medications? You appear anxious. What is causing your distress? Do you have a history of anxiety attacks? You are breathing fast. Is this causing you to feel light-headed? 15. A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via nasal cannula. The following clinical data are available: Arterial Blood Gases Vital Signs pH = 7.28 Pulse rate = 96 beats/min PaO2 = 85 mm Hg Blood pressure = 135/45 PaCO2 = 55 mm Hg Respiratory rate = 6 breaths/min HCO3 = 26 mEq/L O2 saturation = 88% Which action should the nurse take first? Notify the Rapid Response Team and provide ventilation support. Change the nasal cannula to a mask and reassess in 10 minutes. Place the client in Fowlers position if he or she is able to tolerate it. Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess. MULTIPLE RESPONSE 1. A nurse is planning interventions that regulate acid-base balance to ensure the pH of a clients blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid- base imbalance? (Select all that apply.) Reduction in the function of hormones Fluid and electrolyte imbalances Increase in the function of selected enzymes Excitable cardiac muscle membranes Increase in the effectiveness of many drugs 2. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L. For which clinical manifestations should the nurse assess? (Select all that apply.) Reduced deep tendon reflexes Drowsiness Increased respiratory rate Decreased urinary output Positive Trousseaus sign 3. A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.) Metabolic alkalosis Young adult who is prescribed intravenous morphine sulfate for pain Metabolic acidosis Older adult who is following a carbohydrate-free diet Respiratory alkalosis Client on mechanical ventilation at a rate of 28 breaths/min Respiratory acidosis Postoperative client who received 6 units of packed red blood cells Metabolic alkalosis Older client prescribed antacids for gastroesophageal reflux disease 4. A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an acid-base imbalance should the nurse assess? (Select all that apply.) Positive Chvosteks sign Elevated blood pressure Bradycardia Increased muscle strength Anxiety and irritability 5. A nurse is planning care for a client who is anxious and irritable. The clients arterial blood gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L. Which questions should the nurse ask the client and spouse when developing the plan of care? (Select all that apply.) Are you taking any antacid medications? Is your spouses current behavior typical? Do you drink any alcoholic beverages? Have you been experiencing any vomiting? Are you experiencing any shortness of breath? Chapter 13: Infusion Therapy 1.A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? Begin the prescribed infusion via the new access. Ensure an x-ray is completed to confirm placement. Check medication calculations with a second RN. Make sure the solution is appropriate for a central line. 2.A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first? Amount of pressure in fluid container Date of catheter tubing change Percent of heparin in infusion container Presence of an ulnar pulse 3.A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching? Avoid carrying your grandchild with the arm that has the central catheter. Be sure to place the arm with the central catheter in a sling during the day. Flush the peripherally inserted central catheter line with normal saline daily. You can use the arm with the central catheter for most activities of daily living. 4.A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next? Administer a sublingual nitroglycerin tablet. Prepare to assist with chest tube insertion. Place a sterile dressing over the IV site. Re-position the client into the Trendelenburg position. 5.A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? Redness at the catheter insertion site Report of headache and stiff neck Temperature of 100.1 F (37.8 C) Pain rating of 8 on a scale of 0 to 10 6.A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? The catheter has been in place for 20 hours. The client has poor vascular access in the upper extremities. The catheter is placed in the proximal tibia. The clients left lower extremity is cool to the touch. 7.A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? The initial site dressing is 3 days old. The PICC was inserted 4 weeks ago. A securement device is absent. Upper extremity swelling is noted. 8.A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? Apply cold compresses to the IV site. Elevate the extremity on a pillow. Flush the catheter with normal saline. Stop the infusion of intravenous fluids. 9.While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding? Grade 3 phlebitis at IV site Infection at IV site Thrombosed area at IV site Infiltration at IV site 10.A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first? Check for kinking of the catheter. Flush the catheter with a thrombolytic enzyme. Get a new infusion pump. Remove the IV catheter. 11.A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure? Lower the extremity below the level of the heart. Apply warm compresses to the extremity. Tap the skin lightly and avoid slapping. Place a washcloth between the skin and tourniquet. 12.A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device? Provide a bed bath instead of letting the client take a shower. Use sterile technique when changing the dressing. Disconnect the intravenous fluid tubing prior to the clients bath. Use a plastic bag to cover the extremity with the device. 13.A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching? You will need to wear a sling on your arm while the device is in place. There is no risk of infection because sterile technique will be used during insertion. Ask all providers to vigorously clean the connections prior to accessing the device. You will not be able to take a bath with this vascular access device. 14.A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain? Administer topical lidocaine to the site. Place warm compresses on the site. Administer prescribed oral pain medication. Massage the site with scented oils. 15.A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client? Allergic reaction Bowel obstruction Catheter lumen occlusion Infection 16.A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications? Initiate a dedicated team to insert access devices. Require additional education for all nurses. Limit the use of peripheral venous access devices. Perform quality control testing on skin preparation products. 17.A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below should the nurse use to draw up and administer the heparin? a. 1.5 mL  b. 3 mL  c. 5 mL  d. 10 mL ANS: D 18.A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and free from manifestations of infiltration, irritation, and infection. Sue Franks, RN January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified and updated on client status. New orders received for intravenous antibiotics. Sue Franks, RN January 13: Client alert and oriented. Sacral wound dressing changed. Sue Franks, RN January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. Dr. Smith Based on the information provided, which action should the nurse take? Notify the health care provider. Administer the prescribed medication. Discontinue the PICC. Switch the medication to the oral route. MULTIPLE RESPONSE 1.A registered nurse (RN) delegates client care to an experienced licensed practical nurse (LPN). Which standards should guide the RN when delegating aspects of IV therapy to the LPN? (Select all that apply.) State Nurse Practice Act The facilitys Policies and Procedures manual The LPNs level of education and experience The Joint Commissions goals and criterion e. Client needs and prescribed orders 2.A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.) Phlebitis Pneumothorax Thrombophlebitis Excessive bleeding Extravasation 3.A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) Unique facility identifier Lot number related to the donor Name of the client receiving blood ABO group and Rh type of the donor Blood type of the client receiving blood 4.A nurse assists with the insertion of a central vascular access device. Which actions should the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.) Include a review for the need of the device each day in the clients plan of care. Remind the provider to perform hand hygiene prior to starting the procedure. Cleanse the preferred site with alcohol and let it dry completely before insertion. Ask everyone in the room to wear a surgical mask during the procedure. Plan to complete a sterile dressing change on the device every day. SHORT ANSWER 1.A client is prescribed 1000 mL of normal saline to infuse over 24 hours. At what rate should the nurse set the pump (mL/hr) to deliver this infusion? (Record your answer using a whole number.) ____ mL/hr 2.A client is prescribed 250 mL of normal saline to infuse over 4 hours via gravity. The facility supplies gravity tubing with a drip factor of 15 drops/mL. At what rate (drops/min) should the nurse set the infusion to deliver? (Record your answer using a whole number.) _____ drops/min