Nephro
A patient with diabetes has had many renal calculi over the past 20 years and now has chronic renal failure. Which substance must be reduced in this patient's diet?
A. Carbohydrates
B. Fats
C. Protein
D. Vitamin C
C. Protein
Rationale: Because of damage to the nephrons, the kidney can't excrete all the metabolic wastes of protein, so this patient's protein intake must be restricted. A higher intake of carbs, fats, and vitamin supplements is needed to ensure the growth and maintenance of the patient's tissues.
A nurse notices frequent artifacts on the ECG monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact?
A. Frequent movement of the patient
B. Tightly secured cable connections
C. Leads applied of hairy areas
D. Leads applied to the limbs
B. Tightly secured cable connections.
Motion artifact, or “noise,” can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference can also occur with electrode removal and cable disconnection. The artifacts produced by alternating current cause a “darkened reinforcement” in the ECG baseline, often making an analysis of rhythm difficult. This is due to lack of filters for alternating current systems or a poor operation of the device.
Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnosed asthma. When teaching the patient about this drug, the nurse should explain that it may cause:
A. Hyperkalemia
B. Nervousness
C. Nasal Congestions
D. Lethargy
B. Nervousness
Albuterol may cause nervousness. The primary adverse effects of albuterol therapy are tremors and nervousness, mostly seen in children who are 2 to 6 years of age, though can be seen at any age. Tremors are the result of activation of the beta-2 receptors found on the motor nerve terminals which increases intracellular cAMP. These side effects occur in approximately one in every five patients. Other adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting and muscle cramps.
Sucralfate (Carafate) achieves a therapeutic effect by:
A. Neutralizing gastric acid.
B. Enhancing gastric absorption.
C. Forming a protective barrier around gastric mucosa.
D. Inhibiting gastric acid secretion.
C. Forming a protective barrier around gastric mucosa.
Sucralfate has a local effect only on the gastric mucosa. It forms a paste-like substance in the stomach, which adheres to the gastric lining, protecting against adverse effects related to gastric acid. It also stimulates healing of any ulcerated areas of the gastric mucosa.
A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing interventions should be done first?
A. Assess full ROM to determine extent of injuries.
B. Call for an immediate chest x-ray.
C. Immobilize the client’s head and neck.
D. Open the airway with the head-tilt-chin-lift maneuver.
C. Immobilize the client’s head and neck.
All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. The airway doesn’t need to be opened since the client appears alert and not in respiratory distress. The management of patients with head trauma should always consider C-spine motion restriction. Hold the neck immobile in line with the body, apply a rigid or semi rigid cervical collar, and (unless the patient is very restless) secure the head to the trolley with sandbags and tape.
You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining?
A. Check for kinks in the outflow tubing
B. Raise the drainage bag above the level of the abdomen
C. Place the patient in a reverse Trendelenburg position
D. Ask the patient to cough
A. Check for kinks in the outflow tubing
Rationale: Tubing problems are a common cause of outflow difficulties, check the tubing for kinks and ensure that all clamps are open. Other measures include having the patient change positions (moving side to side or sitting up), applying gentle pressure over the abdomen, or having a bowel movement
A nurse is viewing the cardiac monitor in a client’s room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following?
A. Immediately defibrillate
B. Prep for pacemaker insertion
C. Administer amiodarone (Cordadone) via IV
D. Administer epinephrine (Adrenaline) via IV
C. Administer amiodarone (Cordarone) intravenously.
First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of antidysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Procainamide will terminate between 50% and 80% of ventricular tachycardias, and it will slow the conduction of those that it does not terminate. Amiodarone will convert about 30% of patients to sinus rhythm but is very effective in reducing the reversion rate of refractory SVT.
On auscultation, which finding suggests a right pneumothorax?
A. Bilateral inspiratory and expiratory crackles.
B. Absence of breaths sound in the right thorax.
C. Inspiratory wheezes in the right thorax.
D. Bilateral pleural friction rub.
B. Absence of breaths sound in the right thorax
In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. A pneumothorax is defined as a collection of air outside the lung but within the pleural cavity. It occurs when air accumulates between the parietal and visceral pleura inside the chest. The air accumulation can apply pressure on the lung and make it collapse. The degree of collapse determines the clinical presentation of pneumothorax. None of the other options are associated with pneumothorax.
The nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right:
A. Upper quadrant and radiates to the left scapula and shoulder.
B. Upper quadrant and radiates to the right scapula and shoulder.
C. Lower quadrant and radiates to the umbilicus.
D. Lower quadrant and radiates to the back.
B. Upper quadrant and radiates to the right scapula and shoulder
During an acute “gallbladder attack,” the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is governed by the pattern on dermatomes in the body. Acute cholecystitis is inflammation of the gallbladder that occurs due to occlusion of the cystic duct or impaired emptying of the gallbladder. Often this impaired emptying is due to stones or biliary sludge.
A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
A. Position the client flat in bed.
B. Check the fluid for dextrose with a dipstick.
C. Suction the nose to maintain airway patency.
D. Insert nasal and ear packing with sterile gauze.
B. Check the fluid for dextrose with a dipstick.
Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. CSF Leak is a condition in which CSF is able to escape from the subarachnoid space through a hole in the surrounding dura. The volume of CSF lost in a leak is very variable, ranging from insignificant to very substantial amounts.
Which cause of HTN is the most common in acute renal failure?
A. Pulmonary edema
B. Hypervolemia
C. Hypovolemia
D. Anemia
B. Hypervolemia
Rationale: Acute renal failure causes hypervolemia as a result of over expansion of extracellular fluid and plasma volume with the hyper secretion of renin. Therefore, hypervolemia causes HTN.
A client has developed atrial fibrillation, which has a ventricular rate of 150 beats per minute. A nurse assesses the client for:
A. Hypotension and dizziness
B. Nausea and vomiting
C. Hypertension and headache
D. Flat neck veins
A. Hypotension and dizziness
The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. A physical exam should always begin with the assessment of airway breathing and circulation as it is going to affect the decision making regarding management. On general physical examination, patients may have tachycardia with an irregularly irregular pulse.
A male patient is admitted to the healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?
A. Activity intolerance related to fatigue.
B. Anxiety related to actual threat to health status.
C. Risk for infection related to retained secretions.
D. Impaired gas exchange related to airflow obstruction.
Correct Answer: D. Impaired gas exchange related to airflow obstruction.
A patient airway and an adequate breathing pattern are the top priority for any patient, making “impaired gas exchange related to airflow obstruction” the most important nursing diagnosis. Monitor O2 saturation and titrate oxygen to maintain Sp02 between 88% to 92%. Pulse oximetry reading of 87% below may indicate the need for oxygen administration while a pulse oximetry reading of 92% or higher may require oxygen titration. The other options also may apply to this patient but less important.
Which of the following symptoms best describes Blumberg's sign/rebound tenderness?
A. Periumbilical ecchymosis exists.
B. On deep palpation and release, pain elicited.
C. On deep inspiration, pain is elicited and breathing stops.
D. Abdominal muscles are tightened in anticipation of palpation.
B. On deep palpation and release, pain elicited
Pain on deep palpation and release is rebound tenderness. Blumberg’s sign (also referred to as rebound tenderness or the Shyotkin-Blumberg sign) is a clinical sign in which there is pain upon removal of pressure rather than the application of pressure to the abdomen. (The latter is referred to simply as abdominal tenderness.) It is indicative of peritonitis.
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions?
A. Extent of intracranial bleeding.
B. Sites of brain injury.
C. Activity of the brain.
C. Activity of the brain.
An EEG measures the electrical activity of the brain. An electroencephalogram (EEG) is an essential tool that studies the brain’s electrical activity. It is primarily used to assess seizures and conditions that may mimic seizures. It is also useful to classify seizure types, assess comatose patients in the intensive care unit, and evaluate encephalopathies, among other indications.
B. Anemia
The answer is B. EPO (erythropoietin) helps create red blood cells in the bone marrow. The kidneys produce EPO and when the kidneys are damaged in CKD they can decrease in the production of EPO. Therefore, the patient is at risk for anemia.
A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)?
A. Administer ordered morphine sulfate.
B. Position patient in a semi-Fowler's position.
C. Position patient on left side with head of bed flat.
D. Instruct patient on the use of relaxation techniques.
E. Use a calm, reassuring approach while talking to patient.
A, B, D, E.
Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semi-Fowler's position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety.
A male adult client is suspected of having a pulmonary embolism. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism?
A. Dyspnea
B. Bradypnea
C. Bradycardia
D. Decreased respirations
A. Dyspnea
The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain. PE leads to impaired gas exchange due to obstruction of the pulmonary vascular bed leading to a mismatch in the ventilation to perfusion ratio because alveolar ventilation remains the same, but pulmonary capillary blood flow decreases, effectively leading to dead space ventilation and hypoxemia.
The client has orders for a nasogastric (NG) tube insertion. During the procedure, instructions that will assist in the insertion would be:
A. Instruct the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion.
B. After insertion into the nostril, instruct the client to extend his neck.
C. Introduce the tube with the client’s head tilted back, then instruct him to keep his head upright for final insertion.
D. Instruct the client to hold his chin down, then back for insertion of the tube.
A. Instruct the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion.
NG insertion technique is to have the client first tilt his head back for insertion into the nostril, then to flex his neck forward and swallow. A common error when placing the tube is to direct the tube in an upward direction as it enters the nares; this will cause the tube to push against the top of the sinus cavity and cause increased discomfort. The tip should instead be directed parallel to the floor, directly toward the back of the patient’s throat.
The nurse is caring for a client recovering from a stroke in the rehabilitation setting. Which is the goal of care during this stage?
A. Minimizing brain injury
B. Dispatching rapid emergency medical services (EMS)
C. Diagnosing the type and cause of stroke
D. Improving muscle strength and coordination
D. Improving muscle strength and coordination
During the rehabilitation treatment stage of stroke, the focus is on client safety and improvement of muscle strength and coordination. Priorities during the treatment stage of acute care immediately following a stroke include rapid EMS dispatch, diagnosing the type and cause of stroke, and other interventions to minimize brain injury and maximize client recovery.
6. Your patient with chronic kidney disease is scheduled for dialysis in the morning. While examining the patient's telemetry strip, you note tall peaked T-waves. You notify the physician who orders a STAT basic metabolic panel (BMP). What result from the BMP confirms the EKG abnormality?
D. Potassium 7.1 mEq/L
The answer is D. The patient's potassium level is extremely elevated. A normal potassium level is 3.5-5.1 mEq/L. This patient is experiencing hyperkalemia, which can cause tall peak T-waves. Remember in CKD (especially prior to dialysis), the patient will experience electrolyte imbalances, especially hyperkalemia.
What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply.
A. The RR intervals are relatively consistent.
B. One P wave precedes each QRS complex.
C. Four to eight complexes occur in a 6-second strip.
D. The ST segment is higher than the PR interval.
E. The QRS complex ranges from 0.12 to 0.20 second.
A, B.
The consistency of the RR interval indicates regular rhythm. A normal P wave before each complex indicates the impulse originated in the SA node. Sinus arrhythmia is most typically present in young, healthy individuals. Studies have attempted to establish an increased prevalence in patients with underlying hypertension, obesity, and diabetes.
A male patient has a sucking stab wound to the chest. Which action should the nurse take first?
A. Drawing blood for a hematocrit and hemoglobin level.
B. Applying a dressing over the wound and taping it on three sides.
C. Preparing a chest tube insertion tray.
D. Preparing to start an I.V. line.
B. Applying a dressing over the wound and taping it on three sides.
The nurse immediately should apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). The nurse may use a first aid device called a chest seal or improvise with the packaging sterile dressings coming in. Peel open the packaging and tape the entire plastic portion over the wound.Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.
Hepatic encephalopathy develops when the blood level of which substance increases?
A. Ammonia
B. Amylase
C. Calcium
D. Potassium
A. Ammonia
Ammonia levels increase d/t improper shunting of blood, causing ammonia to enter systemic circulation, which carries it to the brain. Under normal conditions, ammonia is produced by bacteria in the gastrointestinal tract (e.g., breakdown product of amines, amino acids, purines, and urea) followed by metabolism and clearance by the liver. In the case of cirrhosis or advanced liver dysfunction, however, there is either a decrease in the number of functioning hepatocytes, portosystemic shunting, or both, resulting in decreased ammonia clearance and hyperammonemia.
A patient arrives at the emergency department with slurred speech, right facial droop, and right arm weakness. Which of these actions by the healthcare provider is the priority?
A. Call the Speech Pathologist to the ED
B. Prepare the patient for a computerized tomography (CT) scan of the head
C. Transfer the patient to the neurological care unit
D. Prepare to administer a thrombolytic medication
B. Prepare the patient for a computerized tomography (CT) scan of the head