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Terms in this set (29)hypocalcemia tetany hypercalcemia decreased deep tendon reflexes (DTRs), hypokalemia flat T waves on ECG hyperkalemia tall peaked T waves on ECG Sudden loss of vision without pain Retinal detachment Rapid onset of elevated IOP Angle-closure glaucoma Progressive and painless loss of vision cataract Central loss of vision macular degeneration Loss of peripheral vision open-angle glaucoma A nurse is caring for a client experiencing hypovolemic shock. How should the nurse position this client? Select one: c. Supine with legs elevated CorrectThe nurse should place the client in shock position (on back with legs elevated). A nurse is caring for a client admitted with wheezing and coughing due to an allergic reaction to a newly prescribed medication. Which of the following medications should be administered first? Select one: The correct answer is: Albuterol 3 mL via nebulizer A nurse is caring for client who is 24 hr postoperative following a below-the-knee amputation of his right leg. What postoperative measures should the nurse provide to the client to avoid hip or knee flexion contractures? Select one: d. The client should be placed in the prone position several times a day to prevent hip flexion contraction contractions. Elevating the residual limb on a pillow may increase the risk for hip flexion contracture. Wrapping the stump will decrease swelling, but this will not prevent contractures. Lastly, use of the over-bed trapeze by the client will promote independence and mobility, but it will not prevent contractures. A nurse is caring for a client in the emergency department who was just admitted with chest pain, possible acute coronary syndrome. Which of the following actions should the nurse take first? Select one: The correct answer is: Administer sublingual nitroglycerin When caring for a client with a chest tube, the nurse notes continuous bubbling in the chest tube water seal chamber. What does this indicate? Select one: The correct answer is: An air leak. A nurse is caring for a client following repair of a fracture. Which of the following findings should alert the nurse that the client is experiencing compartment syndrome? Select all that apply. Select one or more: The correct answer is: Increased pain unrelieved by elevation or pain medication, Numbness, burning and tingling, The affected area is pale, Pulselessness A nurse is caring for an adult client who is experiencing delayed wound healing. Which of the following interventions should the nurse take? Select one: c. Monitor serum albumin levels and notify provider if below 3.5g/dL. CorrectThe nurse should monitor the client's serum albumin levels because a lack of protein increases the risk for a delay in wound healing and infection. A nurse is caring for a client with stage 3 HIV infection (AIDS). Which of the following are defining conditions of this stage? Select all that apply. Select one or more: The correct answer is: Candidiasis of the esophagus, bronchi, trachea, or lungs, Herpes simplex - Chronic ulcers (more than 1 month's duration), Disseminated or extrapulmonary histoplasmosis, Kaposi's sarcoma, Burkitt's lymphoma A nurse is caring for a client who is experiencing ventricular tachycardia with a pulse. The rapid response team is at the bedside. What electrical intervention should be used to correct this dysrhythmia? Select one: b. Synchronized cardioversion CorrectSynchronized cardioversion is the electrical management of choice for atrial fibrillation, supraventricular tachycardia (SVT) and ventricular tachycardia with a pulse. Review the following arterial blood gas (ABG) result and identify the acid/base imbalance: pH 7.18 PaO2 80 mm Hg PaCO2 38 mm Hg HCO3 15 mEq per L Select one: d. Metabolic acidosis CorrectCorrect. The pH is decreased, the PaCO2 is normal and the HCO3 is decreased. This is metabolic acidosis. A nurse is caring for a client with pericarditis. Which of the following findings should the nurse report to the provider? Select one: b. Paradoxical pulse. CorrectParadoxical pulse (variance of 10 mm Hg or more in systolic blood pressure between expiration and inspiration) is a sign of cardiac tamponade - a complication of pericarditis and should be reported to the provider. A nurse is caring for a client with the following vital signs: Temperature 37.3° C (99.1° F), respiratory rate 30/min, blood pressure 130/76 mm Hg, pulse 110 beats/min, and an oxygen saturation of 91% on room air. Which of the following prescribed interventions is the nurse's priority action? Select one: b. Begin oxygen therapy. CorrectCorrect. The client's respiratory and heart rates are elevated, and the oxygen saturation is 91% on room air. These signs indicate that oxygenation needs are not being met. Therefore, according to the ABC priority-setting framework, providing oxygen is the highest priority. After starting the oxygen, it is important to obtain the sputum specimen before starting the antibiotics and administering an antipyretic. Review the following arterial blood gas (ABG) result and Identify the acid/base imbalance: pH 7.36 PaO2 90 mm Hg PaCO2 67 mm Hg HCO3 37 mEq per L Select one: d. Compensated respiratory acidosis CorrectCorrect. The pH is normal (due to full
compensation), the PaCO2 is elevated, the HCO3 is elevated. This is respiratory acidosis. Possible causes for this imbalance include: A nurse is providing triage at the scene of an industrial fire. An adult client has sustained burns to the head and neck, anterior trunk and left arm and hand. Using the rule of nines, what percentage of this client's body surface should the nurse document as burn injury? Correct. The Rule of nines is used to establish the extent of body surface burned in adult clients. The head and neck receive 9%, the anterior trunk 18%, the posterior trunk 18%, each arm including hands is 9%, each leg including feet is 18% and the genitalia is 1%. The correct answer is: 36 A client is 3 days postoperative and complaints of localized pain of 6/10 at surgical site and chills. Upon review of the surgical site, edema is noted. What does the nurse suspect is the cause of this presentation? Select one: c. Surgical site infection CorrectYes. Correct. Manifestations of surgical site infection include pain, redness, edema, chills, fever, purulent drainage and odor. A client with a hiatal hernia presents with pyrosis. What is pyrosis? Select one: d. Burning sensation in the esophagus CorrectCorrect; Pyrosis is burning sensation in the esophagus. A nurse is reviewing labs for a newly admitted client with polycythemia vera. Which lab value trends would be seen with this disorder? Select one: RBC 7.4 million/uL is present with polycythemia. The values for iron, hemoglobin and platelets do not correlated with the values seen with polycythemia vera. The correct answer is: RBC 7.4 million/uL Which lab value would be an expected finding for a client with abdominal ascites? Select one: Low albumin is seen with clients who have liver disease. Clients will also have low total protein, high bilirubin and high AST levels. The correct answer is low albumin. The correct answer is: Low albumin A client with low red blood cell count is diagnosed with pernicious anemia. What deficiency leads to this disorder? Select one: Pernicious anemia is caused by Vitamin B12 deficiency which is a deficiency of intrinsic factor produced by gastric mucosa, which is necessary for absorption of vitamin B12. The other deficiency are not related to pernicious anemia. The correct answer is: Vitamin B12 deficiency A head injury client is being monitored for brain herniation. Which clinical manifestation is noted with brain herniation? Select one: Brain herniation and increased intracranial pressure result in decreased level of consciousness, dilation and fixation of pupils, Cheyne-Stokes respirations, hemodynamic instability and abnormal posturing. Coughing and blinking are absent with brain herniation. The correct answer is: Cheyne-Stokes reparations Sets with similar termsMed-Surg ATI65 terms fawnmeloneykeenan ATI MEDICAL SURGICAL65 terms Paytton_Reser ati AAA39 terms boss411 ATI NCLEX Practice Questions88 terms EvangelivingPLUS Sets found in the same folderMedical-Surgical Pre-Assignment67 terms withabowlofrice ATI Med Surg Pre-assessment25 terms crh95 Medsurg 2 ATI questions192 terms Torpowel ATI Capstone Pediatrics78 terms goandstudy Other sets by this creatorFundamentals Pre-assessment18 terms Alexandra_Marques Lab Values5 terms Alexandra_Marques Endocrine 48, 5039 terms Alexandra_Marques Postop 2034 terms Alexandra_Marques Other Quizlet setsChapter 5 - Political Parties27 terms KURTS56TEACHER 166 Exam 151 terms Samantha_BacalsoPLUS CVP-GI Pathology Final Exam40 terms isastansbury Unit 3 Biomedical Technology Review55 terms ma022505 Related questionsQUESTION The nurse is providing instructions to the client following application of a fiberglass cast. Which statement by the client indicates further education is needed? 8 answers QUESTION What are complication of the Thoracentesis procedure? 15 answers QUESTION What are the Patients Bill of Rights? 15 answers QUESTION A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which action should the nurse take? 2 answers |
A nurse is caring for a client in the emergency department who was just admitted with chest pain
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