NURS1460 complete study guide 2020 | NURS 1460 complete study guide 2020 - El Centro College

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NURS1460 complete study guide 2020 | NURS 1460 complete study guide 2020 - El Centro College EXAM#1 The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. T ... he nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation? Client with itching Client with flushing Client with pruritus Client with wheezing The nurse observes that a client with sickle cell anemia and on a blood transfusion regimen has cardiac dysrhythmias due to iron overdose toxicity. Which medication is most beneficial to this client? Deferasirox Deferiprone Deferoxamine Ferrous gluconate Which type of immune preparation, made from donated blood, contains antibodies that provide passive immunity? Toxoid Killed vaccine Live attenuated vaccine Specific immune globin Arrange the sequence of steps required to stimulate antibody-mediated immunity in its correct sequence. 1. Exposure of antigen 2. Antigen recognition 3. Sensitization 4. Antibody production 5. Antigen eliminationWhich leukocytes should the nurse include when teaching about antibody-mediated immunity? Select all that apply. Monocyte Memory Cell Helper T cell B-lymphocyte Cytotoxic T cell Which conditions result in humoral immunity? Select all that apply. Tuberculosis Atopic diseases Bacterial infections Anaphylactic shock Contact dermatitis Which type of immunity will clients acquire through immunizations with live or killed vaccines? Natural active immunity Artificial active immunity Natural passive immunity Artificial passive immunity Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity? Urticaria A drug reactionAtopic dermatitis Allergic contact dermatitis A nurse is caring for a client with pruritic lesions from an IgE-mediated hypersensitivity reaction. Which mediator of injury is involved? Histamine Cytokine Neutrophil Macrophage A client is admitted with systemic lupus erythematosus (SLE). The laboratory report shows the presence of neutrophils and monocytes as mediators of injury. Which type of hypersensitivity reaction most likely occurred in the client? Type I Type II Type III Type IV A client presents with sneezing; lacrimation; swelling with an airway obstruction; and pruritus around the eyes, nose, throat, and mouth. The nurse interprets these findings as a Type I hypersensitivity reaction. Which disease might have occurred in the client? Angioedema Allergic rhinitis Contact dermatitis Good pasture syndromeA client has received ABO-incompatible blood from a donor by mistake. Which type of hypersensitivity reaction will occur in the client? Type I Type II Type III Type IV The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation? Client with itching Client with flushing Client with pruritus Client with wheezing While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation? Report to the primary healthcare provider Stop the blood transfusion immediately Recheck identifying tags and numbers on the client Maintain a patent intravenous (IV) line with saline solution The nurse is preparing a blood transfusion for a client with renal failure. Why does anemia often complicate renal failure? Increase in blood pressure Decrease in erythropoietin Increase in serum phosphate levels Decrease in serum sodium concentrationAn elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? The nurse should wait for the court’s order to give blood to the client. The nurse should proceed with the transfusion in order to save the client’s life. The nurse should inform the primary healthcare provider and not give blood to the client. The nurse should explain to the family member that the client needs this transfusion. Ten minutes after the initiation of a blood transfusion, a client reports lumbar pain. What is the next nursing action? Obtain the vital signs. Stop the transfusion. Assess the pain further Increase the flow of normal saline. While receiving a blood transfusion, a client develops acute dyspnea, generalized urticaria, a heart rate of 128, and a blood pressure of 70/38. What type of reaction does the nurse conclude that the client probably is experiencing? Panic Hemolytic Anaphylactic Pyrogenic During administration of a whole blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize ​the following nursing actions 1. Elevate the head of the bed to 45 degrees 2. Apply oxygen via nasal cannula 3. Reduce the flow rate of the transfusion 4. Administer furosemide (Lasix) per provider prescription 5. Document findings in the client recordA prescribed blood transfusion of packed red blood cells was started five minutes ago. Now the client is complaining of chest pain, flank pain, difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 100.8° F (38.2° C), and the client seems less alert. What should the nurse suspect? Urticarial reaction Hemolytic reaction Circulatory overload Anaphylactic reaction A client who is about to have a blood transfusion asks the nurse, "Which type of hepatitis is most frequently transmitted thru food?" The nurse should respond, "The type of hepatitis associated with food is hepatitis: A B C D Th e nurse is teaching a client who is prescribed iron supplements for iron-deficiency anemia. Which food should the nurse encourage the patient to take to enhance absorption of iron? Cereal Spinach Whole milk Orange Juice A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention Inability of the renal tubules to reabsorb water to dilute the acid contents of blood Impaired glomerular filtration, causing retention of sodium and metabolic waste productsOn admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? Muscle twitching Mental instability Deep and rapid respirations Tachycardia and cardiac dysrhythmias Which blood gas result should the nurse expect a client with diabetic ketoacidosis to exhibit? pH 7.35, CO2 47 mm Hg, HCO3- 24 mEq/L (24 mmol/L) pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L (20 mmol/L) pH 7.46, CO2 30 mm Hg, HCO3- 24 mEq/L (24 mmol/L) pH 7.50, CO2 50 mm Hg, HCO3- 22 mEq/L (22 mmol/L) A client on diuretic therapy developed metabolic alkalosis. What does the nurse consider to be the priority nursing care while correcting alkalosis? Montitoring electrolytes Preventing falls Giving antiemetics Adjusting diuretic therapy A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? An elevated pH, elevated PCO2 A decreased pH, elevated PCO2 An elevated pH, decreased PCO2 A decreased pH, decreased PCO2A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? Chronic pain Risk for injury Electrolyte imbalance Inadequate gas exchange Which medication requires the nurse to monitor the client for signs of hyperkalemia? Furosemide Spironolactone Metolazone Hydrochlorothiazide Which hormone synthesis does the nurse state is inhibited by hypokalemia? Aldosterone Norepinehrine Somatostatin Androstenedione Findings on a client's cardiac monitor indicate a need for an intravenous infusion that contains potassium for a client with hypokalemia. The nurse concludes that what finding on the monitor indicated a need for potassium replacement? Elevation of the ST segment Lowering of the T wave Shortening of the QRS complex Increased deflection of the Q waveA client is admitted to the hospital with a diagnosis of dehydration and hypokalemia. Which statement/intervention is most accurate when administering potassium chloride intravenously to this client with hypokalemia? Rapid infusion of potassium prevents burning at the IV site. Oliguria is an indication for withholding intravenous (IV) potassium Clients with severe deficits should be given IV push potassium. Average IV dosage of potassium should not exceed 60 mEq in one hour. A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings? Furosemide (Lasix) Propranolol (Inderal) Digoxin (Lanoxin) Spironolactone (Aldactone) Which assessment finding in a client signifies a mild form of hypocalcemia? Seizures Hand spasms Numbness around the mouth Severe muscle cramps A registered nurse is teaching a student nurse regarding the interventions for a client with human immunodeficiency virus (HIV) infection. Which statement by the student nurse indicates the nurse needs to follow up? “I will ask the client to avoid exposure to new infectious agents." "I will ask the client about intake of vitamins and micronutrients." "I will ask the client to avoid involvement in community activities." "I will ask the client if he or she is up to date with recommended vaccines."The laboratory report of a client reveals the presence of 350 cells/mm3 (350 cells/uL) of CD4+ T-cell count. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client? STAGE 1 STAGE 2 STAGE 3 STAGE 4 The nurse is taking care of four clients with human immunodeficiency virus (HIV) infections. Which client’s condition should the nurse report to the primary healthcare provider within 24 hours after observation? Client A Client B Client C Client DA nurse is educating a client with human immunodeficiency virus (HIV) about self-management. Which suggestion by the nurse benefits the client? "Limit your daily fluid intake "Rinse your mouth with normal saline after every meal." "Eat more roughage." "Maintain a 4-to-5-hour gap in between meals." The registered nurse instructs the nursing student about caring for a hospitalized client with a human immunodeficiency (HIV) infection. Which action made by the nursing student indicates effective learning? Keeping fresh flowers in the client’s room Encouraging the client to eat fresh fruits and vegetables Keeping a dedicated disposable glove box in the client’s room Changing gauze-containing wound dressings every other day Which is the most common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? Pneumocystis jiroveci pneumonia Oropharyngeal candidiasis Cryptosporidiosis Toxoplasmosis encephalitis A circulating nurse in the operating room learns of being HIV positive. What should this nurse do regarding participation in exposure-prone procedures? Adhere to standard precautions at all times Avoid handling equipment used in direct client care Discuss procedures that can be performed with a review panelDisinfect all equipment used for non-invasive procedures A client comes to the clinic for a physical and asks to be tested for acquired immune deficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for human immunodeficiency virus (HIV)? CD4 T cell count Western blot test Enzyme-linked immunosorbent assay (ELISA) Polymerase chain reaction test The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89 mm Hg, PCO2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? Respiratory alkalosis Normal acid-base balance Poor oxygen perfusion Compensated metabolic acidosis When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is what? Potassium Sodium Calcium Calcitonin The nurse is preparing to insert an intravenous catheter in a thin, emaciated patient who is scheduled to begin intravenous fluid therapy. Which interventions should the nurse follow to provide high-quality care? Select all that apply. Insert an 18-guage IV catheter Change the intravenous line every 7 days Flush the intravenous line with normal saline Insert the intravenous catheter in the patient’s femurStop the insertion procedure when there is a break in technique A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? Skin turgor Intake and output results Client’s report about fluid intake Blood lab results A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention? Get an additional IV infusion pump for the medication Check the compatibility of the medication and the continuous IV solution Disconnect the continuous IV solution while giving the piggyback medication Flush the client’s access device to ensure patency A client admitted with dehydration is prescribed a bolus infusion of 0.9% sodium chloride(normal saline) 500 ml. IV for 1 hour. An infusion device is available that counts the number of drops per minute delivered. The IV tubing has a drop factor of 10 drops/ml. If the bolus is to infuse on time, the nurse should set the drip rate to ---------- drops per minute. Record your answer, rounding to the nearest whole number. 83 A client presents to emergency department following a motor cycle accident. The client is in hypovolemic shock. The healthcare provider has ordered plasma expansion. What blood product should the nurse anticipate that the client will receive? Packed RBCs Platelets Albumin CryoprecipitateA nurse has received a report on a client being admitted with anemia who requires a blood transfusion. The nurse will anticipate which assessment findings? Select all that apply. Tachycardia Hypertension Headache Diaphoresis Bounding Peripheral pulses QUIZ#1 What is a nursing priority to prevent complications in clients with respiratory acidosis? Assessing the nail beds Listening to breath sounds Monitoring breathing status Checking muscle contractions The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? PO2 value is 80 mm Hg PCO2 value is 60 mm Hg HCO3 value is 50 mEq/L (50 mmol/L) Serum potassium level is 4 mEq/L A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply. HeadacheIrritability Restlessness Hypertension Lightheadedness A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? Question the client about the confusion Change the method of oxygen therapy Percuss and vibrate the client’s chest wall Discontinue or decrease the oxygen flow rate To determine the presence of respiratory alkalosis in a client, what should the nurse evaluate for? A change in the respiratory A tingling sensation in the hands Periodic changes in heart rate A pulse oximetry reading of less than 98% A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? An elevated pH, elevated PCO2 A decreased pH, elevated PCO2 An elevated pH, decreased PCO2 A decreased pH, decreased PCO2A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? Skeletal and nervous Circulatory and urinary Respiratory and urinary Muscular and endocrine A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Inability of the renal tubules to reabsorb water to dilute the acid contents of blood Impaired glomerular filtration, causing retention of sodium and metabolic waste products On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? Muscle twitching Mental instability Deep and rapid respirations Tachycardia and cardiac dysrhythmias Which type of immune preparation, made from donated blood, contains antibodies that provide passive immunity?Toxoid Killed Vaccine Live attenuated vaccine Specific immune globin A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity? It increases production of short-lived antibodies It accelerates antigen-antibody union at the hepatic sites. The lymphatic system is stimulated to produce antibodies The antigen is neutralized by the antibodies that it supplies. What action describes artificial active immunity? Antibodies are passed from one person to another Antibodies against an antigen are made naturally in the body Antibodies are made after an antigen is injected into the body Antibodies are transferred into the body after being made in another body or animal On initial assessment of an older patient, the nurse knows to look for certain types of diseases because which immunologic response increases with age? Autoimmune response Hypersensitivity response Cell-mediated response Humoral immune response A healthy 65-year-old man who lives at home is at the clinic requesting a "flu shot." When assessing the patient, what other vaccinations should the nurse ask the patient about receiving (select all that apply)? Shingles PneumoniaMeningococcal Measles, mumps, and rubella (MMR) Haemophilus influenzae type b (Hib) The patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse's first action? Administer IV diphenhydramine (Benadryl). Administer nitroprusside as soon as possible Anticipate tracheostomy with laryngeal edema Place the patient recumbent and elevate the legs. Which statement by the patient who has had an organ transplant would indicate that the patient understands the teaching about the immunosuppressive medications? Taking more than one medication will put me at risk for developing allergies." "The lower doses of my medications can prevent rejection and minimize the side effects." I will be more prone to malignancies because I will be taking more than one drug." My drug dosages will be lower because the medications enhance each other." Ten days after receiving a bone marrow transplant, a patient develops a skin rash on his palms and soles, jaundice, and diarrhea. What is the most likely etiology of these clinical manifestations? Cells in the transplanted bone marrow are attacking the host tissue An atopic reaction is causing the patient's symptoms The patient is experiencing a type I allergic reaction The patient is experiencing rejection of the bone marrow The patient with diabetes mellitus has been ill for some time with a severe lung infection needing corticosteroids and antibiotics. The patient does not feel like eating. The nurse understands that this patient is likely to develop. Secondary immunodeficiencyPrimary immunodeficiency Acute hypersensitivity reaction Major histoincompatibility When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods (select all that apply)? Grapes Oranges Bananas Potatoes Tomatoes A 21-year-old student had taken amoxicillin once as a child for an ear infection. She is given an injection of Penicillin V and develops a systemic anaphylactic reaction. What manifestations would be seen first? Dyspnea Dilated pupils Itching and edema Wheal-and-flare reaction You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? Sodium falling to 138 mEq/L Potassium rising to 4.1 mEq/L Phosphorus falling to 2.1 mg/dL Magnesium rising to 2.9 mg/d While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? WeaknessParesthesias Facial spasms Muscle tremors You are caring for a patient admitted with diabetes mellitus, malnutrition, and massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply)? The potassium level may be increased if the patient has renal nephropathy. There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. The patient has been overeating raisins, baked beans, and salt substitute that increase the potassium level. ​The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. The patient may be excreting extra sodium and retaining potassium because of malnutrition. You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the physician? Loop diuretics Bronchodilators Antibiotics Antihypertensives The patient has chronic kidney disease and is admitted with loss of deep tendon reflexes, somnolence, and altered respiratory status. What treatment should the nurse expect for this patient? IV Furosemide (Lasix) Renal dialysis IV potassium chlorideIV normal saline at 250 mL per hour You are caring for a patient receiving D5W at a rate of 125 mL/hr. During the 4:00 PM assessment of the patient, you determine that 500 mL is left in the present IV bag. In how many hours should the nurse anticipate hanging the next bag of D5W? __________ hours 4 Y ou are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? Slow the rate to keep vein open until next bag is due at noon Listen to the patient’s lung sounds and assess respiratory status Obtain a new bag of IV solution to maintain patency of the site Notify the physician and complete an incident report OUIZ #2 A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nursemake it a priority to use? Select all that apply. Goggles Surgical Mask Gown Shoes covers N95 mask Gloves The nurse finds that a client becomes dyspneic during activities of daily living, such as showering and dressing. The client can walk for more than a city block but at his or her own pace and cannot keep up with others. Which class of dyspnea describes this client? Class III Class IIClass IV Class I Which chest examination findings can be observed in a client with pneumonia? Absent sounds on auscultation Prolonged expiration on inspection Hyperresonance on percussion Increased fremitus over affected area on palpation Which client would the nurse consider to have the highest risk of pneumonia? Client 1 Client 2 Client 3Client 4 The nurse suspects pneumonia in a client who underwent placement of an epistaxis catheter due to posterior nasal bleeding. Which activity of the client might have led to this condition? Using drugs such as aspirin Applying excess petroleum jelly to the nares Using nasal saline sprays Blowing the nose vigorously The nurse is using the CURB-65 scale in the assessment of four clients with manifestations of pneumonia. Which client requires immediate admission to the intensive care unit? Client 1 Client 2 Client 3 Client 4A client is hospitalized with pneumococcal pneumonia. Which drug will the nurse most likely administer? Penicillin G Vancomycin Meropenem Ceftriaxone The nurse is caring for a client on antiretroviral therapy who has Pneumocystis jiroveci pneumonia. Which action is priority? Maintaining fluid balance in the client Encouraging the client to perform breathing exercises Providing adequate oxygenation for the client Assisting the client in eating and drinking The nurse is evaluating the actions of a client with pneumonia performing incentive spirometry. Which action by the client indicates a need for correction? Inhaling air fully before inserting the mouthpiece Performing 10 breaths per session every hour Taking a long slow, deep breath keeping the mouthpiece in place Recording the volume of the air inspired ​Levofloxacin 750 mg intravenous piggyback (IVPB) is prescribed for a client with pneumonia. The dose is available in 150 mL of 5% dextrose and is to infuse over 90 minutes. The administration set has a drop factor of 15 drops per mL. At how many drops per minute should the nurse regulate the IVPB to infuse? ​Record your answer using a whole number. ___ gtt/minute25 A client with a history of parkinsonism recently developed rigidity, tremors, and signs of pneumonia. The client is hospitalized for treatment. What should the nursing plan of care include? Active range-of-motion exercises at least every four hours Isometric exercises every two hours while awake Gait training in the physical therapy department daily Passive range-of motion exercises at least every eight hours When caring for a client with pneumonia, which nursing intervention is the highest priority​? Employ breathing exercises and controlled coughing increase fluid intake maintain a NPO status Ambulate as much as possible A client with a history of coronary artery disease is admitted with pneumonia. The healthcare provider prescribes atenolol. What should the nurse monitor to determine the therapeutic effect of atenolol? Temperature Respirations Heart rate Pulse oximetry ​A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is ​most​ likely to be present when the nurse assesses the client's right side?Adventitious sounds Wheezing Decreased sounds Crackling A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, what should the nurse do? Increase fluid intake to at least 2L per day Place the client in a high-Fowler position Administer continuous O2 Instruct the client to gargle deep in the throat using warmed normal saline A Patient who is scheduled for open-heart surgery ask why he will be getting chest tubes after surgery. What should the nurse consider before responding in language that the patient will understand? Chest tubes increase tidal volume Chest tubes facilitate drainage of air and fluid Chest tubes regulate pressure on the pericardium and chest wall Chest tubes maintain positive intrapleural pressure A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed chest drainage system. When caring for this client, what should the nurse do? Clamp the chest tubes when suctioning the patientPalpate the area around the tubes for crepitus Change the clients dressing daily using aseptic technique Empty the drainage chamber at the end of the shift A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. While planning care for a stationary chest tube drainage system, which purpose of the first chamber will the nurse consider? Sustain a continuance of the water seal Ensure adequate suction Collect drainage Maintain negative pressure During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What ​initial​ action should the nurse take? Turn the client to the unaffected side Check the tube to ensure that it is not kinked Take the client’s vital signs Inform the healthcare provider A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? Permit the development of positive pressure between the layers of the pleuraRemove the air that is present in the intrapleural space Drain serosanguineous fluid from the intrapleural compartment Provide access for the installation of medication into the pleural space ​Nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation? Stop giving the medication Elevate the head of the client’s bed Measure the other vital signs Report to the primary healthcare provider A client has an IV of D​ 5​W 250 mL to which 100 mg of morphine is added. The healthcare provider prescribes 14 mg of morphine per hour for end of life palliative treatment of a client . At how many mL per hour should the nurse set the intravenous pump? ​Record your answer using a whole number. ___mL/hr 35 A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? Discuss with spouse the risk for morphine addiction Add a placebo to the morphine to appease the spouse Assess the client’s pain before increasing the dose of morphine Check the client’s heart rate before increasing the morphine to the next level​POP QUIZ #2 A nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How should the nurse proceed? Cleanse the site with the new product first and then follow the agency’s protocol Use the new product sample when changing the dressing Follow the agency’s policy unless it is contraindicated by a primary healthcare provider’s prescription Cleanse the site with alcohol first and the with povidone-iodine A nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How should the nurse proceed? There is less chance of this infusion infiltrating It is more convenient so clients can use their hands It prevents the development of infection The large amount of blood helps dilute the unconcentrated solutionA client with esophageal cancer is to receive total parenteral nutrition. A right subclavian catheter is inserted. What is the primary reason total parenteral nutrition is infused through a central line rather than a peripheral line? Apply oxygen Raise the head of the bed Call the primary healthcare provider Assess breath sounds A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. What should a nurse do ​first​? Determine which days to self-administer the PPN solution Arranging for professional help to monitor the alternative solution Learning how to change the percutaneous catheter Scheduling administration of the PPN solution around mealtimes A client will be discharged with a peripherally inserted central venous catheter (PICC) for administration of peripheral parenteral nutrition (PPN). What would be appropriate for the nurse to include in the client's discharge teaching? Notify the healthcare provider Inspect the catheter Clamp the remaining device Assess the respiratory status The nurse is caring for a client who has a peripherally inserted central catheter (PICC). The client notifies the nurse that the catheter got tangled up in bedclothes and came out. What should the nurse do ​first​? Apply warm compress to the affected extremity Check the IV access for blood return Slow the IV infusion until the burning sensation is goneRequest an oral supplement from the primary healthcare provider A client, receiving a potassium infusion via a peripheral intravenous (IV) site, reports a burning sensation above the IV site. What should the nurse do ​first? Healthcare provider UAP LPN RN A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a ​priority​ for the nurse to assess which of the following? ​Select all that apply. Deep tendon reflexes Urinary output ABG results Last bowel movement Patency of the IV access Last serum potassium level ​A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a ​priority​ for the nurse to assess which of the following? ​Select all that apply. Administering 100% oxygen manually to the client Administering IV fluids to the client Reporting to the primary healthcare providerStopping the suctioning procedure immediately ​A nurse is providing tracheostomy care. Which action is ​priority​? Monitor body temperature after the procedure is completed Maintain sterile technique during the procedure Clean the inner cannula with sterile water when it is removed Place the client in the semi-Fowler position Surgical incision in the chest to gain access to the internal organs is ​THORACOTOMY VATS=​Video assisted thoracoscopic surgery The valve used to evacuate air from the pleural space is called ​Flutter valve of Heimlich valve Give the patient pain medication 30-60 minutes before chest tube removal TRUE QUIZ#3 A client is admitted via the emergency department with the tentative diagnosis of diverticulitis. Which test commonly is prescribed to assess for this problem? Barium enema Colonoscopy Gastroscopy CT scan An older client's colonoscopy reveals the presence of extensive diverticulosis. Which type of diet should the nurse encourage the client to follow? High fiber Low fat Low carb High proteinA client who had surgery for a ruptured appendix develops peritonitis. Which clinical findings related to peritonitis should the nurse expect the client to exhibit? ​Select all that apply​. Abdominal muscle rigidity Hyperactivity Urinary retention Extreme hunger Fever A client had surgery for a perforated appendix with localized peritonitis. In which position should the nurse place this client? Dorsal recumbent Semi-Fowler Sims Trendelenburg A colectomy is scheduled for a 38-year-old woman with ulcerative colitis. The nurse should plan to include what prescribed measure in the preoperative preparation of this patient? Administration of a cleansing enema A high fiber diet the day before the surgery Administration of IV antibiotics for bowel preparation Instruction on irrigating a colostomy A 61-year-old patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? 8:00AM, 12:00PM and 4:00PM 7:00AM, 10:00AM, and 1:00PM 9:00AM and 3:00PM9:00AM, 12:00PM, and 3:00PM Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of Nasogastric suctioning Impaired peristalsis Irritation of the bowel Inflammation of the incision site The nurse should administer an as-needed dose of magnesium hydroxide (MOM) after noting what information while reviewing a patient's medical record? A decrease in appetite by 50% over 24 HRs Muscle tremors and other signs of hypomagnesemia Abdominal pain and bloating No bowel movement for 3 days The nurse asks a 68-year-old patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the ​most​ appropriate action by the nurse? Delay the patient’s signature on the consent and notify the physician about the conversation with the patient Ask the family members whether they have discussed the surgical procedure with the physician. Explain the planned surgical procedure as well as possible and have the patient sign the consent form Have the patient sign the consent form and state the physician will visit to explain the procedure before surgery The nurse is preparing to insert a nasogastric (NG) tube into a 68-year-old female patient who is nauseated and vomiting. She has an abdominal mass and suspected small intestinal obstruction. The patient asks the nurse why this procedure is necessary. What response by the nurse is ​most ​appropriate?The tube will push past the area that is blocked and thus help to stop the vomiting The tube will help to drain the stomach and prevent further vomiting The tube is just a standard procedure before many types of surgery to the abdomen The tube will let us measure your stomach contents so that we can plan what type of IV fluid replacement would be best A stroke patient who primarily uses a wheelchair for mobility has diarrhea with fecal incontinence. What should the nurse assess ​first​? Fecal impaction Antidiarrheal agent use Dietary fiber intake Perineal hygiene What information would have the ​highest priority​ to be included in preoperative teaching for a 68-year-old patient scheduled for a colectomy? Which medications will be used during surgery The location and care of drains after surgery How to care for the wound How to deep breathe and cough The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the patient, the nurse would explain that it acts in what way? Increases peristalsis by stimulating nerves in the colon wall Increases fluid by retention in the intestinal tract Increases bulk in the stool Lubricates the intestinal tract to soften feces The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation? Maintain a high intake of fluid and fiber in the diet Eat several small meals per day to maintain bowel motility Reduce intake of medications causing constipation Sit upright during meals to increase bowel motility by gravityA patient is scheduled to receive "Colace 100 mg PO." The patient asks to take the medication in liquid form, and the nurse obtains an order for the interchange. Available is a syrup that contains 150 mg/15 mL. Calculate how many milliliters the nurse should administer. _______________ mL 10 Following bowel resection, a patient has a nasogastric (NG) tube to suction, but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority​ action by the nurse? Notify the physician Reposition the tube and check for placement Auscultate for bowel sounds Remove the tube and replace it with a new one When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend? Dried beans, All bran (100%) cereal, and raspberries Oranges, baked potatoes, and raw carrots White bread, cheese, and green beans Fresh tomatoes, pears, and corn flakes The wound, ostomy, and continence (WOC) nurse selects the site where the ostomy will be placed. What should be included in the consideration for the site? The patient must be able to access the site The ostomy will need to be irrigated so the area should not be tender Outside the rectus muscle area is the best site It is easier to seal the drainage bag to a protruding area When evaluating the patient's understanding about the care of the ileostomy, what statement by the patient indicates the patient needs more teaching? Dried fruit and popcorn must be chewed very well The drainage from the stoma can damage my skinI will be able to wear the pouch until it leaks I will be able to regulate when I have stools The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? High-pitched and hyperactive above the area of obstruction Low-pitched and rumbling above the area of obstruction Low-pitched and hyperactive below the area of obstruction High-pitched and hypoactive below the area of obstruction What should the nurse instruct the patient to do to ​best​ enhance the effectiveness of a daily dose of docusate sodium (Colace)? Ensure dietary intake of 10g of fiber each day Take a dose of mineral oil at the same time Add extra salt to food on at least one meal tray Take each dose with a full glass of water or other liquid A client with a diagnosis of gastric cancer has a gastric resection with a vagotomy. Which clinical response should alert the nurse that the client is experiencing dumping syndrome? Constipation Clay-colored stools Reactive hypoglycemia Sensations of hunger A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? Low-protein, high-carb diet Fluid intake below 500mL Small, frequent feeding schedule Low-residue, bland dietThe nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which statement by the client indicates a good understanding of preventing dumping syndrome after meals? ​Select all that apply​. I will not drink fluids when I eat meals I will eat a bland diet I will eat a low-protein, high carb diet I will avoid artificially-sweetened foods I will eat small, frequent meals instead of three large meals a day After a subtotal gastrectomy a client demonstrates signs of dumping syndrome. About 90 minutes after the initial attack, the client reports feeling shaky. What does the nurse determine is the cause of the latter effect? A distention of the duodenum from an excessive amount of chyme A second more extensive rise in glucose An overproduction of insulin that occurs in response to the rise in blood glucose An overwhelmed insulin-adjusting mechanism The nurse is creating a discharge teaching plan for a client who had a subtotal gastrectomy. The nurse should include what instructions about minimizing dumping syndrome? ​Select all that apply. Eat small frequent meals Select foods that are low in fiber Drink fluids with meals Lie down for one hour after eating Chew food five times before swallowing A client has circumgastric banding, a bariatric surgical procedure. The nurse provides discharge teaching about signs and symptoms of dumping syndrome and includes what physiologic response? Constipation Vomiting FeverPalpitations CRANIAL NERVES QUIZ Glossopharyngeal Nerve: innervates the pharynx Optic Nerve: vision Facial Nerve: control of facial muscles Vestibulocochlear: equilibrium and hearing Hypoglossal: innervates the tongue muscles Vagus: controls visceral and cardiac muscles; cranial nerve that innervates smooth muscle and glands of the heart, lungs, larynx, trachea, and most abdominal organs Trigeminal: controls muscles of mastication Cerebellum: controls posture, balance, and the coordination of body movements Medulla oblongata: the respiratory, cardiac, and vasomotor control centers are located here After a major head trauma, the patient's respiratory and cardiac functions are affected. Which area of the brain is damaged? Temporal lobe of the cerebrum Brainstem Cerebellum Spinal Nerves What is the purpose of the blood-brain barrier? To protect the brain by cushioning To inhibit damage from external trauma To keep harmful agents away from brain tissue To provide the blood supply to brain tissueWhen assessing a patient with a traumatic brain injury, you notice uncoordinated movement of the extremities. How would you document this? Ataxia How do you assess the accessory nerve? Assess the gag reflex by stoking the posterior pharynx Ask the patient to shrug their shoulders against resistance Ask the patient to push the tongue to either side against resistance Have the client say “ah” while visualizing elevation of the soft palate When assessing motor function of a patient admitted with a stroke, you notice mild weakness of the arm demonstrated by downward drifting of the extremity. How would you accurately document this finding? Athetosis Hypotonia Hemiparesis Pronator drift DIABETES QUIZ A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which of the following anticipated physician's prescriptions? Endotracheal intubation 100 units of NPH insulin IV infusion of normal saline IV infusion of sodium bicarbonate "A client is taking Humulin NPH insulin daily every morning. The nurse instructs the client that the most likely time for a hypoglycemic reaction to occur is: 2-4 HRS after administration 4-12 HRS after administration16-18 HRS after administration 18-24 HRS after administration A client with diabetes mellitus has a blood glucose of 644 mg/dl. The nurse interprets that this client is most at risk of developing which type of acid base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis A client with type I diabetes is placed on an insulin pump. The most appropriate short-term goal when teaching this client to control the diabetes is: Adhere to the medical regimen Remain normoglycemic for 3 weeks Demonstrate the correct use of the administration equipment List 3 self-care activities that are necessary to control the diabetes "A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. Following assessment of the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding of Polyuria Severe dehydration Rapid, deep respirations Decreased serum potassium ​An 18-year-old female client, 5'4'' tall, weighing 113 kg, comes to the clinic for a non-healing wound on her lower leg, which she has had for two weeks. Which disease process should the nurse suspect the client is developing? Type 1 diabetes Type 2 diabetes Gestational diabetes Acanthosis nigricansAn external insulin pump is prescribed for a client with DM. The client asks the nurse about the functioning of the pump. The nurse bases the response on the information that the pump: Gives small continuous dose of regular insulin subcutaneously and the client can self-administer a bolus with an additional dosage from the pump before each meal Is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? BP 126/80 A1C 9% FBG 130 mg/dL LDL cholesterol 100 mg/dL One of the benefits of glargine (Lantus) insulin is its ability to: Release insulin during the day to help control the basal glucose Release insulin evenly throughout the day to control basal glucose levels Simplify the dosing and better control blood glucose levels during the day Cause hypoglycemia with other manifestation of other adverse reactions The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with Type 1 diabetes at 1600. Which action should the nurse implement? Ensure the client eats the bedtime snack Determine how much food the client ate at lunch Perform a glucometer reading at 0700 Offer the client protein after administering insulinYour patient’s blood glucose level is 215 mg/dL. The patient is about to eat lunch. Per sliding scale, you administer 4 units of Insulin Lispro (Humalog) subcutaneously at 1130. As the nurse, you know the patient is most at risk for hypoglycemia at what time? 1145 1230 1430 1630 RAPID-ACTING​: onset 15mins, peak 1 hour, duration 3 hours SHORT-ACTING​: onset 30mins, peak 2 hours, duration 4 hours INTERMEDIATE-ACTING​: onset 2 hours, peak 4 hours, duration 16 hours LONG-ACTING​: onset 1 hour, no peak, duration 24 hours Regular ®:short-acting Humalog :rapid-acting Novalog: rapid-acting NPH (N): Intermediate Lantus: long-actingQUIZ #4 The nurse observes a client with kidney failure has increased rate and depth of breathing. Which laboratory parameter does the nurse suspect is associated with this client’s condition? Potassium 8 mEq/L Phosphorus 7 mg/dL Bicarbonate 15 mEq/L Hemoglobin 10 g/dL A client is diagnosed as having kidney failure. During the oliguric phase, what should the nurse assess for in this client? Hyperphosphatemia Hypernatremia Hypocalcemia Hypothermia A nurse is caring for a client with a diagnosis of chronic kidney failure who has just been told by the primary healthcare provider that hemodialysis is necessary. Which clinical manifestation indicates the need for hemodialysis? Hypertension Acidosis Ascites Hyperkalemia A client is experiencing kidney failure. Which is the ​most​ serious complication for which the nurse must monitor a client with kidney failure? Anemia Uremic frost Weight loss HyperkalemiaA nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? ​Select all that apply. Hypotension Muscle twitching Polyuria Respiratory acidosis Lethargy A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? Impaired GFR, causing retention of sodium and metabolic waste products Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention Inability of the renal tubules to reabsorb water to dilute the acid contents of blood A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy? It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion It decreases the need for immobility because it clears toxins in short and intermittent periods It provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end-stage renal disease (ESRD)? Protein Fluid SodiumPotassium A client is diagnosed with acute kidney failure secondary to dehydration. An intravenous (IV) infusion of 50% glucose with regular insulin is prescribed. What does the nurse recognize as the primary purpose of the IV insulin for this client? Increases urinary output Prevent respiratory acidosis Correct Hyperkalemia Increases serum calcium levels A nurse is caring for a client with acute kidney injury. Which findings should the nurse anticipate when reviewing the laboratory report of the client’s blood level of calcium, potassium, and creatinine? Select all that apply. Creatinine 1.1 mg/dL Calcium 7.6 mg/dL Creatinine 3.2 mg/dL Potassium 3.5 mEq/L Calcium 10.5 mg/dL Potassium 6.0 mEq/L ​A client with acute kidney injury states, "Why am I twitching and my fingers and toes tingling?" Which process should the nurse consider when formulating a response to this client? Sodium chloride depletion Calcium depletion Acidosis Potassium depletion A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take ​first? Obtain an ECG strip and obtain an antiarrhythmic medication Take vital signs and notify the HCP Call RRT Call the lab to repeat the testA nurse is caring for a client with acute kidney injury who is receiving a protein-restricted diet. The client asks why this diet is necessary. Which information should the nurse include in a response to the client’s questions? Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen for amino acid synthesis must come from the dietary protein This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys A client is admitted to the hospital in the oliguric phase of acute kidney injury. The nurse estimates that the urine output for the last 12 hours is about 200 mL. The nurse reviews the plan of care and notes a prescription for 900 mL of water to be given orally over the next 24 hours. What does the nurse conclude about the amount of fluid prescribed? It will prevent the development of pneumonia and a high fever It equals the expected urinary output for the next 24 hours It will compensate for both the insensible and expected output over the next 24 hours It will reduce hyperkalemia, which can lead to life-threatening cardiac dysrhythmias Which type of cytokine is used to treat anemia related to chronic kidney disease? Interleukin-2 Erythropoietin Interleukin-11 a-Interferon A client with the diagnosis of chronic kidney disease develops hypocalcemia. Which clinical manifestations should the nurse expect the client with hypocalcemia to exhibit? Select all that apply. Osteomalacia Fractures Lethargy Eye calcium deposits AcidosisA client with chronic kidney disease is admitted to the hospital with severe infection and anemia. The client is depressed and irritable. The client’s spouse asks the nurse about the anticipated plan of care. Which is an appropriate nursing response? The staff will provide total care, because the infection causes severe fatigue Mood elevators will be prescribed to improve depressions and irritability Vitamin B12 will be prescribed for the anemia and the stools will be dark The intake of meat, eggs, and cheese will be restricted so the kidneys can clear the body of waste products A client is admitted to the hospital with a diagnosis of severe chronic kidney disease. Which assessment findings should the nurse expect the client to exhibit? Select all that apply. Paresthesias Widening pulse pressure HTN Polyuria Metabolic alkalosisEXAM #2 When a nurse brings a dinner tray to a 44 year old patient hospitalized with pneumonia, the patient says, "I'm too sick to feed myself." What is the best response by the nurse? You can eat later when you feel better." You're really not that sick, and I'm sure you can feed yourself. Try to eat as much as you can. Wait a few minutes, and I will be back to help you. An 50-year-old patient with viral pneumonia is admitted to the telemetry unit. The admitting nurse reviews the instructions from the healthcare provider. Which prescription should the nurse question? Start IV fluids D5% 0.45% NS at 80 mL/hr Aspirin 325 mg every 4 hours prn for fever higher than 101.4° F (38.6° C) physiotherapy twice a day Encourage oral fluids A client is admitted to the hospital with a tentative diagnosis of pneumonia. The client has a high fever and is short of breath. Bed rest, oxygen via nasal cannula, an intravenous antibiotic, and blood and sputum specimens for culture and sensitivity (C & S) are prescribed. Place these interventions in the order in which they should be implemented. 1. Promote bed rest with raised head of bed 2. Provide oxygen via nasal cannula 3. Obtain blood specimens for C&S 4. Administer prescribed antibiotic A client is admitted to the hospital with a diagnosis of pneumonia. List the following nursing actions in the order they should be accomplished. 1. Obtain data about the client’s history and physical status 2. Insert an IV catheter to establish venous access 3. Collect sputum sample for culture and sensitivity 4. Administer prescribed antibiotic IVPB 5. Check peak and trough levels of the antibioticA client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? Permit the development of positive pressure between the layers of the pleura Provide access for the instillation of medication into the pleural space Remove the air that is present in the intrapleural space Drain serosanguineous fluid from the intrapleural compartment A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason identified by the nurse for suctioning the client? The weaning process increases the amount of respiratory secretions. Humidified oxygen is saturated with fluid. The tracheostomy tube interferes with effective coughing. The inner cannula of the tracheostomy tube irritates the mucosa. A platelet transfusion is to be administered for a patient with acute lymphocytic leukemia. What will the nurse do first? Check the vital signs every 2 hours during the transfusion Administer the platelets rapidly through the intravenous (IV) line Flush the IV line with a dextrose solution Set the IV pump to run for 8 hours For a patient with the diagnosis of acute lymphocytic leukemia (ALL). A blood transfusion is ordered, and an intravenous line is started. What will the nurse do in regard to administering the transfusion? Take the vital signs 3 hours after the transfusion. Have the blood warm at room temperature for 1 hour before administration. Infuse the blood over no more than 4 hours. Check the vital signs 15 minutes after starting the transfusion.A Patient who has been prescribed prednisone and vincristine for leukemia tells the nurse that he is very constipated. What should the nurse cite as the probable cause of the constipation? The leukemic mass is obstructing the bowel. The spleen is compressing the bowel. It is a toxic effect from the prednisone. It is a side effect of the vincristine. A nurse is caring for a Patient with acute lymphoid leukemia. While examining the laboratory results, the nurse notes that the patient is neutropenic. What does the nurse recognize as the cause of the neutropenia? Overwhelming infection Increased immature cell growth Internal bleeding Decreased intake of iron-rich nutrients When providing care for a patient with leukemia, a nurse notes blood on the pillowcase and several bloody tissues. What blood component value on the patient's laboratory results should the nurse verify? Erythrocytes Platelets Neutrophils Lymphoblasts A patient who is recently diagnosed leukemia ask the nurse why he was told that he has too many white blood cells. How should the nurse respond? The bone marrow is not controlling your white blood cell production as it should You seem to be focusing on your white blood cells The doctor is the best one to answer that question for you You apparently don't understand what occurs in this disease. A nurse is performing an assessment on a patient who has been admitted to the medical unit with the diagnosis of acute lymphocytic leukemia (ALL). What early clinical findings does the nurse expect to identify? Nosebleeds and papilledemaEnlargement of the axillary and groin lymph nodes Abdominal pain and reddened complexion Fatigue and ecchymotic areas A patient who has acute lymphoblastic leukemia is scheduled to receive cranial radiation. What should the nurse explain to the patient and family about radiation? It reduces the risk for systemic infection. It prevents central nervous system involvement. It limits metastasis to the lymphatic system. It avoids the need for chemotherapy. A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? Conjunctiva Mucous membrane Sclera Lips - - - - - - - - - - - - - - - - - - - - - - - geminal nerveThe registered nurse is caring for a client in the emergency department. Which conditions of the client made the nurse stabilize the cervical spine as the primary nursing intervention? Select all that apply. Blunt abdominal pain Facial chemical burns Flail chest Head injuries Renal colic pain After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? Polyuria and increased specific gravity of urine Hyperkalemia and poor skin turgor Increased blood urea nitrogen (BUN) and hypotension Hyponatremia and decreased urine output A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? Select all that apply. Hyperthermia Decreased level of consciousness Bradycardia Increased weight Nausea and vomiting Decreased serum sodium What interventions should the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply. Instituting fall risk precautions Placing the client in high-Fowler position Providing frequent oral care Restricting fluids to 2 L per day Monitoring for and reporting neurologic changesThe nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which finding in the client is consistent with the diagnosis? Presence of pedal edema Preservation of salt Decrease of vasopressin Retention of water A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion? fruity odor to the breath Deep respirations Erythema toxicum rash and pruritus Diaphoresis and altered mental state Nervousness and tachycardia The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which intervention? Administer insulin glargine subcutaneously at hour of sleep Intravenous administration of 10% dextrose Intravenous administration of regular insulin Maintain nothing prescribed orally (NPO) status The nurse is teaching a client about safe insulin administration. Which statement made by the client indicates the need for further education? "I should administer insulin only if there are any symptoms." "I should keep a daily logbook of times of insulin injection." "I should keep my medication in its original labeled container." "I should see whether the insulin is expired." A healthcare provider's prescription for a client in ketoacidosis is an insulin infusion rate calculated as: Glucose mg/dL ÷ 100 = ____ units/hour. The pharmacy dispensed 100 units regular insulin in 100 mL normal saline and the client's glucose level is 350 mg/dL. At how many milliliters per hour should the nurse set the IV infusion device to administerthe correct amount of medication? Record your answer using one decimal place. _____ mL/hr 3.5 A 59-year-old female patient, who has frontotemporal lobar degeneration, has difficulty with verbal expression. One day she walks out of the house and goes to the gas station to get a soda but does not understand that she needs to pay for it. What is the best thing the nurse can suggest to this patient's husband to keep the patient safe during the day while the husband is at work? Advance directives Assisted living Monitor for behavioral changes Adult day care Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? Headache and rising blood pressure Decreased level of consciousness or hallucinations Irregular respirations and shortness of breath Abdominal distention and absence of bowel sounds After learning about rehabilitation for his spinal cord tumor, which statement shows the patient understands what rehabilitation is and can do for him? "I will be able to do all my normal activities after I go through rehabilitation." "With rehabilitation, I will be able to function at my highest level of wellness." "Rehabilitation will be more work done by me alone to try to get better." "I want to be rehabilitated for my daughter's wedding in 2 weeks." Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? Bradycardia Neurogenic spasticityHypertension Bounding pedal pulses Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia? Suctioning of the patient's upper airway Placement of the patient in the Trendelenburg position Administration of benzodiazepines Urinary catheterization A 68-year-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl (Dulcolax) suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver to assist the patient with bowel evacuation (select all that apply)? Drink more milk Establish bowel evacuation time at bedtime. Use oral laxatives every day. Eat 20-30 g of fiber per day. Drink 1800 to 2800 mL of water or juice. When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority? Altered patterns of urinary elimination caused by tetraplegia Risk for impairment of tissue integrity caused by paralysis Ineffective airway clearance caused by high cervical spinal cord injury Altered family and individual coping caused by the extent of trauma The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? Spinal shock syndrome Brown-Séquard syndromeAnterior cord syndrome Central cord syndrome The nurse is caring for a 76-year-old man who has undergone left knee arthroplasty with prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis. Postoperatively the nurse expects what to be included in the care of the affected leg? Progressive leg exercises to obtain 90-degree flexion Early ambulation with full weight bearing on the left leg Bed rest for 3 days with the left leg immobilized in extension Immobilization of the left knee in 30-degree flexion for 2 weeks to prevent dislocation The patient is brought to the emergency department after a car accident and has a femur fracture. What nursing intervention should the nurse implement to prevent a fat embolus in this patient? Provide range-of-motion exercises. Administer enoxaparin (Lovenox). Apply sequential compression boots. Immobilize the fracture preoperatively. This morning a 21-year-old male patient had a long leg cast applied and wants to get up and try out his crutches before dinner. The nurse will not allow this. What is the best rationale that the nurse should give the patient for this decision? The nurse does not have anyone available to accompany the patient. The cast is not dry yet, and it may be damaged while using crutches. Excess edema and other problems are prevented when the leg is elevated for 24 hours. Rest, ice, compression, and elevation are in process to decrease pain. The nurse is completing a neurovascular assessment on the patient with a tibial fracture and a cast. The feet are pulseless, pale, and cool. The patient says they are numb. What should the nurse suspect is occurring? Paresthesia Pitting edemaCompartment syndrome Poor venous return The nurse is planning health promotion teaching for a 45-year-old patient with asthma, low back pain from herniated lumbar disc, and schizophrenia. What does the nurse determine would be the best exercise to include in an individualized exercise plan for the patient? Walking Yoga Weight lifting Calisthenics During a health screening event which assessment finding would alert the nurse to the possible presence of osteoporosis in a white 61-year-old female? Poor appetite and aversion to dairy products The presence of bowed legs A measurable loss of height Development of unstable, wide-gait ambulation The nurse is caring for a patient hospitalized with exacerbation of chronic bronchitis and herniated lumbar disc. Which breakfast choice would be most appropriate for the nurse to encourage the patient to check on the breakfast menu? Bran muffin Scrambled eggs Buttered white toast Puffed rice cereal Which nursing intervention is most appropriate when turning a patient following spinal surgery? Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed Elevating the head of bed 30 degrees and having the patient extend the legs while turningPlacing a pillow between the patient's legs and turning the body as a unit Having the patient turn to the side by grasping the side rails to help turn over A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? Allow the patient to dangle legs at the bedside every 2 to 4 hours. Ask the patient about preferred activities to relieve boredom. Perform frequent position changes and range-of-motion exercises. Ambulate the patient to the bathroom every 2 hours. The nurse is admitting a patient who complains of a new onset of lower back pain. To differentiate between the pain of a lumbar herniated disc and lower back pain from other causes, what would be the best question for the nurse to ask the patient? "Is the pain worse in the morning or in the evening?" "Is the pain sharp or stabbing or burning or aching?" "Does the pain radiate down the buttock or into the leg?" "Is the pain totally relieved by analgesics, such as acetaminophen (Tylenol)?" The nurse is reinforcing health teaching about osteoporosis with a 72-year-old patient admitted to the hospital. In reviewing this disorder, what should the nurse explain to the patient? Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis.The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-year-old patient who has low back pain from a herniated lumbar disc. What would be an appropriate nursing intervention to treat this problem? Elevate the head of the bed 20 degrees and flex the knees. Place a small pillow under the patient's upper back to gently flex the lumbar spine. Place the bed in reverse Trendelenburg with the feet firmly against the footboard. Provide gentle ROM to the lower extremities. The nurse has reviewed proper body mechanics with a patient with a history of low back pain caused by a herniated lumbar disc. Which statement made by the patient indicates a need for further teaching? "I should exercise at least 15 minutes every morning and evening." "I should try to keep one foot on a stool whenever I have to stand for a period of time." "I should pick up items by leaning forward without bending my knees." "I should sleep on my side or back with my hips and knees bent." When reinforcing health teaching about the management of osteoarthritis (OA), the nurse determines that the patient needs additional instruction after making which statement? "I can use a cane if I find it helpful in relieving the pressure on my back and hip." "I should try to stay standing all day to keep my joints from becoming stiff." "I should take the Naprosyn as prescribed to help control the pain." "A warm shower in the morning will help relieve the stiffness I have when I get up." A patient with diabetes mellitus who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively? Obtain comprehensive dental care. Maintain hemoglobin A1c below 7%. Avoid sick people and wash hands. Coughing and deep breathing with splintingA 65-year-old patient with type 2 diabetes has a urinary tract infection (UTI). The unlicensed assistive personnel (UAP) reported to the nurse that the patient's blood glucose is 642 mg/dL and the patient is hard to arouse. When the nurse assesses the urine, there are no ketones present. What collaborative care should the nurse expect for this patient? Routine insulin therapy and exercise Administer a different antibiotic for the UTI. Cardiac monitoring to detect potassium changes Administer IV fluids rapidly to correct dehydration The nurse is beginning to teach a diabetic patient about vascular complications of diabetes. What information is appropriate for the nurse to include? Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by a majority of patients with diabetes. Macroangiopathy does not occur in type 1 diabetes but rather in type 2 diabetics who have severe disease. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control. Laboratory results have been obtained for a 50-year-old patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? Increased high-density lipoproteins (HDL) Increased triglyceride levels Decreased low-density lipoproteins (LDL) Decreased very-low-density lipoproteins (VLDL) A college student is newly diagnosed with type 1 diabetes. She now has a headache, changes in her vision, and is anxious, but does not have her portable blood glucose monitor with her. Which action should the campus nurse advise her to take?Eat a piece of pizza. Eat 15 g of simple carbohydrates Take an extra dose of rapid-acting insulin. Drink some diet pop. The nurse has been teaching a patient with diabetes mellitus how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does what? Washes hands with soap and water to cleanse the site to be used. Tells the nurse that the result of 110 mg/dL indicates good control of diabetes. Warms the finger before puncturing the finger to obtain a drop of blood. Chooses a puncture site in the center of the finger pad. The surgeon was unable to spare a patient's parathyroid gland during a thyroidectomy. Which assessments should the nurse prioritize when providing postoperative care for this patient? Monitoring the patient's serum calcium levels and assessing for signs of hypocalcemia Monitoring the patient's hemoglobin, hematocrit, and red blood cell levels Assessing the patient's white blood cell levels and assessing for infection Monitoring the patient's level of consciousness and assessing for acute delirium or agitation The nurse is providing discharge instructions to a patient with diabetes insipidus. Which instructions regarding desmopressin acetate (DDAVP) would be most appropriate? The patient should report any decrease in urinary elimination to the health care provider. The patient can expect to experience weight loss resulting from increased diuresis The patient should alternate nostrils during administration to prevent nasal irritation. The patient should monitor for symptoms of hypernatremia as a side effect of this drug.The nurse should monitor for increases in which laboratory value for the patient as a result of being treated with dexamethasone (Decadron)? Potassium Sodium Calcium Blood glucose The patient has an order to receive 45 mg of prednisone by mouth daily. Available are 10 mg tablets. How many tablets should the nurse prepare to give? _______ tablets 4.5 What is a nursing priority in the care of a patient with a diagnosis of hypothyroidism? Closely monitoring the patient's intake and output Patient teaching related to levothyroxine (Synthroid) Providing a dark, low-stimulation environment Patient teaching related to radioactive iodine therapy During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do for the patient? Administer antiemetic medications. Administer a blood transfusion. Administer hypertonic saline. Decrease the rate of fluid removal. Which statement by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? "It is important for you to maintain a daily written record of blood pressure and weight." "It is essential that you maintain aseptic technique to prevent peritonitis." "You will need to continue regular medical and nursing follow-up visits while performing CAPD." "You will be allowed a more liberal protein diet once you complete CAPD."The nurse preparing to administer a dose of calcium acetate (PhosLo) to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value? Potassium Sodium Magnesium Phosphorus An intravenous piggyback (IVPB) of cefazolin 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record your answer using a whole number. ______ gtts/min 38 While reviewing the medical reports in an acute care setting, the nurse finds that the client is at risk for kidney damage and requests the healthcare provider to increase the intravenous fluid rate as a priority nursing intervention. Which finding supports the nurse’s conclusion? Systolic blood pressure is 120 mm Hg Pulse pressure is 40 mm Hg Blood osmolality is 280 milliosmoles per kg Urine output is 25 mL per hr A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? Skin turgor Client's report about fluid intake Intake and output results Blood lab resultsThe nurse is assessing four clients in the postoperative unit. Which client will be monitored for fluid volume overload as nursing safety priority? ABCD A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention? Get an additional IV infusion pump for the medication. Check the compatibility of the medication and the continuous IV solution. Flush the client's venous access device to ensure patency. Disconnect the continuous IV solution while administering the piggyback medication.A client has an IV of D5W 250 mL to which 100 mg of morphine is added. The healthcare provider prescribes 14 mg of morphine per hour for end of life palliative treatment of a client . At how many mL per hour should the nurse set the intravenous pump? Record your answer using a whole number. ___mL/hr 35 The nurse who is working during the 8:00 am to 4:00 pm shift must document a client’s fluid intake and output. An intravenous drip is infusing at 50 mL per hour. The client drinks 4 oz of orange juice and 6 oz of tea at 8:30 am and vomits 200 mL at 9:00 am. At 10:00 am the client drinks 60 mL of water with medications; the client voids 550 mL of urine at 11:00 am. At 12:30 pm, 3 oz of soup and 4 oz of ice cream are ingested. The client voids 450 mL at 2:00 pm. Calculate the total intake for the 8:00 am to 4:00 pm shift. Record your answer using a whole number. ___mL 970 What should a nurse assess after applying a body jacket brace to a client with severe spine injuries following a car accident? Select all that apply. Abdomen for decreased bowel sounds Areas of pressure over the bony prominences Development of cast syndrome Signs of compartment syndrome Pin sites A critically injured client was brought to the hospital following a car accident and the client should be immediately triaged for determining the nature and acuity of the injuries. Who is delegated to perform the task? Nurse manager Primary healthcare provider Licensed practical nurse Registered nurseWhat is the action of vasopressin? Stimulates bone marrow to make red blood cells Promotes sodium reabsorption Reabsorbs water into the capillaries Promotes tubular secretion of sodium What is the action of the vasopressin hormone released from the client’s posterior pituitary? Helps produce concentrated urine Enhances sodium reabsorption in the distal convoluted tubule Causes tubular secretion of sodium Promotes potassium secretion in the collecting duct The primary health care provider prescribed tolvaptan to a client whose laboratory reports reveal low plasma osmolarity and continued secretion of vasopressin from syndrome of inappropriate antidiuretic hormone. During follow-up care, which finding in the client indicates a side effect of medication? Increased urine osmolarity Increased demyelination of brain neurons Decreased hyponatremia Decreased deep tendon reflexes - [Show More]

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