Endo/Electrolytes
a. Potassium 5.4
b. Cr 1.04
c. BUN 21
d. Na 150
d. Na 150
What is the most accurate assessment of fluid volume status?
a. I/Os
b. fluid restriction compliance
c. daily weight
d. Serum sodium levels
c; daily weights should be taken early in the morning when you are the "lightest"
Pt with continuous NGT suctioning is at higher risk for which imbalance:
a. respiratory acidosis
b. respiratory alkalosis
c. metabolic acidosis
d. metabolic alkalosis
d. metabolic alkalosis
think about throwing up or NGT suctioning
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6
a. Begin the transfusion as prescribed.
b. Administer an antihistamine and begin the transfusion.
c. Delay hanging the blood and notify the health care provider.
d. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion.F orally. Which action should the nurse take?
C; not in your scope to make this decision
Pt admitted for a recent SI attempt via ingesting a bottle of acetaminophen. Pt being treated with IV acetylecystine. Your patient has orders for suicide precautions. How frequently does charting need to occur on a 1:1?
Q15 minutes at least in addition to Q2 hour charting and environmental checks
A client with diabetes mellitus visits a health care clinic. The client’s diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL (10.2 to 11.4 mmol/L). Which medication, if added to the client’s regimen, may have contributed to the hyperglycemia?
A. Prednisone
B. Atenolol
C. Phenelzine
D. Allopurinol
A; corticosteroids increase BG levels
A patient with brainstem damage is demonstrating what kind of positioning or rigidity when:
- feet are plantar flexing
- wrists are flexed with forearm pronation
- arm extension and abduction
decerebrate rigidity
What is this ABG showing?
Ph 7.40, CO2 37, HcO3 23
Normal ABG
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
a. Urine output of 20ml/hour
b. Temperature of 37.6 C
c. Blood pressure of 114/70
d. Serous drainage on the surgical dressing
a; UOP should be 30mL/hr
Pt presented to floor with dx of ETOH withdrawal. Based on the dx, what precautions should you place your patient on?
*hint: there's two*
Seizure and Aspiration
Pt is experiencing hypocalcemia due to CKD. What could you see when you tap their face in front of ear and causes facial twitching?
a. Chovstek's sign
b. Trousseu's sign
c. Murphy's sign
d. Homan's sign
a; Chovstek's
Pt has noted buffalo hump which is a common sign for which endocrinology pathology?
Cushings Syndrome
Ph 7.23, CO2 50, HcO3 22
What is this ABG showing and is it compensated?
uncompensated respiratory acidosis
The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY?
A. Place the patient in supine position and clamp the tubing.
B. Notify the physician immediately.
C. Disconnect the drainage system and get a new one.
D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
SLE (systemic lupus) is characterized by what symptom?
Butterfly or malar rash
A patient is post-opt from a thyroidectomy for treatment of Grave's Disease. When you walk into the patient's room to perform an assessment, which of the following findings causes the MOST concern and needs nursing intervention?
A. The patient complains of a pain rating of 4 on 1-10 at the surgical site
B. The patient is positioned in supine position
C. The patient's Foley catheter is draining 50 cc of urine per hour
D. The patient is splinting the neck while coughing and deep breathing.
B; maintain 30 degrees or higher due to airway and breathing risk from swelling immediately after surgery
45 year old female with hx of SUD, HFrEF EF 21%, hyperthyroidism, and PTSD BIBA for SOB and CP for 2 days. Noted heart murmur on auscultation with DOE. Provider noted splinter hemorrhaging of fingertips and osler notes. What do you suspect based on findings?
Endocarditis
pH 7.50, CO2 42, HcO3 33
What is this ABG showing and is it compensated?
uncompensated metabolic alkalosis
Four year old boy presents to ED c/o poor PO intake, not playing with other kids, and fatigue. Temporal temp 38.6C that started 3 days ago. Notable swollen neck lymph nodes with genital rashes. Mouth noted to have dry, cracked lips with a "strawberry tongue."
*hint: not scarlet fever*
Kawasaki Disease; rare acute vasculitis
Which of the following patients should the nurse question taking on their patient assignment? Select all that apply
a. Patient with stage 3 breast cancer admitted for chemotherapy
b. Pt w/ a varicella PCR positive swab.
c. Pt w/ hx of IV drug use who is Hep B positive.
d. 45 yr male diagnosed with BPH taking daily 5 mg PO finasteride in the morning
A: yellow tier precautions are a Big NO NO
b. Varicella; huge risk for fetal harm
c. finasteride should be avoided if pregnant; can promote birth defects
Which problem should the nurse anticipate for a patient admitted to the hospital with diabetes insipidus?
a. Generalized edema.
b. Fluid volume overload.
c. Disturbed sleep pattern.
d. Decreased gas exchange
C. Nocturia occurs because of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected.
Physician suspects pt might be experiencing cardiac tamponade. What are the three criterion for beck's triad?
1. distended jugular neck veins
2. diminished or muffled heart sounds
3. hypotension due to decreased cardiac output
pH 7.50, CO2 18, HcO3 24
What is this ABG showing and is it compensated?
uncompensated respiratory alkalosis
45 yr M BIBA for MVC accident with positive head strike and LOC. Three days later, the day nurse is assessing her patient and worried pt's ICP has increased drastically within the hour. Pt is lethargic and unable to follow commands. What are the criterion for cushing's triad?
1. widened pulse pressure/HTN
2. bradycardia
3. irregular respirations such as cheyne stokes
Doctor ordered a lab CSF PCR after a spinal tap to test for bacterial meningitis. What precautions should you place your patient on?