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Concept 3 Final
CLOCK THAT TEA
| Question | Answer |
|---|---|
| By taking care of the acute respiratory distress system (ARDS) under the ventilator, the nurse understands which of the following are the best interventions to implement the ventilator bundle? SATA: | Assess readiness to extubate, Administer DVT prophylaxis (enoxaparin), Administer Stress ulcer prophylaxis (famotidine), daily chlorhexidine oral care |
| Vent is set at 12 bpm, tidal volume 500 with total resp 15bpm, Fraction of 40 the 3.....200cc of volume, the nurse knows that the pt is .. What mode of mechanical ventilation is this pt on? | SIMV |
| The nurse is caring for a long-term ventilator-dependent client. Which physiological factors can contribute to long-term ventilator dependence? SATA: | Increase respiratory muscle fatigue, Improper positioning, Ventilator perfusion mismatching |
| The nurse caring for a client with acute respiratory failure interrupts the following ABGS: PH 7.30, CO2 50, HCO3 31, O2 60 | Hypoxia due to Partially compensated respiratory acidosis |
| Ph 7.12, PaCO2 65, HCO3 24, PaO2 56, which clinical situation does the nurse correlate with these values? → (bronchospasm and hypoxia) | Bronchial obstruction due to patient swallowing a peanut |
| A client involved in a MVA has dyspnea, tachycardia, hypotension, JVD, tracheal deviation to the left, & decreased breath sounds to the right. Findings are indicative of Tension Pneumothorax. What should the nurse prepare the patient for? | Chest Tube insertion |
| Which statement made by the nurse is a correct explanation in regard to “PEEP”? | PEEP can prevent the lungs from collapsing during exhalation. |
| The client is on propofol. The nurse knows that under-sedating the client causes complications. SATA: | Unplanned extubating, Aspiration, Dysrhythmias, Sleep deprivation |
| UNKNOWN QUESTION → Signs of TEA COLOR URINE, electrolyte decrease | GFR increase, creatine increase, (BUN, urine anuric olio uric) |
| You are caring for an elder client who was in a mentor vehicle accident, with a significant hemorrhage to the chest. Nurses know the client is at greatest risk of developing which category of acute kidney injury? | Prerenal stage |
| The client was diagnosed with AKI, and which event from the client’s history was the most probable cause of AKI? | CT head (with contrast) |
| The PT was admitted with respiratory failure & is mechanically ventilated. The nurse overhears the conversation and knows that further teaching is needed.... mechanical ventilation alters kidney function | |
| Poached egg, apple juice, English muffin | |
| The nurse is caring for a client with AKI who has the following lab values: WBC 10 850, Hgb 7.2, HCT 24%, potassium 4.4, sodium 139, calcium 8.5, bun 20, creatinine 1.5. What will the provider give? | Erythropoietin |
| The nurse is caring for the following client on med-surg. Which client will the nurse be at risk for post-renal injury? | A pt. who has a blood clot in the urinary tract |
| 82-year-old client admitted with clinical manifestations r/t digoxin toxicity. The nurse knows which age-related change may have contributed to this problem. | Decrease renal blood flow |
| Pt 25% burn area = hematocrit 56% hemoglobin 17.2, potassium 4.8, sodium 135 what would you anticipate the provider order to do? | Increase fluids (Initiate fluids) → if pt. already on fluids, INCREASE the fluids |
| The primary reason that older adults develop pressure ulcer elbow.. compared to middle-aged adults.. | Decrease sub q fat |
| The nurse is assessing a client admitted after an electrical burn injury. Which ordered intervention should she complete first? | Do an EKG |
| A nurse has burns of the ears, head, neck and right arm and hand. In caring for this client, the nurse knows to place this client in which position? | Elevate the right arm and hand on a pillow and extend the fingers |
| Question of TBSA → pt. has burn in perineum, left arm, SUPERFICIAL right arm, entire chest, left/right leg. Calculate the TBSA: | 32.5% |
| Elder pt diagnosed with osteoporosis, which intervention should be taught to the client? | Place non-solid – rugs (ANSWER CHOICE SAYS DIFFERENT, but its rugs) |
| A client in the emergency department was admitted with T5 spinal cord injury, diaphoretic.. BP 201/98..headache.. The nurse understands which nursing intervention are appropriate. SATA: | Administer clonidine, Loosen constrictive clothing, Check for distended bladder |
| Spinal cord injury- The nurse knows which patient is at risk of developing neurogenic shock? | Heart rate 48 bpm (low HR = pt. at risk for neurogenic) |
| A client who had a traumatic head injury. Oculocephalic reflex(doll’s eyes)? The nurse know the physician must verify which ... | Absence of cervical injury |
| Neuro ICU handoff: Which client should see first? | Glasgow score of 10 and now 7 |
| Clear fluid coming from the nose, which action should the nurse implement first? | Test for glucose |
| Caring for a client in the ED following a head injury, and now has regained consciousness. The client has lost consciousness again. The nurse takes quick action, knowing this presentation is indicative of which injury? | Epidural hematoma |
| The nurse knows an independent nursing measure that can assist in reducing increased ICP is? | Decrease in noxious stimulus |
| The nurse understands that the most common contributing factor to the development of delirium in critically ill clients in the ICU is: | Sleep deprivation |
| A client in the ICU has just expired and the family is on the way to say their last goodbye. The nurse knows which of the following before the family’s arrival? SATA: | Remove IV tubing and NG/gastric tube, Dress the client in a clean gown, Bathe the patient as/if needed, Apply a waterproof pad under |
| A 65-year-old man manages sildenafil (Viagra used to treat rectal dysfunction). Which action should the nurse take first before prescribing a drug? | Ask what other medications they are taking. |
| Pt. was talking about sex life is declining and not sexually active as he was.... What should the nurse ask the pt.? | Tell me more about how your sexual response has changed. |
| Perimenopausal... which client statement? | SATA... everything but E lol |
| Responsible for triage 4 recently admitted. Which client will the nurse put immediately in seclusion? | A 70 y/o woman who has been a victim of sexual assault |
| Post-menopausal breast self-examination.. the nurse knows which in the explanation... | Perform the same exam day every month |
| The nurse is teaching a group of menopausal women about normal changes in sexual response. The nurse knows the information is understood by one woman when the woman states that ... | It takes me longer to reach an orgasm |
| When obtaining a health history from a geriatric patient, which of the following suspect increase or sexually transmitted infection for STI? | 5 different sexual partners |
| 42 y/o man... Which medication... Erectile dysfunction that also affects sexual desire and response? | Propranolol, a blood pressure medication |
| The client is scheduled for radiation therapy for the head and neck. The nurse knows that which statement by the client that teaching is effective? | I will need to buy a water bottle to bring with me |
| A client scheduled for a total laryngectomy and radical neck dissection for cancer of the head and neck ask the nurse, "will I able to talk normal after surgery?" | You will have a permanent opening in your neck and will need rehab for stoma type of voice restoration |
| A nurse is caring for a post-op patient who arrived on the unit 2 hours ago. Which assessment finding will alert the patient that they may be developing hypovolemic shock? | BP of 90/50 and HR of 138 |
| The nurse caring for any client with hypovolemic shock prepares to administer which treatment first? | CRYSTALLOIDS (NS, LR) |
| When caring for clients with shock, the nurse knows all forms of shock are categorized by inadequate? | Tissue perfusion |
| Four days after admission, a PT with sepsis has bright red blood in the NG tube & the Foley as well as bright red blood draining from the chest tube system & old IV sites. The nurse knows that the significance to these changes is that the PT is: | DIC ( Disseminated Intravascular Coagulation) |
| A priority assessment for the client admitted for DIC(disseminated intravascular coagulation) is: | Changes in LOC |
| The nurse assesses a 24 postoperative PT & got the following: the skin is pale, cool, & moist, the pulses are weak & thready, heart rate is 110, blood pressure is 90/65, temperature is 98.6, flat neck veins, clear lung sounds. Which type of shock is this? | Hypovolemic |
| A pulmonary catheter is placed in a client who has cardiogenic shock. Which hemodynamic change would anticipate finding an increase? SATA: | Increased PAOP(Pulmonary Artery Occlusion Pressure), Increased CVP (Central Venous Pressure), Increased SVR( Systemic vascular resistance) |
| What are the 3 distributive shocks? | Anaphylactic, Neurogenive, Septic |
| A client is admitted to the ICU with an acute MI. The nurse reviews the following info in the client’s history and physical (image). The nurse knows that the plan of care would include interventions to the shock state? | Cardiogenic |
| The treatment to septic shock is? | Finding and eradicating the cause of the infection |
| The nurse prepares to administer which medication for anaphylactic shock? | Epinephrine |
| The HCP prescribes actions for a PT W/ septic shock who has a BP 70/43, O2 sat 90%. Put in ORDER: a. Obtain a urine culture, b. Give vancomycin, c. Infuse vasopressin, d. Administer IV normal saline 1000 ml for 30 mins e. Titrate 02 sat to keep above 95% | E, D, C, A, B |
| A nurse understands that the personal purpose of a radial art line is? | Continuous BP reading |
| The nurse observes a rhythm in a client (EKG IMAGE IS V-FIB) Which action should the nurse perform for the client after ensuring the electrodes are on properly? | Defibrillate the client |
| The nurse SHOULD KNOW that the signs of myocardial irritability include: SATA: | Multifocal Premature Ventricular Contractions (PVCs), Increase Premature Ventricular Contractions (PVCs) |
| The nurse is assigning the following clients on a med surge floor. Which client needs to be assessed first? | 42 y/o with v tach and 140 bpm |
| The nurse observes the following on a tele monitor and notices the client is having which type of PVC? (EKG IMAGE) | Couplets |
| The nurses caring for a client with AKI that has a pulmonary art occlusion pressure of 4. CVP of 1 and a BP of 93/49. The BUN is 44 and the creatinine is 3.2. The pt UOP IS 15 ml/hr. The lungs are clear. The HCP will most likely order? | NS at 125 ml/hr |
| THERE WAS ANOTHER QUESTION WITH A BUNCH OF LABS (CVP WAS 10) AND BP WAS LOW, what medication should the nurse prepare to administer? | Norepinephrine |
| The nurse is preparing meds for a client with syndrome of inappropriate diuretic hormone (SIADH). The nurse knows which med will most likely be prescribed for the client? | CONIVAPTAN |
| A client is admitted with DKA. The top priority is: | Administering IV fluids |
| The nurse is caring for a client who has a head injury and has developed DI. The client is also severely hypotensive. The nurse would expect to administer which medication? | Desmopressin |
| A client with a head injury has a drop in their UOP. the lab reports a serum sodium level of 124, osmolality of 220, and a urine specific gravity of 1.035. The nurse suspects what problem is occurring? | SIADH (Syndrome of Inappropriate Antidiuretic Hormone) |
| The nurse includes which priority nursing diagnosis for a client with HHS? | Deficient fluid volume (Hypovolemia) → you NEED to give fluids |
| A nurse is planning care for a client who was admitted for myxedema coma and pneumonia. The nurse that which priority? | Ensure working suction equipment in the room |
| The nurse is caring for the client who is hospitalized with suspected Cholecystitis, the nurse should know that which findings indicates Cholecystitis? | Murphy’s sign |
| The nurse understands that esophageal varices are a result of? | Portal HTN secondary to hepatic liver cirrhosis |
| The PT presents to the ED with complaints of acute abdominal pain over past 24 hours. After obtaining HXs, nurse seen hxs of gallstones & have used alcohol daily for the past 5 years. The nurse understands that the client is most likely experiencing? | Pancreatitis |
| The nurse administers lactulose to a patient with acute liver failure and hepatic encephalopathy. Which outcome indicates the desired therapeutic outcome of the medication? SATA: | Decrease ammonia, Decrease confusion, Increase frequency of stools |
| A 76-year-old client has asthma, diabetes, HTN, and heart disease and takes many other meds during the day. The client reports difficulty falling asleep at night. The nurse knows to ask the client about which med? | Methylprednisolone |
| An 81-year-old nursing home client is admitted with an acute onset of mental status changes and recent falls. Which mental status change is the most common? | Urosepsis |
| An 82yr PT was hospitalized for exacerbation of their COPD, for which the PT is on chronic steroid use. The PT also has a fresh wound on the arm, which is not red nor swollen, but is tender. The PT is afebrile, confused, & agitated. Which action is next? | Perform a sepsis screening exam (mental health screening exam) |
| A pt with ESKD who receives hemodialysis treatments presents to the ED with altered mental status following dialysis treatment. The nurse reviews the following document in the EHR. (image). What Objective data meets Sepsis and SIRS criteria (SATA) | Creatinine is 5.7, HR 101, WBC 14800 |
| A client has newly diagnosed systemic lupus erythematosus (SLE). Which instruction by the nurse is most important? | Notify your provider if you get a fever |
| The nurse is caring for a client with type1 diabetes and a urinary diversion pancreas transplant. The nurse knows which statement by the client indicates the need for further teaching? | I no longer need to monitor my blood glucose. |
| The nurse is caring for a vent client; 48 hrs post-heart transplant. The client is AAO x3, sitting up in bed, trying to communicate. The client’s cap refill is less than 3 secs, pedal pulses of 2+. Based on the data, which is a priority? | Weaning the pt from the ventilator |
| The day shift nurse receives the following report (image). After receiving the report, the day shift nurse knows that this client is having a kidney transplant rejection. The nurse will probably administer which medication? | Methylpredisone |
| A client develops a hyperacute liver rejection. The nurse understands the treatment of a hyperacute liver rejection is? | Removing the transplanted liver |
| The client who has had a heart and lung transplant takes the immunosuppressant tacrolimus (Prograf). The nurse knows a common side effect of this med is? | Hyperkalemia |
| The nurse is discharging a client with SLE and renal involvement. The nurse anticipates that which drug will be a part of the management plan? | Methotrexate (rheumatrex) |
| A patient who is receiving a transplant is being taught about azathioprine. In SG, which statement indicates that teaching was effective? | I will notify my HCP if my gums start to bleed |
| Which statement made by a client who has had an organ transplant and is taking corticosteroids indicates that teaching was effective? | Establishing a routine for any skin changes |
| A 57 y/o client is being worked up for a liver transplant evaluation. The family approaches the nurse about organ donation. The following data is in the client’s chart are Contraindications for organ transplantation? | A secondary diagnosis of metastatic bone cancer |
| While providing care to an organ donor, the nurse knows to call the if which changes occur within the client’s? SATA: | A BG of 80, A MAP of 68 |
| When a client is having an acute rejection of a lung transplant, the nurse knows to prepare the client for which procedure? | Pulmonary Function Test (PFT) |
| The nurse knows that the clinical manifestations of a heart transplant include. (SATA) | Onset of hypotension, Pulmonary crackles, Sudden onset on edema |
| The nurse is caring for the following clients. Which client does the nurse assess first? | A pt with systemic lupus who is complaining of chest pain |
| An 86-year-old woman who has a history of diabetes, chronic kidney disease, and pneumonia after aspiration of gastric contents, and has cloudy, foul-smelling urine. The client is also diaphoretic. What actions are appropriate? SATA: | Place client on cardiac monitor, Obtain a urine sample for UAA sample, Check bedside glucose, Assess the client for confusion |
| The nurse receives a report on a client with pneumococcal pneumonia from the previous shift. (image) The nurse knows that the client has developed which syndrome? | SIRS (systemic inflammatory response syndrome) |
| Which hemodynamic value would be INCREASED in a patient experiencing SEPTIC SHOCK? | CO (cardiac output) |
| The most important goal for nutritional support in systemic inflammatory response and MODS is to | Preserve organ function and structure |
| During an assessment of a client with MODS, which elevated lab value is an indicator of decreased tissue perfusion and decreased cellular oxygen supply? | Lactic acid |
Created by:
fsanoe