Acid Base
The nurse is caring for a client in diabetic ketoacidosis. An intravenous insulin gtt is infusing with normal saline @ 250mL/hr. The client is becoming increasingly responsive and the glucose level has decreased each hour. Which finding would indicate that the client’s metabolic acidosis is improving?
1.Glucose 132
2.HCO3 20
3.PaCo2 36
4.pH 7.39
pH 7.39
The nurse explains the effects of chemotherapy to an adolescent diagnosed with leukemia. The nurse notes that there is increased risk for injury due to neutropenia. What comment by the client indicates teaching was effective?
1.I will brush my teeth using a soft-bristle toothbrush
2.Using an alcohol-based mouthwash 2x a day is best
3.A humidifier will help when I sleep at night
4.I will eat only fresh uncooked fruits and vegetables
I will brush my teeth using a soft-bristle toothbrush
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
1.Potential for injury
2.Powerlessness
3.Disturbed thought processes
4.Sexual Dysfunction
Powerlessness
The ICU burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority?
1.Risk for infection
2.Ineffective coping
3.Impaired physical mobility
4.Knowledge deficit
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Risk for Infection
The nurse is caring for a client diagnosed with acute renal failure. Which lab values are most significant for diagnosing ARF?
1.BUN and Creatinine
2.WBC and Hgb
3.Potassium and Sodium
4.Bilirubin and Ammonia level
BUN and Creatinine
During assessment of the postoperative client following abdominal surgery, the nurse notes that respirations are shallow. Which priority intervention should the nurse plan for this client to avoid respiratory acidosis?
1. Administer oxygen via nasal cannula
2. Auscultate lung sounds every 4 hours
3. Use of incentive spirometer every hour while awake
4. Administer pain medication as indicated
Use of incentive spirometer every hour while awake
A 6 yo with acute lymphocytic leukemia received induction chemotherapy. The client’s neutrophil count is 0. The client is fatigued and experiences mild nausea. Which nursing action is highest priority?
1.Administer antiemetics and assess hydration/nutrition
2.Limit contacts with infected visitors
3.Assess for sources of bleeding
4.Monitor energy levels and begin energy conserving techniques
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Limit contacts with infected visitors
A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?
1.Administer the stool softener bid
2.Encourage the client to cough hourly
3.Monitor neurological status every shift
4.Maintain the dopamine gtt to keep B/P at 160/90
Administer the stool softener BID
The nurse writes the nursing diagnosis “impaired skin integrity r/t open burn wounds.” Which client problem has priority?
1.Provide analgesia before pain becomes severe
2.Clean the client’s wounds daily
3.Screen visitors for respiratory infections
4.Encourage visitors to bring flowers
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Clean the client’s wounds daily
The nurse is caring for a client diagnosed with rule-out ARF. Which condition predisposes the client to developing prerenal failure?
1.Diabetes Mellitus
2.Hypotension
3.Aminoglycosides
4.Benign prostatic hypertrophy
Hypotension
The nurse is caring for a client with anorexia nervosa. Arterial blood gas results are pH 7.26, PaCO2 40, and HCO3 16. What is the nurse’s priority intervention?
1.Assist the client when moving from bed to chair
2.Administer medication for seizure precaution
3.Insert urinary catheter to monitor output
4.Provide meal with high potassium options
Assist the client when moving from bed to chair
Which client is at the highest risk for developing a lymphoma?
1. The client diagnosed with chronic lung disease who is taking a steroid.
2. The client diagnosed with breast cancer who has extensive lymph involvement
3. The client who received a kidney transplant several years ago
4. The client who has had ureteral stent placement for a neurogenic bladder.
The client who received a kidney transplant several years ago
The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?
1.Discuss how to correctly remove the insertion pins
2.Instruct the client to report reddened or irritated skin areas
3.Inform the client that the vest liner cannot be changed
4.Encourage the client to remain in the recliner as much as possible
Instruct the client to report the reddened or irritated skin areas
The client comes into the ER in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document?
1.Superficial
2.Deep partial-thickness
3.Full-thickness
4.First-degree
Deep partial-thickness
The client diagnosed with ARF is experiencing hyperkalemia. Which medication should the nurse prepare to administer to help decrease the potassium level?
1.Erythropoietin
2.Calcium gluconate
3.Regular insulin
4.Osmotic diuretic
Regular insulin
The nurse is caring for a client receiving dialysis for chronic renal failure. Which assessment finding requires immediate intervention by the nurse?
1. Potassium level 2.8
2. Two diarrhea stools in past 4 hours
3. Client reports not taking daily dose of potassium
4. Glucose level of 140
Potassium level 2.8
The nurse is discharging a client diagnosed with anemia. Which discharge instructions should the nurse teach?
1.Take the prescribed iron until it is completely gone
2.Monitor HR and B/P at a local pharmacy
3.Have CBC checked at the providers office
4.Perform isometric exercise 3x a week
Have a CBC checked at the providers office
The client is admitted to the ICU experiencing status epilepticus. Which collaborative intervention should the nurse anticipate?
1. Assess the client’s neurological status every hour
2. Monitor the client’s heart rhythm via telemetry
3. Administer the anticonvulsant medication by IVP
4. Prepare to administer a glucocorticosteroid orally
Administer the anticonvulsant medication via IVP
The client sustained a hot grease burn to the right hand and calls the emergency department for advice. Which information should the nurse provide to the client?
1.Apply an ice pack to the right hand
2.Place the hand in cool water
3.Be sure to rupture any blister formation
4.Go immediately to the doctor’s office
Place the hand in cool water
The nurse is caring for a group of clients on a medical-surgical unit. Which client does the nurse anticipate to be at the greatest risk for alterations in urinary elimination?
1. The client with hypertension who takes a diuretic to manage blood pressure
2. An 80-year-old male client reporting frequent urination at night
3. A 25-year-old female client with low self-esteem
4. A client who had bladder cancer and now has a newly created ileal conduit
An 80-year-old male client reporting frequent urination at night
The nurse is assessing a client who has been admitted with abdominal pain. The client reports vomiting after meals and use of oral antacids several times daily. An NG tube is inserted to low intermittent suction. What assessment finding would require immediate follow-up by the nurse?
1.Return of 200 mL dark green liquid from NG tube
2.Complaints of dizziness and lightheadedness
3.RR of 10
4.pH 7.47, PaCO2 40, and HCO3 30
Complaints of dizziness and lightheadedness
Which sign/symptom should the nurse expect to assess in the client diagnosed with hemophilia A?
1.Epistaxis
2.Petechiae
3.Subcutaneous emphysema
4.Intermittent claudication
Epistaxis
The nurse is caring for a client diagnosed with encephalitis. Which is an expected outcome for the client?
1.The client will regain as much neurological function as possible
2.The client will have no short-term memory loss
3.The client will have improved renal function
4.The client will apply hydrocortisone cream daily
The client will regain as much neurological function as possible
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the provider?
1.The client is c/o severe pain
2.The client’s pulse ox reads 95%
3.The client has T 100.4, HR 100, RR 24 and B/P 102/60
4.The client’s urine out is 50 mL in 2 hrs
The client’s urine output is 50 mL in 2 hrs
The nurse is providing care to a client who is experiencing urinary retention. Which diagnostic tool does the nurse anticipate will be ordered for this client?
1. Ultrasonic bladder scan
2. Urinalysis
3. Intravenous pyelography (IVP)
4. Cystoscopy
Ultrasonic bladder scan