Med surg
A client with a diagnosis of diabetic ketoacidosis (DKA) is being treates in the emergency department. Which findings support the diagnosis? Select all that apply.
A. Fever
B. Nausea
C. Lethargy
D. Tremors
E. Confusion
F. Brdaycardia
B. Nausea
C. Lethargy
D. Confusion
An increase in which serum laboratory value indicates to the nurse that a prescription for atorvastatin is having the desired effect for a client at risk for coronary artery disease?
A. LDL (Low-density lipoprotein)
B. Triglycerides (Type of fat)
C. HDL (High-density lipoprotein)
D. VLDL (Very low-density lipoprotein)
C. HDL (High-density lipoprotein)
The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority problem should the nurse assign to this client?
A. Deficient fluid voulme related to acute blood loss
B. Risk for aspiration related to acute bleeding in the GI tract
C. Risk for infection related to acute disease process and medications
D. Imbalanced nutrition, less than body requirments, related to lack of nutrients and increased metabolism
A. Deficient fluid volume related to acute blood loss
The priority problem for the client with acute gastrointestinal bleeding among these options is deficient fluid volume related to acute blood less. This state can result in decreased cardiac output and hypovolemic shock. Although nutrition is a problem, fluid volume deficit is more of a priority. The client is at risk for aspiration and infection, but these are not actual problems at this point in time.
The nurse is performing an assessment on a client who is at 38 weeks’ gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action?
A. Document the finding.
B. Check the mother’s heart rate.
C. Notify the obstetrician (OB).
D. Tell the client that the fetal heart rate is normal.
C. Notify the obstetrician (OB)
The FHR depends on gestational age and ranges from 160 to 170 beats per minute in the first trimester but slows with fetal growth to 110 to 160 beats per minute. If the FHR is less than 110 beats per minute or more than 160 beats per minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the OB. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the OB needs to be notified.
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client’s breath sounds?
A. Stridor
B. Crackles
C. Scattered rhonchi
D. Diminished breath sounds
B. Crackles
The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply.
A. Tremors
B. Weight loss
C. Feeling Cold
D. Loss of body hair
E. Persistent lethargy
F. Puffiness of the face
C. Feeling Cold
D. Loss of body hair
E. Persistent lethargy
F. Puffiness of face
Which action should the nurse implement to assess the effectiveness of calcium channel blocker amlodipine?
A. Note the clients serum calcium levels
B. Monitor the clients serum electrolytes
C. Review the clients intake and output
D. Measure the clients blood pressure
D. Measure the clients blood pressure
A client in shock develops a central venous pressure (CVP) of 2 mm Hg and mean arterial pressure (MAP) of 60 mm Hg. Which prescribed intervention should the nurse implement first?
A. Increase the rate of O2 flow
B. Obtain arterial blood gas results
C. Insert an indwelling urinary catheter
D. Increase the rate of intravenous (IV) fluids
D. Increase the rate of intravenous (IV) fluids
The MAP and CVP are both low for this client, indicating a shock state. Shock is the result of inadequate tissue perfusion. Fluid volume should be immediately restored first to provide adequate perfusion for the client in a shock state. Although increasing the rate of O2 flow may be a necessary intervention, perfusion is the first priority. Obtaining arterial blood gas results and inserting an indwelling urinary catheter may be necessary interventions to monitor the client’s response to prescribed therapy, but these are not the priority.
A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate?
A. “Have you ever had surgery?”
B. “Do you plan to have any other children?”
C. “Do either of you have diabetes mellitus?”
D. “Do either of you have problems with high blood pressure?”
B. “Do you plan to have any other children?”
Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility, because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future. Options 1, 3, and 4 are unrelated to this procedure.
A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition?
A. Pyelonephritis
B. Glomerulonephritis
C. Trauma to the Bladder or abdomen
D. Renal cancer in the client's family
C. Trauma to the bladder or abdomen
A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client’s care plan?
A. Monitoring the temperature
B. Monitoring compliants of heartburn
C. Giving warm gargles for sore throat
D. Assessing for the return of the gag reflex
D. Assessing for the return of gag reflex
A client receives a prescription for ciprofloxacin 400 mg intravenously (IV) every 12 hours which is to be infused over an hour. The IV bag contains ciprofloxacin 400 mg in dextrose 5%in water (D5W) 200 mL. How many mL/hr should the nurse program the infusion pump to deliver?
200 mL/hr
Rationale:
xmL/hr =
200 mL x 400 mg = 80,000 = 200 mL/hr
400 mg 1 hr 400
A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.
A. Restrict fluids
B. Assess for airway patency
C. Administer oxygen as prescribed
D. Place a cooling blanket on the client
E. Elevate extremities if no fractures are present
F. Prepare to give oral pain medication as prescribed
B. Assess for airway patency
C. Administer oxygen as prescribed
E. Elevate extremities if no fractures are present
The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm, because the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury.
The nurse is reviewing the primary health care provider's documentation in the record of a child admitted with a diagnosis of intussusception. The nurse expects to note that the primary health care provider has documented which manifestation?
A.Scleral jaundice
B.Projectile vomiting
C.Currant jelly-like stools
D.Pale-colored and hard stools
C. Currant jelly-like stools
The nurse is reviewing a client’s record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?
A. Elevated creatinine level
B. Decreased hemoglobin level
C. Decreased red blood cell count
D. Increased number of white blood cells in the urine
A. Elevated creatinine level
The creatinine level is the most specific laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count are associated with anemia or blood loss and not specifically with decreased renal function. Increased white blood cells in the urine are noted with urinary tract infection.
A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?
A. Hot, flushed feeling
B. Sudden chills and fever
C. Chest pain that occurs suddenly
D. Dyspnea when deep breaths are taken
C. Chest pain that occurs suddenly
Hormone replacement therapy with levothyroxine sodium is prescribed for a client with hypothyroidism. The nurse should instruct the client to report which symptom because it indicates that the client is taking too much of the hormonal agent, levothyroxine?
A. Intolerance to cold
B. Constipation
C. Restlessness
D. Decreased appetite
C. Restlessness
The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?
A. Increased temerpature, increasing pulse, increasing respirations, decreasing blood pressure
B. Increasing temperature, decreasing pulse, decreasing repirations,increasing blood pressure
C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
D. Decreasing temerapture, increasing pulse, decreasing respirations, increasing blood pressure
B. Increasing temperature, decreasing pulse, decreasing repirations,increasing blood pressure
A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.
The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?
A.Meningitis
B.Spinal cord injury
C.Intracranial bleeding
B.Decreased cerebral blood flow
A.Meningitis
The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client’s peripheral response to pain?
A. Sternal rub
B. Nailed pressure
C. Pressure on the orbital rim
D. Squeezing of the sternocleidomastoid muscle
B. Nailed Pressure
Nailbed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mm Hg, reports dizziness. Which intervention should the nurse anticipate will be prescribed?
A. Administer digoxin
B. Defibrillate the client
C. Continue to monitor the client
D. Prepare for transcutaneous pacing
A client with atrial fibrillation receives a new prescription for dabigatran. Which instruction should the nurse include in this client's teaching plan?
A: Eliminate spinach and other green vegetables in the diet.
B: Continue obtaining scheduled laboratory bleeding tests.
C: Keep an antidote available in the event of hemorrhage.
D: Avoid use of nonsteroidal anti-inflammatory drugs (NSAIDs).
D: Avoid use of nonsteroidal anti-inflammatory drugs (NSAIDs).
Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply.
A. Urine output 50ml/hy
B. Hypoactive bowel sounds
C. Temperature of 102F
D. Heart rate of 96 beats per minute
E. Mean arterial pressure 65 mmHg
F. Systolic blood pressure 110 mmHG
C. Temperature of 102F
D. Heart rate of 96 beats per minute
E. Mean arterial pressure 65 mmHg
Sepsis diagnostic criteria with regard to signs and symptoms include the following: Fever (temperature higher than 100.9° F [38.3° C]) or hypothermia (core temperature lower than 97° F [36° C]), tachycardia (heart rate above 90 beats per minute), tachypnea (respiratory rate above 22 breaths per minute), systolic blood pressure (SBP) less than or equal to 100 mm Hg or arterial hypotension (SBP below 90 mm Hg), MAP less than 70 mm Hg, or a decrease in SBP of more than 40 mm Hg, altered mental status, edema or positive fluid balance, oliguria, ileus (absent bowel sounds), and decreased capillary refill or mottling of skin.
The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?
A.Initiate strict enteric precautions.
B.Move the infant to a room with another child with RSV.
C.Leave the infant in the present room because RSV is not contagious.
D.Inform the staff that they must wear a mask, gloves, and a gown when caring for the child.
B.Move the infant to a room with another child with RSV.
The nurse review's a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level?
A. Malnutrition
B. Renal insufficiency
C. Hypoparathyroidism
D. Tumor lysis syndrome
A. Malnutrition
The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.