Respiratory Therapists and Nurses are friends, right?
Our worlds are constantly colliding, there’s no denying that. As RT’s, we work closely with nurses on a daily basis, and it’s vital to the organization that we work well together. Through my experience, it seems that many Respiratory Therapists are interested in the field of Nursing, and many Nurses are interested in Respiratory. I’ve seen quite a few RT’s make the decision to go back to school for nursing, and that’s totally fine. I can understand that, at times, there are opportunities in that field and it’s a great way to expand your healthcare educational background. For those interested in become a nurse, I have compiled a nice study guide for you here. Or for those RT’s who are just interested in what nurses do; here are some questions for you to review. By learning the content in this post, it will definitely make you a better RT because it will help you have a better understanding of the ones you work most closely with on a daily basis – the nurses.
A Respiratory Therapist’s Nursing Study Guide
The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30 mm Hg, and HCO3– of 20 mEq/L. The nurse analyzes these results as indicating which condition?1. Metabolic acidosis, compensated2. Respiratory alkalosis, compensated3. Metabolic alkalosis, uncompensated4. Respiratory acidosis, uncompensated2. Respiratory alkalosis, compensated
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder?1. Metabolic acidosis2. Metabolic alkalosis3. Respiratory acidosis4. Respiratory alkalosis2. Metabolic alkalosis
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?1. A decreased pH and an increased CO22. An increased pH and a decreased CO23. A decreased pH and a decreased HCO3-4. An increased pH with an increased HCO3–4. An increased pH with an increased HCO3–
The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder?1. Metabolic acidosis2. Metabolic alkalosis3. Respiratory acidosis4. Respiratory alkalosis1. Metabolic acidosis
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. On the basis of this documentation, which pattern did the nurse observe?1. Respirations that cease for several seconds2. Respirations that are regular but abnormally slow3. Respirations that are labored and increased in depth and rate4. Respirations that are abnormally deep, regular, and increased in rate4. Respirations that are abnormally deep, regular, and increased in rate
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco2 is 90 mm Hg, and HCO3– is 22 mEq/L. The nurse interprets the results as indicating which condition?1. Metabolic acidosis with compensation2. Respiratory acidosis with compensation3. Metabolic acidosis without compensation4. Respiratory acidosis without compensation4. Respiratory acidosis without compensation
The nurse notes that a client’s arterial blood gas results reveal a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these arterial blood gas results? Select all that apply.1. Nausea2. Confusion3. Bradypnea4. Tachycardia5. Hyperkalemia6. Lightheadedness
- 1. Nausea
- 2. Confusion
- 4. Tachycardia
- 6. Lightheadedness
The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse’s findings?1. pH 7.25, Pco2 50 mm Hg2. pH 7.35, Pco2 40 mm Hg3. pH 7.50, Pco2 52 mm Hg4. pH 7.52, Pco2 28 mm Hg1. pH 7.25, Pco2 50 mm Hg
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?1. Sodium level of 145 mEq/L2. Potassium level of 3.0 mEq/L3. Magnesium level of 2.0 mg/dL4. Phosphorus level of 4.0 mg/dL2. Potassium level of 3.0 mEq/L
The nurse plans care for a client with chronic obstructive pulmonary disease (COPD), understanding that the client is most likely to experience what type of acid-base imbalance?1. Metabolic acidosis2. Metabolic alkalosis3. Respiratory acidosis4. Respiratory alkalosis3. Respiratory acidosis
The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Pco2 of 58 mm Hg, Po2 of 80 mm Hg, and Hco3– of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance?1. Metabolic acidosis2. Metabolic alkalosis3. Respiratory acidosis4. Respiratory alkalosis3. Respiratory acidosis
A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?1. Bradycardia and hyperactivity2. Decreased respiratory rate and depth3. Headache, restlessness, and confusion4. Bradypnea, dizziness, and paresthesias3. Headache, restlessness, and confusion
The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit and notes a pH of 7.38, PaCO2 of 38 mm Hg, PaO2 of 86 mm Hg, and HCO3– of 23 mEq/L. The nurse interprets that these values indicate which result?1. Normal results2. Metabolic acidosis3. Metabolic alkalosis4. Respiratory acidosis1. Normal results
A client has had an arterial blood gas sample drawn from the radial artery, and the nurse is asked to hold pressure on the site. The nurse should apply pressure for at least how many minute(s)?1. 1 minute2. 2 minutes3. 5 minutes4. 10 minutes3. 5 minutes
The nurse is reviewing the arterial blood gas (ABG) values of a client and notes that the pH is 7.31, Pco2 is 50 mm Hg, and the bicarbonate (HCO3–) level is 27 mEq/L. The nurse concludes that which acid-base disturbance is present in this client?1. Metabolic acidosis2. Metabolic alkalosis3. Respiratory acidosis4. Respiratory alkalosis3. Respiratory acidosis
In a client seen in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, Pco2 32 mm Hg, Po2 94 mm Hg, HCO3– level 24 mEq/L. The nurse interprets that the client has which acid-base disturbance?1. Metabolic acidosis2. Metabolic alkalosis3. Respiratory acidosis4. Respiratory alkalosis4. Respiratory alkalosis
A client has a prescription for arterial blood gas (ABG) analysis on radial artery specimens. The nurse ensures that which intervention has been performed or tested before the ABG specimens are drawn?1. Allen’s test2. Goodell’s sign3. Babinski reflex4. Brudzinski’s sign1. Allen’s test
An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?1. Headache and tachypnea2. Hyperactivity and dyspnea3. Muscle twitches and cyanosis4. Lightheadedness and paresthesias4. Lightheadedness and paresthesias
The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission work-up on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention?1. Perform the Allen’s test.2. Apply a warm compress.3. Administer the antidote for heparin.4. Notify the hospital laboratory supervisor.2. Apply a warm compress.
A client has a prescription for a set of arterial blood gas (ABGs) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action?1. Remove the nasal cannula for 15 minutes; then have the ABG samples drawn.2. Change the nasal cannula to a shovel face mask; then have the ABG samples drawn.3. Leave the nasal cannula in place for 15 minutes; then have the ABG samples drawn.4. Change the nasal cannula to a Venturi face mask; then have the ABG samples drawn.1. Remove the nasal cannula for 15 minutes; then have the ABG samples drawn.
A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse develops a plan of care to support the client physiologically until the tubular cells secrete a sufficient amount of which substance?1. Phosphates2. Hydrogen ions3. Ammonium ions4. Carbon dioxide molecules2. Hydrogen ions
A client suffering from prolonged vomiting has developed metabolic alkalosis. The nurse plans care, knowing that this imbalance will be corrected primarily when the kidneys do which function?1. Secrete sufficient water.2. Retain sufficient chloride.3. Secrete sufficient potassium.4. Retain sufficient hydrogen ions.4. Retain sufficient hydrogen ions.
A nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse understands that as the client’s CO2 level rises, what will occur with the blood pH?1. Fall2. Rise3. Double4. Remain unchanged1. Fall
The nurse is planning to obtain blood for arterial blood gas (ABG) analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn?1. Holding a warm compress over the puncture site for 5 minutes2. Encouraging the client to open and close the hand rapidly for 2 minutes3. Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes4. Having the client keep the radial pulse puncture site in a dependent position for 5 minutes3. Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes
A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse should develop a plan of care because the client is at risk for the development of which type of acid-base imbalance?1. Metabolic acidosis2. Metabolic alkalosis3. Respiratory acidosis4. Respiratory alkalosis1. Metabolic acidosis
A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse should plan to carry out which prescribed measure as the most effective means to treat the problem?1. Administer prescribed antibiotics.2. Have the client breathe into a paper bag.3. Administer antipyretics as needed (on PRN basis).4. Request a prescription for a partial rebreather oxygen mask.1. Administer prescribed antibiotics.
The nurse is caring for a client with chronic kidney disease. Arterial blood gas (ABG) results indicate a pH of 7.30, a Pco2 of 32 mm Hg, and a bicarbonate concentration of 20 mEq/L. Which laboratory value should the nurse expect to note?1. Sodium level of 145 mEq/L2. Potassium level of 5.2 mEq/L3. Phosphorus level of 4.0 mg/dL4. Magnesium level of 2.0 mg/dL2. Potassium level of 5.2 mEq/L
The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?1. Metabolic acidosis2. Metabolic alkalosis3. Respiratory acidosis4. Respiratory alkalosis2. Metabolic alkalosis
The nurse reviews the arterial blood gas (ABG) results of an assigned client and notes that the laboratory report indicates a pH of 7.30, a Pco2 of 58 mm Hg, a Po2 of 80 mm Hg, and an Hco3– of 27 mEq/L. The nurse should interpret this to mean that the client has which acid-base disturbance?1. Metabolic acidosis2. Metabolic alkalosis3. Respiratory acidosis4. Respiratory alkalosis3. Respiratory acidosis
The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse assesses this client for which signs/symptoms that are characteristic of this disorder?1. Bradycardia and hyperactivity2. Decreased respiratory rate and depth3. Headache, restlessness, and confusion4. Bradypnea, dizziness, and paresthesias3. Headache, restlessness, and confusion
A nurse reviews the arterial blood gas results of a client with Guillain-Barré syndrome. The pH is 7.34 and the Pco2 is 50 mm Hg. Which acid-base imbalance should the nurse interpret that this client is experiencing?1. Metabolic acidosis2. Metabolic alkalosis3. Respiratory acidosis4. Respiratory alkalosis3. Respiratory acidosis
A client is admitted to the hospital 24 hours following an aspirin (acetylsalicylic acid) overdose. The nurse assesses this client for which signs/symptoms, indicating the acid-base disturbance that could occur in the client?1. Bradypnea, dizziness, and paresthesias2. Bradycardia, listlessness, and hyperactivity3. Headache, nausea, vomiting, and diarrhea4. Restlessness, confusion, and a positive Trousseau’s sign3. Headache, nausea, vomiting, and diarrhea
A nurse reviews a client’s arterial blood gas values and notes a pH of 7.50, a Pco2 of 30 mm Hg, and an HCO3– of 25 mEq/L. The nurse should interpret these values as an indication of which condition?1. Metabolic acidosis, uncompensated2. Respiratory acidosis, uncompensated3. Respiratory alkalosis, uncompensated4. Metabolic acidosis, partially compensated3. Respiratory alkalosis, uncompensated
The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen’s test on the client. The nurse would perform the steps in which order to conduct an Allen’s test? Arrange the actions in the order that they should be performed. All options must be used.1. Apply pressure over the ulnar and radial arteries.2. Release pressure from the ulnar artery.3. Explain the procedure to the client.4. Document the findings.5.Ask the client to open and close the hand repeatedly.6. Assess the color of the extremity distal to the pressure point.
- 3. Explain the procedure to the client.
- 1. Apply pressure over the ulnar and radial arteries.
- 5. Ask the client to open and close the hand repeatedly.
- 2. Release pressure from the ulnar artery.
- 6. Assess the color of the extremity distal to the pressure point.
- 4. Document the findings.
A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas determination. Before the blood is drawn, an Allen’s test is performed to determine the adequacy of which?1. Ulnar circulation2. Carotid circulation3. Femoral circulation4. Popliteal circulation1. Ulnar circulation
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which did the nurse observe?1. Respirations that cease for several seconds2. Respirations that are regular but abnormally slow3. Respirations that are labored and increased in depth and rate4. Respirations that are abnormally deep, regular, and increased in rate4. Respirations that are abnormally deep, regular, and increased in rate
The nurse reviews a client’s arterial blood gas results and notes that the pH is 7.30, the Pco2 is 52 mm Hg, and the HCO3– is 22 mEq/L. The nurse interprets these results as indicating which condition?1. Metabolic acidosis, compensated2. Respiratory alkalosis, compensated3. Metabolic alkalosis, uncompensated4. Respiratory acidosis, uncompensated4. Respiratory acidosis, uncompensated
A client with diabetes mellitus has a blood glucose level on admission of 596 mg/dL. The nurse should anticipate that this client could be experiencing which type of acid-base imbalance?1. Metabolic acidosis2. Metabolic alkalosis3. Respiratory acidosis4. Respiratory alkalosis1. Metabolic acidosis
A nurse is admitting a client with a diagnosis of Guillain-Barré syndrome to the hospital. The nurse knows that if the disease is severe enough, the client will be at risk for which acid-base imbalance?1. Metabolic acidosis2. Metabolic alkalosis3. Respiratory acidosis4. Respiratory alkalosis3. Respiratory acidosis
A client is determined to be in respiratory alkalosis by blood gas analysis. Which electrolyte disorder should the nurse monitor for that could accompany the acid-base balance?1. Hypokalemia2. Hypercalcemia3. Hypochloremia4. Hypernatremia1. Hypokalemia
A client with a chronic airflow limitation (CAL) is experiencing respiratory acidosis as a complication. A nurse who is trying to enhance the client’s respiratory status should avoid which action?1. Keeping the head of the bed elevated2. Monitoring the flow rate of supplemental oxygen3. Assisting the client to turn, cough, and breathe deeply4. Encouraging the client to breathe slowly and shallowly4. Encouraging the client to breathe slowly and shallowly
An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid-base disorder?1. Put the client in a supine position.2. Provide emotional support and reassurance.3. Withhold all sedative or antianxiety medications.4. Tell the client to breathe very deeply but more slowly.2. Provide emotional support and reassurance.
A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis?1. Sodium2. Potassium3. Magnesium4. Phosphorus2. Potassium
A nurse is caring for a client who is experiencing metabolic alkalosis. The nurse plans to protect the client’s safety knowing the risks of this imbalance, by carefully implementing which prescribed precaution?1. Contact isolation2. Seizure precautions3. Bleeding precautions4. Neutropenic precautions2. Seizure precautions
A nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse should expect to note which findings associated with an anticipated acid-base disturbance?1. Disorientation and dyspnea2. Drowsiness, headache, and tachypnea3. Tachypnea, dizziness, and paresthesias4. Decreased respiratory rate and depth, cardiac irregularities2. Drowsiness, headache, and tachypnea
A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse should monitor this client, expecting to note which signs/symptoms?1. Disorientation and dyspnea2. Decreased respiratory rate and depth3. Drowsiness, headache, and tachypnea4. Tachypnea, dizziness, and paresthesias2. Decreased respiratory rate and depth
A nurse is providing care to a client with the following arterial blood gas (ABG) results: pH 7.50; Pao2 90 mm Hg; Paco2 40 mm Hg; and bicarbonate 35 mEq/L. When the nurse notifies the health care provider (HCP) about these levels, the nurse should anticipate receiving which prescription for this client from the HCP?1. Obtain a serum alcohol level.2. Obtain a serum salicylate level.3. Discontinue nasogastric suctioning.4. Discontinue the client’s Fentanyl patch.3. Discontinue nasogastric suctioning.
The nurse in a neonatal intensive care nursery (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse’s highest priority?1. Turn on the apnea and cardiorespiratory monitors.2. Connect the resuscitation bag to the oxygen outlet.3. Set up the intravenous line with 5% dextrose in water.4. Set the radiant warmer control temperature at 36.5° C (97.6° F).2. Connect the resuscitation bag to the oxygen outlet.
A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.1. Restrict fluids.2. Assess for airway patency.3. Administer oxygen as prescribed.4. Place a cooling blanket on the client.5. Elevate extremities if no fractures are present.6. Prepare to give oral pain medication as prescribed.
- 2. Assess for airway patency.
- 3. Administer oxygen as prescribed.
- 5. Elevate extremities if no fractures are present.
A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?1. 100% oxygen via an aerosol mask2. Oxygen via nasal cannula at 6 L/minute3. Oxygen via nasal cannula at 15 L/minute4. 100% oxygen via a tight-fitting, nonrebreather face mask4. 100% oxygen via a tight-fitting, nonrebreather face mask
A client is admitted to an emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the client’s chart. The nurse should alert the health care provider because these changes are most consistent with which complication?1. Cardiogenic shock2. Cardiac tamponade3. Pulmonary embolism4. Dissecting thoracic aortic aneurysm1. Cardiogenic shock
A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed?1. Defibrillate the client.2. Administer digoxin (Lanoxin).3. Continue to monitor the client.4. Prepare for transcutaneous pacing.4. Prepare for transcutaneous pacing.
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply.1. Administering oxygen2. Inserting a Foley catheter3. Administering furosemide (Lasix)4. Administering morphine sulfate intravenously5. Transporting the client to the coronary care unit6. Placing the client in a low Fowler’s side-lying position
- 1. Administering oxygen
- 2. Inserting a Foley catheter
- 3. Administering furosemide (Lasix)
- 4. Administering morphine sulfate intravenously
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client’s breath sounds?1. Stridor2. Crackles3. Scattered rhonchi4. Diminished breath sounds2. Crackles
A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for?1. Bradycardia2. Ventricular dysrhythmias3. Rising diastolic blood pressure4. Falling central venous pressure2. Ventricular dysrhythmias
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?1. Hypovolemia2. Acute kidney injury3. Glomerulonephritis4. Urinary tract infection2. Acute kidney injury
The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia?1. Sinus tachycardia2. Ventricular fibrillation3. Ventricular tachycardia4. Premature ventricular contractions3. Ventricular tachycardia
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia?1. It can develop into ventricular fibrillation at any time.2. It is almost impossible to convert to a normal rhythm.3. It is uncomfortable for the client, giving a sense of impending doom.4. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.1. It can develop into ventricular fibrillation at any time.
A client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs/symptoms?1. Flat neck veins2. Nausea and vomiting3. Hypotension and dizziness4. Hypertension and headache3. Hypotension and dizziness
The nurse is watching the cardiac monitor, and a client’s rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client’s heart rhythm?1. Atrial fibrillation2. Sinus tachycardia3. Ventricular fibrillation4. Ventricular tachycardia1. Atrial fibrillation
The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client’s urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL most recent). The client’s blood urea nitrogen level is 35 mg/dL and the serum creatinine level is 1.8 mg/dL, measured this morning. Which nursing action is the priority?1. Check the urine specific gravity.2. Call the health care provider (HCP).3. Check to see if the client had a sample for a serum albumin level drawn.4. Put the intravenous (IV) line on a pump so that the infusion rate is sure to stay stable.2. Call the health care provider (HCP).
The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client’s rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm?1. Asystole2. Atrial fibrillation3. Ventricular fibrillation4. Ventricular tachycardia3. Ventricular fibrillation
A client receiving thrombolytic therapy with a continuous infusion of alteplase (Activase) suddenly becomes extremely anxious and complains of itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which nursing action is the priority?1. Administer oxygen and protamine sulfate.2. Cut the infusion rate in half and sit the client up in bed.3. Stop the infusion and call the health care provider (HCP).4. Administer diphenhydramine (Benadryl) and continue the infusion.3. Stop the infusion and call the health care provider (HCP).
The nurse should report which assessment finding to the health care provider (HCP) before initiating thrombolytic therapy in a client with pulmonary embolism?1. Adventitious breath sounds2. Temperature of 99.4° F orally3. Blood pressure of 198/110 mm Hg4. Respiratory rate of 28 breaths/minute3. Blood pressure of 198/110 mm Hg
A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What is the priority nursing action?1. Monitor vital signs every 15 minutes for the next hour.2. Discontinue dialysis and notify the health care provider (HCP).3. Continue dialysis at a slower rate after checking the lines for air.4. Bolus the client with 500 mL of normal saline to break up the air embolus.2. Discontinue dialysis and notify the health care provider (HCP).
During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action?1. Call the health care provider (HCP).2. Reassure the client that this is normal.3. Turn the client onto his or her operative side.4. Administer the prescribed pain medication and antiemetic.1. Call the health care provider (HCP).
A client arrives in the emergency department following an automobile crash. The client’s forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position?1. Flat in bed2. A semi-Fowler’s position3. Lateral on the affected side4. Lateral on the unaffected side2. A semi-Fowler’s position
The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately?1. Apply ice to the affected eye.2. Irrigate the eye with cool water.3. Notify the health care provider (HCP).4. Accompany the client to the emergency department.1. Apply ice to the affected eye.
A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initialnursing action?1. Apply an eye patch.2. Perform visual acuity tests.3. Irrigate the eye with sterile saline.4. Remove the piece of wood using a sterile eye clamp.2. Perform visual acuity tests.
A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take whichimmediate action?1. Irrigate the eyes with water.2. Come to the emergency department.3. Call the health care provider (HCP).4. Irrigate the eyes with diluted hydrogen peroxide.1. Irrigate the eyes with water.
A client develops an anaphylactic reaction after receiving morphine sulfate. The nurse should plan to institute which actions? Select all that apply.1. Administer oxygen.2. Quickly assess the client’s respiratory status.3. Document the event, interventions, and client’s response.4. Leave the client briefly to contact a health care provider.5. Keep the client supine regardless of the blood pressure readings.6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.
- 1. Administer oxygen.
- 2. Quickly assess the client’s respiratory status.
- 3. Document the event, interventions, and client’s response.
A child is receiving succimer (Chemet) for the treatment of lead poisoning. A nurse should monitor which most important laboratory result?1. Iron level2. Calcium level3. Red blood cell count4. Blood urea nitrogen level4. Blood urea nitrogen level
A client with a probable minor head injury resulting from a motor vehicle crash is admitted to the hospital for observation. The nurse leaves the cervical collar applied to the client in place until when?1. The family comes to visit.2. The nurse needs to do physical care.3. The health care provider makes rounds.4. The results of spinal radiography are known.4. The results of spinal radiography are known.
A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action?1. Remove the dressing.2. Reinforce the dressing.3. Call the health care provider (HCP).4. Measure oxygen saturation by oximetry.1. Remove the dressing.
The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving greater than 25% of total body surface area. In performing the assessment, the nurse knows that the maximum amount of edema that occurs from a burn normally is noted at which time frame?1. Immediately after the injury2. Within 12 hours after the injury3. Between 18 and 24 hours after the injury4. Between 42 and 72 hours after the injury3. Between 18 and 24 hours after the injury
The nurse in the emergency department is caring for a client who was in a motor vehicle crash and is experiencing hypovolemic shock. A pneumatic antishock garment (PASG), also known as shock trousers, is applied for treatment until the client can be transferred to the intensive care unit (ICU). While awaiting client transfer to the ICU, the emergency department nurse should perform which critical assessment?1. Assessing radial pulses2. Monitoring hemoglobin and hematocrit levels3. Assessing vascular status of the upper extremities4. Monitoring vascular status of the lower extremities4. Monitoring vascular status of the lower extremities
A left atrial catheter is inserted into a client during cardiac surgery. The nurse is monitoring the left atrial pressure (LAP) and documents the following pressure. Which readings are within normal limits (WNL) for the client? Select all that apply.1. 6 mm Hg2. 8 mm Hg3. 15 mm Hg4. 25 mm Hg5. 32 mm Hg
- 1. 6 mm Hg
- 2. 8 mm Hg
The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction?1. “Flames should be doused with water.”2. “Flames may be extinguished by rolling the client on the ground.”3. “Flames may be smothered by the use of a blanket or another cover.”4. “The client should be maintained in a standing position because the flames may spread to the other parts of the body.”4. “The client should be maintained in a standing position because the flames may spread to the other parts of the body.”
The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action?1. Cooling the injury with water2. Removing all clothing immediately3. Removing the tar from the burn injury4. Leaving any clothing that is saturated with tar in place1. Cooling the injury with water
The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care?1. Removing all clothing, including gloves and shoes2. Determining the antidote for the chemical and placing the antidote on the burn site3. Leaving all clothing in place until the client is brought to the emergency department4. Lavaging the skin with water and avoiding brushing powdered chemicals off the clothing1. Removing all clothing, including gloves and shoes
A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is most likelyexperiencing which condition?1. Pain2. Fear3. Hypoxia4. Anxiety3. Hypoxia
A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment?1. Pain medication2. Endotracheal intubation3. Oxygen via nasal cannula4. 100% humidified oxygen by face mask4. 100% humidified oxygen by face mask
The nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a fire. Which assessment finding would indicate that the client sustained a respiratory injury as a result of the burn?1. Fear and anxiety2. Complaints of pain3. Clear breath sounds4. Use of accessory muscles for breathing4. Use of accessory muscles for breathing
The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client?1. Assessing heart rate2. Assessing respiratory rate3. Assessing peripheral pulses4. Assessing blood pressure (BP)3. Assessing peripheral pulses
The nurse has developed a client problem of ineffective airway clearance for a client who sustained an inhalation burn injury. Which nursing intervention should the nurse include in the plan of care for this client?1. Elevate the head of the bed.2. Monitor oxygen saturation levels every 4 hours.3. Encourage coughing and deep breathing every 4 hours.4. Assess respiratory rate and breath sounds every 4 hours.1. Elevate the head of the bed.
The nurse has developed a nursing care plan for a client with a burn injury. The client problem states deficient fluid volume. Which intervention should the nurse include in the plan of care as a priority intervention?1. Monitor vital signs every 4 hours.2. Monitor mental status every hour.3. Monitor intake and output every shift.4. Obtain and record weight every other day.2. Monitor mental status every hour.
The nurse is developing a nursing care plan for a client with a circumferential burn injury of the extremity. The client problem states ineffective tissue perfusion. Which nursing intervention should the nurse include in the plan of care for the client?1. Monitor peripheral pulses every hour.2. Keep the extremities in a dependent position.3. Document any changes that occur in the pulse.4. Place pressure dressings and wraps around the burn sites.1. Monitor peripheral pulses every hour.
Vasopressin is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse should prepare to administer this medication by which route?1. Orally2. By inhalation3. By intramuscular route4. Through a Sengstaken-Blakemore tube3. By intramuscular route
Vasopressin therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which essential item is needed during the administration of this medication?1. An airway2. A suction setup3. A cardiac monitor4. A tracheotomy set3. A cardiac monitor
The nurse is monitoring a client who required a Sengstaken-Blakemore tube because other measures for treating bleeding esophageal varices were unsuccessful. The client complains of severe pain of abrupt onset. Which nursing action is most appropriate?1. Cut the tube.2. Reposition the client.3. Assess the lumens of the tubes.4. Administer the prescribed analgesics.1. Cut the tube.
A postpartum client who received an epidural analgesic after giving birth by cesarean section is lethargic and has a respiratory rate of 8 breaths per minute. The nurse should obtain which medication from the emergency cart after notifying the health care provider?1. Betamethasone2. Morphine sulfate3. Naloxone (Narcan)4. Meperidine hydrochloride (Demerol)3. Naloxone (Narcan)
The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition?1. Heart failure2. Pulmonary edema3. Cardiogenic shock4. Aortic insufficiency3. Cardiogenic shock
The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The nurse documents this assessment finding as expected because the edema is caused by which factor?1. A decrease in capillary permeability and hypoproteinemia2. A decrease in capillary permeability and hyperproteinemia3. An increase in capillary permeability and hypoproteinemia4. An increase in capillary permeability and hyperproteinemia3. An increase in capillary permeability and hypoproteinemia
The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client’s respiratory status had worsened if which is noted on assessment?1. Diminished breath sounds2. Wheezing during inhalation3. Wheezing during exhalation4. Wheezing throughout the lung fields1. Diminished breath sounds
The nurse is performing an assessment on a client who was admitted with a diagnosis of carbon monoxide poisoning. Which assessment performed by the nurse would primarily elicit data related to a deterioration of the client’s condition?1. Skin color2. Apical rate3. Respiratory rate4. Level of consciousness4. Level of consciousness
The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report?1. Hematocrit 60%2. Serum albumin 4.8 g/dL3. Serum sodium 144 mEq/L4. White blood cell (WBC) count 9000 cells/mm31. Hematocrit 60%
The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item?1. Pain level2. Lung sounds3. Ability to swallow4. Laboratory results2. Lung sounds
Acetylcysteine (Mucomyst) is prescribed for a client in the hospital emergency department after diagnosis of acetaminophen (Tylenol) overdose. The nurse prepares to administer the medication using which procedure?1. Diluting the medication in cola and administering it to the client orally2. Calling the respiratory department to administer the medication via inhaler3. Obtaining a 1-mL syringe to administer the small dose via the subcutaneous route4. Initiating an intravenous line and diluting the medication in 100 mL of normal saline for administration1. Diluting the medication in cola and administering it to the client orally
A nurse receives a telephone call from a neighbor, who states that her 3-year-old child was found sitting on the kitchen floor with an empty bottle of liquid furniture polish. The mother of the child tells the nurse that the bottle was half full, that the child’s breath smells like the polish, and that spilled polish is present on the front of the child’s shirt. What should the nurse tell the mother to do?1. Call the pediatrician.2. Induce vomiting immediately.3. Call the poison control center.4. Wait until the nurse comes to bring the child to the emergency department.3. Call the poison control center.
The nurse is caring for a client who sustained multiple fractures in a motor vehicle crash 12 hours earlier. The client now exhibits severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the initial nursing action?1. Reassess the vital signs.2. Perform a neurological assessment.3. Position the client in a supine position.4. Position the client in a Fowler’s position.4. Position the client in a Fowler’s position.
The home health nurse is visiting an older client whose family has gone out for the day. During the visit, the client experiences chest pain that is unrelieved by sublingual nitroglycerin tablets given by the nurse. Which action by the nurse would be appropriate at this time?1. Notify a family member who is the next of kin.2. Drive the client to the health care provider’s (HCP) office.3. Inform the home care agency supervisor that the visit may be prolonged.4. Call for an ambulance to transport the client to the hospital emergency department.4. Call for an ambulance to transport the client to the hospital emergency department.
The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse knows that which observation of the client’s clinical condition is most favorable?1. Urine output of 40 mL/hr2. Heart rate of 110 beats/min3. Frequent premature ventricular contractions4. Central venous pressure (CVP) of 15 mm Hg1. Urine output of 40 mL/hr
A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable?1. CO 5 L/min, PCWP low2. CO 3 L/min, PCWP low3. CO 4 L/min, PCWP high4. CO 3 L/min, PCWP high4. CO 3 L/min, PCWP high
A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client’s left foot is cool and mottled and the left pedal pulse is weak. Which action should the nurse take?1. Call the health care provider immediately.2. Re-evaluate the neurovascular status in 1 hour.3. Increase the rate of intravenous nitroglycerin that is infusing.4. Document these findings, which are expected because of the catheter size.1. Call the health care provider immediately.
A nurse reading the operative record for a client who has undergone cardiac surgery notes that the client’s cardiac output immediately after surgery was 3.6 L/min. The nurse determines that this measurement indicates which finding?1. Above the normal range2. In the high-normal range3. In the low-normal range4. Below the normal range4. Below the normal range
The nurse has a prescription to administer acetylcysteine (Mucomyst) to a client admitted to the emergency department with acetaminophen (Tylenol) overdose. Before giving this medication, the nurse should ensure that which measure is done?1. The solution is given full strength.2. The client knows how to use a nebulizer.3. The stomach is empty by emesis or lavage.4. The antidote to acetylcysteine is readily available.3. The stomach is empty by emesis or lavage.
A postoperative client receives a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse should assess the client for which change?1. Pupillary changes2. Scattered lung wheezes3. Sudden increase in pain4. Sudden episodes of vomiting3. Sudden increase in pain
A new nursing graduate is caring for a client who is attached to a cardiac monitor. While assisting the client with bathing, the nurse observes the sudden development of ventricular tachycardia (VT), but the client remains alert and oriented and has a pulse. Which interventions would the nurse take? Select all that apply.1. Administer oxygen.2. Defibrillate the client.3. Obtain an electrocardiogram (ECG).4. Contact the health care provider (HCP).5. Assess circulation, airway, and breathing.6. Initiate cardiopulmonary resuscitation (CPR).
- 1. Administer oxygen.
- 3. Obtain an electrocardiogram (ECG).
- 4. Contact the health care provider (HCP).
- 5. Assess circulation, airway, and breathing.
An emergency department nurse is caring for a child with suspected acute epiglottitis. Which nursing interventions apply in the care of this child? Select all that apply.1. Ensure a patent airway.2. Obtain a throat culture.3. Maintain the child in a supine position.4. Obtain a pediatric-size tracheostomy tray.5. Prepare the child for a chest radiographic study.6. Place the child on an oxygen saturation monitor.
- 1.Ensure a patent airway.
- 4. Obtain a pediatric-size tracheostomy tray.
- 5. Prepare the child for a chest radiographic study.
- 6. Place the child on an oxygen saturation monitor.
A client with a left arm fracture supported in a cast complains of loss of sensation in the left fingers. The nursing assessment identifies pallor in the distal portion of the arm, poor capillary refill, and a diminished left radial pulse. On the basis of these findings, the nurse would take which as a priority action?1. Apply ice to the site.2. Document the findings.3. Administer pain medication.4. Contact the health care provider (HCP).4. Contact the health care provider (HCP).
A delivery room nurse is caring for a client in labor. The client tells the nurse that she feels that something is coming through the vagina. The nurse performs an assessment and notes the presence of the umbilical cord protruding from the vagina. The nurse should immediately place the client in which position?1. Prone2. Supine3. On the side4. Reverse Trendelenburg3. On the side
The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all that apply.1. Bradycardia2. Pulsus paradoxus3. Distant heart sounds4. Falling blood pressure5. Distended jugular veins
- 2. Pulsus paradoxus
- 3. Distant heart sounds
- 4. Falling blood pressure
- 5. Distended jugular veins
A client has frequent runs of ventricular tachycardia. The health care provider has prescribed an antidysrhythmic, flecainide (Tambocor). What is the best nursing action related to the effects of this medication?1. Monitor the client’s urinary output.2. Assess the client for neurological changes.3. Keep the call bell within the client’s reach.4. Monitor the client’s vital signs and cardiac rhythm frequently.4. Monitor the client’s vital signs and cardiac rhythm frequently.
The nurse suspects that a pulmonary embolism has developed in a postpartum client with femoral thrombophlebitis. What is the nurse’s priority action for this client?1. Check the vital signs.2. Elevate the head of the bed to 30 to 45 degrees.3. Initiate an intravenous line if one is not already in place.4. Administer oxygen by face mask as per protocol at 8 to 10 L/min.4. Administer oxygen by face mask as per protocol at 8 to 10 L/min.
The child with croup is being discharged from the hospital. The nurse provides instructions to the mother and advises the mother to bring the child to the emergency department if which occurs?1. The child is irritable.2. The child appears tired.3. The child develops stridor.4. The child takes fluids poorly.3. The child develops stridor.
The nurse employed at an industrial work site is summoned to attend to an employee who experienced a traumatic amputation of a finger. Which actions should the nurse take to provide emergency care and prepare the client for transport to the hospital? Select all that apply.1. Elevate the extremity above heart level.2. Assess the employee for airway or breathing problems.3. Remove the layered gauze every 10 minutes to check the bleeding.4. Wrap the severed finger in moistened gauze, and place it in a bag of ice water.5. Examine the amputation site and apply direct pressure to the site using layers of gauze.
- 1. Elevate the extremity above heart level.
- 2. Assess the employee for airway or breathing problems.
- 5. Examine the amputation site and apply direct pressure to the site using layers of gauze.
An emergency department nurse is caring for a conscious child who was brought to the emergency department after the ingestion of half of a bottle of acetylsalicylic acid (aspirin). The nurse anticipates that most likely what will be the initial treatment?1. Dialysis2. The administration of an emetic3. The administration of vitamin K4. The administration of sodium bicarbonate2. The administration of an emetic
The nurse is providing care for a client with new onset of a dysrhythmia. The nurse anticipates which prescriptions from the health care provider? Select all that apply. Refer to Figure.1. Oxygen therapy2. An echocardiogram3. An intravenous dose of metoprolol (Lopressor)4. One dose of atropine to promote slowing of the rate5. A bolus of intravenous heparin followed by a continuous infusion
- 1. Oxygen therapy
- 2. An echocardiogram
- 3. An intravenous dose of metoprolol (Lopressor)
- 5. A bolus of intravenous heparin followed by a continuous infusion
A depressed client is found unconscious on the floor in the dayroom. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. Which is the priority action of the nurse?1. Call the Poison Control Center.2. Try to figure out the number of pills taken.3. Induce vomiting and notify the health care provider for further prescriptions.4. Call the emergency response team because this incident presents a medical emergency.4. Call the emergency response team because this incident presents a medical emergency.
A client who is experiencing an anaphylactic reaction from eating shellfish is brought to the emergency department. Which immediate action should the nurse implement?1. Maintain a patent airway.2. Administer a corticosteroid.3. Administer epinephrine (Adrenalin).4. Instruct the client on the importance of obtaining a Medic-Alert bracelet.1. Maintain a patent airway.
The nurse prepares to administer acetylcysteine (Mucomyst) to the client with an overdose of acetaminophen (Tylenol). What is the appropriate action when administering this antidote?1. Administer the medication subcutaneously in the deltoid muscle.2. Administer the medication by intramuscular (IM) injection in the gluteal muscle.3. Mix the medication in a flavored ice drink and allowing the client to drink the medication.4. Administer the medication by an intravenous (IV) line, mixed in 50 mL of normal saline and piggybacked through the main IV line.3. Mix the medication in a flavored ice drink and allowing the client to drink the medication.
A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client’s central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing?1. Fat embolism2. Mediastinal shift3. Mediastinal flutter4. Hypovolemic shock3. Mediastinal flutter
A client develops atrial fibrillation with a ventricular rate of 140 beats/min and signs of decreased cardiac output. Which medication should the nurse anticipate administering first?1. Atropine sulfate2. Warfarin (Coumadin)3. Lidocaine (Xylocaine)4. Metoprolol (Lopressor)4. Metoprolol (Lopressor)
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. Which complication should the nurse immediately assess the client for?1. Pneumonia2. Pulmonary edema3. Pulmonary embolism4. Myocardial infarction3. Pulmonary embolism
A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report should the nurse expect to note, that are consistent with this disorder?1. Pao2 58 mm Hg, Paco2 32 mm Hg2. Pao2 60 mm Hg, Paco2 45 mm Hg3. Pao2 49 mm Hg, Paco2 52 mm Hg4. Pao2 73 mm Hg, Paco2 62 mm Hg3. Pao2 49 mm Hg, Paco2 52 mm Hg
The nurse in the labor room is performing an initial assessment on a newborn. The infant is evidencing mild to moderate respiratory distress, audible bowel sounds in the chest, and a scaphoid abdomen. The infant is responding poorly to bag and mask ventilation. The nurse plans for which actions in the care of this infant? Select all that apply.1. Start chest compressions.2. Notify the health care provider.3. Orally administer a sucrose solution.4. Position the infant flat on his right side.5. Insert an orogastric tube and connect it to low suction.6. Provide support for respiratory distress via an endotracheal (ET) tube.
- 2. Notify the health care provider.
- 5. Insert an orogastric tube and connect it to low suction.
- 6. Provide support for respiratory distress via an endotracheal (ET) tube.
A child is admitted to the hospital after being seen in the emergency department with complaints of right lower quadrant abdominal pain, nausea and vomiting, fever, and chills. The health care provider suspects appendicitis. Which assessment finding should the nurse immediately report to the health care provider?1. Sudden relief of pain2. Decreasing oral temperature3. Increasing complaints of pain4. Refusal to take fluids by mouth1. Sudden relief of pain
The mother of a 5-year-old boy is brought to the emergency department after ingesting a bottle of acetylsalicylic acid (ASA). Which procedure should be initially instituted with this child?1. Administer ipecac by mouth and monitor emesis.2. Institute a gastric lavage and administer activated charcoal.3. Administer a chelating agent such as calcium disodium edetate (calcium EDTA).4. Institute a gastric lavage and administer the antidote acetylcysteine (Mucomyst).2. Institute a gastric lavage and administer activated charcoal.
A mother brings her child to the emergency department. Based on the child’s sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. In anticipation of the health care provider’s prescriptions, in which order of priority would the nurse implement the actions? Arrange the actions in the order that they should be performed. All options must be used.1. Maintain a patent airway.2. Administer an antipyretic.3. Obtain an axillary temperature.4. Assess breath sounds by auscultation.5. Insert an intravenous line for fluid administration.6. Obtain an oxygen saturation level using pulse oximetry.
- 1. Maintain a patent airway.
- 4. Assess breath sounds by auscultation.
- 6. Obtain an oxygen saturation level using pulse oximetry.
- 5. Insert an intravenous line for fluid administration.
- 3. Obtain an axillary temperature.
- 2. Administer an antipyretic.
The nurse is caring for a client who has overdosed on phenobarbital (Luminal). The nurse anticipates which assessment finding with this client?1. Hyperthermia2. Hyperreflexia3. Deep respirations4. Shallow respirations4. Shallow respirations
The nurse is caring for a client who has overdosed on amphetamines. The nurse anticipates noting which assessment finding in this client?1. Bradypnea2. Bradycardia3. Hypothermia4. Hypertension4. Hypertension
A client experiencing cocaine toxicity is brought to the emergency department. The nurse should prepare to take which initial action?1. Ensure a patent airway.2. Administer naloxone (Narcan).3. Establish an intravenous access.4. Obtain a 12-lead electrocardiogram (ECG).1. Ensure a patent airway.
Which readings obtained from a client’s pulmonary artery catheter suggest that the client is in left-sided heart failure?1. Cardiac output of 5 L/min2. Right atrial pressure of 9 mm Hg3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg4. Pulmonary artery systolic/diastolic pressures of 24/10 mm Hg3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg
When developing a mechanically ventilated client’s plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply.1. Suction the oral cavity whenever needed.2. Apply topical antibiotics to the oral cavity.3. Change the ventilator circuit tubing every 2 hours.4. Maintain the client in a supine position at all times.5. Practice frequent oral hygiene, including teeth brushing.6. Practice meticulous hand hygiene, and wear gloves when suctioning or handling the endotracheal tube.
- 1. Suction the oral cavity whenever needed.
- 5. Practice frequent oral hygiene, including teeth brushing.
- 6. Practice meticulous hand hygiene, and wear gloves when suctioning or handling the endotracheal tube.
Which steps should occur first when using an automated external defibrillator (AED)?1. Place the AED in the analyze mode.2. Press the shock button if indicated.3. Check to see that no one is touching the client.4. Apply defibrillator pads on the client and attach cables to the AED.4. Apply defibrillator pads on the client and attach cables to the AED.
Which should the nurse do when setting up an arterial line?1. Tighten all tubing connections.2. Use macrodrop intravenous tubing.3. Level the transducer to the ventricle.4. Raise the height of the normal saline infusion to prevent backup.1. Tighten all tubing connections.
Which interventions would be included in the care of a client with a head injury and a subarachnoid bolt? Select all that apply.1. Monitor vital signs.2. Monitor neurological status.3. Monitor the dressing for signs of infection.4. Monitor for signs of increased intracranial pressure.5. Drain cerebrospinal fluid when the intracranial pressure is elevated.
- 1. Monitor vital signs.
- 2. Monitor neurological status.
- 3. Monitor the dressing for signs of infection.
- 4. Monitor for signs of increased intracranial pressure.
Which clinical manifestations of a tension pneumothorax should be of immediate concern to the nurse? Select all that apply.1. Bradypnea2. Flattened neck veins3. Decreased cardiac output4. Hyperresonance to percussion5. Tracheal deviation to the opposite side
- 3. Decreased cardiac output
- 4. Hyperresonance to percussion
- 5. Tracheal deviation to the opposite side
The nurse recognizes that which arterial blood gas value indicates impending hypoxemic respiratory failure?1. Pao2 65 mm Hg2. Paco2 70 mm Hg3. Pao2 55 mm Hg4. Paco2 60 mm Hg3. Pao2 55 mm Hg
A client is admitted to the hospital for an acute episode of angina pectoris. Which parameter is the priority for the nurse to monitor?1. Pulse and blood pressure2. Temperature and chest pain3. Food tolerance and urinary output4. Right upper quadrant pain and fatigue1. Pulse and blood pressure
The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition?1. Concussion2. Skull fracture3. Subdural hematoma4. Epidural hematoma4. Epidural hematoma
The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition?1. Spinal shock2. Pulmonary embolism3. Autonomic dysreflexia4. Malignant hyperthermia3. Autonomic dysreflexia
A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client’s vital signs, the nurse takes the following actions. Arrange the actions in the order that they should be performed. All options must be used.1. Raise the head of the bed.2. Check for bladder distention.3. Contact the health care provider.4. Loosen tight clothing on the client.5. Administer an antihypertensive medication.6. Document the occurrence treatment, and response.
- 1. Raise the head of the bed.
- 4. Loosen tight clothing on the client.
- 2. Check for bladder distention.
- 3. Contact the health care provider.
- 5. Administer an antihypertensive medication.
- 6. Document the occurrence treatment, and response.
A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic, and the respiratory rate is increased. The health care provider diagnoses a pulmonary embolism. Which actions should the nurse plan to take? Select all that apply.1. Administer oxygen.2. Assess the blood pressure.3. Start an intravenous (IV) line.4. Prepare to administer morphine sulfate.5. Place the client on bed rest in a supine position.6. Prepare to administer warfarin sodium (Coumadin).
- 1. Administer oxygen.
- 2. Assess the blood pressure.
- 3. Start an intravenous (IV) line.
- 4. Prepare to administer morphine sulfate.
A client whose cardiac rhythm was normal sinus rhythm suddenly exhibits a different rhythm on the monitor. The nurse should take which action?1. Continue to watch the monitor.2. Contact the health care provider.3. Check to see if cardiac medications are due.4. Call respiratory therapy to do a respiratory treatment.2. Contact the health care provider.
The nurse is assisting in the care of a client who is being seen in the clinic with a suspected acetaminophen (Tylenol) overdose. Which medication should the nurse plan to have readily available if the suspected diagnosis is confirmed?1. Auranofin (Ridaura)2. Pentostatin (Nipent)3. Fludarabine (Fludara)4. Acetylcysteine (Mucomyst)4. Acetylcysteine (Mucomyst)
A client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which is the priority nursing action?1. Take the client’s vital signs.2. Perform a complete abdominal assessment.3. Obtain a thorough history of the recent health status.4. Prepare to insert a nasogastric tube and test pH and occult blood.1. Take the client’s vital signs.
The nurse is admitting a child who arrived from the emergency department after treatment for acetaminophen (Tylenol) overdose. The nurse reviews the child’s record and expects to note that the child received which medication for the acetaminophen overdose?1. Protamine sulfate2. Epoetin alfa (Epogen)3. Acetylcysteine (Mucomyst)4. Ethylenediaminetetraacetic acid (EDTA)3. Acetylcysteine (Mucomyst)
The nurse is monitoring a child who is receiving ethylenediaminetetraacetic acid (EDTA) with BAL (British anti-Lewisite) for the treatment of lead poisoning. The nurse reviews the laboratory results of the child during treatment with this medication and is particularly concerned with monitoring which laboratory test result?1. Cholesterol level2. Blood urea nitrogen (BUN) level3. Complete blood cell (CBC) count4. Hemoglobin and hematocrit (H&H) levels2. Blood urea nitrogen (BUN) level
A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which treatment will be prescribed initially?1. Insertion of a Foley catheter2. Insertion of a nasogastric tube3. Administration of an anesthetic agent for sedation4. Application of an antimicrobial agent to the burns1. Insertion of a Foley catheter
A mother brings her child to the emergency department. Based on the child’s sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottis is suspected. In anticipation of the health care providers prescriptions, in which order should the nurse deliver interventions for this child? Arrange the actions in the order that they should be performed. All options much be used.1. Assess breath sounds.2. Obtain a pulse oximetry reading.3. Ask the mother about the precipitating events.4. Obtain weight for correct antibiotic dose infusion.5. Prepare for assisted ventilation and have necessary equipment available.
- 5. Prepare for assisted ventilation and have necessary equipment available.
- 1. Assess breath sounds.
- 2. Obtain a pulse oximetry reading.
- 4. Obtain weight for correct antibiotic dose infusion.
- 3. Ask the mother about the precipitating events.
A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse, making rounds at 1545, finds the client is apprehensive, complaining of a pounding headache, is dyspneic with chills, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?1. Shut off the infusion.2. Sit the client up in bed.3. Remove the angiocatheter and IV quickly.4. Place the client in Trendelenburg’s position.1. Shut off the infusion.
When performing a surgical dressing change of a client’s abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. What should the nurse do next?1. Apply a sterile dressing soaked with normal saline.2. Irrigate the wound, and apply a dry sterile dressing.3. Leave the incision exposed to the air to dry the area.4. Apply a povidone-iodine (Betadine)–soaked sterile dressing.1. Apply a sterile dressing soaked with normal saline.
The nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse should take which immediate action?1. Immerses the end of the tube in sterile saline2. Applies oxygen per nasal cannula at 2 L per minute3. Places in prone position while the client holds a breath4. Places a sterile dressing over the end of the chest tube1. Immerses the end of the tube in sterile saline
Which client situation is most appropriate for the nurse to consult with the rapid response team (RRT)?1. A 56-year-old, fourth hospital day after coronary artery bypass procedure, sore chest, pain with walking, temperature 97° F, heart rate 84 beats/min, respirations 22 breaths/min, blood pressure 122/78 mm Hg, bored with hospitalization2. A 45-year-old, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4° F, heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg3. A 72-year-old, 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion), temperature 97.8° F, heart rate 92 beats/min, respirations 28 breaths/min, blood pressure 136/86 mm Hg, anxious about going home4. An 86-year-old, 48 hours after operative repair of fractured hip (nail inserted), alert, oriented, using patient-controlled analgesia (PCA) pump, temperature 96.8° F, heart rate 60 beats/min, respirations 16 breaths/min, blood pressure 120/82 mm Hg, talking with daughter2. A 45-year-old, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4° F, heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg
1.4 stages of infection: incubation period, prodromal stage, illness stage, convalescence
2.ability to learn: developmental / physical ability
3.affective learning: expression of feelings and acceptance of attitude, opinion, values
4.allocating scares resources: a key issue in discussions about access to care
5.Anesthetics: depresses CNS from consciousness to unconsciousness; loss of responsiveness to sensory stimuli including pain; muscle, skeletal, and visceral smooth muscle relaxation; general or local
6.anuria: irreversible renal disease; need kidney transplant or dialysis; not producing urine; increased phosphorus in system
7.arteriosclerosis: hardening of arteries
8.Assessment:: collecting vital signs, pain levels, other signs/ symptoms
9.asymptomatic infection: when the infection does not cause any signs or symptoms, making the diagnosis
10.atherosclerosis: affects intima of arteries; plaque froms and narrows lumen of arteries; pain when tissues don’t get oxygen
11.autonomy: commitment to include clients in decisions
12.avian flu: H5N1; bird to human trough droppings, saliva, blood; stayed in Asia
13.bariatrics-: lap band reduction; gastric bypass
14.Basal metabolic rate (BMR): energy needed to maintain life
15.Behavioral responses to pain: clenching teeth, holding painful part, bent posture, grimaces, cries or moans, restlessness, frequent requests of the nurse; confused patient may not show reaction
16.beneficence: taking positive actions to help others
17.block and parish nursing: services based on need vs availability of reimbursement; religous involvement
18.body image affecting hygiene: a person’s subjective concept of his/her body appearance
19.Carbohydrates: main source of energy; glucose needed for brain, skeletal muscles, production of RBC/WBC, all functions of renal medulla; obtained from grains, fruits, veggies, milk, sugar, honey
20.cardiac panel: sodium, LDL/HDL, potassium, ABG, CKMB, triponin, C-Reactive, protein
21.causes of atherosclerosis: lifestyle; HTN; smoking; diabetes; genetic
22.causes of obesity: corticosteroids, estrogen, antidepression meds, overeating, unconscious eating, physical inactivity, genetics, Pretnezone
23.causes of urinary incontinence: urethral obstruction, surgical trauma, alterations in sensory/ motor innervation, medication side effects, anxiety
24.chain of infection: infectious agent/ pathogen > reservoir/ source for pathogen growth > portal of exit > mode of transportation > portal of entry > susceptible host
25.changes in pattern affecting sleep: illness (cardiac, resp, pain), RLS; food before bed; change in daily pattern
26.chenye-strokes: irregular breathing; altering rapid/apnea episodes; near death breathing pattern
27.clinics: screening to comprehensive care
28.cognitive learning: includes all intelectual behavior/ requires thinking
29.colonization: occurs when a microorganism invades the host but doesn’t cause infection
30.communicable disease: the infectious process transmitted from one person to another
31.communication-: process by which people affect one another; exchange of info, ideas, feelings; basic
component of human relationships; fundamental element of nurse-client relationship
32.consent: a signed form required for all routine treatment, hazardous procedures, and some other treatments; provisions made for deaf, illiterate, and foreign language clients
33.constipation: stool gets lodged in the intestines; a symptom not a disease
34.cultural variables in hygiene: people from diverse cultures practice different hygiene rituals
35.deep vein thrombosis: clots in the veins; usually in the extremities
36.definition of health: state of complete physical, mental, and social well being not merely the absence of
disease or infirmity
37.definition of nursing: an art and a science with limitless opportunities; client, family, and community centered; diagnosis and treatment of human response to actual and potential health problems
38.deontology: defines actions as right or wrong
39.developmental stage in hygiene: affects the patient’s ability to preform hygiene care
40.Diagnosis:: nurse makes a nursing diagnosis based on assessment of patient; not a medical diagnosis
41.diarrhea: liquid stool; associated with disorders affecting digestion, absorption, and secretion in GI tract
42.disinfection: eliminates many or all microorganisms with exception of spores from inaminate objects
43.dreams: occur in NREM and REM; REM in color; important for learning, memory, and adopting to stress
44.dysuris: pain or burning on urination
45.elements of communication: referent sender; message, receiver, channels, feedback, interpersonal
46.Endogenous HAI: when patient’s normal flora becomes altered (C.diff)
47.Erikson’s 8 stages of development: trust vs mistrust
autonomy vs shame and doubt
initiative vs guilt
industry vs inferiority
identity vs identity confusion
intimacy vs isolation
generativity vs stagnation
integrity vs despair
48.eschar: necrotic/black; surgically removed
49.ESRD: irreversible damage to kidney tissue
50.ethic of care: emphasizes the importance of understanding relationships, especially as they are revealed in narratives
51.Evaluation:: goal was met, partially met, not met; how effective the plan was for the patient and what should be changed for the patient
52.evidence based practice: interventions nurses do that are based on evidence
53.Exogenous HAI: from microorganisms outside the individual ( Salmonella)
54.factors affecting bowel elimination: age, diet/fluid intake, physical activity, psychological factors, personal habits, position during defecation, pregnancy, surgery/ anesthesia, meds/laxatives/ cathartics
55.factors influenceing infection: age, stress, disease process, treatment/ condition that compromise the immune system
56.factors influencing communication process: developmental level, gender, values/ perception, personal space, territoriality, roles/ relationships, environment, congruence
57.Factors influencing pain: age, fatigue, genes, neurological functions, social factors, spiritual factors, psychological factors, cultural factors
58.factors that affect med absorption: route of administration; ability to dissolve; blood flow to site of administration; body surface area; lipid solubility of medication
59.Fats: triglycerides and fatty acids; saturated or unsaturated; monounsaturated or polyunsaturated fatty acids; essential or nonessential
60.feminine ethics: focuses on the inequality between people
61.fidelity: agreement to keep promises
62.forms of communication: verbal, non-verbal
63.Free Radical Theory: presence of free radicals produced through normal respiration and metabolism cause damage to existing cells, some believe this can be reversed through consumption of vitamins and other products
64.functional incontinence: can’t make it to the bathroom in time; every 1/2 hr or 1 hr bring patient to bathroom/ put on schedule
65.futile care: interventions unlikely to produce benefit for the client
66.gastric bypass: malabsorption surgery; can cause dehydration and electrolyte problems; overeating can cause dumping syndrome-food deposits into small intestines too quickly
67.granulation tissue: healing tissue; looks beefy
68.hand hygiene: the most important technique used in preventing and controlling transmission of infection
69.health beliefs and motivation: motivation is the key factor in hygiene
70.health care delivery system: complex, dynamic, constantly changing; past 10-15 yrs managed care, primary care provider; services provided by a wide variety of licensed/ non-licensed staff
71.hematuria: blood in urine; not a good sign
72.hemodialysis: 3 days out of week, 3-4 hr long process; blood circulated through the machine and nitrogenous waste, fluid, electrolytes removed; BP before and after treatment; weight before and after; can be used for drug overdose
73.hospital and med centers: inpatient services, diagnostic and treatment services
74.how to process an ethical dilemma: 1. ask if this is an ethical dilemma
2. gather all relevant info
3. clarify values
4. verbalize problem
5. identify possible courses of action
6. negotiate a plan
7. evaluate plan
75.hyperventillation (kussmaul): >40 RR; over-breathing, decreased CO2 leads to alkaline; panic attack, stress/anxiety, fever/infection, intense exercise
76.hypoventillation: decreased ability to remove CO2 from body; pH below 7.35; RR below 12; emphysema/ CVA; hypoxic
77.hypoxia: decreased tissue oxygenation; restlessness, anxiety, confusion, increased heart rate and RR
78.ICU: close monitoring; 1:2 staffing; equipped with most advanced technology; staff educated in critical care principles/ techniques
79.impaction: result of unrelieved constipation; leaky drainage
80.Implementing:: following through with plan that was developed for the patient
81.incontinence: inability to control passage of feces or gas through rectum
82.infection: invasion of a susceptible host by pathogens or microorganisms. resulting in disease
83.insomnia: more than 45 min to fall asleep/ trouble staying asleep
84.interpersonal communication: one on one interaction; most frequently used; exchange of idea, problem solving, decision making
85.intrapersonal communication: occurs within, self verbalization, self awareness, self talk, guided imagery
86.JCAHO’s ethical standards: mandate that health care institutions provide multidisciplinary ethics committees or similar structures to write guidelines and policies, provides education, counselling, and support for staff on ethical issues
87.justice: being fair
88.kidney/ renal disease: not enough RBCs; anemia; metabolizes calcium and Vitamin D; ADL intolerance; risk for hyper/hypotension, anemia, soft bones, and fractures; caused by diabetes; patient has to out out at least 30mls per hour
89.labs for kidney/ renal disease: BUN, creatinine, GRF, Rennin, EPO
90.labs for obesity: electrolyte/sodium/potassium, blood glucose, triglycerides, hemoglobin, serum albumin
91.lab work for atherosclerosis: cholesterol; LDL/HDL, homocystine; C-Reactive protein
92.lap band reduction: removable, premanent life cange; can cause dehydration, electrolyte problem, backup into esophagus, blockage
93.laryngitits: inflammation/ swelling of larynx; occurs as single problem or with resp infection; risk/irritant-smoking; dry coughing; voice changes; throat cultures to check for strep; comfort care
94.Latrogenic HAI: from a procedure in a hospital
95.learning: purposeful acquisition of new knowledge, attitudes, behavior, or skills
96.learning environment: privacy, room temperature, lighting, noise, furniture, ventilation
97.left sided failure: blood backing up into lungs; shortness of breath; impaired gas exchange; hypertrophied left ventricle wall; coughing up blood; orthopnea; exertional dyspnea; cyanosis of extremities; paroxymal nocturnal dyspnea
98.loose stool: chunks of stool
99.management of obesity: decreased food intake, increased physical activity
100.MD, APRN office: annual PE and screening/ preventative education
101.Measurements for obesity: waist size, BMI, ideal weight for height
102.Medication absorption: the passage of medication molecules into the blood from the site of administration
103.medication interactions: when one med modifies the action of another
104.meds are excreted through:: kidney, liver, bowel, lungs, exocrine glands
105.Minerals: inorganic elements essential as catalysts in biochemical reactions; obtained in milk, eggs, meats, grains; maintains acid/base balance, osmotic pressure, oxygen transport
106.Morbid Obesity: 100% over weight for height
107.motivation to learn: person’s desire/ willingness to learn
108.myocardial infarction: pain (sudden onset, substernal, crushing/ tightness/severe; affects back, neck, jaw, arm, shoulder), dyspnea, syncope with low BP, shortness of breath, nausea, vomiting, sweating, increased heart rate, DENIAL
109.myocardial ischemia: chest pain, aching, associated with activity, pain leaves when patient rests
110.Naloxone (Narcan): opiate antagonist, reverses opioid induced resiratory depression
111.narcolepsy: falling asleep at inappropriate times
112.need for nurse to teach client: clarify info given by doc or other health care providers; has to be complete, accurate, and relevant; should be based on patient’s needs and learning ability
113.nephrostomy: urinary diversion; bypasses the ureters, bladder, urethra; used in patient with kidney stones, cancer, ureter problem, any GU problem
114.new philosophy of health care: manage health; wellness and prevention
115.nocturia: voiding at night; early sign of hypertension; pressure on bladder during pregnancy
116.non-maleficence: avoidance of harm/ hurt
117.Normal range for BP: 100/60-140-90
118.Normal range for pulse: 60-100
119.Normal range for pulse ox.: >95%
120.Normal range for respirations: 12-20
121.Normal range for temperature: 96.8-100.4
122.NSAIDS & non-opiates: has analgesic/ antipyretic effects; available OTC; used for moderate to mild pain; blocks pain impulses by inhibiting prostaglandin synthesis; lethal when overdosed; do not take with
alcohol; do not take if liver dysfunction, possible liver failure
123.nursing centers: focus on health promotion/ health education, disease prevention, chronic disease management, support for self-care and caregivers
124.the nursing shortage: produces difficult working conditions and affects client outcomes
125.Obese: increased weight for height by 10% or more
126.occupational health: health promotion, accident or illness prevention
127.old philosophy of health care: manage illness; disease management
128.oliguria: patient has some form of renal failure; not producing as much urine as regular patient; strict I&Os
129.Opioids: pain relivers that contain opium or chemically related to opium; ordered for moderate to severe pain such as post-op, chronic non-cancer, or cancer; depresses respiratory center, causes constipation, itching, altered mental status
130.Pain threshold: level of stimulus needed to produce the perception of pain
131.Pain tolerance: amount of pain a patient endures without its interference of ADLs
132.parasomnias: night terrors, sleep walking/talking/eating/driving, bed wetting
133.Patient Controlled Analgesia (PCA): client has control with minimum risk of overdose; system designed to deliver no more than specific number of doses
134.peripheral artery disease: caused by atherosclerosis; usually lower extremities; deprives lower extremities of oxygen; cramps and muscle pain with activity
135.peritoneal dialysis: shunt placed in peritoneum; diasolate poured in peritoneum, about 1hr later diasolate, nitrogenous waste, fluid, electrolytes removed
136.personal preferences affecting hygiene: dictates personal hygiene practices for individual patients
137.Pharmacokinetics: the study of how meds enter the body; are absorbed and distributed into cells, tissues, or organs; alter physiological functions
138.Pharmacological pain relief: analgesics (NSAIDS & non-opioids, opioids, adjuvants)
139.physical condition in hygiene: may lack physical energy / dexterity to preform self-care
140.Planning:: nurse comes up with client-centered goals; need to be measurable (client will ambulate 10 meters 3x daily for 2 wks)
141.polyuria: excessive urine; sign of diabetes or hormone issue
142.pressure ulcers: tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period; tissue ischemia that leads to necrosis
143.primary care in community: health professionals, community members, govt
144.professional nursing code of ethics: a set of guiding principles that all members of a profession accept; helps professional groups settle questions about practice or behavior; includes responsibility, accountability, and confidentiality
145.Proteins: essential from growth, maintenance, and repair of body tissue; amino acids; complete and complementary; nitrogen balance
146.pruritis: chemical, allergic, physical agent; drugs, food, sweat-act on nerve fibers, releases histamine and affects itch receptors; insect bites, scabies, medication (opioid) , systemic effect
147.psych facilities: focus on clients with emotional / behavioral problems
148.psychomotor learning: acquiring skills that require the integration of mental / muscular activity
149.public communication: with an audience; speaking at conferences; leading class
150.pulmonary emboli: complication of DVT
151.purpose of teaching: gaining new knowledge, change attitudes, adopt new behaviors, preform new skills,
152.quality of life: central to discussions about futile care, cancer therapy, physician assisted suicide, DNR
153.reflex incontinence: on urge to go; it just comes out
154.right sided failure: lower extremity edema; dependent edema; HTN; daily weights; increased peripheral venous pressure; distended jugular veins; cyanosis of extremities; asites, GI distress
155.roles of nurse: caregiver, advocate, educator, communicator, manager, autonomy and accountability
156.safety guidelines in hygiene: communicate with team members; incorporate patient’s priorities; move from cleanest to less clean areas; use clean gloves for contact with non-intact skin, mucous membranes, secretions, excretions, or blood; test tempo of water or solutions; use principles of body mechanics and safe patient handling; be sensitive to invasion of privacy
157.school health: support educational success by enhancing health
158.sleep: purpose unclear; physiological and psychological restoration; maintenance of biological function; regulated by reticular activating system > regulates sleep cycle in hypothalamus
159.sleep apnea: lack of airflow through mouth/nose >10sec during sleep; airway collapses, blocking airflow to lungs
160.sleep deprivation causes: irritability, cognitive impairment, memory lapses/loss, severe yawning, s/s like ADHA, impaired immune system, risk of type 2 diabetes, increased heart rate variability, decreased reaction time and accuracy, tremors, aches, growth suppression, decreased temp, risk of obesity, hallucinations
161.slough: dead tissue; yellowish, brownish; makes wound unstageable; has to be debritied
162.small group communication: small number of people meet; committees; group meetings
163.social patterns affecting hygiene: ethnic, social, and family influences on hygiene patterns
164.socioeconomic status affecting hygiene: influences type and extent of hygiene practice used
165.SOLER: sit close, observe, lean forward, eye contact, relax
166.source of laws: legal guidelines that come from statutory, regulatory, and common law
167.s/s of PAD: red, inflammed, shortness of breath, coughing, increased heart rate, sweating, anxious
168.stable angina: predictable
169.stage 1 of sleep: 4-5%; light sleep; muscle activity slows
170.stage 1 PAD: asymptomatic; Bruit may be present; toes cool to touch; slow capillary bed refill
171.stage 1 ulcer: intact skin; red/irritation; unblanchable
172.stage 2 of sleep: 45-55%; breathing and heart rate slow
173.stage 2 PAD: claudication; muscle pain/ cramping
174.stage 2 ulcer: broken skin; partial thickness; blister epidermis and dermis; can ooze
175.stage 3 of sleep: 4-6%; deep sleep
176.stage 3 PAD: rest pain
177.stage 3 ulcer: epidermis, dermis, and subQ tissue; oozing, signs of infection; full thickness loss
178.stage 4 of sleep: 12-15%; very deep sleep; rhythmic breathing
179.stage 4 PAD: necrosis/ gangrene; loss of oxygen to toes > toes fall off/ need to be removed
180.stage 4 ulcer: full thickness loss; can see organs/ bones; very painful
181.stage 5 of sleep: 20-25%; REM; brainwaves speed up and dreaming occurs; increased heart rate; rapid and shallow breathing
182.standards of care: legal guidelines for defining nursing practice and identifying the minimum acceptable nursing care
183.sterilization: complete elimination or destruction of all microorganisms including spores
184.stress incontinence: usually in women who didn’t do kegels during labor
185.swine flu: H1N1; person to person transmission; touching infected surfaces; nose/throat culture; vaccine
186.symptomatic infection: when the infection has signs and symptoms like fever, cough, etc
187.tamaflu: stops flu virus multiplication; increases risk for self injury; take within 48 hr of onset
188.teaching: interactive process that promotes learning
189.transpersonal communication: persons spiritual domain; higher power; prayer, meditation, guided reflexion
190.treating CHF: upright position, high semi fowlers; nitrates- vasodilate coronary arteries and myocardium (dizzy feeling, hypotension); Lasix- diuretic/ urine output; oxygen- when pulse ox. under 95%; ACE inhibitors- Vasotech, Nosinopro (check BP before admin, low potassium or under 60 bpm hold); Digoxin- slows heart rate; apical pulse before admin; nausea and vomiting; toxic if stays in blood for too long; cardiac glycocide- increases contraction, slows heart rate, increases CO and oxygen in blood; decrease fluids to 1500ml; decrease salt to 2000-3000mg; test dig level, ABGs, potassium
191.treatment for atherosclerosis: decreased cholesterol intake; smoking cessation; blood work; exercise
192.treatment for hyperventillation: have patient hold one nostril; try to reduce patient;s stress/panic; purse-lipped breathing
193.treatment for hypoventillation: if narcotic based, reduce/ discontinue; stroke- high fowlers/ oxygen; other meds to increase breathing
194.treatment for MI: stent angioplasty or balloon; thrombolytic therapy- breaks clot apart; M-morphine, O-oxygen, N-nitrates, A-aspirin
195.treatment for PAD: Statins- help metabolize cholesterol; Crestor, Lipitor- muscle pain, leg pain, cramping, diarrhea
196.treatment for pulmonary emboli: prevention- anticoagulant therapy; thrombolytic therapy; surgery to remove thrombus
197.Types of pain: acute, chronic, cancer, by inferred pathology, idiopathic
198.unstable angina: spontaneous pain
199.uremic syndrome: increase in nitrogenous wastes in the blood
200.urinalysis: pH; protein; glucose; ketones; blood; specific gravity; WBCs; bacteria
201.urinary incontinence: can be temporary; affects everyone especially elderly
202.uriticaria: reddish, whitish, plaques edematous; usually show up on torso; usually caused by drugs, histamine, bed linen detergent
203.UTI causes: E. coli, young and old women at risk; uncircumcised men (smegma); frequent sexual intercourse/ unprotected/ multiple partners; poor hygiene; HAI; med/surg related
204.utilitarianism: proposes that the value of something is determined by its usefulness
205.UTI s/s: frequency/ urgency; burning pain when voiding; hematuria; fever; chills; nausea; vomiting; pyelonenephritis; malaise
206.UTI treatment: antibiotic- Siproflaxin; cranberry juice for prevention
207.Values: personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior
208.varient angina/ prinz metals: occurs at rest (sort of constant)
209.Virchow’s triad: stasis-immobility, bed ridden, car/plane/ train travel
vessel wall injury, fracture, trauma
hypercoagulability- altered coagulation (birth control, hormone therapy, smokers, dehydration)
210.Vitamins: essential to normal metabolism; fat soluble(A,D, K,E) can be stored in body except D; water soluble(C and B complex) cannot be stored in body; obtained from fruits, milk, veggies, fish, cereal, grains, nuts, sunlight
211.Water: comprises 60-70% of body weight; cell function depends on a fluid environment, you can only survive a few days without it, illness increases need for fluids
212.what does mobility mean?: allows ability to move freely about; musculoskeletal and nervous systems working together to make movement; decreases risk for injury
213.xerosis: dry skin; becomes reddish; low humidity; frequent washing
|1.||A client with bipolar disorder, manic type, exhibits extreme excitement, delusional thinking, and command hallucinations. Which of the following is the priority nursing diagnosis?|
|B.||Impaired social interaction|
|C.||Disturbed sensory-perceptual alteration (auditory)|
|D.||Risk for other-directed violence|
|2.||A 45-year-old woman with a history of depression tells a nurse in her doctor’s office that she has difficulty with sexual arousal and is fearful that her husband will have an affair. Which of the following factors would the nurse identify as least significant in contributing to the client’s sexual difficulty?|
|A.||Education and work history|
|C.||Physical health status|
|D.||Quality of spousal relationship|
|3.||The nurse is administering a psychotropic drug to an elderly client who has history of benign prostatic hypertrophy. It is most important for the nurse to teach this client to:|
|A.||Add fiber to his diet.|
|B.||Exercise on a regular basis.|
|C.||Report incomplete bladder emptying|
|D.||Take the prescribed dose at bedtime.|
|4.||The parents of a young man with schizophrenia express feelings of responsibility and guilt for their son’s problems. How can the nurse best educate the family?|
|A.||Acknowledge the parent’s responsibility.|
|B.||Explain the biological nature of schizophrenia.|
|C.||Refer the family to a support group|
|D.||Teach the parents various ways they must change.|
|5.||A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful?|
|A.||The parents reinforce increased decision making by the client|
|B.||The parents clearly verbalize their expectations for the client|
|C.||The client verbalizes that family meals are now enjoyable.|
|D.||The client tells her parents about feelings of low-self-esteem.|
|6.||Which factors are most essential for the nurse to assess when providing crisis intervention foe a client?|
|A.||The client’s communication and coping skills|
|B.||The client’s anxiety level and ability to express feelings|
|C.||The client’s perception of the triggering event and availability of situational supports|
|D.||The client’s use of reality testing and level of depression|
|7.||Prior to administering chlorpromazine (Thorazine) to an agitated client, the nurse should|
|A.||Assess skin color and sclera|
|B.||Assess the radial pulse|
|C.||Take the client’s blood pressure|
|D.||Ask the client to void|
|8.||The school guidance counselor refers a family with an 8-year-old child to the mental health clinic because of the child’s frequent fighting in school and truancy. Which of the following data would be a priority to the nurse doing the initial family assessment?|
|A.||The child’s performance in school|
|B.||Family education and work history|
|C.||The family’s perception of the current problem|
|D.||The teacher’s attempts to solve the problem|
|9.||The nurse understands that electroconvulsive therapy is primary used in psychiatric care for the treatment of:|
|10.||Which factor is least important in the decision regarding whether a victim of family violence can safely remain in the home?|
|A.||The availability of appropriate community shelters|
|B.||The non abusing caretaker’s ability to intervene on the client’s behalf|
|C.||The client’s possible response to relocation|
|D.||The family’s socioeconomic status|
|11.||A client with a bipolar disorder exhibits manic behavior. The nursing diagnosis is Disturbed thought processes related to difficulty concentrating, secondary to flight of ideas. Which of the following outcome criteria would indicate improvement in the client?|
|A.||The client verbalizes feelings directly during treatment.|
|B.||The client verbalizes positive “self” statement.|
|C.||The client speaks in coherent sentences.|
|D.||The client reports feelings calmer.|
|12.||Which neurotransmitter has been implicated in the development of Alzheimer’s disease?|
|13.||A client tells a nurse. “Everyone would be better off if I wasn’t alive.” Which nursing diagnosis would be made based on this statement?|
|A.||Disturbed thought processes|
|C.||Risk for self-directed violence|
|D.||Impaired social interaction|
|14.||An elderly client with Alzheimer’s disease becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to:|
|A.||Tell the client family that it is time to get dressed.|
|B.||Obtain assistance to restrain the client for safety.|
|C.||Remain calm and talk quietly to the client.|
|D.||Call the doctor and request an order for sedation|
|15.||Which nursing intervention is most appropriate for a client with anorexia nervosa during initial hospitalization on a behavioral therapy unit?|
|A.||Emphasize the importance of good nutrition to establish normal weight.|
|B.||Ignore the client’s mealtime behavior and focus instead on issues of dependence and independence.|
|C.||Help establish a plan using privileges and restrictions based on compliance with refeeding.|
|D.||Teach the client information about the long-term physical consequence of anorexia.|
|16.||Two nurses are co-leading group therapy for seven clients in the psychiatric unit. The leaders observe that the group members are anxious and look to the leaders for answers. Which phase of development is this group in?|
|C.||Conflict resolution phase|
|17.||The nurse is interacting with a family consisting of a mother, a father, and a hospitalized adolescent who has a diagnosis of alcohol abuse. The nurse analyzes the situation and agrees with the adolescent’s view about family rules. Which intervention is most appropriate?|
|A.||The nurse should align with the adolescent, who is the family scapegoat.|
|B.||The nurse should encourage the parents to adopt more realistic rules.|
|C.||The nurse should encourage the adolescent to comply with parental rules.|
|D.||The nurse should remain objective and encourage mutual negotiation of issues.|
|18.||Which method would a nurse use to determine a client’s potential risk for suicide?|
|A.||Wait for the client to bring up the subject of suicide.|
|B.||Observe the client’s behavior for cues of suicide ideation.|
|C.||Question the client directly about suicidal thoughts.|
|D.||Question the client about future plans.|
|19.||A client who abuses alcohol and cocaine tells a nurse that he only uses substances because of his stressful marriage and difficult job. Which defense mechanisms is this client using?|
|20.||A client with obsessive-compulsive disorder is hospitalized on an inpatient unit. Which nursing response is most therapeutic?|
|A.||Accepting the client’s obsessive-compulsive behaviors|
|B.||Challenging the client’s obsessive-compulsive behaviors|
|C.||Preventing the client’s obsessive-compulsive behaviors|
|D.||Rejecting the client’s obsessive-compulsive behaviors|
|21.||The nurse provides a referral to Alcoholics Anonymous to a client who describes a 20-year history of alcohol abuse. The primary function of this group is to:|
|A.||Encourage the use of a 12-step program.|
|B.||Help members maintain sobriety.|
|C.||Provide fellowship among members.|
|D.||Teach positive coping mechanisms.|
|22.||A 16-year-old girl has retuned home following hospitalization for treatment of anorexia nervosa. The parents tell the family nurse performing a home visit that their child has always done everything to please them and they cannot understand her current stubbornness about eating. The nurse analyzes the family situation and determines it is characteristic of which relationship style?|
|23.||The nurse explains to a mental health care technician that a client’s obsessive-compulsive behaviors are related to unconscious conflict between id impulses and the superego (or conscience). On which of the following theories does the nurse base this statement?|
|24.||The nurse understands that if a client continues to be dependent on heroin throughout her pregnancy, her baby will be at high risk for:|
|C.||Addiction in adulthood.|
|25.||A 75-year-old client has dementia of the Alzheimer’s type and confabulates. The nurse understands that this client:|
|A.||Denies confusion by being jovial.|
|B.||Pretends to be someone else.|
|C.||Rationalizes various behaviors.|
|D.||Fills in memory gaps with fantasy.|
|26.||An 11-year-old child diagnosed with conduct disorder is admitted to the psychiatric unit for treatment. Which of the following behaviors would the nurse assess?|
|A.||Restlessness, short attention span, hyperactivity|
|B.||Physical aggressiveness, low stress tolerance disregard for the rights of others|
|C.||Deterioration in social functioning, excessive anxiety and worry, bizarre behavior|
|D.||Sadness, poor appetite and sleeplessness, loss of interest in activities|
|27.||Group members have worked very hard, and the nurse reminds them that termination is approaching. Termination is considered successful if group members:|
|A.||Decide to continue.|
|B.||Elevate group progress|
|C.||Focus on positive experience|
|D.||Stop attending prior to termination.|
|28.||Which nursing intervention is best for facilitating communication with a psychiatric client who speaks a foreign language?|
|A.||Rely on nonverbal communication.|
|B.||Select symbolic pictures as aids.|
|C.||Speak in universal phrases.|
|D.||Use the services of an interpreter.|
|29.||The nurse observes a client pacing in the hall. Which statement by the nurse may help the client recognize his anxiety?|
|A.||“I guess you’re worried about something, aren’t you?|
|B.||“Can I get you some medication to help calm you?”|
|C.||“Have you been pacing for a long time?”|
|D.||“I notice that you’re pacing. How are you feeling?”|
|30.||A client taking the MAOI phenelzine (Nardil) tells the nurse that he routinely takes all of the medications listed below. Which medication would cause the nurse to express concern and therefore initiate further teaching?|
|D.||Isosorbide dinitrate (Isordil)|
|31.||Which information is most essential in the initial teaching session for the family of a young adult recently diagnosed with schizophrenia?|
|A.||Symptoms of this disease imbalance in the brain.|
|B.||Genetic history is an important factor related to the development of schizophrenia.|
|C.||Schizophrenia is a serious disease affecting every aspect of a person’s functioning.|
|D.||The distressing symptoms of this disorder can respond to treatment with medications.|
|32.||Which of the following outcome criteria is appropriate for the client with dementia?|
|A.||The client will return to an adequate level of self-functioning.|
|B.||The client will learn new coping mechanisms to handle anxiety.|
|C.||The client will seek out resources in the community for support.|
|D.||The client will follow an establishing schedule for activities of daily living.|
|33.||A client with panic disorder experiences an acute attack while the nurse is completing an admission assessment. List the following interventions according to their level of priority. a. Remain with the client. b. Encourage physical activity. c. Encourage low, deep breathing. d. Reduce external stimuli. e. Teach coping measures. ___,___,___,___,___|
|34.||According to the family systems theory, which of the following best describes the process of differentiation?|
|A.||Cooperative action among members of the family|
|B.||Development of autonomy within the family|
|C.||Incongruent massages wherein the recipient is a victim|
|D.||Maintenance of system continuity or equilibrium|
|35.||The nurse is teaching a group of clients about the mood-stabilizing medications lithium carbonate. Which medications should she instruct the clients to avoid because of the increased risk of lithium toxicity?|
|36.||The emergency department nurse is assigned to provide care for a victim of a sexual assault. When following legal and agency guidelines, which intervention is most important?|
|A.||Determine the assailant’s identity.|
|B.||Preserve the client’s privacy.|
|C.||Identify the extent of injury.|
|D.||Ensure an unbroken chain of evidence.|
|37.||The nurse is working with a client with a somatoform disorder. Which client outcome goal would the nurse most likely establish in this situation?|
|A.||The client will recognize signs and symptoms of physical illness.|
|B.||The client will cope with physical illness.|
|C.||The client will take prescribed medications.|
|D.||The client will express anxiety verbally rather than through physical symptoms.|
|38.||The nurse correctly teaches a client taking the benzodiazepine oxazepam (Serax) to avoid excessive intake of:|
|39.||The doctor has prescribed haloperidol (Haldol) 2.5 mg. I.M. for an agitated client. The medication is labeled haloperidol 10 mg/2 ml. The nurse prepares the correct dose by drawing up how many milliliters in the syringe?|
|40.||Which client outcome is most appropriately achieved in a community approach setting in psychiatric nursing?|
|A.||The client performs activities of daily living and learns about crafts.|
|B.||The client’s is able to prevent aggressive behavior and monitors his use of medications.|
|C.||The client demonstrates self-reliance and social adaptation.|
|D.||The client experience experiences anxiety relief and learns about his symptoms.|
|41.||A client taking the monoamine oxidase inhibitor (MAOI) antidepressant isocarboxazid (Marplan) is instructed by the nurse to avoid which foods and beverages?|
|A.||Aged cheese and red wine|
|B.||Milk and green, leaf vegetables|
|C.||Carbonated beverages and tomato products|
|D.||Lean red meats and fruit juices|
|42.||The nurse enters the room of a client with a cognitive impairment disorder and asks what day of the week it is: what the date, month, and year are; and where the client is. The nurse is attempting to assess:|
|43.||In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early evening hours is called:|
|44.||A nurse is working with a client who has schizophrenia, paranoid type. Which of the following outcomes related to the client’s delusional perceptions would the nurse establish?|
|A.||The client will demonstrate realistic interpretation of daily events in the unit.|
|B.||The client will perform daily hygiene and grooming without assistance.|
|C.||The client will take prescribed medications without difficulty.|
|D.||The client will participate in unit activities.|
|45.||The nurse would expect a client with early Alzheimer’s disease to have problems with:|
|A.||Balancing a checkbook.|
|C.||Relating to family members.|
|D.||Remembering his own name|
|46.||The nurse considers a client’s response to crisis intervention successful if the client:|
|A.||Changes coping skills and behavioral patterns.|
|B.||Develops insight into reasons why the crisis occurred.|
|C.||Learns to relate better to others.|
|D.||Returns to his previous level of functioning.|
|47.||The nurse collecting family assessment data asks. “Who is in your family and where do they live?” which of the following is the nurse attempting o identify?|
|48.||When providing family therapy, the nurse analyzes the functioning of healthy family systems. Which situations would not increase stress on a healthy family system?|
|A.||An adolescent’s going away to college|
|B.||The birth of a child|
|C.||The death of a grandparent|
|49.||Which of the following will the nurse use when communicating with a client who has a cognitive impairment?|
|A.||Complete explanations with multiple details|
|B.||Picture or gestures instead of words|
|C.||Stimulating words and phrases to capture the client’s attention|
|D.||Short words and simple sentences|
|50.||Which nursing intervention is most appropriate for a client with Alzheimer’s disease who has frequent episodes emotional lability?|
|A.||Attempt humor to alter the client mood.|
|B.||Explore reasons for the client’s altered mood.|
|C.||Reduce environmental stimuli to redirect the client’s attention.|
|D.||Use logic to point out reality aspects.|