Priority
A client with acute myelogenous leukemia is receiving induction-phase chemotherapy. Which assessment finding requires the MOST rapid action?
1.) Serum potassium level 7.8 mEq/L
2.) Urine output less than intake by 400 mL
3.) Inflammation and redness of the oral mucosa
Fatal hyperkalemia may be caused by tumor lysis syndrome, a potentially serious consequence of chemotherapy in acute leukemia.
When a client is being prepared for a colonoscopy procedure, which task is most suitable to delegate to an unlicensed assistive personnel (UAP)?
1.) Explaining the need for a clear liquid diet
2.) Reinforcing 'NPO" status
3.)Administering an enema to prepare the bowel
The UAP can reinforce dietary and fluid restrictions after the RN has explained the information to the client.
The nurse is caring for a client with cirrhosis and portal hypertension. Which statement by the client is cause for GREATEST concern?
1.)" I'm very constipated and have been straining during bowel movements."
2.) "I can't button my pants anymore because my belly is so swollen."
3.) " When I sleep, I have to sit in a recliner so that I can breathe more easily."
There is a potential for sudden rupture of blood vessels with massive hemorrhage because straining increases thoracic or abdominal pressure.
For clients with peptic ulcer disease (PUD), what is the MOST important lifestyle modification?
1.) Avoid caffeine
2.) Decrease alcohol intake
3.) Smoking cessation
Smoking is associated with the development of PUD
A client with familial hypercholesterolemia is prescribed atorvastin 10 mg once a day. Which finding will the nurse immediately report to the healthcare provider?
1.) stomach upset
2.) Constipation
3.) Bloating
4.) Muscle soreness
Clients who are prescribed statins can develop the adverse effect of rhabdomyolysis such as muscle pain, weakness, vomiting stomach pain and brown urine. When any of these symptoms appear, the drug needs to be discontinued and another type of drug prescribed.
The nurse is caring for a client with peptic ulcer disease (PUD). Which assessment finding is the MOST serious?
1.) Projectile vomiting
2.) Burning sensation 2 hours after eating
3.) Boardlike abdomen with shoulder pain
A boardlike abdomen with shoulder pain is a symptom of a perforation, which is the most lethal complication of PUD.
The nurse is preparing to review a teaching plan for a client with type 2 diabetes mellitus. To determine the client's level of compliance with the diabetic regimen, which value would the nurse first check?
1.) Fasting glucose level
2.) Glycosylated hemoglobin (HgbA1c) level
3.) Fingerstick glucose findings for 24 hours
The higher the blood glucose is over time, the more glycosylated the hemoglobin becomes. The AIC is a good indicator of blood glucose levels over the previous 120 days.
What should an AIC be?
The client tells the nurse that he drinks 3 or 4 servings of alcohol every day. He also reports frequently taking acetaminophen for stress-related headaches. Based on this information, which laboratory results are the most important to follow up on?
1.) Renal function test
2.) Liver function test
3.) Cardiac enzymes
4.) Serum electrolytes
Regular, even moderate consumption of alcohol and excessive use of acetaminophen can cause fatal liver damage.
Which risk factors in Ms. J's history indicate increased risk for chronic kidney disease? Select all that apply.
1.) GERD
2.) Hypertension
3.) Four pregnancies
4.) Type 2 diabetes
5.) Coronary artery disease
6.) Cataracts
Major risk factors for CKD include hypertension, diabetes and CAD
A client with hypertension is prescribed metoprolol 50mg orally once a day. Which change would be most important for the nurse to report to the health care provider after the client begins taking this drug?
1.) Heart rate of 58 beats/min
2.) cold hands and feet
3.) Client report of fatigue
4.) Client report of depression.
Metoprolol is a beta blocker. Depression is a side effect of beta blockers. These drugs may cause first time depression or worsening depression. Decreased heart rate and blood pressure are expected responses.
The client has portal hypertension and hepatic encephalopathy secondary to liver disease and is being treated with lactulose. Which laboratory result will the nurse check FIRST to see if the medication is having the desired effect?
1.) WBC
2.) Ammonia level
3.) Potassium level
4.) Platelet count
The healthy liver breaks down ammonia, but in liver disease, the ammonia accumulates and serum levels increase. Lactulose helps by enhancing intestinal excretion of ammonia.
The nurse is providing care for a client who underwent a thyroidectomy 2 days ago. Which laboratory value requires close monitoring by the nurse?
1.) Calcium level
2.) Sodium level
3.) Potassium level
4.) WBC
The parathyroids are located on the back of the thyroid gland. The parathyroids are important in maintaining calcium and phosphorous balance.
Ms S. tells the nurse that she has worsening chest discomfort. The cardiac monitor shows ST segment elevation and the nurse notifies the healthcare provider. Which prescribed action takes priority at this time?
1.) Administer morphine sulfate 2mg IV push
2.) Schedule an ECG
3.) Draw blood for coagulation studies.
4.) Administer ranitidine 75 mg po every 12 hours.
Relief from the chest pain is the priority at this time. Morphine sulfate has been ordered to relieve the chest discomfort that is common when a client has an acute myocardial infarction.
The nurse understands that which conditions are at increased risk for development when a client has hypertension?
1.) gastric ulcers
2.) Kidney disease
3.) Stroke
4.) Emphysema
5.) Myocardial infarction
6.) Parkinsons disease
Hypertension is the most common health problem seen in primary care settings and can cause stroke, myocardial infarction, kidney failure, and death.
Which medications does the nurse anticipate including in the discharge teaching for Mr. S's self management of gastritis?
1.) H2 receptor antagonists, PPI's and antacids
2.) Diuretics, beta blockers, and angiotensin converting enzymes inhibitors (ACE)
3.) Mucolytics, expectorants, and nonopioid antitussives
4.) Statins and bile acid sequestrants
H2 receptor antagonists, PPIs and antacids are typically prescribed to manage gastritis and other gastrointestinal disorders.
A client with type 1 diabetes reports feeling dizzy. What should the nurse do FIRST?
1.) Check the clients blood pressure
2.) Give the client some orange juice.
3.) Check the clients blood sugar with glucometer
4.) Give the clients morning dose of insulin.
Before orange juice or insulin is given, the clients blood glucose level should be checked.
The nurse is caring for a client with risk for kidney disease for whom a urinalysis has been ordered. What time would the nurse instruct the UAP is best to collect this sample?
1.) With first morning void
2.) Immediately
3.) At bedtime
Urinalysis is a part of any complete physical examination and is very useful in clients with suspected kidney or urological disorders. Ideally, the urine is collected first thing in the morning...specimens obtained at other times might be diluted.
Mrs. D (bowel obstruction) reports feeling weak. She seems more confused compared with her baseline. The NG drainage container has a large amount of watery bile colored fluid. Which lab values should be checked first?
1.) BUN and creatinine levels
2.) Platelet count and WBC
3.) Sodium level, potassium level and ph of blood
4.) Bilirubin, HCT and HGB level
With continuous NG suction, there is a loss of sodium and potassium. Also the loss of acid via suctioning will result in an increase of blood ph or metabolic alkalosis.
The RN is teaching the nursing student how to differentiate peripheral arterial from peripheral venous ulcers. Which characteristics would the RN stress are indications of arterial ulcers? Select all that apply
1.) claudication is absent
2.) rest pain is present
3.) Ulcers occur at ends of and between toes.
4.) Brown pigmentation is usually present
5.) pallor is seen when raising the extremity
6.) Treatment involves damp to dry dressings.
With PAD ulcers, claudication and rest pain are present. Ulcers are deep and occur at end of toes or in between toes. Arterial ulcers are pale when elevated and treatment involves surgical intervention
After infusing the KCL, the nurse administers the furosemide to Ms. C. ( pulmonary edema). Which nursing action will be most useful in evaluating whether the furosemide is having the desired effect?
1.) Weighing the client daily
2.) Measuring hourly output
3.) Monitoring blood pressure
4.) Assessing lung sounds
Because Ms. C's major problem is pulmonary edema, the most useful information will be changes in her lung sounds.
The healthcare provider orders a STAT blood transfusion. In the event of an emergency, a type specific non-cross-matched blood product could be used. Which blood product could be used in this case?
1.) O negative
2.) AB negative
3.) AB positive
4.) A negative
In an emergency, a client may receive O negative blood. An antibody reaction could result if type A or B blood is administered.
The UAP is delegated the task of measuring morning vital signs for all six clients. Which finding would the nurse instruct the UAP to report immediately?
1.) Oral temperature higher than 102F
2.) blood pressure higher than 140/80
3.) Heart rate lower than 65 beats/min
4.) Respiratory rate lower than 18 breaths/min
A temperature elevation to 102F is likely an indicator of an infectious process. The other values are near normal
Mr. L ( kidney stone) reports that the pain has decreased compared with earlier, but now he is having other symptoms. Which symptom is of greatest concern?
1.) Painless hematuria with small clots
2.) Dull pain that radiates into the genitalia
3.) Absence of pain but scant urine output
4.) Sensation of urine urgency.
Scant output suggests that the stone is lodged and obstructing the outflow of urine.
A client with newly diagnosed multiple sclerosis tells the UAP after physical therapy that she is too tired to take a bath. What is the priority nursing concern at this time?
1.) Fatigue
2.) Inability to perform ADL's
3.) Decreased mobility
4.) Muscular weakness
At this time, based on the clients statement, the priority is ability to perform ADL's most likely related to fatigue after physical therapy.
What lab value is of most interest to a nurse taking care of a client currently taking coumadin for afib?
For clients taking coumadin, most laboratories report PT results that have been adjusted to the INR. These people should have an INR of 2.0-3.0 for basic blood thinning needs.