A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal AV fistula in the RA. Which intervention should the nurse implement in caring for the client? SATA

a. Assessing the radial pulse in the right extremity

b. Using the LA ti take BP readings

c. Drawing pre-dialysis blood specimens from the LA

d. Assessing the area over the AV fistula for a bruit and three each shift

e. Placing a pressure dressing over the site after each dialysis treatment

f. Administering IV fluids through the venous site of the AV fistula as needed

A, B, C, D

A nurse is evaluating outcomes for a client with Guillain-Barre syndrome. Which outcome does the nurse recognize as optimal respiratory outcomes for the client?

a. Normal deep tendon reflexes

b. Improved skeletal muscle tone

c. Absences of paresthesias in the lower extremities

d. Clear sound in the lower lung fields bilaterally

e. pO2 of 85 mmHg and pCO2 of 40 mmHg

D, E

A nurse of the telemetry unit is caring for a client who has had a MI and is now attached to a cardiac monitor. The nurse is monitoring the client's cardiac rhythm and nots ventricular fibrillation. Which nursing intervention should the nurse take first?

a. Calling the rapid response team

b. Preparing the client for cardioversion

c. Asking the client to bear down and cough

d. Preparing to administer diltiazem

A

The pattern of ventricular fibrillation is identified and can be a result after a patient with an MI. VF makes the patient feel faint, then loses consciousness and becomes pulseless and apneic (BP and heart sounds absent). Treatment is to terminate VF and covert it into a rhythm via defibrillation-> call a rapid and initiate CPR. Cardioversion is used for ventricular or supraventricular tachydysrhythmias.

A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse incorporate into the plan to prevent this complication?

a. Keeping the fan running in the client's room

b. Keeping the linens wrinkle free under the client

c. Limiting bladder catheterization to once every 12 hours

d. Avoiding the administration of enemas and rectal suppositories

B

The most frequent cause of autonomic dysreflexias are a distended bladder and impacted feces. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize these risks.

A nurse provides home care instructions to a client who has been fitted with a halo device to treat a cervical fracture. Which statement by the client indicates the need for further teaching?

a. I need to get more fluids and fiber into my diet

b. I should cut my food into small pieces before I eat

c. I need to put powder under the vest twice a day to prevent sweating

d. I have to check the pin sites everyday and watch for signs of infection

C

Cleanse the skin under the wool liner each day to prevent rashes and soars.

A nurse is caring for a client with increased intracranial pressure. In which position should the nurse maintain the client?

a. Supine with the head extended

b. Side lying with the neck flexed

c. Supine with the head turned to the side

d. Head midline and elevated 30-45 degrees

D

Proper positioning promotes venous drainage from the cranium to minimize ICP.

A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should take which action first?

a. Asses the clear fluid for protein

b. Check the clear fluid for glucose

c. Place cotton calls or dry gauze loosely in the ears

d. Use an otoscope to assess the tympanic membrane for rupture

B

CSF contains glucose not protein.

A nurse is caring for a client who has just undergone cardioversion. Which intervention is the nurse's priority after this procedure.

a. Administer oxygen

b. Monitoring the BP

c. Administering antidysrhythmic medications

d. Monitoring the client's LOC

A

ABC's of nursing. All other choices are correct, but not priority.

A client with diabetes mellitus who is scheduled to have blood drawn for determination of the glycosylated hemoglobin (HbA1c) level asks the nurse why the test is necessary if he is performing blood glucose monitoring at home. Which is the best response for the nurse to provide?

a. Detect diabetic complications

b. Assess long-term glycemic control

c. Determine whether the client is at risk for hypoglycemia

d Determine whether the prescribed insulin dosage is correct

B

A nurse caring for a client with acquired immunodeficiency syndrome is monitoring the client for signs of complications. Which of the following would cause the nurse to suspect infection with Pneumocystis jirovec? SATA

a. Diarrhea

b. Tachypnea

c. Pedal edema

d. Intermittent fever

e. Dyspnea with ambulating

f. Expectoration of frothy mucus

B, D, E

A opportunistic respiratory infection associated with AIDs that causes dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia, tachypnea, wt. loss.

Zidovudine is prescribed for a client with AIDS. The nurse tells the client that it is important to report back to the clinic as scheduled for which follow-up diagnostic?

a. Blood glucose checks

b. Blood pressure checks

c. Complete blood counts (CBC)

d. Electrocradiographic studies

C

Zidovudine is an antiviral medication that cause cause agranulocytosis and anemia.

After a non-immunocompromised client undergoes a Mantoux test for TB infection, an area of induration 6 mm wide developed. The client asks the nurse what this result means. Which is the best response?

a. We'll have to repeat the test because the result was inconclusive

b. The swollen area is small, so that means your test result is negative

c. You've been exposed to TB so you will need to have a chest x-ray

d. You need to get started on medication right away because you have TB

B

Indurations less than 10 mm (non-immunocompromised) and 5 mm (immunocompromised) is considered a negative result after 48-72 hrs. Results greater indicate exposure and possible TB infection. Morse testing (x-ray) will be needed.

A clients arterial blood gases are analyzed; pH 1.49, paO2 97 mmHg, HCO3- 22 mEq/L. Which acid base balance disturbance does the nurse identify from these results?

a. Metabolic acidosis

b. Metabolic alkalosis

c. Respiratory acidosis

d. Respiratory alkalosis

D

RAcidosis: paCo2 >45 mmHg and RAlkalosis is paCo2 <35>

A client has recently been diagnosed with deep vein thrombosis of the right leg. Which of the following interventions of the nurse immediately implement?

a. Elevating the foot of the bed 6 inches

b. Placing ice packs on and under the right leg

c. Documenting the need for hourly calf measurements

d. Performing the need for hourly calf measurements

A

DVT treatment includes bed rest, leg elevation, and application of warm, moist heat. Elevation decreases the venous pressure with relieves edema and pain. ROM cause cause the thrombus to mobilize to the lungs causing PEs.

A nurse provides instruction to a client with COPD about home oxygen therapy. Which statement made by the client indicates need for further instruction?

a. I should limit activity as much as possible

b. If I have trouble breathing, I need to call the doctor

c. I need to drink lots of fluids to keep my mucus thin

d. I can apply petroleum jelly to my nose if the oxygen dries it out

e. I should wear a scarf over my nose and mouth in cold weather

f. If I get a flu shot, I do not have to worry about being around people with colds

A, D, F

A nurse is monitoring the neurological status of a client who underwent craniotomy 3 days ago. Which signs or symptoms would prompt the nurse to notify the primary health care provider immediately?

a. Disorientation to date

b. Pupils equal and reactive at 4 mm

c. Mild headache relieved by acetaminophen with codeine

d. Pain with forward flexion of the neck onto the chest

D

A complication of cranial surgery is meningitis.

A man calls the clinic and tells the nurse that he sustained a bee sting on his leg while working in his yard. The client states that he is not allergic to bees and wants to know how to treat the sting. The nurse tells the client to first take which action?

a. Place a cool compress on the sting site

b. Apply an antipruritic lotion to the sting site

c. Apply a topical corticosteroid to the sting site

d. Take an oral antihistamine such as diphenhydramine (Benadryl)

A

A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should take which action first?

a. Ask the client to sign a no-harm contract

b. Ask the client to report any suicidal thoughts immediately

c. Place the client under suicide precautions with 15-minute checks

d. Check the dressings that were placed over the client's wrists in the emergency department

D

First assess the physical state of the patient for safety then implement precautions.