American Federalism

A nurse is caring for a client who has heart falture and a potassium level of 2 4 mEg/L The nurse should identify which of the following medications as the cause of the client's low potassium level? a. Nitroglycerin! b. Metoprolol! c. Furosemide! d. Spironolactone! A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following Þndings should the nurse? a. Potassium 3.3 mEg/L X! b. pH 7.45! c. PaCO2 50 mm Hg d. HC03- 30 mEg/L! An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information would the nurse include in the nurse-to-nurse hand-oû report? (Select all that apply.) a Isolation Precautions b. Immunizations ! c. Diagnostic Test Resuits d. Mechanism of Injury A public health nurse is assessing an older adult dient who lives with a family member. The nurse identiÞes several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take Þrst? a. Discuss respite care with the client's family. ! b. Provide the client with a crisis hotline number! c. Document the bruises in the client's chart! d. Report the Þndings to a supervisor. A nurse is reviewing a cilent's laboratory values and discovers the client has a serum potassium of 6.2 mEg/L. Which of the following interventions should the nurse anticipate? a. Initiating an IV potassium infusion.! b. Encouraging the client to eat bananas! c. Administering sodium potystyrene sulfonate d. Administering a potassium-sparing diuretic.! A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk fo metabolic acidosis? a. A client who is taking a thiazide diuretic X! b. A client who is vomiting! c. A client who has salicylate intoxication d. A client who has diarrhea A nurse is preparing to administer potassium chloride elixir 40 mEg divided into 2 equal doses every 12 hr. Available is 6.7 mEg/5 mL How many ml should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) a. 15 mL b. 30 ml ! c. 4 mL! d. 10 mL! A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PIC). When assessingthe client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take Þrst? a. Remove the PIC line! b. Measure the circumference of both upper arms. c. Notify the provider who inserted the PIC Þne. d. Apply a cold pack to the client's upper arm. ! A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identity the client as being at risk for developing initially? a. Respiratory alkalosis! b. Metabolic alkalosis! c. Metabolic acidosis ! d. Respiratory acidosis A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for Þuld volume deÞcit? a. The client who has gastroenteritis and is febrile b. The client who has been NO since midnight for endoscopy.! c. The client who has left-sided heart failure and has ˆ brain naturetic peptide (BP) level of 600 pg/mL! d. The client who has end-stage renal failure and is scheduled for dialysis today! A nurse is caring for four dients on a medical-surgical unit. Which of the following clients should the nurse assess Þrst? a. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a ph of 5.3 X! b. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided c. A client who has COPD and the capillary reÞll time on both hands is 4 seconds! d. A client who has late-stage cirrhosis and whose breath has a fruity odor! A nurse is assessing a client who returned to the unit 4 hr ago after a partial colectomy. Which of the following Þndings should the nurse attend to Þrst? a. Sa02 of 95%! b. Report of severe incisional pain c. A moderately saturated dressing! d. A distended bladder ! A nurse is reviewing the artenal blood gas (AB) results of a chient who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? a. PaO2 below 70 mm Hg! b. Paco2 above 45 mm Hg! c. pH below 7.35 d. HC03 above 26 mEa/1! A nurse is triaging clients injured during a tornado. The nurse assess a client who has an open fracture of his arm. Which of the following actions should the nurse take? A. Place a red tag on the clients upper body! B. Place a yellow tag on the clients upper body C. Perform a rapid head-to-toe assessment ! D. Have the clients wife drive him to the hospital ! A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following Þndings should the nurse expect? a. Bounding peripheral pulses! b. Hyperactive deep tendon reßexes c. Warm, ßushed skin! d. Widened ORS complexes A nurse is assessing a client who has ßuid overload. Which of the following Þndings should the nurse expect? (Select all that apply) a. Increased respiratory rate b. Increased temperature! c. Increased blood pressure d. Increased heart rate A nurse is caring for a client who is using a patient-controlled analgesia (PA) pump for postoperative pain management, The nurse enters the room to Þnd the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make? a. Next time you think he needs more medication, call me and I'll push the button.! b. Your husband should decide when more medication is needed. c. ÓIt's a good idea to help make sure your husband can sleep comfortably."! d. Why do you think your husband needs more medication when he is asleep? ! A nurse triages clients arriving at the hospital after a mass casualty. which dients are correctly classiÞed? (Select all that apply) a A 20 vear-old malle with an open fracture with distal pulses yellow tag b. A 55-year-old female with a scalp laceration: black tag! c. An 88-year-old male with shortness of breath and chest bruises, green tag! d. A 35-year-old female with severe chest pain: red tag. While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take Þrst? a. Initiate a new IV line in the other extremity.! b. Discontinue the existing IV line. c Apply a hot pack to the irritated site.! d. Determine if the client needs to continue IV therapy! A nurse is preparing a client for outpatient surgery. After the nurse inserts the TV catheter, the client reports pain in the insertion area. Which of the following actions should the muse take? a. Remove the catheter and insert another into a diûerent site. b. Request a prescription for placement of a central venous access device! c. Administer an analgesic PO.! d. Administer a local anesthetic! An emergency department (ED) nurse is preparing to transfer ˆ client to the trauma intensive care unit. Which information would the nurse include in the nurse-to-nurse hand-oû report? (Select all that apply) a. Isolation Precautions b. Immunizations ! c Diagnostic Test Results d. Mechanism of Injury A nurse in a provider's oûce is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEg/L. The nurse should monitor the client for which of the following complications? a. Neurogenic shock! b. Seizures! c. Cardiac dysrhythmias d. Hypoglycemia! A nurse is assessing a client 15 min after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following Þndings as an adverse eûect of the medication? a. Respiratory rate 8/min b. Sleepy, but arousing when her name is called! c. Pain level of 6 on a scale from 0 to 10! d. Sa02 94%! A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7SO, Paco2 29 mm Hg. PaO2 60 mm Hg, HCO3 20 mEg/L, and Sa02 86% Which of the following is the priority nursing intervention? a. Administer oxygen via face mask. b. Prepare to administer a sedative.! c. Prepare for mechanical ventilation. d. Assess for indications of pulmonary embolism! A nurse is performing an admission assessment on a client. Which of the following Þndings should the nurse identify as an indication that the client is dehydrated? a. Low body temperature! b. Blood pressure 178/90 mm Ha! c. Jugular vein distention d. Skin tenting present A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take Þrst? a. Ask the client to rate her pain on a scale from 0 to 10. b. Reposition the client and oûer her a back rub.! c. Measure the client's vital signs, including temperature.! d. Determine the time the client last received pain medication.! A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. which of the following is an appropriate analysis of the ABGs? pH 7.22 PacO2 68 mm Hg Base excess -2 Pa02 78 mm Ha Saturation 80% Bicarbonate 26 mEg/L a. Respiratory acidosis b. Respiratory alkalosis! c. Metabolic alkalosis! d. Metabolic acidosis! A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PacO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? a. Respiratory alkalosis! b. Metabolic acidosis! c. Respiratory acidosis d. Metabolic alkalosis! A nurse is assessing four clients for ßuid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration? a. A client who has a urine speciÞc gravity of 1.010. b. A client who has a weight gain of 2.2 kg (2 ID) in 24 hr.! c. A client who has a hematocrit of 45%! d. A client who has a temperature of 39* C (102* F) A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following Þndings should the nurse expect? a. Hyperactive bowel sounds! b. Hyperactive reßexes! c. Weak, irregular pulse d. Extreme thirst! A nurse is preparing to administer potassium chioride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the clientÕs serum potassium level results and discovers the client's potassium level is 3.2 mEg/L. Which of the following actions should the nurse take? a. Omit the KCL dose and document that it was not given! b. Call the lab to verify the client's results.! c Hold the prescribed dose and notify the provider of the serum potassium level! d. Give the ordered KCL as prescribed A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients Þrst? a. A client who has anemia, hemoglobin of 11 g/dL, and is prescribed epoetin alfˆ.! b. A client who has pneumonia, a WBC count of 11,500/mm3, and is prescribed piperacillin.! c. A client who has renal failure, a serum potassium of 5.8/mEd/L and is prescribed sodium polystyrene sulfonate d. A client who is post-coronary artery bypass graft (CABG), has total cholesterol of 318 mg/ dL, and is prescribed atorvastatin! A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following Þndings should the nurse assess the client? a. BrudzinskiÕs sign! b. Kernig's sign! c. BabinskiÕs sign! d. Chvostek's sign A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe? a. B-type natriuretic peptide (BNP)! b. Lipase! c. Troponin 1 d. Aspartate aminotransferŠse (AST)! A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia? a. Hypertensive Crisis! b. Shallow Respirations c. Diarrhea! d. Hyperreßexia! A nurse is reviewing the EKG strip of a client who has prolonged vomiting Which of the following abnormalities on the clients EKG should the nurse interpret as a sign of hypokalemia? a. Wide ORS! b. Elevated ST segment! c. Abnormally prominent U wave d. Inverted P wave! A nurse is caring for a client who has opioid toxicity and has a respiratory rate of 6/min. Which of the following medications should the nurse plan to administer? a. Epinephrine! b. Naloxone c. Protamine! d. Flumazenil! A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment? a. Apical Heart Rate! b. Temperature! c. Blood Pressure! d. Respiratory Rate A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PacO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? a. Respiratory alkalosis! b. Metabolic acidosis! c. Respiratory acidosis d. Metabolic alkalosis! A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority Þnding? a. Potassium 2.9 mEg/L b. Phosphorous 4.5 mEq/L! c. Calcium 8.2 mg/dL! d. Sodium 145 mEg/L! A nurse is reviewing the laboratory report of a client and identiÞes a serum potassium level of 6.8 mEg/L. Which of the following medications should the nurse plan to administer? a. Lactulose! b. Darbepoetin alfa! c. Sodium polystyrene d. Sevelamer! A client admitted to the emergency department following a lightning strike, What is the priority assessment the nurse focuses on? a. Cardiopulmonary b. Integumentary! c. Renal! d. Peripheral Vascular! A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PacO2 48 mm Hg and the HCO3 is 23 mEg/L The nurse should recognize that these Þndings indicate of which of the following acid base balances? a. Respiratory alkalosis! b. Metabolic acidosis! c. Metabolic alkalosis! d. Respiratory acidosis A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following Þndings should the nurse expect? a. Shortened OT intervals! b. Hypoactive deep tendon reßexes.! c Tingling of the extremities d. Constipation! A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority? a. Respiratory Rate b. Pupil Reaction! c. Bowel Sounds! d. Urinary Output! A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for Þrst? a. A client who has questions about his new prescription! b. A client asking about his PCA pump that contains morphine c. A client requesting a referral for home health services! d. A client who needs assistance with a bath! Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge? a. A young adult client who has Crohns disease and is 1 day preoperative for an ileostomy b. A middle adult who is 36 hr postoperative from an open laminectomy! c. An older adult client who was admitted for diabetic kefcacidosis and his most recent ABGs show his pH is now 7.32! d. An adolescent client who was admitted 24 hr ago due to ˆ spontaneous pneumothorax! A nurse is reviewing the serum laboratory Þndings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following Þndings should the nurse report to the provider? a. Chloride 99 mEg/L! b. Calcium 10 ma/dL! c. Sodium 136 mEq/L! d. Potassium 2.3 mEa/L A nurse is triaging clients injured during a tornado. The nurse assesses a client who has an open fracture of his arm. Which of the following actions should the nurse take? a. Place a red tag on the client's upper body.! b. Place a yellow tag on the client's upper body c. Perform a rapid head-to-toe assessment.! d. Have the client's wife drive him to the hospital.! A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? a. pH 750, HC03- 20 mEG/L. PaCO2 32 mm Hg! b. pH 7.25, HC03- 19 mEg/L, Paco2 30 mm Hg c. pH 7.5S. HC03 - 30 mEg/L, PaCO2 31 mm Hg! d. pH 7.30, HC03- 26 mEg/L, Paco2 50 mm Hg! A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin leveis report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? a. Troponin is a lipid whose levels reßect the risk for coronary artery disease.! b. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. c. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues.! d. Troponin is a protein that helps transport oxygen throughout the body.