GI/GU
Elevated Blood Urea Nitrogen (BUN) and Creatinine levels indicate impaired kidney function. In reviewing their patient's labs, the nurse knows that normal BUN and Creatinine levels are:
a. BUN 9-28 mg/dl and Creatinine 0.4- 0.8 mg/dl
b. BUN 7-20 mg/dl and Creatinine 0.8-1.3 mg/dl
c. BUN 54 mg/dl and Creatinine 1.3-3.45 mg/dl
b. BUN 7-20 mg/dl and Creatinine 0.8-1.3 mg/dl
A nurse teaches a patient how to use an incentive spirometer. Which projected patient outcome supports the conclusion that the use of the incentive spirometer was effective?
a. Expiratory volume will be decreased
b. Inspiratory volume will be increased
c. Sputum will be expectorated
d. Coughing will be stimulated
b. Inspiratory volume will be increased
The nurse is caring for a patient admitted to MMC for seizure monitoring. Which statement(s) made by the family member staying with the patient indicate that the nurse needs to provide education on the seizure monitoring process? Select all that apply.
a. If I notice seizure activity, I will immediately stick my wallet in my daughters mouth so she doesn't swallow her tongue.
b. I can take a 20 minute break from the room to have a cigarette outside every morning if my daughter did not have a seizure the night before.
c. I will press the button attached to the seizure monitor if I notice any seizure activity.
d. The neurologist has prescribed sleep deprivation for my daughter tonight, but it is okay for me to be asleep around 9:00 pm.
A. B. and D. Nothing should be put in the patients mouth during a seizure. The nurse will assess for and provide interventions for an obstructed airway. The patient has to be observed for seizure activity by either a human companion or tele sitter at all times.
A client at the outpatient clinic reports increasing joint pain due to arthritis. The physician prescribes ibuprofen 600 mg QID for joint pain. What should the nurse teach the client about this medication. Select all that apply:
a. Take it with a few sips of water
b. Do not exceed 4000 mg of this drug per day
c. Double a dose if a previous dose is forgotten
d. Report the intake of the drug if dental treatment or surgery is necessary
e. Use an oatmeal bath for a mild skin rash, as this is a common side effect
d. Report the intake of the drug if dental treatment or surgery is necessary. Research demonstrates that bleeding time is increased when taking ibuprofen. This drug should be discontinued if dental treatment or surgery is scheduled.
An older adult is with an indwelling catheter is receiving 75ml of NS per hour. The patient has had several hospitalizations for dehydration in the last year. What is the best intervention by the nurse to to assess the patient's renal function?
a. Inspect the patient for peripheral edema
b. Calculate the intake and output every shift
c. Monitor the patient's output hourly
d. Obtain the patient's weight daily
c. The kidneys should produce more than 30ml/hr. The patient has an indwelling catheter that facilitates the assessment of urine output hourly. Clients without an indwelling catheter should void a minimum of 240ml of urine in 8 hours.
A meal tray arrives for a patient who is receiving 6-7 liters of oxygen via a simple face mask. Which should the nurse do to best meet this patient's needs?
a. Discontinue the oxygen when the patient is eating meals. Monitor for desaturation.
b. Speak to the provider about using an nasal cannula during meals. Monitor for desaturation.
c. Obtain an order to change the mask to a non-rebreather mask during meals.
d. Arrange for liquid supplements that can be administered via straw through the a valve in the mask.
b. Speak to the provider about using an nasal cannula during meals. Monitor for desaturation.
1-6L of oxygen can be delivered via nasal cannula and will allow the mouth to be unobstructed
The nurse is assigned a patient who is recovering from a left CVA. The nurse know which assessment findings are associated with damage to this part of the brain:
a. Right hand numbness and loss of sight
b. Expressive aphasia and right hemiparesis
c. Increased agitation and inability to recognize family members
d. Left facial droop and right tongue deviation
b. Expressive aphasia and right hemiparesis
A nurse is administering 0900 medications to several patients on the unit. Which condition should the nurse anticipate places a patient at the highest risk for toxicity associated with most drugs?
a. Liver disease
b. Kidney insufficiency
c. Respiratory difficulty
d. Malabsorption syndrome
a. Liver disease. Drug metabolizing enzymes in the liver detoxify drugs to a less active form (biotransformation). With liver dysfunction, biotransformation is impaired and drugs accumulate, ultimately reaching toxic levels.
A nurse identifies that the patient has overflow incontinence. What factor contributes to this manifestation?
a. Coughing
b. Mobility deficits
c. Prostate enlargement
d. Urinary tract infection
C. An enlarged prostate compresses the urethra and interferes with the outflow of urine resulting in urinary retention. The pressure within the bladder builds until the external urinary sphincter temporarily opens to let out a small amount of urine escape (25-60 ml).
A nurse is assessing a patient with a respiratory disease. Which clinical manifestation is an early sign of hypoxia? Select all that apply:
a. Dysrhythmias
b. Restlessness
c. Irritability
d. Cyanosis
e. Apnea
C and D are both early signs of hypoxia caused by impaired cerebral perfusion of oxygen. Dysrhythmias are a late sign of hypoxia. Apnea is the cause of, not response to, hypoxia.
A patient presents to the E.D. reporting the sudden onset of "the worst headache of my life". The nurse knows this is potentially a medical emergency as this complaint is commonly associated with:
a. A rare, but life threatening, fungal infection of the cervical spine.
b. An anaphylactic reaction to MSG
c. The post-ictal period of a generalized (tonic-clonic) seizure
d. A SAH secondary to a brain aneurysm.
d. A SAH secondary to a brain aneurysm
A patient who has 4+ pitting edema is receiving a diuretic. What is the best way for the nurse to evaluate the effectiveness of diuretic therapy?
a. Weigh daily
b. Assess skin turgor
c. Measure calf girth
d. Monitor urine specific gravity
a. Weigh daily. To obtain the most accurate comparable data, patients should be weighed at the same time everyday . Approximately 1 kg (2.2lb) of weight gained or lost is equal to one liter of fluid.
A nurse should use a fracture bedpan for patients with which condition? Select all that apply
a. Below the knee amputation
b. Peripheral vascular disease
c. Dementia
d. Spinal cord injury
e . Obesity
D. Spinal cord injury. A fracture pan has a low back and promotes alignment of patient's lower back while on the bedpan
A physician prescribes chest physiotherapy with percussion and vibration for a patient. Which information in the patient's health history should alert the nurse to question the providers order?
a. Emphysema
b. Osteoporosis
c. Cystic fibrosis
d. Chronic bronchitis
b. Osteoporosis. Implementing chest percussion and vibration may compromise patient safety because percussion and vibration in the presence of osteoporosis may cause fractures
A nurse is caring for a patient who is recovering from a a right MCA ischemic stroke. To comply with the patient's dysphagia diet of pureed foods and honey thickened liquids the nurse administers the patient's medications crushed in:
a. Jello
b. Ice cream
c. Whipped potatoes
d. Ginger-ale
C. Whipped Potatoes are the only food listed that are okay to give the patient with these dietary restrictions. Ice cream, although thick when frozen, is too thin at room temperature.
A client has a prescription for sertraline, an antidepressant. Which is most important for the nurse to do?
a. Monitor the client for suicidal tendencies
b. Advise the client to engage in psychotherapy
c. Teach the client to limit ETOH intake to one drink per day
d. Encourage the client to diet because weight gain is a common side effect of this drug
a. Monitor the client for suicidal tendencies. When depression lifts during the early stage of therapy, the individual has renewed energy that may allow the client act on suicidal thoughts. Client safety is priority.
A nurse is assessing a patient who is admitted to the hospital with withdrawal from ETOH. Which effect of alcohol on the body will influence the patient's plan of care?
a. Interferes with the absorption of glucose
b. Decreases the absorption of many important nutrients
c. Accelerates the absorption of medications
d. Lengthens the passage of stool through the intestinal tract.
b. Decreases the absorption of many important nutrients
Which clinical manifestation is of most concern when the nurse assesses the patient who has impaired mobility?
a. Shallow respirations
b. Increased oxygen saturation
c. Decreased chest wall expansion
d. Course Rhonchi heard upon auscultation
d. Course Rhonchi heard upon auscultation. Impaired mobility contributes to the accumulation of respiratory secretions in the airway. While activity promotes the drainage of secretions. Rhonchi indicate air passing through narrowed passage due to secretions. Partial or total obstruction can occur, which is life threatening.
The nurse is caring for a patient recovering from a transphenoidal resection of a pituitary tumor. By understanding a potential complication of this surgery, the nurse knows to monitor for:
a. Urine output greater than 300 ml per hour
b. Acromegaly or acute enlargement of the face, hands or feet
c. Hypoglycemia
d. Emotional disregulation
a. Urine output greater than 300 ml per hour. The pituitary gland stores and releases Antidiuretic Hormone. This acts on the kidneys to control the amount of water released as urine from the body. Diabetes Insipidus, characterized by excessive urine output and thirst, can occur with damage to the pituitary gland.