Show:
F/E & Acid Base
Burns
Oncology
Endocrine
Cardiac
100

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

1.When you are in a fluid volume deficit your blood pressure goes down and pulse goes up

100
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
3. All are important but priority with this scenario has to be airway
100

A nurse is caring for a client newly diagnosed with acute myelogenous leukemia(AML). Which assessment finding needs to be reported to client's health care provider immediately? 1. Absolute neutrophil count 1500 cells/mm2  2. Oral temp of 99.O F  3. New onset of headache 4.Hgb 10.5 g/dl 


3. New onset of headache needs to be reported immediately can indicate cerebral hemorrhage related to decreased platelet level. At onset of the disease abnormal bleeding because of the proliferation of myeloblasts  Low WBC and anemia are common

100

A client with type 2 diabetes mellitus is admitted to the Emergency department with a blood glucose of 650mg/dl and confusion. A diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is made. What other lab values would be consistent with this diagnosis? 1, Elevated sodium levels 2. Ketosis 3. Low potassium levels 4. Normal phosphorous levels 


3. Low potassium levels. InHHNS theindividual may have enough insulin on board to prevent DKA and ketosis but not enough to prevent severe hyperglycemia and profound dehydration with low potassium levels, low sodium levels 

100
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
1. You do not put cold on veins. You use warm, moist heat to decrease inflammation
200

The nurse is caringfor a client with ketoacidosis. An IV insulin drip is infusing 250ml/hr. The client is becoming more responsive and the glucose levels have decreased each hour. Which finding indicates acidosis is improving?  1. Glucose 132 mg/dl 2. HCO3 20meq/L 3. PACO2 36 mmHG  4. PH 7.39


4. PH is indicator of acidosis or alkalosis. HCO3 and PaCO2 remain below normal, Glucose does not directly indicate resolving acidosis

200
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
4. Electrical burns can be deceptive as underlying tissue is damaged
200
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
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
200

The nurse plans to teach the client about a diagnosis of hypoparathyroidism secondary to a thyroidectomy 6 weeks ago. What would be important to teach the client to prevent complications? 1. Avoid foods high in Vitamin D 2. Minimize stress in your life 3. Rebreathe in a paper bag if you feel numb or tingly 4. Report any painful spasms in muscles

4. Report any painful spasms in muscles. Goal is to treatment is prevent complications which includes ensuring calcium levels are normal and preventing tetany

200
Which of the following signs indicate effective CPR? 1. Adequate capillary refill 2. Normal skin color 3. Symmetrically dilated pupils 4. Palpable carotid pulse
4. Palpable carotid pulse
300

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

4. Hypokalemia-The clues are poor appetite, vomiting, heart all of those things only point to one electrolyte and what’s the electrolyte? Potassium.

300
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
3.These are signs and symptoms of early shock
300
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
4. Bone metastisis is one of the worst kinds of pain, you would not hold off on the pain medicine.
300
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
2. Patient will have exothalmus and need eye drops
300

The nurse is completing an assessment of the client being treated for pulmonary embolism. The nurse notes mild bleeding from the gums following oral care. What action is a priority for the nurse? 1. Decrease the rate of anticoagulant infusion 2. Provide client education on prevention of bleeding 3. Notify the healthcare provider of the bleeding gums 4. Evaluate the INR or the PTT results


4. Evaluate the INR or PTT results. While the healthcare provider needs to be notified they will ask what the latest INR/TT result was to determine how to proceed. The nurse should be prepared with that information. Client education is necessary but not the priority

400

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

1.If you had just had a thoracotomy would you be taking nice big deep breaths. So what would you be retaining? CO2 which makes your PCO2 go up which makes your pH go down. I’m acidotic.

400
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.
2. If dirty clothes are around the wound you remove them and wrap in a clean sheet.
400
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
1.Watch the temperature. If temperature goes up then you order the blood cultures
400
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.”
1. Steroids, in some people, cause insomnia
400
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
3. If the problem is hypokalemia then do something to fix the problem. This is the only answer that addresses the problem
500
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
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.
500
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.
1.After airway, the most urgent need is pre venting irreversible shock by replacing fluids and electrolytes.
500
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
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
500
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
2. Arrhythmias are the most life threatening
500

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

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.