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WorksheetsNUR112 Final Exam Practice
Total questions: 169
Worksheet time: 2hrs 59mins
An accumulation of tissue fluid in the alveoli of the lungs:
pulmonary edema
pneumonia
pleural effusion
pulmonary thromboembolism
Inelasticity of the lungs due to chronic inflammation and scarring of the lung tissue:
pleuritis/pleurisy
pneumothorax
pneumonia
emphysema
Disease characterized by inflamed, narrow airways that make it difficult for air to pass through.
COPD
Pulmonary Edema
Pneumothorax
Asthma
what are the first symptoms of pneumonia?
chest pain when you breathe or cough, confusion or changes in mental awareness, cough that will include phlegm, fatigue, fever, sweating and shaking chills, lower than normal body temp, nausea, vomiting, diarrhea, and shortness of breath
chess pain when u breathe or cough, confusion or changes in mental awareness, cough that will include phlegm, fatigue, fever, sweating and shaking chills, lower than normal body temp, nausea, vomiting, diarrhea, and shortness of breath
chest pain when you breathe or coff, confusion or changes in mental awareness, coff that will include phlegm, fatigue, fever, sweating and shaking chills, lower than normal body temp, nausea, vomiting, diarrhea, and shortness of breath
chest pain when you breathe or cough, confusion or changes in mental awareness, cough that will include phlegm, fatigue, fever, sweating and shaking chills, lower than normal body temp, nausea, vomiting, diarrhea
What is pleuritic chest pain?
Pain that worsens when you sit down
Pain that hurts when you poke your chest
Pain that hurts more on the affected side
Pain that gets worse when breathing
Which medication has an onset of action of 30 minutes?
Famotidine
Omeprazole
Sodium Bicarbonate
Calcium Carbonate
Most common etiologic factor for appendicitis
tumors
lymphoid hyperplasia
fecalith
vascular compromise
In this step, the patient's identification, surgical site marking, signed consent and procedure to be done are all verified
time out
consent
anethesia record
operating technique
You are the recovery room nurse who is admitting a patient from the OR. What is the first assessment you would make on a newly admitted patient?
heart rate
nail perfusion
airway patency
core temperature
You admit a patient to the PACU who has undergone a surgical procedure that required the use of general anesthesia. What is the patient most at risk for following general anesthesia?
Anemia
Dehydration
Atelectasis
Peripheral edema
You admit a patient to the postanesthesia care unit with a blood pressure of 130/90 and a pulse of 68 beats per minute. After 30 minutes, the patient's blood pressure is 120/65, and the pulse is 100. You document the patient's skin as cold, moist, and pale. What is the patient showing signs of?
Hypothermia
Hypovolemic shock
Neurogenic shock
Malignant hypothermia
You are the nurse caring for 82-year-old women in the PACU. The woman begins to awaken and responds to her name but is confused, restless, and agitated. What are you aware of?
Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery.
Confusion, restlessness, and agitation are normal postoperative findings and will diminish in time.
Postoperative confusion is common in the elderly, but it could also indicate a significant blood loss.
Confusion, restlessness, and agitation indicate inadequate pain management, and analgesics will help.
A 38-year-old patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is restless and asking for "a drink of water." The nurse checks his skin and it is cold, moist, and pale. What is the nurse concerned the patient may be at risk for?
Hemorrhage and shock
Loss of airway and hypotension
Pain and anxiety
Hypertension and dysrhythmias
What things must you take into consideration while anesthetizing a patient? More than one answer is possible.
Pregnancy
Age
Social history
Psychological diagnostic
Medical History
Because general anesthetics affect the CNS, patients may feel:
normal immediately after awakening from anesthesia
overly alert and excited after anesthesia
drowsy, weak, or tired for as long as a few days after having general anesthesia
drowsy, weak, or tired for up to 24 hours after having general anesthesia
When teaching a patient about foods high in magnesium, the nurse would include:
Green vegetables
Butter
Cheese
Tomatoes
The type of fluid used to manipulate fluid shifts among compartments states is:
Whole Blood
Total Parentral Nutrition
Albumin
Ensure
A nurse is reviewing lab reports. The nurse recalls blood plasma is located in which of the following fluid compartments?
Intracellular fluid (ICF)
Extracellular fluid (ECF)
Interstitial fluid
Intravascular fluid
While planning care for elderly individuals, the nurse remembers the elderly are at a higher risk for developing dehydration because they have a(n):
Higher total body water volume
Decreased muscle mass
Increase in thirst
Increased tendency towards developing edema
Water movement between the ICF and ECF compartments is determined by:
Osmotic forces
Plasma oncotic pressure
Antidiuretic hormone
Buffer systems
When planning care for a dehydrated patient, the nurse remembers the principle of water balance is closely related to _____ balance.
Potassium
Chloride
Bicarbonate
Sodium
A nurse is teaching the staff about antidiuretic hormone (ADH). Which information should the nurse include? Secretion of ADH is stimulated by:
Increased serum potassium
Increased plasma osmolality
Decreased renal blood flow
Generalized edema
Which statement by the staff indicates teaching was successful concerning aldosterone? Secretion of aldosterone results in:
Decreased plasma osmolality
Increased serum potassium levels
Increased blood volume
Localized edema
A 5-year-old male presents to the ER with delirium and sunken eyes. After diagnosing him with severe dehydration, the primary care provider orders fluid replacement. The nurse administers a hypertonic intravenous solution. Which of the following would be expected?
Symptoms subside quickly
Increased ICF volume
Decreased ECF volume
Intracellular dehydration
Which of the following patients is the most at risk for developing hypernatremia? A patient with:
Vomiting
Diuretic use
Dehydration
Hypoaldosteronism
A 60-year-old female is diagnosed with hyperkalemia. Which assessment finding should the nurse expect to observe?
Weak pulse
Excessive thirst
Oliguria
Constipation
Which of the following buffer pairs is considered the major plasma buffering system?
Which of the following buffer pairs is considered the major plasma buffering system?
Carbonic acid/bicarbonate
Sodium/potassium
Amylase/albumin
For a patient experiencing metabolic acidosis, the body will compensate by:
Excreting H+ through the kidneys
Hyperventilating
Retaining CO2 in the lungs
Secreting aldosterone
Renal failure would likely lead to
volume depletion.
hypotonicity.
volume excess.
hypertonic ascites.
The stimuli that trigger the release of ADH are
high blood pressure, high blood volume, and high blood osmolarity.
high blood pressure, low blood volume, and low blood osmolarity.
low blood pressure, low blood volume, and high blood osmolarity.
low blood pressure, high blood volume, and high blood osmolarity.
When comparing a lean adult female to a lean adult male, which will most likely have a higher percentage of body fluid?
MALE
FEMALE
The bicarbonate system is composed of H2CO3 and HCO3-. Which statement accurately describes these molecules?
H2CO3 is a strong base, and HCO3- is a weak acid.
H2CO3 and HCO3- are both weak acids.
H2CO3 is a weak acid, and HCO3- is a weak base.
H2CO3 is a weak base, and HCO3- is a weak acid.
H2CO3 and HCO3- are both strong bases.
H2CO3 is a strong base, and HCO3- is a weak acid.
When blood starts to become too acidic, the kidneys respond by
synthesizing and secreting bicarbonate ions while reabsorbing H+.
synthesizing and reabsorbing H+ while filtering bicarbonate ions.
synthesizing and reabsorbing bicarbonate ions while secreting H+.
decreasing filtration rate and increasing reabsorption of both bicarbonate ions and H+.
increasing filtration rate and increasing reabsorption of H+.
If someone begins to hyperventilate due to anxiety, the CO2 concentration in their blood decreases; this causes __________ in blood pH.
an increase
a decrease
no change
The most abundant anion in the extracellular fluid is
negatively charged proteins.
phosphate.
chloride.
hydrogen.
acetic acid.
The plasma of our blood constitutes ______ than half of the fluid in our body; plasma is part of the _____________ fluid.
more; intracellular
more; extracellular
less; intracellular
less; extracellular
In this pH scale, the pH is 7.0
Neutral
Acidic
Basic/Alkaline
In this pH scale, have an equal concentration of H+ and OH-
Neutral
Acidic
Basic/Alkaline
In this pH scale, has a pH below 7.0
Neutral
Acidic
Basic/Alkaline
In this pH scale, has a greater number of H+
Neutral
Acidic
Basic/Alkaline
In this pH scale, has a pH above 7.0
Neutral
Acidic
Basic/Alkaline
In this pH scale, has fewer H+
Neutral
Acidic
Basic/Alkaline
How does body maintain pH
Buffer System
Respiration
Kidneys
Liver
this pH balance system ____________ secretes H+ and regulates H+ in blood and pH is regulated
Buffer System
Respiration
Kidneys
Liver
In pH balance of Respiration, cells produce CO2 which is dissolved in the blood and forms...
carbonic acid
Bicarbonate
H+
H-
In pH balance of Respiration, cells produce CO2 which is dissolved in the blood and forms carbonic acid and it _______ blood pH
Lowers
raises
In pH balance of Respiration, cells produce CO2 which is dissolved in the blood and forms carbonic acid and it lowers blood pH which stimulates.......
breathing
RBC production
carbon dioxide
H2O
what is true about buffers when maintaining pH
buffers are weak acids
buffers are weak bases
They release H+
They accept H+
The prevent changes in pH
in pH balance system, Carbonic acid-bicarbonate is an example of...
Buffer System
Respiration
Kidneys
Liver
What is true about carbonic acid-bicarbonate buffering system [in maintaining pH balance]
Most common buffering system in blood and other body fluids
Carbonic acid (h2CO3) is a weak acid that releases H+ when pH is rising
Bicarbonate (HCO3-) is a weak base that accepts H+ when pH is dropping
Carbonic acid (h2CO3)is a weak base that accepts H+ when pH is dropping
Bicarbonate (HCO3-) is a weak acid that releases H+ when pH is rising
Hypovolemia refers to a condition resulting from:
dehydration caused by loss of intracellular and extracellular fluids
water losses that are greater than electrolyte losses
excessive loss of equal proportions of extracellular fluid and electrolytes
excessive loss of electrolytes in greater proportions than the loss of fluids
Prime the blood transfusion set with:
Ringer’s Lactate
D5 1/2 Normal Saline
0.9% Normal Saline
0.45% Normal Saline
The duration of a transfusion should not exceed "x" hours post issue from the blood bank
3
3.5
4
4.5
If you suspect a transfusion reaction, your first steps are to
stop the transfusion and flush the tubing with 10cc NS and call the provider.
reduce the rate of transfusion to < 2.5 mLs/kg/hr and complete an assessment and then call the provider.
stop the transfusion, disconnect the tubing, and flush at the hub.
reduce the rate of transfusion to KVO and call the provider.
Signs and symptoms of Transfusion Associated Circulatory Overload (TACO) include
sudden shortness of breath, acute cyanosis and cardiac arrhythmia.
fever, urticaria, bronchospasm and local edema.
dyspnea, cough, tachycardia, and hypertension.
The "Four Checks" completed at the bedside are: Order, Product, Patient, Pump.
True
False
Is known as a Long Basal Acting Insulin?
Gargline
Detemir
NPH
Lispro
Is Known As a Basal Intermediate Acting Insulin
Regular Insulin
Gargline
NPH
Lispro
Is consider as a Postpandrial short acting insulin
Lispro
Degludec
Aspart
Gargline
Regular Insulin
Her onset is 15-30 minutes and peak is 0.5-1.5 hours with a duration of 3-5 hours.
Regular insulin
NPH
Lispro
Gargline
her onset is 30-60 minutes her peak is 1-5 hours and has a duration of 6-10 hours?
Isophane
Lispro
Regular
Gargline
Has a onset of 3-4 hours, does not have any peak and a duration of 24 hours.
Lispro
Isophane
Aspart
Gargline
Which Insulin is known as Cloudy Insulin?
Regular
Gargline
NPH
Aspart
How to prepare the insulin using Humalin R and Humalin N
1-Inject Air into Humalin NPH Cloudy Solution.
2-Draw up Humalin Regular (Clear solution)
3-Inject Air in the Humalin Regular Clear Solution.
4-Draw Up Humalin NPH (Cloudy Solution)
1-Inject Air into Humalin NPH Cloudy Solution.
2-Draw up Humalin Regular (Clear solution)
3-Draw Up Humalin NPH (Cloudy Solution)
4-Inject Air in the Humalin Regular Clear Solution.
1-Inject Air in the Humalin Regular Clear Solution.
2-Draw up Humalin Regular (Clear solution)
3-Draw Up Humalin NPH (Cloudy Solution)
4-Draw up Humalin Regular (Clear solution)
1-Inject Air into Humalin NPH Cloudy Solution.
2-Inject Air in the Humalin Regular Clear Solution.
3-Draw Up Humalin NPH (Cloudy Solution)
4-Draw up Humalin Regular (Clear solution)
1-Inject Air into Humalin NPH Cloudy Solution.
2-Inject Air in the Humalin Regular Clear Solution.
3-Draw up Humalin Regular (Clear solution)
4-Draw Up Humalin NPH (Cloudy Solution)
Insulin inhibits the release of what
Glucagon
ADH
Beta cells
Somatostatin
in a diet for diabetes you must limit your intakes of..(choose 3)
salt
sugar
Simple carbohydrates
carbohydrates
Saturated fats
If you suspect a transfusion reaction, your first steps are to
stop the transfusion and flush the tubing with 10cc NS and call the provider.
reduce the rate of transfusion to < 2.5 mLs/kg/hr and complete an assessment and then call the provider.
stop the transfusion, disconnect the tubing, and flush at the hub.
reduce the rate of transfusion to KVO and call the provider.
The doctor must inform the patient about surgery and obtain written consent.
True
False
The handoff report to the PACU nurse should include which of the following?
Patient Name
Surgical Procedure
Current Medications and Allergies
All Of The Above
The PACU nurse assess the patient's:
Airway
Breathing
Circulation
All Of The Above
Which health care provider informs the patient of the benefits and risks of surgery prior to going to surgery?
Registered Nurse
Surgeon
OR administrator
Licensed Physicians Assistant
Deep breathing is an important pre-operative teaching area. Which one of the following would be included in your teaching for the pre-operative patient?
Take a deep breath and hold for 5 seconds, repeat 15 times twice daily
Take a deep breath and hold for 10 seconds
Take a deep breath and hold for 3 seconds, repeat 15 times twice daily
Take a deep breath and hold for 5 seconds, repeat 5 times twice daily
The patient who is considered at risk for surgical complications is...
A patient with arthritis
A patient with HTN (hypertension)
A dehydrated patient
A patient who smokes
Which of the following are goals of Preoperative Evaluation?
Identification of comorbid conditions
Assessment of perioperative risk
Procurement of informed consent
All of the following
Informatics is the use of information and technology to (Choose all that apply)
Communicate
Manage knowledge
Mitigate error
Support decision making
Solution used for IV fluid replacement fall into 2 categories
(i) Crytalloids
(ii) Colloids
True
False
Crystalloids are solution with small molecules that flow easily from the bloodstream into the tissues. Examples: isotonic, hypotonic & hypertonic
True
False
Complications of IV therapy include infiltration, extravasation, phlebitis, thrombophlebitis, localized infection, septicemia, severed cannula, air embolism, circulatory fluid overload, and speed shock.
T
F
The difference(s) between a primary IV administration set and a secondary IVPB administration set include(s) which of the following?
The secondary IVPB administration set is used for administering IV push medication.
The primary IV administration set always has a drop factor of 60.
The primary IV administration set is longer than the secondary IVPB administration set.
The secondary IVPB administration set has a drip chamber for visualizing the drip rate, while the primary administration set does not.
There is no difference except the drop factor.
Hypovolemia refers to a condition resulting from:
dehydration caused by loss of intracellular and extracellular fluids
water losses that are greater than electrolyte losses
excessive loss of equal proportions of extracellular fluid and electrolytes
excessive loss of electrolytes in greater proportions than the loss of fluids
A nurse is reviewing lab reports. The nurse recalls blood plasma is located in which of the following fluid compartments?
Intracellular fluid (ICF)
Extracellular fluid (ECF)
Interstitial fluid
Intravascular fluid
While planning care for elderly individuals, the nurse remembers the elderly are at a higher risk for developing dehydration because they have a(n):
Higher total body water volume
Decreased muscle mass
Increase in thirst
Increased tendency towards developing edema
A 5-year-old male presents to the ER with delirium and sunken eyes. After diagnosing him with severe dehydration, the primary care provider orders fluid replacement. The nurse administers a hypertonic intravenous solution. Which of the following would be expected?
Symptoms subside quickly
Increased ICF volume
Decreased ECF volume
Intracellular dehydration
Which of the following patients is the most at risk for developing hypernatremia? A patient with:
Vomiting
Diuretic use
Dehydration
Hypoaldosteronism
Which of the following patients is the most at risk for developing hypernatremia? A patient with:
Vomiting
Diuretic use
Dehydration
Hypoaldosteronism
A 60-year-old female is diagnosed with hyperkalemia. Which assessment finding should the nurse expect to observe?
Weak pulse
Excessive thirst
Oliguria
Constipation
Which of the following buffer pairs is considered the major plasma buffering system?
Which of the following buffer pairs is considered the major plasma buffering system?
Carbonic acid/bicarbonate
Sodium/potassium
Amylase/albumin
For a patient experiencing metabolic acidosis, the body will compensate by:
Excreting H+ through the kidneys
Hyperventilating
Retaining CO2 in the lungs
Secreting aldosterone
The appropriate fraction of body weight that is attributed to water is more than:
one-fourth
one half
two-thirds
three-fourths
The normal serum pH is:
7.25 to 7.35
7.35 to 7.45
8.15 to 8.35
8.35 to 8.55
An elevated serum pH causes a condition known as:
alkalosis
acidosis
equal bicarbonate
neutral carbonic acid
The acid-base balance is regulated by the lungs and the:
cerebellum
electrolytes
kidneys
liver
The shift of calcium excess into the bone creates a condition known as:
hyperkalemia
hypervolemia
hypocalcemia
hyponatremia
The patient with excess fluid volume will have blood pressure that is:
elevated
normal
lowered
even
The nurse is aware that an infant is more at risk for dehydration because the infant:
has kidneys that reabsorb water from the intravascular space.
has a larger body surface compared with body weight.
urinates more frequently.
has fat that absorbs water.
A patient has been identified as having a dietary deficiency of vitamin D. The nurse understands that this patient is also at risk for having a deficiency of:
calcium.
magnesium.
sodium.
potassium.
A patient who is experiencing severe diarrhea is losing excessive bicarbonate ions. This patient is at risk for developing:
respiratory alkalosis.
respiratory acidosis.
metabolic alkalosis.
metabolic acidosis
The body responds to low body fluid levels and increased osmolality with what actions?
Diarrhea
Diuresis
Tears
Thirst
A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this?
This is an expected finding.
The lung may have re-expanded or there is a kink in the system.
The system is broken and needs to be replaced.
There is an air leak in the tubing.
For a pneumothorax, a chest tube is inserted where?
The eighth intercostal space
The second intercostal space.
On the proximal portion of the fifth intercostal space
Distal to the injury
During transport the chest tube gets disconnected from the CDU and cannot be reconnected, the nurse should immediately…
Leave in place and contact the HCP
Wrap in sterile gauze and secure with tape
Immediately immerse in (2cm) sterile water
Lift exposed in above the level of the patient's heart
Tidaling is an expected finding in which chamber of CDU?
Tidaling is an emergency and the HCP should be notified
Water-seal chamber
Suction control chamber
Collection chamber
Chest tubes reestablish what type of pressure?
Peer pressure
Positive pressure
Med-Surg pressure
Negative pressure
What nursing intervention will you perform pre-and post suctioning in regard to Oxygen delivery?
Hyperoxygenation
Suction
Nebulization
Vigorous coughing, or manipulation of the tracheostomy can cause what complication?
tachycardia
infection
accidental decannulation
The rationale for providing adequate hydration for a client with a tracheostomy is...
to prevent heart failure.
to provide essential electrolytes.
to thin the mucous secretions.
to suppress the patients cough reflex.
Lab values: 7.25, paCO2 55, HCO3 45
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
metabolic alkalosis
What is the condition when you compensate by hyperventilating?
Respiratory Acidosis
Metabolic Acidosis
Respiratory Alkalosis
Metabolic Alkalosis
What is the body's compensation when having Respiratory Acidosis?
The kidney's excretes HCO3-
Your lungs will hyperventilate
The kidney's will reabsorb HCO3-
Your lungs will hypoventilate
pH= 7.55; pCO2= 55; HCO3= 55
respiratory acidosis
respiratory alkalosis
metabolic acidosis
metabolic alkalosis
pH= 7.32; PCO2= 22; HCO3= 20
respiratory acidosis
respiratory alkalosis
metabolic acidosis
metabolic alkalosis
pH= 7.28; pCO2= 48; HCO3= 25
respiratory acidosis
respiratory alkalosis
metabolic acidosis
metabolic alkalosis
pH= 7.38 ; PCO3= 28; HCO3= 26
respiratory acidosis
respiratoty alkalosis
metabolic acidosis
metabolic alkalosis
Which abnormal value indicates a respiratory problem?
pH
HCO3-
paCO2
Which abnormal value indicates a metabolic problem?
pH
HCO3-
paCO2
Normal values for HCO3- or bicarbonate is:
7.35-7.45
22-26
35-45
4-5
Normal values for paCO2 is:
7.35-7.45
22-26
35-45
4-5
. Christoff is diagnosed with hypermagnesemia. Symptoms of her condition may include:
hypertension
tachycardia
hyperactive deep-tendon reflex
cardiac arrhythmias
The nurse administers furosemide (Lasix) to treat a client with heart failure. This adverse effect must the nurse watch for most carefully.
Increase in blood pressure
Increase in blood volume
Low serum potassium level
High serum sodium level
Tom is ready to be discharged from medical -surgical unit after 5 days of hospitalization. This statement indicates, Tom understands the discharge teaching given by the nurse.
“I do not have to see my doctor unless I have problems”.
“I can stop taking my antibiotics once I am feeling better”.
“If I have redness, drainage or fever, I should call my healthcare provider.”
“I can return to my normal activities as soon as I go home”.
The most common reasons for IV therapy include all of these, EXCEPT
To replace fluids and electrolytes
To administer diagnostic reagants
To restores circulating volumes
To follow hospital policy when patient admit to the hospital.
Postoperatively, a patient's fingers are cold and pale. What action should the nurse take?
apply warm blankets
check o2 saturation on finger
encourage deep breathing
check blood sugar
A client with diabetes has a blood sugar of 300mg/dL and an Na+ of 133. What nursing intervention is indicated to manage the sodium with this lient
Pad the side rails to protect from injury during possible seizure
Notify dietary department to send salt tablets
encourage the client to drink water
monitor Na+ return to normal with lowering of blood sugar.
What action is appropriate if a client has a K+ of 8 mEq/L ?
NO change is required
restrict intake of K+ and or give sodium polystyrene sulfonate (kayexalate)
Restrict fluids to reduce K+
Give Insulin, glucose, calcium and or bicarbonate STAT as ordered
Which client has the GREATEST need for K+ replacement?
A client with renal failure with a post-dialysis serum K+ of 3.4
A patient with a large NG output who is receiving kayexalate with a serum K+ of 5.5
A client with cardiac disease who is about to recieve furosemide with a K+ of 3.5
A client with cardiac disease who is about to receive spironolactone with a K+ of 3.5
Which aspect of care is most important for a client with diabetic neuropathy?
Teach the client to inspect the feet using a mirror
Teach the client to wash feet, then pat dry
Have client moisturize feet with lotion to prevent dryness
Teach the client to cut toenails straight across
A client with diabetic ketoacidosis has been treated with an insulin drip for the past 3 hours. Which imbalance is this client at greatest risk for?
hypovolemia
hypokalemia
hyponatremia
hypoglycemia
A nurse is observing a client for possible complications of postoperative peritonitis, which manifestations are MOST indicative of peritonitis? (select all that apply)
Hyperactive bowel sounds
Localized or diffuse pain
abdominal rigidity
shallow respirations
Temperature over 102 F
A client is admitted with mild symptoms of novel H1N1 Flu. Which family member is at greatest risk for developing the infection?
The elderly grandmother
A 6 yr old daughter
the healthy 45 yr old spouse
the 13 yr old son with asthma
Which is the most common treatment for a client in addisonian crisis?
IV normal saline and glucocorticoids
IV lactated ringers and packed cells
IV 5% dextrose in normal saline and dopamine
IV total partenteral nutrion and insulin coverage
When a client is on chemotherapy for which manifestations of bone marrow depression should a nurse continuously asses?
Night sweats and fatigue
Loss of skin turgor and weight loss
low urine output and elevated BUN levels
Ecchymosis, weakness, and fatigue
A client is admitted to the hospital in a terminal stage of illness. At this time a nurse who is planning end of life care, should recognize that the client is most likely to fear:
The terminal diagnosis
Further chemotherapy
being socially inadequate
dying alone and in pain
A client returns from an operating room. The client's IV is running at 150ml/hr; pulse is 90 and full; respirations are moist and wheezy. A nurse's INITIAL action should be to:
speed up the IV and call the MD
check the electrolyte levels
report the IV rate to the charge nurse
Slow down the IV and call the physician
An indicator of worsening hypovolemic shock related to GI bleeding would be:
decreased level of conciousness (LOC)
complaints of abd pain with hematemisis
deepening, rapid respirations
increasinly rapid, thready pulse
A nurse should expect that a client with a severe loss of potassium (hypokalemia) from diarrhea, will have:
Fatigue, tetany, cardiac standstill
Kussmaul's respirations, thirst, furrowed tongue
muscle weakness, cramps, cardiac irritability
Confusion, pitting edema, irregular pulse
To promote maximum ventilation in a client who is postoperative, the nurse should:
Auscultate breath sounds bilaterally
Give humidified oxygen via nasal cannula
maintain placement of airway until the client is awake
position the client on the side with the neck extended
The nurse should assess for hypercalcemia by checking a client for:
Chvostek's sign
Trousseau's sign
Deep tendon reflex
Babinski reflex
Which nursing intervention should a nurse complete first for a client experiencing addisonian crisis?
maintain a quiet nonstressful environment
take measures to avoid exertion by the client
administer hormone replacement as prescribed
IV administraton of fluid glucose and electrolytes
A client who is malnourished is admitted with a serum calcium level of 7.5. The nurse should:
Administer glucocorticoids as ordered
check urine for ketones
check the serum albumin lab results
administer neutra-phos as ordered
Following a thyroidectomy, a nurse assesses for complications related to damage or removal of the parathyroid. The nurse should asses for:
hypertension
numbness around the mouth
polyuria
muscle weakness
Which finding is consistent with a client developing fluid overload?
pulse over 100
pulmonary crackles that clear with deep breathing
concentrated urine
o2 saturation of less than 92%on 40% o2 via facemask
A client with diabetes and hypertension has returned from surgery. Which nursing intervention will most likely reduce the risk of wound infection?
monitor blood sugar and keep it under 200
place the client in contact isolation
administer prophylactic antibiotics 48 hours preoperatively as ordered
administer glucocorticoid stress hormone replacements post op as orderd
