shock/oxygenation
A client develops anaphylaxis after receiving IV medication. What is the first medication the nurse should anticipate administering?
Epinephrine
A nurse is caring for a client with an arteriovenous (AV) fistula. What is the priority assessment?
palpable thrill
Which finding is expected in Cushing’s syndrome?
A. Weight loss
B. Hypotension
C. Moon face and truncal obesity
D. Hyperkalemia
c
A nurse is caring for a client with suspected increased intracranial pressure. Which finding requires immediate intervention?
A. Headache
B. Vomiting
C. Widening pulse pressure
D. Restlessness
Widening pulse pressure
A client has a burn with blisters, moist appearance, and severe pain. How should the nurse classify this burn?
Superficial partial-thickness
A client with a history of myocardial infarction develops hypotension and pulmonary edema. Which type of shock is this?
Cardiogenic
Which finding is most characteristic of nephrotic syndrome?
Severe proteinuria
Which finding indicates a client may be experiencing thyroid storm?
Severe tachycardia and fever
A client is admitted with a suspected stroke. Which action is the nurse’s priority?
A. Obtain a detailed health history
B. Perform a swallow evaluation
C. Check blood glucose level
D. Administer aspirin
C. Check blood glucose level- hypoglycemia can mimic a stroke
A client weighs 70 kg and has 30% TBSA burns. How much fluid should be given in the first 24 hours?
8,400 mL
A client in shock has an elevated serum lactate level. What does this indicate?
Anaerobic metabolism
Which urine finding is expected in nephrotic syndrome?
Frothy/foamy urine
A client develops tingling in the fingers and muscle cramps after thyroid surgery. What is the nurse’s priority action?
A. Encourage fluids
B. Check serum calcium level
C. Administer potassium
D. Monitor blood glucose
B
A client with a cervical spinal cord injury is at risk for which complication?
A. Hypotension and bradycardia
B. Hypertension and tachycardia
C. Hyperthermia
D. Increased urine output
A. Hypotension and bradycardia
A client with a long bone fracture suddenly develops shortness of breath and confusion. What is the nurse’s priority action? and what should the nurse suspect
Apply oxygen
fat embolism
Which condition most likely triggers a high-pressure alarm on the ventilator?
a kink in the tubing (secretions, coughing, bronchospasm)
During the oliguric phase of AKI, which finding is expected?
Hyperkalemia
Which finding is characteristic of Addison’s disease?
A. Hypernatremia
B. Hypokalemia
C. Hypotension
D. Hyperglycemia
c
A client is diagnosed with bacterial meningitis. Which precautions should the nurse implement?
C. Droplet precautions
Which symptom represents a late sign of compartment syndrome?
A. Pain
B. Paresthesia
C. Pulselessness
D. Pallor
C. Pulselessness
Which intervention helps prevent ventilator-associated pneumonia (VAP)?
VAP bundle
Which medication order should the nurse question for a client with AKI?
A. Furosemide
B. Gentamicin
C. Insulin with glucose
D. Calcium gluconate
B. aminoglycosides are nephrotoxic
A client with adrenal insufficiency presents with hypotension and weakness. What is the priority intervention?
Administer IV corticosteroids
A client taking phenytoin should be monitored for which adverse effect?
A. Hypertension
B. Gingival hyperplasia
C. Weight loss
D. Tachycardia
Gingival hyperplasia
Which findings are expected in the emergent phase of burns? (Select all that apply)
A. Edema
B. Decreased urine output
C. Hypotension
D. Hypernatremia
E. Tachycardia
A, B, C, E