Fluid & Electrolytes
The normal range for serum calcium levels
9.0 - 10.5 mg/dL
This is the main nursing process that should be followed when establishing quality patient care; describe this process.
A.A.P.I.E.
Assess, analyze, plan, implement, evaluate.
What is the most common location that a nurse uses to assess a patient’s temperature?
Temporal or axillary
Atherosclerosis impedes coronary blood flow by which of the following mechanisms?
A. Plaques obstruct the vein
B. Plaques obstruct the artery
C. Blood clots form outside of the vessel wall
D. Hardened vessels dilate to allow the blood to flow through
A nurse is tasked with the education of an elderly female patient who has been recently diagnosed with osteoporosis. The patient lives a sedentary lifestyle, has a diet low in calcium, has undergone menopause ten years prior, and has a visibly kyphotic posture. In planning the education for this patient, which of the following complications should the nurse emphasize as the most significant risk associated with osteoporosis, especially considering the patient’s profile?
A. Consequences of long-term post-menopausal estrogen deficiency
B. Increased susceptibility to bone fractures from minimal trauma
C. The progression of the kyphotic spinal deformity
D. Potential for weight gain due to sedentary lifestyle
Diuretics or laxatives
A patient is suffering from recurring bed sores; name three tasks the nurse can delegate to the AP to aid in providing comfort/health to the patient
Repositioning/q2 turns, placing pillows/cushions, cleaning/drying patient, assist with nutrition, ensure call light is within reach, enabling a calm environment to reduce stress and/or sleep disruptions
This telltale sign is one of the earliest signs that indicates a patient is going into shock
Tachycardia and/or hypotension
A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?
A. Monitor for fever q4h
B. Require visitors to wear protective masks
C. Consider transfusion of packed red blood cells
D. Check for signs of bleeding when examining urine and stool
A nurse is evaluating a 63-year-old female patient who has been admitted with worsening heart failure. The patient presents with shortness of breath, a cough that worsens when lying down, and fatigue. Which type of breath sounds is the nurse most likely to auscultate that are typically associated with heart failure?
A. Friction rub
B. Wheezes
C. Stridor
D. Fine crackles
E. Pleural knock
This term, coined by a French Physician in 1861, is the medical sign that indicates severely low serum calcium levels
What is Trousseau's Sign
A nurse is performing a pain assessment on a 6-year-old patient. This pain scale can be a helpful tool to evaluate this patient’s pain
Wong-Baker Faces Pain Rating Scale
A patient has been admitted with COPD. Diagnostic tests have been ordered. What test would be the most accurate in indicating the patient’s acid-base balance?
Arterial blood gasses (ABG's)
You are providing care for a patient with an acute hemorrhage stroke. The patient’s husband has been reading a lot about strokes and asks why his wife did not receive alteplase. What is your best response?
A. “Your wife was not admitted within the time frame that alteplase is usually given.”
B. “This drug is used primarily for patients who experience an acute heart attack.”
C. “Alteplase dissolves clots and may cause more bleeding into your wife’s brain.”
D. “Your wife had gallbladder surgery just 6 months ago and this prevents the use of alteplase.”
A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure (ICP) after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?
A. Bulging anterior fontanelle
B. Repeated vomiting
C. Signs of sleepiness at 2200
D. Inability to read short words from 18 inches away
Your patient is experiencing severe diarrhea & vomiting and regularly uses diuretics to manage their edema. Chief complaints are heart palpations, extreme fatigue, muscle weakness & tingling in extremities. What lab value are you expecting to be diminished?
Low potassium (hypokalemia)
The nurse observes an 80 y.o. patient exhibiting adverse signs and symptoms: the patient is pale, trembling, tachycardic, complaining of hunger, lightheadedness, and has non-baseline confusion. What assessment/diagnostic would a nurse prioritize obtaining?
The nurse, after ABC's, would prioritize checking the patients blood glucose level for suspected hypoglycemia
A patient is observed to have tachycardia, acute confusion, tachypnea, and has fruity smelling breath. What acid-base imbalance would the nurse likely identify in this patient?
Metabolic acidosis
Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
A. Pallor, bradycardia, and reduced pulse pressure
B. Pallor, tachycardia, and a sore tongue
C. Sore tongue, dyspnea, and weight gain
D. Angina, double vision, and anorexia
A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with I.V. fluids. Assessment shows a fever of 103°F (39.4°C), a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Myocardial infarction
C. Pneumonia
D. Sepsis
E. Tuberculosis
The nurse is reviewing a patient’s lab values and notes a calcium level of 115 mEq/L. Name five signs & symptoms that may be observed in a patient with this lab value.
Altered level of consciousness/cognition, confusion, muscle weakness, diminished deep tendon reflexes, nausea, diarrhea, abdominal cramping, seizures. Weak pulses, tachycardia, hypotension & dizziness (with hypovolemic hyponatremia) or bounding pulse, & normal or hypertension (with hypervolemic hyponatremia)
A 2 y.o. male diagnosed with Down syndrome & congestive heart failure and is receiving intravenous furosemide (Lasix). The child is not toilet trained. Accurate measurement of urine output is crucial in managing the child’s condition, as furosemide is a potent diuretic. The nurse needs to choose the most appropriate method for measuring the toddler’s urine output. Which of the following measures is the most appropriate for measuring the urine output?
A. Inserting a foley catheter
B. Asking the mother about number of dirty diapers
C. Observing the color and odor of the urine
D. Weighing the diaper on a scale
E. Using a urine collection bag
List four dietary changes that would be anticipated for a patient who is experiencing active renal failure
Restricted protein, sodium, potassium and phosphorus
Prolonged occlusion of the right coronary artery produces an infarction in which of the following areas of the heart?
A. Anterior
B. Apical
C. Inferior
D. Lateral
A patient with primary adrenal insufficiency (Addison's Disease) asks a nurse for nutrition and diet advice. Which of the following diet modifications is not recommended?
A. A diet that includes grains
B. Constant/consistent fluids
C. A diet with restricted sodium
D. A diet high in protein