That's when I could finally breathe
The nurse is assigned four clients. Which client does the nurse need to see first?
A client with chronic obstructive pulmonary disease who is in a tripod position
A client with type 1 diabetes who is using respiratory accessory muscles
A client with asthma who is wheezing and has RR 19
A client who has pneumonia, a fever, and bloody sputum
Who is a client with type 1 diabetes who is using respiratory accessory muscles?
The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be MOST appropriate?
Fluid restriction 1000cc per day
Administer analgesic therapy as ordered
Encourage increased caloric intake
Ambulate in hallway four times a day
What is administer analgesic therapy as ordered?
The student nurse is reviewing the electrical activity of the heart. The student nurse is aware that the electrical impulse begins with which of the following?
What is the SA node?
A diabetic patient has the following presentation: unresponsive to voice or touch, tachycardia, diaphoresis, and pallor. Which of the following actions by the healthcare provider is the priority?
Send blood to the laboratory for analysis
Administer 50% dextrose IV per protocol
Administer oxygen per nasal cannula
Administer the prescribed insulin
What is administer 50% dextrose?
A nurse in a long-term care facility is caring for a 78-year-old man with dementia. Which of the following are the main signs and symptoms of Alzheimer’s dementia?
Impaired motor skills and lack of coordination
Delusions and hallucinations
Weight loss, fatigue, and hopelessness
Poor judgment, memory deficit, and irritability
What is poor judgment, memory deficit, and irritability?
When caring for a patient with emphysema requiring supplemental oxygen, the healthcare provider carefully titrates the oxygen to the lowest effective dose in order to avoid
Obstructive apnea
Respiratory alkalosis
Hypoventilation
Hyperventilation
What is hypoventilation?
Angiotensin can directly stimulate the adrenal cortex, leading to the release of this certain hormone.
What is aldosterone?
A client is admitted with the diagnosis of Myocardial Infarction. Which lab value would be consistent with this diagnosis?
What is Troponin?
The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse?
Serum blood glucose level of 74 mg/dL.
Telemetry reading showing sinus bradycardia.
The client is lethargic and sleeps all the time.
Pulse oximeter reading of 90%.
What is a pulse of 90%?
Which of the following symptoms would the nurse expect could be associated with an acute subdural hemorrhage in the right occipital lobe?
Hemorrhagic shock
Left homonymous hemianopia
Cushing’s Disease
Paralysis of the lower extremities
What is left homonymous hemianopia?
A patient who has a history of chronic bronchitis is admitted to the medical unit. The healthcare provider notes the red blood cell count is elevated. Which of these is the likely contributing factor to this lab result in this patient?
Hypercapnia
Chronic hypoxia
Insensible water loss
Decreased fluid intake
What is chronic hypoxia?
A nurse working on the medical floor is assessing patients. Which action will prevent a type II hypersensitivity reaction in the clients?
Steroid administration for severe serum sickness
Correctly identifying patients prior to blood transfusions
Keeping the patient free of offending agents
Providing a latex-free environment for patients
What is correctly identifying patients prior to blood transfusions?
In a client with mitral regurgitation the nurse would expect to see which of the following signs and symptoms?
Elevated white blood cell count
Crushing chest pain
Low red blood cell count
Exertional dyspnea
What is exertional dyspnea?
Which of the following is a physiological function that is mediated by a hormone released by the posterior pituitary?
Water retention
Decrease in calcium levels
Maturation of the egg and sperm
Increase in thyroid hormone level
What is water retention?
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?
Hyperreflexia
Positive reflexes
Flaccid paralysis
Reflex emptying of the bladder
What is flaccid paralysis?
A 19-year-old patient has been diagnosed with pneumonia. Upon the healthcare provider’s initial assessment, she notes the patient's breathing is rapid and shallow. Place the healthcare provider’s next steps in the order in which they should be performed.
What is Administer O2
Pulse ox
listen
record rate
document
The physician orders a patient with suspected iron deficiency anemia a blood smear test to assess the quality of the RBCs. How would the red blood cells appear if the patient had iron deficiency anemia
What is hypochromic and microcytic?
When discussing hypertension with a student, which of the following will the healthcare provider identify as a factor related to hypertension?
Increased afterload
Decreased cardiac output
Hypovolemia
What is increased afterload?
A nursing student is studying the difference between hypo and hyperthyroidism. Which of the following show they have a grasp on the information?
Graves disease is the most common cause of hypothyroidism.
Increased amounts of TH cause a decrease in cardiac output and peripheral blood flow.
Decreased renal blood flow and glomerular filtration rate reduces the kidney's ability to excrete water, which may cause hyponatremia.
Deficient amounts of TH cause abnormalities in lipidmetabolism with decreased serum cholesterol and triglyceride levels.
What is decreased renal blood flow and glomerular filtration rate reduces the kidney's ability to excrete water, which may cause hyponatremia?
The nurse is caring for a patient who sustained a spinal cord injury at T6, three weeks ago. The patient abruptly complains of a severe headache. On assessment, the nurse notes the patient is diaphoretic. Vitals are significant for a heart rate of 45 bpm, blood pressure 156/98 mmHg, respirations of 16 breaths per minute, and 94% oxygen saturation on room air. Which of the following is the next best step in management?
Call the rapid response team
Administer morphine as ordered
Ensure the patient’s urinary catheter is draining properly
Insert a large-bore IV catheter and prepare the patient for surgery
What is ensure the patient’s urinary catheter is draining properly?
Several family members of a patient diagnosed with a pleural effusion are concerned that the patient has not been “coughing up any of the fluid.” The healthcare provider understands that nonproductive cough is expected because the:
Fluid collection is outside of the airways and alveoli.
Effusion has most likely resolved.
Fluid collection is excreted through circulation.
Pressure of the fluid is restricting the airway.
What is Fluid collection is outside of the airways and alveoli?
The student nurse is caring for a patient on the medical-surgical unit for splenectomy. The student learns the functions of the spleen include which of the following? (Select all that apply.)
Breakdown of hemoglobin
Destruction of red blood cells that are old or defective
Production of vitamin K
Storage of iron
Storage of platelets
What is breakdown of hemoglobin, destruction of red blood cells that are old or defective and storage of platelets
A patient who has a history of pulmonary valve stenosis tells the healthcare provider, “I don’t have a lot of energy anymore, and both of my feet get swollen in the late afternoon.” Which of these problems does the healthcare provider conclude is the likely cause of these clinical findings?
Acute pericarditis
Deep vein thrombosis (DVT)
Peripheral artery disease
Right ventricular failure
What is right ventricular failure?
The nurse is teaching diet restrictions for a client with Addison’s disease. The client would indicate an understanding of the diet by stating?
“I will increase potassium and sodium and restrict fluids.”
“I will increase sodium and fluids and restrict potassium.”
“I will increase sodium, potassium and fluids.”
“I will increase fluids and restrict sodium and potassium.”
What is “I will increase sodium and fluids and restrict potassium.”?
The nurse is assigned to a patient who presents to the emergency department with a severe headache. Upon physical assessment, the patient’s heart rate is 114, temperature is 100.8 and the blood pressure is 149/93 mmHg. Which of the following questions by the nurse is most important?
“Are you experiencing neck stiffness?”
“Are you experiencing joint or muscle pain in your legs?”
“Have you had nausea and vomiting in the last two days?”
“Have you come in contact with anyone who was sick recently?”
What is “Are you experiencing neck stiffness?”