Pain/End of Life
Hem
F/E
Acid/Base
Endocrine
Cardiac
Resp
Labs/Meds
100
A nurse is obtaining a health history from the newly-admitted client who has chronic pain in the right knee. What should the nurse include in the pain assessment? Select all that apply.
Pain history, including location, intensity, and quality of pain
Client's purposeful body movement in arranging the papers on the bedside table
Pain pattern, including precipitating and alleviating factors
Vital signs, such as increased blood pressure and heart rate
The client's family statement about increases in pain with ambulation
A. Pain history, including location, intensity, and quality of pain
C. Pain pattern, including precipitating and alleviating factors Initial assessment: location, quality, intensity, onset, duration, frequency, what relieves/exacerbates pain
Vitals are a secondary assessment. Pain is subjective so ask client instead of accepting statements from family members.
100
While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation?
A. Stop the blood transfusion immediately.
B. Report to the primary healthcare provider.
C. Recheck identifying tags and numbers on the client.
D. Maintain a patent intravenous (IV) line with saline solution.
A. Stop the blood transfusion immediately.
An incompatible blood transfusion can result in an acute hemolytic reaction in the client.
The nurse should stop the blood transfusion, report it to the healthcare provider, recheck the client’s ID tags and numbers, maintain a patent IV line with saline solution, and continue to monitor the client.
100
A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply.
A. Supple skin turgor
B. Rapid, thready pulse
C. Decreased hematocrit
D. Elevated specific gravity
E. Adventitious breath sounds
B. Rapid, thready pulse
D. Elevated specific gravity
The pulse is rapid and thready because of the decreased blood volume associated with dehydration.
The urine specific gravity is elevated because the urine is concentrated.
Skin turgor would be decreased with evidence of tenting. Hct would be increased because of hemoconcentration. Adventitious breath sounds (crackles) would occur with FVE.
100
A client’s arterial blood gas report indicates that pH is 7.25, PaCO2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results?
A. A 65-year-old with pulmonary fibrosis
B. A 24-year-old with uncontrolled type 1 diabetes
C. A 45-year-old who has been vomiting for 3 days
D. A 54-year-old who takes sodium bicarbonate for indigestion
A. A 65-year-old with pulmonary fibrosis
The low pH and elevated PaCO2 = respiratory acidosis - this can be caused by pulmonary fibrosis (impedes the exchange of oxygen and carbon dioxide in the lung).
A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the blood.
A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting.
A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience metabolic alkalosis from an excess of base bircarbonate.
100
What interventions should the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply.
A. Instituting fall risk precautions
B. Restricting fluids to 2 L per day
C. Placing the client in high-Fowler position
D. Monitoring for and reporting neurologic changes
A. Instituting fall risk precautions
D. Monitoring for and reporting neurologic changes
The excess production of antidiuretic hormone associated with SIADH leads to increased water reabsorption by the kidneys. This then leads to decreased urinary output, increased intravascular fluid volume, low serum osmolarity, and dilutional hyponatremia.
Fall risk precautions are in place to protect the client from injury that might occur as a result of neurologic changes associated with declining serum sodium. Look for and report changes from cerebral edema and hyponatremia.
We need to immediately restore fluid balance - but fluids are restricted to no more than 1000mL. Also, laying supine helps promote venous return to the heart, which increases ventricular filling pressure, which tells the pituitary that ADH release should decrease.
100
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect?
A. "My ankles are swollen."
B. "I am tired at the end of the day."
C. "When I eat a large meal, I feel bloated."
D. "I have trouble breathing when I walk rapidly."
D. "I have trouble breathing when I walk rapidly."
Dyspnea on exertion often occurs with left ventricular heart failure - the heart is unable to pump oxygenated blood to meet the energy requirements for muscle contractions related to the activity.
Swollen ankles are more likely with right ventricular heart failure.
Being tired at the end of the day is not specific to left ventricular heart failure.
When someone eats a large meal and feels bloated afterwards, it’s not specific to left ventricular heart failure.
100
When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate?
A. Remove secretions by suctioning.
B. Lower the setting of the tidal volume.
C. Check that tubing connections are secure.
D. Obtain a specimen for arterial blood gases (ABGs).
A. Remove secretions by suctioning.
Secretions in the airway will increase pressure by blocking air flow and must be removed.
The nurse must identify/correct the problem so that the set tidal volume can be delivered.
Connections that are not intact would cause a low-pressure alarm.
ABG’s are used to assess client status, but they are not taken each time a pressure alarm is heard.
100
A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication?
A. Aspirin
B. Midazolam
C. Gabapentin
D. Alprazolam
A. Aspirin
Early administration of aspirin in the setting of acute myocardial infarction (MI) has been demonstrated to significantly reduce mortality. Aspirin inhibits the action of platelets, preventing their ability to clump together and form clots. The mechanism of acute coronary syndrome usually is ruptured plaque in one of the coronary arteries with clot formation obstructing blood flow.
Gabapentin is an anticonvulsant and is not the drug of choice to relieve the pain associated with an MI.
Midazolam HCl is a sedative-hypnotic that is used for its calming effect, but it will not relieve the pain of an MI.
Alprazolam is an anxiolytic that is used for its calming effect, but it will not relieve the pain of an MI.
200
A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement?
A. Turning on the television for diversion
B. Calling the primary healthcare provider for another analgesic prescription
C. Placing the prescribed as-needed warm, wet compress on the elbow
D. Informing her gently that she must wait until the pump reactivates to get more medication
C. Placing the prescribed as-needed warm, wet compress on the elbow
Vasodilation helps reduce pain from cellular clumping. The warmth can help the pain until the pump can be activated.
Television is a good distractor for mild pain, not moderate or severe.
Nursing measures should be attempted first before calling the provider.
Telling the adolescent to wait provides no comfort.
200
A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia?
A. Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques
B. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion
C. Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture
D. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes
A. Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques
Patients with leukemia are at very high risk of infection, due to their low neutrophil count. Placing the child in a private room, restricting visitors who are ill, and using strict hand washing techniques are the best ways to minimize complications.
The diet and avoiding overexertion are relevant to anemia. Avoiding rectal temps, limiting injections, and applying pressure after venipuncture are relevant to preventing bleeding.
200
Which nursing intervention should the nurse consider to be a priority for clients with fluid overload?
A. Ensuring client safety
B. Providing drug therapy
C. Providing nutritional therapy
D. Preventing future fluid overload
A. Ensuring client safety
Priority interventions include ensuring client safety and restoring normal fluid balance - this will help prevent complications like pulmonary edema and heart failure. Serum sodium levels are low during fluid overload - resulting in potential neuro changes.
Providing drug therapy and nutritional therapy are secondary nursing interventions. Prevention of future overload should be done after restoring the fluids to normal levels.
200
The nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which arterial blood gas report is indicative of diabetic ketoacidosis?
A. PCO 2: 49, HCO 3: 32, pH: 7.50
B. PCO 2: 26, HCO 3: 20, pH: 7.52
C. PCO 2: 54, HCO 3: 28, pH: 7.30
D. PCO 2: 28, HCO 3: 18, pH: 7.28
D. PCO 2: 28, HCO 3: 18, pH: 7.28
Decreased pH and bicarb values = metabolic acidosis; a decreased PaCO2 = compensatory hyperventilation.
Increased pH and bicarb = metabolic alkalosis; an increased PaCO2 = compensatory hypoventilation.
Increased pH and decreased PaCO2 = hyperventilation and respiratory alkalosis.
Decreased pH and increased PaCO2 = hypoventilation and respiratory acidosis.
200
A client who is suspected of having Cushing syndrome is admitted to the hospital. When checking the laboratory reports, which condition should the nurse expect?
A. Hypokalemia
B. Hypovolemia
C. Hypocalcemia
D. Hyponatremia
A. Hypokalemia
With glucocorticoid excess, aldosterone hypersecretion occurs and sodium is retained; therefore potassium is excreted, leading to hypokalemia.
Hypervolemia occurs because of sodium and water retention precipitated by aldosterone.
Hypocalcemia is not associated with aldosteronism.
Aldosterone hypersecretion causes sodium retention and hypernatremia, no hyponatremia.
200
Which is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease?
A. Incisional pain
B. Popliteal pulse rate
C. Degree of hair growth
D. Lower extremity color
D. Lower extremity color
Checking color and temperature (neuro assessment) provides data about current perfusion of the extremity and the possibility of graft occlusion/blockage.
Although pain assessment is essential, incisional pain does not provide data about the neuro status of the extremity - a dramatic increase in pain or severe continuous, aching pain is indicative of a graft occlusion.
Although the presense and quality of the pedal pulse provide data about peripheral circulation, it is not necessary to count the popliteal rate.
Clients with PAD experience loss of extreme hair, which will not suddenly change because of surgery.
200
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia?
A. Red blood cell count
B. Sputum culture
C. Arterial blood gas
D. Total hemoglobin
C. Arterial blood gas
RBC count, sputum culture, and Hgb tests assist in the evaluation of a client with respiratory difficulties; however, ABG analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client’s oxygenation status.
200
The nurse is preparing discharge instructions for a client who was prescribed enalapril for treatment of hypertension. Which instruction is appropriate for the nurse to include in the client's teaching?
A. Do not change to a standing position suddenly.
B. Lightheadedness is a common adverse effect that need not be reported.
C. The medication may cause a sore throat for the first few days.
D. Schedule blood tests weekly for the first 2 months.
A. Do not change to a standing position suddenly.
Enalapril is classified as an ACE inhibitor. It is used to treat hypertension and congestive heart failure by relaxing the blood vessels so they can open up. It can also be used to treat a disorder of the ventricles. Angiotensin is a chemical that causes the arteries to become narrow.
Clients should be advised to change positions slowly to minimize orthostatic hypotension. A healthcare provider should be notified immediately if the client is experiencing lightheadedness or feeling like he or she is about to faint, as this is a serious side effect.
This medication does not cause a sore throat the first few days of treatment.
Presently, there are no guidelines that suggest blood tests are required weekly for the first 2 months.
300
A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply.
A. Chemotherapy
B. Repositioning
C. Regular oral care
D. Blood transfusion
E. Radiation therapy
A. Chemotherapy
D. Blood transfusion
E. Radiation therapy
Palliative care is a combination of care provided when cure is not possible for a chronic disease. It may include symptom management and comfort measures.
Chemotherapy, radiation, blood transfusions - help alleviate symptoms and promote well being. Other cares include oral care and repositioning.
300
A client has a platelet count of 49,000/mL (40 × 10 9/L). The nurse should instruct the client to avoid which activity?
A. Ambulation
B. Blowing the nose
C. Visiting with children
D. The semi-Fowler position
B. Blowing the nose
Clients with thrombocytopenia are at a greater risk of excessive bleeding in response to minimal trauma.
Instruct the client to avoid blowing the nose - this can increase the risk of bleeding.
Ambulation, visiting with children, and semi-Fowler’s position are not contraindicated with thrombocytopenia.
300
A client’s serum potassium level is below the normal range. Which clinical indicators should the nurse determine are consistent with hypokalemia? Select all that apply.
A. Abdominal cramping
B. Tall, peaked T wave
C. Irregular heart rate
D. Muscular weakness
E. Decreased bowel sounds
F. Hyperactive deep tendon reflexes
A. Abdominal cramping
C. Irregular heart rate
D. Muscular weakness
E. Decreased bowel sounds
Hypokalemia may cause nerve and muscle weakness, which may precipitate irregular heartbeats and dysrhythmias. Decreased bowel sounds, abdominal cramping, and paralytic ileus can be from decreased bowel motility associated with hypokalemia.
On an EKG, the T wave is depressed or flattened with hypokalemia. Deep tendon reflexes are depressed, not hyperactive with hypokalemia.
300
Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO 2 53 mm Hg, and HCO 3 25 mEq/L (25 mmol/L). Which action should the nurse take?
A. Obtain a prescription for a diuretic.
B. Have the client breathe into a rebreather bag.
C. Encourage the client to take deep, cleansing breaths.
D. Request a prescription for the administration of sodium bicarbonate.
C. Encourage the client to take deep, cleansing breaths.
The client is in respiratory acidosis - likely from the depressant effects of an anesthetic or a compromised airway. Deep breaths blow off CO2 and encourage coughing.
Obtaining a prescription for a diuretic will not correct respiratory acidosis and may aggravate hypokalemia if present.
Having the client breathe into a rebreather bag is the treatment for respiratory alkalosis; the client is in respiratory acidosis.
Obtaining a prescription for sodium bicarb is not necessary if clearing of the airway corrects the problem.
300
A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan to encourage this client to modify dietary intake?
A. Increased amounts of potassium are needed to replace renal losses.
B. Increased protein is needed to heal the adrenal tissue and thus cure
the disease.
C. Supplemental vitamins are needed to supply energy and assist in
regaining the lost weight.
D. Extra salt is needed to replace the amount being lost caused by lack
of sufficient aldosterone to conserve sodium.
D. Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium.
Lack of mineralcorticoids (aldosterone) leads to loss of sodium ions in the urine, leading to hyponatremia.
Potassium intake is not encouraged. Hyperkalemia is a problem because of insufficient mineralcorticoids.
Increasing protein is needed to heal the adrenal tissue - tissue repair of the gland is not possible.
Vitamins are not directly energy-producing, nor will they help the client gain weight.
300
The home health nurse is visiting a client with multiple health problems that include a history of chronic atrial fibrillation. The nurse obtains a radial rate of 136 beats per minute. What should the nurse do first?
A. Obtain the other vital signs.
B. Recheck the pulse to verify the rate.
C. Stay with the client until an ambulance arrives.
D. Alert the primary healthcare provider of the client’s status.
A. Obtain the other vital signs.
The radial pulse of a client with chronic a-fib may range from 50-180bpm. Other vital signs should be assessed before notifying the primary healthcare provider.
Although rechecking the pulse to verify the rate may be done, it’s not necessary because a pulse of 136bpm is not unusual for a client with chronic a-fib.
Staying with the client until the ambulance arrives or alerting the primary healthcare provider are not the initial actions.
300
In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)?
A. Chest tube insertion
B. Aggressive diuretic therapy
C. Administration of beta-blockers
D. Positive end-expiratory pressure (PEEP)
D. Positive end-expiratory pressure (PEEP)
Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation.
Fluid is not in the pleural space, so chest tube insertion is not indicated.
Aggressive diuretic therapy and administration of beta blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.
300
A 13-year-old child with type 1 diabetes is receiving 15 units of regular insulin and 20 units of NPH insulin at 7:00 AM each day. At what time does the nurse anticipate a hypoglycemic reaction from the NPH insulin to occur?
A. Before noon
B. In the afternoon
C. Within 30 minutes
D. During the evening
B. In the afternoon
NPH insulin is an intermediate-acting insulin that peaks approximately 6 to 8 hours after administration. It was administered at 7:00 AM, so between 1:00 and 3:00 PM is when the nurse should anticipate that a hypoglycemic reaction will occur.
Noon is when a reaction from a short-acting insulin is expected. Short-acting insulin peaks in 2 to 4 hours after administration.
Within 30 minutes of administration is when a reaction from a rapid-acting insulin is expected. Rapid-acting insulin peaks 30 to 60 minutes after administration.
During the evening or night is when a reaction from a long-acting insulin is expected. Long-acting insulin has a small peak 10 to 16 hours after administration.
400
A client receiving morphine is being monitored by the nurse for adverse effects of the drug. Which clinical findings warrant immediate follow up by the nurse? Select all that apply.
A. Polyuria
B. Sedation
C. Bradycardia
D. Dilated pupils
E. Slow respirations
B. Sedation
C. Bradycardia
E. Slow respirations
Morphine depresses the CNS, leading to sedation - bradycardia, bradypnea.
Morphine does not increase urine output.
Morphine causes constriction of pupils.
400
A 3-year-old child with mild iron deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit?
A. Cold, clammy skin
B. Increased pulse rate
C. Increased blood pressure
D. Cyanosis of the nail beds
B. Increased pulse rate
Tachycardia occurs as the body tries to compensate for hypoxia due to mild iron deficiency anemia.
Severe anemia - pale, cool, clammy skin
Increased BP is not a response associated with anemia. Cyanosis of the nail best is a sign of CO2 poisoning.
400
A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery?
A. Constipation
B. Muscle spasms
C. Hypoactive reflexes
D. Increased specific gravity
B. Muscle spasms
Removal of the parathyroids causes hypocalcemia and associated neuromuscular irritability.
Constipation is a sign of hypercalcemia, hypoactive reflexes are signs of hypercalcemia.
Increased urine specific gravity is a sign of fluid volume deficit.
400
A 3-month-old infant who has a 3-day
history of diarrhea is admitted to the
pediatric unit. The nurse obtains the
infant’s vital signs, performs a physical
assessment, and reviews the infant’s
arterial blood gas results. Which acid-
base imbalance does the nurse suspect?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
A. Metabolic acidosis
The pH indicates acidosis, not alkalosis.
The HCO3 level is further from the expected range than is the PaCO2 level - indicating a metabolic, not respiratory origin (losses from diarrhea).
400
The nurse is teaching a client who underwent a hypophysectomy for hyperpituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply.
A. Nose blowing
B. Teeth brushing
C. Bending forward
D. Breathing through the mouth
E. Lying in a semi-Fowler’s position
A. Nose blowing
B. Teeth brushing
C. Bending forward
After a hypophysectomy a drip pad is placed under the nose of the client for 2-3 days. Therefore, the client should not blow their nose, brush their teeth, or bend forward because these activities can increase intracranial pressure and delay healing.
Because of the nasal packing, the client is advised to breathe through their mouth.
Lying in a semi-Fowler’s position will not interfere with the nasal packing; therefore it will not cause any complication.
400
A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client?
A. The signs and symptoms of pericarditis
B. The signs and symptoms of heart failure
C. That cardiac surgery will have to be done eventually for the other valves
D. That cardiac surgery will have to be done every six months to replace the valve
B. The signs and symptoms of heart failure
The teaching plan for this client should focus on the possibility of heart failure. Clients with a failed valve are prone to heart failure; report any signs of dyspnea, syncope, dizziness, edema, and palpitations.
Infective endocarditis, not pericarditis, may occur. Endocarditis is an infection of the endothelial surface of the heart and valves. Pericarditis is an inflammation of the pericardium, the membranous sac enveloping the heart.
There is no evidence of pathology of other valves.
There is no schedule that valves will be replaced every 6 months.
400
On the second day after surgery, a client reports pain in the right calf. What should the nurse do first?
A. Apply a warm soak.
B. Document the symptom.
C. Elevate the leg above the heart.
D. Notify the primary healthcare provider.
D. Notify the primary healthcare provider.
Calf pain may be a sign of thrombophlebitis, which can lead to pulmonary embolism. A postoperative client with pain in the calf should be confined to bed immediately and the primary healthcare provider notified.
A prescription for application of heat may be given after a diagnosis is made; application of heat is a dependent nursing function.
Documentation is not the priority; this is a potentially serious complication.
The leg should not be elevated above heart level without a prescription; gravity may dislodge a thrombus, creating an embolism.
400
A client presents to the emergency department with symptoms of acute myocardial infarction (MI). Which results will the nurse expect to find upon assessment?
A. Decreased breath sounds
B. Elevated serum troponin
C. Decreased creatine kinase-MB (CK-MB)
D. Elevated brain natriuretic peptide (BNP) level
B. Elevated serum troponin
Elevations of troponin levels are indicative and specific for cardiac muscle damage.
Decreased breath sounds would indicate a pulmonary problem.
An increase in CK-MB would indicate MI.
Elevated BNP levels would indicate heart failure, which is a potential complication of acute myocardial infarction.
500
A client who is admitted to the hospital and requires a colon resection states, "I want to be a do not resuscitate (DNR)." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order?
A. "My doctor will know what to do."
B. "My family can make the decisions for me."
C. "If something happens to me, I do not want CPR."
D. "If I have a heart attack, I do not want any medication."
C. "If something happens to me, I do not want CPR."
If cardiac or respiratory arrest occurs, the client would rather die peacefully and does not want cardiorespiratory resuscitation. If a DNR order is signed by the client, CPR will not be started.
For Power of Attorney, the client gives power to another person to make healthcare decisions on their behalf.
For an Advance Directive, or Living Will, the client determines treatment according to their wishes.
500
A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement?
A. "I’ll start to have symptoms when I drink less fluid."
B. "I’ll start to have symptoms when I have fewer platelets."
C. "I’ll start to have symptoms when I decrease the iron in my diet."
D. "I’ll start to have symptoms when I have fewer white blood cells."
A. "I’ll start to have symptoms when I drink less fluid."
Dehydration precipitates sickling of RBCs - it’s a major cause for painful episodes associated with sickle cell anemia.
Low platelets is associated with thrombocytopenia. Iron is unrelated to sickling. Low WBCs is not associated with sickle cell anemia.
500
The nurse is assessing the respiratory status of the client at 2-hour intervals as a nursing safety priority. Which condition is affecting the client?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypernatremia
A. Hypokalemia
In case of hypokalemia, the nurse should assess the respiratory status of the client q2hrs.
In case of hyperkalemia, the nurse should notify the healthcare team if the heart rate falls below 60bpm or T waves become spiked.
In case of hyponatremia, the nurse should be aware of muscle weakness and immediately check respiratory effectiveness.
In case of hypernatremia, the nurse should assess the client hourly for excessive losses of fluid, sodium, or potassium.
500
A client's arterial blood gas report indicates the pH is 7.52, PCO 2 is 32 mm Hg, and HCO 3 is 24 mEq/L. What does the nurse identify as a possible cause of these results?
A. Airway obstruction
B. Inadequate nutrition
C. Prolonged gastric suction
D. Excessive mechanical ventilation
D. Excessive mechanical ventilation
The high pH and low CO2 levels = respiratory alkalosis. This can be caused by mechanical ventilation that is too aggresive.
Airway obstruction causes CO2 buildup, which leads to respiratory acidosis.
Inadequate nutrition causes excess ketones, which leads to metabolic acidosis.
Prolonged gastric suctioning causes loss of hydrochloric acid, which can lead to metabolic alkalosis.
500
A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause?
A. Increased serum glucose
B. Deficient renal perfusion
C. Inadequate antidiuretic hormone (ADH) secretion
D. Excess amounts of intravenous (IV) fluid
C. Inadequate antidiuretic hormone (ADH) secretion
Deficient ADH from the posterior pituitary results in diabetes insipidus. This can be caused by head trauma; water is not conserved by the body, and excess amounts of urine are produced.
Although increased serum glucose may cause polyuria, it is associated with diabetes mellitus, not diabetes insipidus.
Ineffective renal perfusion will cause decreased urine production.
While excess amounts of IV fluids may cause dilute urine, it is unlikely that a client with head trauma will be receiving excess fluid because of the danger of increased intracranial pressure.
500
The nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually results in central cyanosis?
A. Shunting of blood from right to left
B. Shunting of blood from left to right
C. Obstruction of blood flow from the left side of the heart
D. Obstruction of blood flow between the left and right sides of
the heart
A. Shunting of blood from right to left
Right to left shunting results in inadequate perfusion of blood; not enough blood flows to the lungs for oxygenation.
Left to right shunting results in too much blood flowing to the lungs; blood is adequately perfused.
Left sided obstruction to the flow of blood results in decreased peripheral pulses, not cyanosis.
Obstruction of blood flow between the left and right sides of the heart usually occurs with patent ductus arteriosus. There should be no shunting of blood between the right and left sides of the heart after the ductus arteriosus has closed.
500
The nurse is caring for a client with a respiratory tract infection that started with a common cold but has progressed to whooping cough. The client also has coughing fits that last for several minutes. Which organism is responsible for the client’s condition?
A. Bacillus anthracis
B. Bordetella pertussis
C. Streptococcus pneumonia
D. Mycobacterium tuberculosis
B. Bordetella pertussis
This disease is caused by Bordetella pertussis. Pertussis is a respiratory tract infection that begins with the common cold and progresses to whooping cough. The client also develops coughing fits that last for several minutes. Inhalation anthrax is caused by Bacillus anthracis.
Streptococcus pneumoniae may cause pneumonia.
Mycobacterium tuberculosis infection leads to tuberculosis.
500
A client who had a myocardial infarction is in the coronary care unit on a cardiac monitor. The nurse observes runs of ventricular tachycardia on the screen. What medication should the nurse prepare to administer?
A. Digoxin
B. Furosemide
C. Amiodarone
D. Norepinephrine
C. Amiodarone
Amiodarone decreases the irritability of the ventricles by prolonging the duration of the action potential and refractory period. It is used in the treatment of ventricular dysrhythmias such as ventricular tachycardia.
Digoxin slows and strengthens ventricular contractions; it will not rapidly correct ectopic beats.
Furosemide, a diuretic, does not affect ectopic foci.
Norepinephrine is a sympathomimetic and is not the drug of choice for ventricular irritability.