golden showers
your patient is 78 yrs old and presents w/ new onset confusion, delirium, poor oral intake, temp of 100.6 F, and new onset of urinary incontinence. you anticipate the patient to have what urinary condition?
UTI
older adults w/ UTIs may present with abnormal signs and symptoms, such as new onset confusion, new onset urinary incontinence, delirium, low grade fever or no fever, and a decreased appetite.
If the chemoreceptors within the brain sense an acidic change within the blood's pH level, would the body compensate with hyperventilation or hypoventilation?
Hyperventilation
triggered by an increase in CO2 (acidic) -> increases respiratory rate to cause a decrease in hydrogen ions -> exhaling excess hydrogen ions
Your patient presents with dry mucous membranes, polyuria, blurred vision and weight loss. Do you suspect hyperglycemia or hypoglycemia?
Hyperglycemia
Your patient presents with a severe headache and blurred vision and reports they have not taken their antihypertensive medication for the past week. Which of the following is the nurse's priority action?
A. Administer an analgesic as prescribed for the headache.
B. Instruct the patient to go to the nearest emergency room as they are showing s/s of a hypertensive crisis.
C. Administer and IV antihypertensive.
D. Obtain the patient's blood pressure.
D. Obtain the patient's blood pressure.
Your patient presents to the emergency room for an acute asthma attack. Which of the following manifestation indicates that the patient's respiratory status is declining? SATA
A. SpO2 of 90% on 2L NC
B. Pale conjunctiva
C. HR of 99
D. Wheezing
E. Use of accessor muscles
A, B, D, and E
which of the following food options are appropriate for a patient with renal calculi? select 2
A. Spinach omlete
B. Oat milk
C. Beet juice
D. Orange slices
Oat milk and orange slices; B & D
Oranges can be consumed to alkaline urine
Low sodium, calcium, and purine diets. Avoid oxalate sources and limit animal protein
What is the ABG for the following lab values?
pH: 7.23
PaCO2: 47
HCO3: 23
Uncompensated respiratory acidosis
Your patient was recently diagnosed with DMT1 and you are teaching about sick day rules. Which of the following statements are appropriate for this client?
A. Insulin dosages may need to be adjusted.
B. Blood sugar levels will not be affected by illness.
C. You are at greater risk of developing hyperosmolar hyperglycemic state and need to report s/s to the provider ASAP.
D. It is okay to skip meals while you are sick since you may not feel like eating.
A. Insulin dosages may need to be adjusted.
During illness blood glucose management will become more difficult. While the client sick, the body will do the following:
Oral intake decreases causes blood sugar levels to drop
Stress hormones are release that increase sugar levels
Your patient was prescribed spironolactone for hypertension. Which of the following statements indicates a need for further teaching?
A. I will use salt substitutes for seasoning.
B. I will monitor my blood pressure daily.
C. I should avoid foods that are high in sodium.
D. I should increase my fluid intake.
A. I will use salt substitutes for seasoning.
Salt substitutes are high in potassium. Sprionolactone is potassium-sparing and retains potassium. Patients should avoid foods high in potassium.
Your patient is taking prednisone for COPD. Which of the following adverse effects of this medication should the nurse monitor for?
A. Hyperkalemia
B. Hypokalemia
C. Dehydration
D. Fluid retention
E. Black, tarry stool.
B, D, and E
Your patient was diagnosed with glomerulonephritis? Which of the following assessment findings require immediate intervention?
A. Coca-cola colored urine
B. Perioribital edema
C. Weight gain of 1 kg
D. Blood pressure of 155/82
C. Weight gain of 1 kg
Fluid retention leading to fluid volume excess is a complication of glomerulonephritis. s/s include S3 heart sound, weight gain of 1kg or more, crackles, and SOB
Your patient was admitted for metabolic alkalosis and is being discharged. Which of the following statements by the patient indicates the need for further teaching?
A. I will eat more food rich in potassium.
B. I will take my antacids before and after every meal to prevent vomiting.
C. I will continue to take my spironolactone as prescribed.
D. I will stop drinking red wine with my dinner.
B. I will take my antacids before and after every meal to prevent vomiting.
Antacids can cause metabolic alkalosis and the patient should avoid taking them excessively and take them in moderation or try other interventions to prevent vomiting.
What are appropriate dietary teachings for clients with diabetes? SATA
A. Limit protein intake accordingly per kidney function
B. Avoid omega-3 fatty acids
C. Increase fiber intake
D. Consume a diet high in saturated fats
A & C
Which of the following options are modifiable risk factors for hypertension? SATA
A. Menopause
B. Alcohol consumption
C. Smoking cessation
D. Stress
E. Hyperlipidemia
F. Diabetes type 2
B, C, D, E, and F
Your patient presents with the following vital signs: HR of 130, BP of 145/95, RR of 22, SpO2 of 90% on 2L NC, and chest pain of 8/10. Which of the following is the priority nursing action?
A. Administer morphine for severe pain as prescribed.
B. Increase oxygen to 4L NC.
C. Administer hydralazine for blood pressure
D. Administer metoprolol for tachycardia.
Increase oxygen to 4L NC.
What labs are expected in patients w/ glomerulonephritis? SATA
A. Potassium: 2.4
B. Phosphate: 5
C. Calcium: 7.5
D. Calcium: 11
B & C
Potassium levels will be elevated in patients with severe kidney damage
Hypocalcemia (calcium: 9 to 10.5) and hypophosphatemia (phosphate 3.0 to 4.5)
Your patient was admitted for an overdose of norco and presents with pale skin, anxiety, rapid shallow breathing, a HR of 125 and BP of 150/63. which of the following is the priority nursing action?
A. Provide the patient with a brown paper bag and instruct them to breathe into it
B. Administer lorazepam for anxiety as prescribed.
C. Administer oxygen as prescribed to keep SpO2 > 95%
D. Administer hydralazine for blood pressure as prescribed
C. Administer oxygen as prescribed to keep SpO2 > 95%
Patient is demonstrating s/s of respiratory acidosis and the priority nursing action is to maintain an open airway, address breathing needs, and promote gas exchange.
You give lispro insulin to your patient at 0800. At what time would you anticipate the medication to reach its peak?
A. 0830
B. 1000
C. 1330
D. 1700
A. 0830
The peak time for short acting insulin (lispro) is 15 to 30 minutes after administration
Your patient was prescribed valsartan for hypertension. Which of following statements indicates effective teaching?
A. I will increase my intake in potassium rich foods.
B. I can take this medication every other day.
C. I can expect a dry cough as a side effect of taking this medication.
D. I should report weight gain to my provider.
D. I should report weight gain to my provider.
ARBs can cause heart failure and the client should report s/s of heart failure, such as weight gain.
Your patient presents with diaphoresis, tachypnea, and yellow-tinged sputum. The CXR shows a consolidation within the lower lobe of the left lung. The patient suddenly displays dyspnea and has absent lung sounds. Which of the following is the priority nursing action?
A. Encourage fluid intake of 2-3L daily.
B. Position the client in high fowlers
C. Call a rapid response
D. Administer oxygen via a nonrebreather on 15L
C. Call a rapid response
Absent breath sounds are an emergency situation
Which of the following statements indicates a need further need for understanding in a patient w/ polycystic kidney disease?
A. I can take ibuprofen to relieve pain and inflammation.
B. I will take my weight at the same time every day.
C. I should report changes in my bowel movements to my provider.
D. I will limit my fluid intake to 1L daily.
A & D
Avoid NSAID use d/t kidney impairment
Monitor daily weights and BP daily
Constipation is a complication associated w/ PCKD
Encourage fluid intake 2-3L daily to maintain kidney function and prevent constipation.
Your patient presents w/ metabolic acidosis and is on hemodialysis for CKD stage 5. Which of the following is the priority action the nurse should take?
A. Administer sodium bicarbonate IVP as prescribed.
B. Administer oxygen therapy to keep SpO2 levels > 95% as prescribed
C. Notify the provider
D. Assess vital signs and continue to monitor.
A. Administer sodium bicarbonate IVP as prescribed.
Kidney impairments can cause an inadequate production of bicarbonate.
A. I will take glipizide 30 minutes after my meals.
B. If I miss a dose of the glipizide, I will double it at the next scheduled time.
C. I can take glipizide even if I miss a meal.
D. I will monitor for tachycardia as it is a sign of hypoglycemia.
D. I will monitor for tachycardia as it is a sign of hypoglycemia.
Betablockers (metoprolol) can mask tachycardia associated with hypoglycemia. The nurse should educate about other s/s associated with hypoglycemia.
Which of the following statements are true about the regulatory mechanisms for blood pressure?
A. Chemoreceptors detect a change within blood volume.
B. Angiotensin II will cause vasodilation and controls aldosterone release.
C. Baroreceptors will control blood pressure by altering the heart rate.
D. The kidneys will retain fluid when a client is hypertensive.
C. Baroreceptors will control blood pressure by altering the heart rate.
Pg. 259 in ATI Medsurg book
Your patient has a history of COPD and presents SpO2 of 88% on 2L NC on home oxygen use. The patient presents with distended neck veins and dependent edema. Which of the following orders should the nurse clarify with the doctor?
A. Administer albuterol as needed for shortness of breath
B. Prednisone 10mg daily PO
C. Furosemide 40mg IVP daily
D. Normal saline continuous IV fluids at 100 cc/hr
D. Normal saline continuous IV fluids at 100 cc/hr
IVF are contraindicated for fluid overload patients. The patient presents with s/s associated with heart failure and retention of fluids (edema and distended neck veins).