F
A patient reports acute symptoms of fatigue, fever, headache, and a "bull's eye" looking rash on their lower ankle. They were brought to the ED after fainting, vitals are BP: 100/48, HR: 44, RR: 25, T: 38 C. The patient reports having recently concluded a hiking excursion. Leads are placed on the patient. What EKG finding would the nurse expect to find?
A) Asystole
B) 3rd degree heart block
C) Sinus bradycardia
D) Atrial flutter
B) 3rd degree heart block
The bull's eye rash, the previous hiking trip, the fever, syncope, fatigue, headache all point towards Lyme disease. 3rd degree heart block, where the atrium and ventricle are firing on their own without any regard for the other, is commonly associated with Lyme disease.
A diabetic patients arterial blood gas are ph 7.28, paco2 34, pao2 85, hco3 18. The nurse would expect which findings
A. Decreased venous 02 pressure
B. Kussmaul respirations
C. Cheyne stokes respirations
D. Polyphagia
B. Kussmaul respirations
Rationale: The patient is demonstrating metabolic acidosis, to counteract the low bicarbonate levels hindering the pH below normal range, Kussmaul respirations are a rapid deep breathing at a consistent pace that is triggered to release more CO2 (naturally acidic) to restore balance.
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medications should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition?
A. Sotalol (betapace)
B. Warfarin (coumadin)
C. Atropine (Sal-Tropine)
D. Lidocaine (Xylocaine)
B. Warfarin (coumadin)
Rationale: A fib puts a client at risk for an emboli. Warfarin is a blood thinner that prevents clots from forming.
Which medication taken by a patient with restless legs syndrome should the nurse discuss with
the patient?
Folic Acid
Asprin
Diphenhydramine
Vitamin B-12
Diphenhydramine
Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to restless legs syndrome.
Which option is an abnormal length for a PR interval?
A) 0.24 sec
B) 0.18 sec
C) 0.10 sec
D) 0.14 sec
A) 0.24 sec is abnormally long, PR intervals should be between 0.10-0.20 sec. Increased PR intervals are signs of heart block.
Which option is not an aspect incorporated in the TNM classification scale?
A) Number of palpable nodes
B) Spread to lymph nodes
C) Tumor size and invasiveness
D) Metastasis
A) Number of palpable nodes is not a portion of the TNM classification scale.
Following teaching regarding ways to manage a hiatal hernia, which statement made by the patient indicates a need for further teaching?
A) Do not make diet modifications as this is a mechanical problem causing my symptoms
B) Do not recline for 1 hour after eating
C) Elevate the head of the bed on 4-8 inch blocks to prevent further sliding of hernia
D) Eat frequent, small meals
A) Do not make diet modifications as this is a mechanical problem causing my symptoms
While some people with hiatal hernias are asymptomatic, the close proximity of the hernia to the lower esophageal sphincter (LES) can trigger signs and symptoms of GERD such as pyrosis, regurgitation, and dysphagia.
Additional lifestyle modifications include eliminate alcohol, elevate HOB, stop smoking, avoid lifting/straining, reduce weight, loose fitting clothes, use PPIs and antacids, avoid anticholinergics (delay stomach emptying), 6 small meals per day, no fluids or foods 1-2 hrs before bed, eliminate spicy irritating foods, alcohol, and coffee, increase fiber.
On auscultation of a patients lung the nurse hears low pitched bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding.
A. Bilateral inspiratory wheezing
B. Plural friction rub in the right and lower lobe
C. Inspiratory crackles at the bases
D. Expiratory wheezes in both lungs
C. Inspiratory crackles at the bases
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with chronic obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse?
a. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg
b. 34-year-old with ABG results: pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg
c. 45-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg
d. 65-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
A. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg
Rationale: The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis.
A nurse and a student nurse are with a patient who has GERD. Which statement made by the student nurse requires the nurse to intervene and correct.
A) Antacids, proton pump inhibitors, and H2 receptor antagonists can be used to manage GERD
B) You should maintain an upright position 2-3 hours after eating
C) Chewing gum and oral lozenges should be avoided as they neutralize the effectiveness of PPIs
D) Eat small, frequent meals
C) Chewing gum and oral lozenges should be avoided as they neutralize the effectiveness of PPIs
Gum and oral lozenges will increase saliva production, which can help alleviate some of the minor symptoms.
A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this client’s care?
Electrolyte and fluid imbalance
Edema and pain
Hyperglycemia
Cardiac and respiratory status
Electrolyte and fluid imbalance
This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance is essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the client’s cardiac, respiratory if the electrolyte imbalance is not treated. Hyperglycemia is not associated with the diuretic phase.
A nurse is assessing a patients risk for development of atrial fibrillation. Select all options that increase the risk of a fib.
A) 67 years old
B) Has type 2 diabetes
C) Incorporates daily yoga into life
D) Asian descent
E) HDL level of 65 mg/dL
A) 67 years old, B) Has type 2 diabetes. Other factors that increase the risk are hypertension, heart failure, and left ventricular dysfunction. These risk factors are more prevalent in African Americans, so there would be an increased likelihood of a fib. None of the other options are bad.
Which patient assessment will help the nurse identify potential complications of trigeminal neuralgia?
Inspect the oral mucosa and teeth.
Have the patient clench the jaws.
Identify trigger zones by lightly touching the affected side.
Assess lung sounds for possible aspiration.
Inspect the oral mucosa and teeth.
Oral hygiene is frequently neglected because of fear of triggering facial pain and may lead to gum disease, dental caries, or an abscess. Having the patient clench the facial muscles will not be useful because the sensory branches (rather than motor branches) of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided. Aspiration is not a high priority risk factor for TN.
Which order for a patient with left and right sided heart failure will the nurse question? Available information: T: 36.3 C, HR: 58, BP: 168/114, RR: 32, K 3.2, Na 138, Cl 98, Mg 1.8, Ca 9.2, blood sugar 130, BUN 13, creatinine 1.1
A) Furosemide 40 mg IV push
B) Continuous lead monitoring
C) DASH diet
D) Digoxin 120 mcg tablet q8h
D) Digoxin 120 mcg tab q8h with the potassium of 3.2 mg/dL warrants notifying the health care provider, as low serum potassium increases the risk fo digoxin toxicity.
A 56-yr-old female patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect?
Decreased blood pressure
Elevated urine ketones
Increased urine output
Recent weight gain
Recent weight gain
The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. Ketones are not related to nephrotic syndrome. Decreased urine output is the typical symptom of nephrotic syndrome.
The nurse is assigned a patient with ankylosing spondylitis. The nurse knows all of the following nursing interventions are appropriate except...
A) Applying heat and massages as needed
B) Administration of adalimumab, a tumor necrosis factor antagonist, as ordered
C) Encourage the use of high energy expenditure activities to achieve progress in range of motion activities
D) Ensure a consent form has been signed and understood by the patient prior to spinal fusion
C) Encourage the use of high energy expenditure activities to achieve progress in range of motion activities
The nurse wants to encourage balancing exercise and rest to find a suitable range of comfortable energy levels and lung oxygenation
A nurse cares for a client who has a heart rate averaging 56 bpm with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart?
A. Make certain that your bath water is warm
B. avoid straining while having a bowel movement
C. limit your intake of caffeinated drinks to one a day
D. avoid strenuous exercise such as running
B. Avoid straining while having a bowel movement
Rationale: Bearing down during a bowel movement stimulates the vagus nerve and results in a slowing heart rate.
Which statement made by the nursing student demonstrates a need for further teaching?
A) Left sided heart failure can lead to right sided heart failure
B) Cardiac output in heart failure increases
C) Heart failure decreases blood flow to the kidneys, causing the RAAS system to be activated to raise bp and control fluid and electrolytes, resulting in fluid overload
D) Atrial natriuretic peptides (ANP) and B-type natriuretic peptides (BNP) are released from over-distended cardiac chambers to cause vasodilation and diuresis
B) Cardiac output decreases during heart failure, interventions from the body such as the RAAS may increase CO temporarily.
Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective?
The periorbital and peripheral edema are resolved.
The patient denies frequency with voiding
The patient denies burning with voiding.
The antistreptolysin-O (ASO) titer has decreased.
The periorbital and peripheral edema are resolved.
Because edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Nitrites will be negative and the patient will not experience dysuria because the patient does not have a urinary tract infection. Antibodies to streptococcus will persist after a streptococcal infection.
A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.)
“Take this drug on an empty stomach for best absorption.”
“Seek immediate care if you develop trouble swallowing.”
“Do not eat a full meal for 45 minutes after taking the drug.”
“Your urine may turn a reddish-orange color while on this drug.”
“The dose may change frequently depending on symptoms.”
“Seek immediate care if you develop trouble swallowing.”
“Do not eat a full meal for 45 minutes after taking the drug.”
“The dose may change frequently depending on symptoms.”
Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If difficulty with swallowing occurs, the client should seek immediate attention. The dose can change on a day-to-day basis depending on the client’s manifestations. Taking the drug on an empty stomach is not related although the client needs to eat within 45 to 60 minutes afterwards. The client’s urine will not turn reddish-orange while on this drug.
Which is not a nursing intervention for Guillain-Barre?
A) Enoxaparin injections
B) Assess skin, ensure turning schedule is adhered to
C) Administer neostigmine as ordered
D) Urinary catheter insertion for urinary retention due to autonomic neuropathy
C) Administer neostigmine as ordered
Guillain Barre syndrome is an autoimmune attack on the peripheral nerve myelin, causing rapid segmental demyelination of peripheral nerves and some cranial nerves. Often a viral infection precedes the onset of Guillain Barre syndrome. This syndrome is not due to a lack of acetylcholine.
A patient with left sided heart failure is being monitored by a nurse. What sign would indicate the heart failure has progressed to incorporate right sided heart failure?
A) Coarse crackles bilaterally
B) Orthopnea
C) Abnormal S3 sounds auscultated
D) Generalized edema
D) Generalized edema
With left sided heart failure, the left ventricle does not pump blood out effectively, causing fluid to back up into the lungs, causing the pulmonary edema, orthopnea, abnormal S3 sounds, S4 sounds, hypo/hypertension, dyspnea, cool and clammy skin, anxious pale, cyanotic, accessory muscle usage, tachypnea, pink frothy tinged sputum. Right sided failure will see fluid backed up systematically, so generalized edema, ascites, jugular vein distention, hepatomegaly, weight gain, increased abd girth.
The health care provider suspects the Somogyi effect in a 50-yr-old patient
whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take?
Check the blood glucose during the night
Limit simple carbohydrates in your diet.
Increase the long-acting insulin dose.
Start taking your blood glucose before each meal and use a sliding scale to maintain glucose control.
Check the blood glucose during the night
If the Somogyi effect is causing the patient’s increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night. Glucose and carbohydrate control during the day does not have an effect the Somogyi effect.
Prevention & recognition of the signs of cancer are key. The acronym CAUTION is important. Fill in the missing areas.
C- change in bowel or bladder habits
A-
U- Unusual bleeding or discharge from any body orifice
T-
I-
O-
N- nagging cough or hoarseness
A- A sore that does not heal
T- Thickening or lump of breast or elsewhere
I- Indigestion or difficulty swallowing
O- Obvious change in a wart or mole
A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take?
Document the finding in the client’s record.
Report the tube as working in the hand-off report.
Clamp the tube in preparation for removing it.
Assess the client’s abdomen and vital signs.
Assess the client’s abdomen and vital signs.
The nephrostomy tube should continue to have a consistent amount of drainage. If the drainage slows or stops, it may be obstructed. The nurse must notify the provider, but first should carefully assess the client’s abdomen for pain and distention and check vital signs so that this information can be reported as well. The other interventions are not appropriate.