F/E & Acid Base Burns Oncology Endocrine Cardiac

100

1.When you are in a fluid volume deficit your blood pressure goes down and pulse goes up
Evaluation of successful resolution of a fluid volume deficit may be demonstrated by which of the following? 1. The client demonstrates an absence of postural hypotension and tachycardia 2. The client adheres to prescribed dietary sodium restrictions 3. The client maintains weight loss 4. The client maintains a serum Na above 145 mEq

100

3. All are important but priority with this scenario has to be airway
A client is admitted to the ER with second and third degree burns to her anterior chest, both arms, and right leg. Priority information to determine at the time of admission would include which of the following? 1. Percentage of burned surface area 2. Amount of IV fluid necessary for fluid resuscitation 3. Any evidence of heat inhalation or airway problems 4. Circumstances surrounding the burn and contamination of the area

100

3. You get your act together before you ever go into the room and hurry up and get out
To promote safety in the care of a client receiving internal radiation therapy the nurse would: 1. Restrict visitors who may have an upper respiratory infection 2. Assign only male care givers to the client 3. Plan nursing activities to decrease nurse exposure 4. Wear a lead lined apron whenever delivering client care

100

2. An effort by the body to remove excess acid from the body
A patient is admitted with diabetic ketoacidosis. You note his respiratory rate to be 38. Considering his condition you are aware that this increased rate is a result of: 1. An effort by the body to compensate for respiratory acidosis 2. An effort by the body to remove excess acid from the body 3. An effort by the body to supply more oxygen to the depleted tissues 4. An effort by the body to conserve CO2

100

1. You do not put cold on veins. You use warm, moist heat to decrease inflammation
A client with sudden onset of deep vein thrombosis is started on a Heparin IV drip. Which of the following additional orders should the nurse question? 1. Cold wet packs to the affected leg 2. Elevate foot of bed six inches 3. Commode privileges without weight-bearing 4. Elastic Stockings on unaffected leg

200

1. When you are in a magnesium deficit your muscles are rigid and tight and you might just go ahead and have a seizure.
Ms. Stone is admitted with a serum magnesium deficit. Assessment reveals a positive Trousseau’s and Chvostek’s signs. Which of the following nursing diagnosis would be most appropriate? 1. High risk for injury R/T increased neuromuscular irritability 2. High risk for injury R/T fractures secondary to loss of calcium 3. Fluid volume deficit R/T dehydration 4. Activity intolerance R/T skeletal muscle weakness

200

4. Electrical burns can be deceptive as underlying tissue is damaged
A family member of a client who has sustained an electrical burn states, “I don’t understand why he has been here a week, the burn doesn’t look that bad.” The nurse’s response would be based on which of the following? 1. Electrical burns are more prone to infections 2. Electrical burns are always much worse than they look on the outside 3. Cardiac monitoring is important since burns always affect cardiac function 4. Electrical burns can be deceptive as underlying tissue is damaged

200

2. You want them on a low fiber diet because if they eat too much fiber their bowel will extend and push out the implant
Which of the following measures should the nurse take while a client has a radium implant for the treatment of uterine cancer? 1. Evaluate the position of the applicator every two hours 2. Place on a low residue diet to decrease bowel movements 3. Encourage the use of the bedside commode every 1-2 hours 4. Decrease fluid intake to decrease radiation in bladder

200

1. If applicable, airway always comes first.
The client is admitted with acute hypoparathyroidism. To maintain client safety, which item is most important to have available? 1. Tracheostomy set 2. Cardiac monitor 3. IV monitor 4. Heating pad

200

4. Palpable carotid pulse
Which of the following signs indicate effective CPR? 1. Adequate capillary refill 2. Normal skin color 3. Symmetrically dilated pupils 4. Palpable carotid pulse

300

4. Hypokalemia-The clues are poor appetite, vomiting, heart all of those things only point to one electrolyte and what’s the electrolyte? Potassium.
Ms. Fair is a 77 year old female. Her husband reports that she has had a poor appetite over the past two weeks, with occasional nausea and vomiting. When placed on a cardiac monitor various abnormal heart beats are noted. Based on this data, the nurse would suspect that Ms. Fair is experiencing. 1. Hyponatremia 2. Hypermagnesemia 3. Hypercalcemia 4. Hypokalemia

300

3.These are signs and symptoms of early shock
A client has severe second and third degree burns over 75 percent of his body. Which assessment finding indicates an early problem with shock? 1. Epigastric pain and seizures 2. Widening pulse pressure and bradycardia 3. Cool and clammy skin and tachypnea 4. Kussmaul respirations and lethargy

300

4. Bone metastisis is one of the worst kinds of pain, you would not hold off on the pain medicine.
A client with lung cancer and bone metastasis is grimacing and states, “I am a little uncomfortable, may I have something for pain?” Which of the following should the nurse do first before administering pain medication? 1. Check the chart to determine last medication 2. Encourage client to refocus on something pleasant 3. Notify doctor that medication is not working 4. Assess the severity and location of pain

300

2. Patient will have exothalmus and need eye drops
In planning care for the client with hyperthyroidism, the nurse would anticipate the client to require: 1. Extra blankets for warmth 2. Ophthalmic drops on a regular basis 3. Increased sensory stimulation 4. Frequent low calorie snacks

300

2. You should always worry if rate to drop below set rate.
A permanent demand pacemaker set at a rate of 72 is implanted in a client for persistent third degree block. Which of the following nursing interventions would indicate a pacemaker dysfunction? 1. Pulse rate of 88 and irregular 2. Apical pulse rate regular at 68 3. Blood pressure of 110/80, pulse of 78 4. Tenderness at site of pacemaker implant

400

1.If you had just had a thoracotomy would you be taking nice big deep breaths? No. So what would you be retaining? CO2 which makes your PCO2 go up which makes your pH go down. I’m acidotic aren’t I?
The nurse is caring for a thoracotomy client, one day post operative on 40% humidified oxygen. ABG results are: PO2=90, PCO2=49, pH=7.30, HCO3=26. Based on this information, which of the following nursing actions would be best? 1. Position in high fowlers and encourage coughing, deep breathing, evaluate airway patency 2. Place in prone position and request respiratory therapy to perform postural drainage and percussion therapy 3. Call the doctor and advise him of the ABGs; anticipate increase in oxygen percentage 4. Administer anti-anxiety agent and assist the client with a rebreathing device to increase oxygen levels

400

2. If dirty clothes are around the wound you remove them and wrap in a clean sheet.
During a first aid class, the nurse is instructing clients on the emergency care of second degree burns. Which of the following interventions for second degree burns of the chest and arms will best prevent infection? 1. Wash the burn with an antiseptic soap and water 2. Remove soiled clothing and wrap victim in a clean sheet 3. Leave blisters intact and apply an ointment 4. Do nothing until the victim arrives in a burn unit.

400

1.Watch the temperature. If temperature goes up then you order the blood cultures
A client on chemotherapy has a WBC count of 1200 mm. Based on this data, which of the following nursing actions should the nurse take first? 1. Check temperature q4h 2. Monitor urine output 3. Assess for bleeding gums 4. Obtain an order for blood cultures

400

1. Steroids, in some people, cause insomnia
The nurse is aware that which of the following statements made by the client indicates a correct understanding of steroid therapy for Addison’s Disease? 1. “I’ll take the medicine in the morning because if I take it at night it might keep me awake.” 2. “I’ll take the same amount from now on.” 3. “I’ll increase my potassium by eating more bananas.” 4. I’ll be eating foods low in carbohydrates and salt.”

400

3. If the problem is hypokalemia then do something to fix the problem. This is the only answer that addresses the problem
A client with an irregular pulse rate of 181 and a K level of 3.0 mEq/L has Lanoxin ordered. The nurse should: 1. Give the digoxin since the pulse is within normal limits 2. Holds the digoxin since the pulse is irregular 3. Call the doctor to report the potassium 4. Hold the digoxin since toxicity occurs with high potassium levels

500

3. Since it is a heart cath what electrolyte am I most concerned about, potassium. This lab work was done five days ago and today my patient is having muscle weakness and cramps well if it was 3.0 five days ago and they’re having those kind of symptoms today, I’ll bet it’s even lower. If you send a patient like that to a heart cath could it kill them? Yes, so you don’t send them.
It is 0600 and a client is scheduled for a cardiac catheterization at 0800. Laboratory work completed five days ago showed: K 3.0 mEq/L, Na 148 mEq/L, glucose 178 mg/dL. He complains of muscle weakness and cramps. Which nursing action should be implemented at this time? 1. Hold 0700 dose of spironolactone (Aldactone) 2. Encourage eating bananas for breakfast 3. Call the physician to suggest a stat K level 4. Call for a twelve lead ECG

500

1.After airway, the most urgent need is pre venting irreversible shock by replacing fluids and electrolytes.
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy.

500

4.You should be most worried about infection because white count is too low. Hand washing is the number one way to break the chain of infection
A client is admitted to the outpatient unit in the Cancer Center for his chemotherapy. He is lethargic, weak, pale. His WBC count is 3000. Which of the following nursing interventions would be most important for the nurse to implement? 1. Establish emotional support 2. Position for physical comfort 3. Maintain respiratory isolation 4. Hand washing prior to care

500

2. Arrhythmias are the most life threatening
Which nursing action has the highest priority in caring for the client with hypoparathyroidism? 1. Develop a teaching plan 2. Plan measures to deal with cardiac arrhythmias 3. Take measures to prevent a respiratory infection 4. Assess laboratory results

500

2. Blood pressure decreased too much. Nurse should not leave patient until it comes up and next nurse should be made aware of the drop.
The nurse has administered sublingual nitroglycerin (Nitrostat) to a client complaining of chest pain. Which of the following observations is most important for the nurse to report to the next shift? 1. The client indicates the need to use the bathroom 2. Blood pressure has decreased from 140/80 to 90/60 3. Respiratory rate has increased from 16 to 24 4. The client indicates the chest pain has subsided

NCLEX JEOPARDY I

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