N220 Potpourri
The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patient's admission orders? Select all that apply.
A.Transcranial Doppler flow study
B.Cerebral angiography
C.MRI
D.Cranial radiography
E.Electromyelography (EMG)
What is
A. Transcranial Doppler,
B. Cerebral Angiography, and C. MRI
The Rn and LPN are caring for a client diagnosed with stroke. Which intervention should the RN assign the LPN?
A. Feed the client who is allowed to eat for the first time
B. Administer client's anticoagulant subcutaneously.
C. Check the clients neurological signs and limb movements
D. Teach the client to turn the head and tuck the chin to swallow.
What is
B. Administer client's anticoagulant subcutaneously.
The client was burned at 7 am. The client states that before the burn, the body weight was 198 lbs. The physician estimated that the TBSA burned is 83%. Using the parkland formula, this is the total amount of IV Lactated Ringer’s solution that the client will receive by 3 pm of the same day that the burn occurred.
What is 14,940 mL?
This is the most common cause of Diabetic Ketoacidosis.
What is Infection
An elderly client who was found unresponsive at home now opens his eyes when spoken to; answers simple questions when asked; and when left alone, usually sleeps. These are the categories of the Glascow Coma Scale the nurse uses to document this information.
What is eye opening and best
verbal response?
A client has burns to the anterior trunk. Using the rule of nines, what is the TBSA burned?
What is 18%?
A new graduate nurse is working with a UAP who has been an employee of the hospital for 12 years. However, tasks delegated to the UAP by the nurse are frequently not completed. Which action should the new nurse take first?
A.Tell the charge nurse the UAP will not do tasks as delegated by the nurse.
B.Write up a counseling record with objective data and give it to the manager.
C.Complete the delegated tasks and do nothing about the insubordination.
D.Address the UAP to discuss why the tasks are not being done as requested.
What is
D. Address the UAP to discuss why the tasks are not being done as requested ?
After administering IV fluids as prescribed to a client who sustained second and third degree burns of the back and legs, this is the most reliable indicator for determining the adequacy of fluid resuscitation
What is urine output?
This manifestation of DKA is the difference between a patient experiencing a diabetic coma and a patient with hyperglycemic nonketotic syndrome.
A. Fluid loss
B. Glycosuria
C. Kusmaul Respirations
D. Increased blood glucose
What is Kusmaul Respirations?
This is the position that an ER
nurse should place a client with
a head injury.
What is supine with the HOB
elevated 30 degrees?
When a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome, the nurse’s priority is to provide this.
What is fluid replacement?
The nurse has received shift report. Which client should the nurse assess first?
A.The client diagnosed with DVT who is complaining of dyspnea and coughing.
B.The client diagnosed with gallbladder ulcer disease who refuses to eat the food served.
C.The client diagnosed with pancreatitis who wants the nasogastric tube removed.
D.The client diagnosed with osteoarthritis who is complaining of stiff joints.
What is
A. The client with DVT who is complaining of dyspnea and coughing?
During the first few hours after a patient is admitted to the burn unit with partial thickness burns of the trunk and head, the nurse is least concerned about the development of this.
A.Pain
B.Leukopenia
C.Hypovolemia
D.Laryngeal edema
What is Leukopenia?
This is the type of insulin that is administered to a patient with DKA.
What is regular insulin?
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a surgical complication when this manifestation is exhibited.
A. A negative Kernig’s sign
B. Absence of nuchal rigidity
C. A positive Brudzinski’s sign
D. A glascow coma scale score of 15
What is a positive Brudzinski’s sign?
A client is recovering from a closed-head injury and has an epidural hematoma. Which of the following assessment findings should the nurse report to the physician immediately?
A.Client complains of hunger
B.Awake, alert, and oriented to person, place, and time
C.Drowsiness and disoriented to place
D.Nuchal rigidity
E.Respiratory rate regular
F. Fixed and dilated pupil on side of brain injury
What is fixed and dilated pupil on side of brain injury and drowsiness and disoriented to place?
Will accept Nuchal Rigidity
An RN is working with an LPN and a UAP to care for a group of clients. Which nursing task should not be delegated or assigned?
A.The routine oral medications for the clients.
B.The bed baths and oral care.
C.Evaluating the client’s progress.
D.Transporting a client to dialysis.
What is
C. Evaluating the client’s progress?
The nurse caring for a burn client would monitor the client’s stools for occult blood as assessment for the development of these.
What are stress ulcers?
A client with untreated Type I diabetes mellitus may lapse into a coma because of acidosis. This acidosis is directly caused by an increased concentration in this serum.
What is serum ketones?
A client is admitted to the hospital complaining of increasing neurological changes. The nurse learns this client had fallen off of a ladder 2 weeks prior and sustained a mild concussion. Which of the following conditions might be occurring with this client?
What is chronic subdural hematoma?
The RN is planning the client assignments. Which of the following is the least appropriate assignment for the nursing assistant?
A. Assist a 12 year child, profoundly developmentally disabled, to eat lunch.
B.Obtain a temperature on a 29 year old woman receiving the final 30 minutes of a whole blood transfusion.
C. Accompany a 51 year old man, being discharged to home following a bowel resection 8 days ago, to his transportation.
D.Collect a urine specimen from a 70 year od woman admitted 3 days ago.
What is assisting the child eat lunch?
The charge nurse is making assignments for a 30 bed medical unit that is staffed with 3 RNs, 3 LPNs, and 3 UAPs. Which is assignment is most appropriate?
A.Assign the RN to perform all sterile procedures.
B.Assign the LPN to give all IV medications.
C.Assign the UAP to complete the AM care.
D.Assign the LPN to write the care plans.
What is
C. Assign the UAP to complete the AM care?
A client is admitted to the hospital with deep second-degree burns of the arms, chest, and thighs covering 40% of the total body surface area. As a result of the fluid shift that initially follows such burns, the nurse would expect which change in this client?
A.Increased urine output
B.Increased weight
C.Decreased pulse rate
D.Decreased cardiac output
What is decreased cardiac output?
The nurse is preparing to care for a client with DKA with a pulse of 100, blood pressure 140/80, temperature 98.2 F who is being admitted from the ED. The nurse would anticipate using this IV solution.
What is isotonic saline solution?
A client admitted with a closed-head injury has a large area of ecchymosis along his right jaw line. This is the type of cranial fracture the client has?
What is a basilar skull fracture?