bootcamp adult

which of the following findings would support a diagnosis of pericarditis?

a. splinter hemorrhages in nail beds

b. increased chest pain when leaning forward

c. cardiac murmur at left lower sternal border

d. widespread ST elevations on a 12 lead ECG

widespread ST elevations on a 12 lead ECG

how can pericarditis lead to cardiac tamponade?

inflammation causes fluid build up in pericardial sac that constricts the heart, preventing complete cardiac contractions

how does pericardial inflammation manifests as widespread ST elevations on an ECG?

inflammation impairs the repolarization of cardiac tissue

besides widespread ST elevations, what other manifestations can pericardial inflammation be?

fever, leukocytosis, dyspnea

what are reddish-brown lines on the nails that are characteristic of endocarditits?

splinter hemorrhages

what is a pericardial friction rub?

a scratching, high pitched sound heard at the left lower sternal border caused by rubbing of inflamed, roughened sac against the epicardium

what provides relief in patients with pericarditis?

sitting up and leaning forward

SATA: which of the following clients should the nurse anticipate referring to a burn facility for specialized care?

1. burns to face and neck area

2. superficial burns to genitals and left hip

3. small burn covering right hand and wrist

4. charred, gray burns to chest and abdomen

5. erythema and blisters to right forearm that reports pain

6. deep burns covering entire torso and both lower extremities

burns to face and neck area

superficial burns to genitals and left hip

small burn covering right hand and wrist

charred, gray burns to chest and abdomen

deep burns covering entire torso and both lower extremities

which of the following would be a priority for the nurse to include in the plan of care?

a. administer IV fluids

b. apply ice packs to the neck

c. insert an indwelling urinary catheter

d. collect blood for serum electrolyte analysis

apply ice packs to the neck

what is the highest priority for clients with heat stroke?

cooling measures to reduce body temperature

the nurse is caring for a client who is sedated and receiving mechanical ventilation when the client suddenly becomes agitated and is coughing as the ventilator alarm is going off.
which assessment is the nurse’s priority?

a. auscultate client’s bilateral breath sounds

b. check the endotracheal tube insertion depth

c. verify there are no kinks or disconnections in the tubing

d. assess whether the alarm is due to high or low pressure

check the endotracheal tube insertion depth

what are the correct steps to perform when the ventilator alarm is going off?

1. assess client before equipment

2. check the marked ett insertion depth

3. perform focused respiratory assessment

   1. troubleshoot the equipment

which dietary instruction is most appropriate for the nurse to include in the teaching?

a. eat more leafy green vegetables

b. it’s important to drink plenty of fluids

c. increase intake of red meats or beans

d. choose grains and cereals that are fortified

increase intake of red meats or beans

nurse is teaching a client newly diagnosed with trigeminal neuralgia.

which of the following client statements indicate that teaching was effective?

a. i can use an ice pack for facial pain

b. i should avoid eating food while it is hot

c. my spouse should comb my hair for me

d. chewing gum can help reduce facial pain

i should avoid eating food while it is hot

what is trigeminal neuralgia?

episodes of severe, shooting facial pain

what can trigger trigeminal neuralgia?

speaking, chewing, swallowing, temperature extremes on the face

what should clients with trigeminal neuralgia be instructed?

eat room temperature foods, chew on the unaffected side, avoid temperature extremes, groom during pain free periods

the nurse in the emergency department is caring for a client with burn injuries to the torso and lower extremities who has 32% of their total body surface area burned.

which of the following actions should the nurse take first?

a. insert an indwelling urinary catheter

b. administer warmed crystalloid fluids IV

c. cover burn injuries with sterile dressings

d. obtain blood for an abg analysis

administer warmed crystalloid fluids IV

why would you want to administer warmed crystalloid fluids to a client with large surface area burns?

burns greater than 20-25% of their total body surface area are at high risk for hemodyanmic instability

the nurse is caring for a client who came to the emergency room after a blunt injury to the eye and has periorbital ecchymosis.

which of the following actions should the nurse take?

a. apply an eye patch to the affected eye

b. apply a cold compress to the affected eye

c. irrigate the eye with water for at least 15 minutes

d. prepare the client for a fluorescein stain examination

apply a cold compress to the effected eye

SATA: the nurse is preparing a staff education program about caring for clients who are receiving positive pressure ventilation.

which of the following statement should the nurse include in the teaching?
a. perform oral care using chlorhexidine several times a day

b. it is important to monitor intake and output because ppv often causes oliguria

c. if a paralytic is required to improve oxygenation, make sure the client also receives a sedative

d. if you hear a low-pressure limit alarm, you may need to suction the client or unkink the ventilator tubing

e. include range of motion exercises for ventilated clients when developing a plan of care unless contraindicated

f. anticipate an order for pantoprazole or a similar medication if ppv is anticipated to last for more than a couple of days

a, b, c, e, f

BOWTIE: client reports her menstrual cycle occurs every 28-34 days, and she experiences mild abdominal cramping with each cycle. she and her husband have been trying to conceive for a year. BMI 29 kg/m². client has a history of chlamydia that was treated 2 years ago

actions to take (select 2)

a. prepare the client for transvaginal ultrasound

b. request an order for a broad-spectrum antibiotic

c. administer oral contraceptives

d. prepare to administer clomiphene citrate

e. prepare the client for laparaoscopic surgery

potential condition (select 1)

a. pelvic inflammatory disease

b. uterine fibroids

c. endometriosis

d. polycystic ovarian syndrome

parameters to monitor (select 2)

a. vaginal bleeding

b. ovulation

c. vaginal discharge

d. menstrual cycle pain

e. fasting glucose levels

prepare the client for transvaginal ultrasound, prepare to administer clomiphene, polycystic ovarian syndrome, ovulation, fasting glucose levels

the nurse is planning care for a client with crohn disease who has severe diarrhea and multiple enterocutaneous fistulas and is scheduled to undergo ostomy placement next week.

which of the following would be a priority for the nurse to include in the plan of care?

a. apply barrier ointment to the skin near fistula openings

b. make the client npo and give iv fluids until diarrhea improves

c. regularly monitor the client’s urine output and orthostatic vital signs

d. allow the client to express body image concerns related to ostomy placement

make the client npo and give iv fluids until diarrhea improves

SATA: the public health nurse is caring for a client who has a positive TB skin test.

which of the following should the nurse anticipate before the client begins drug therapy?

a. repeat tst

b. prepare for chest xray

c. draw blood for liver function tests

d. collect sputum culture and sensitivity

e. ask whether client lives with others

f. assess ability to adhere to medication regimen

b, c, d, e, f

the nurse is teaching a client how to manage frequent cerumen impactions.

which of the following information should the nurse include?

a. ear candles are an effective method of removing the wax buildup

b. soften the wax by adding 2-3 drops of mineral oil to the ear at bedtime

c. irrigation of the ear may be required if the wax causes an ear infection

d. use a cotton tipped applicator after showers to dry and clean your ears

soften the wax by adding 2-3 drops of mineral oil to the ear at bedtime

the nurse is teaching a client about screening for breast cancer.

which of the following information should the nurse include?

a. mammograms are recommended after age 40

b. brca gene testing is recommended by age 35

c. clinical breast exams are performed by ultrasound

d. self-breast examination is preferred method for early detection

mammograms are recommended after age 40

SATA: the nurse educates a female client who was recently diagnosed with cushing syndrome/

which of the following information should the nurse include in the teaching?

a. you need to weigh yourself daily with this condition

b. you might notice changes to the shape of your face

c. inspect your skin often and check for bruises and breakdown

d. you may experience scanty menstrual periods that occur less often

e. this is caused by oversecretion of a hormone from your pituitary gland

f. increase calcium intake from dairy products and green leafy vegetables

g. keep some extra candy in your purse in case your blood sugar runs low

h. you might see a bit more hair growth in places you wouldn’t normally see

a, b, c, d, f, h

the nurse is planning care for a client with pneumonia caused by the influenza virus.

which of the following interventions should the nurse include in the client’s plan of care?

a. administer iv antibiotics

b. administer antipyretics as needed

c. place client on contact precautions

d. administer annual influenza vaccine

administer antipyretics as needed

the nurse is assessing a client with suspected diverticulosis.

which of the following symptoms should the nurse ask the client about?

a. epigastric pain, dysphagia, coughing

b. right lower quadrant pain, rigidity, fever

c. left upper quadrant pain, distention, jaundice

d. left lower quadrant pain, bloating, constipation

left lower quadrant pain, bloating, constipation

the nurse is assessing a client with suspected diverticulitis.

which of the following symptoms should the nurse ask the client about

a. epigastric pain, dysphagia, coughing

b. right lower quadrant pain, rigidity, fever

c. left lower quadrant pain, vomiting, bloody stool

d. left lower quadrant pain, bloating, constipation

left lower quadrant pain, vomiting, bloody stool

the nurse is caring for an adult client with an ideal body weight of 110 lbs who has burn injuries to 36% of total body surface area.

using parkland formula, calculate total amount of iv fluids the client will need in the first 24 hours

a. 3600 mL

b. 5400 mL

c. 7200 mL

d. 15840 mL

7200 mL

what is parkland formula?

4mL x % TBSA x weight (kg)

the nurse has been made aware of the following situations.

the nurse should first assess the client

a. in skeletal traction who continues to slide down in bed

b. hip fracture whose heart rate increased from 82 to 138 on telemetry

c. who is ambulating in the hall after receiving a radioactive isotope for bone scan

d. who has a long leg cast and is using a tongue depressor to scratch inside the cast

hip fracture whose heart rate increased from 82 to 138 on telemetry

the nurse is planning a staff education program about skin care for clients with chronic venous insufficiency.

which of the following information should the nurse include?

a. apply moisturizer to the lower extremities to prevent skin breakdown

b. change the unna boot dressing on venous ulcers daily to promote healing

c. apply iodine to the venous ulcer before applying dressings to prevent infection

d. avoid putting compression stockings on the lower extremities to minimize irritation

apply moisturizer to the lower extremities to prevent skin breakdown

the nurse is caring for a client who has a renal calculus.

which client finding is most concerning?

a. gross hematuria

b. urine output 15 mL/hr

c. 10/10 colicky flank pain

d. nausea, vomiting, pallor

urine output 15 mL/hr

SATA: a client is concerned about the development of a retinal detachment and asks the nurse about the risk factors associated with this condition.

which statement by the nurse correctly describes risk factors for retinal detachment?
a. retinal detachment can spontaneously occur for some clients

b. any traumatic injury to the eye can result in retinal detachment

c. older adults are at higher risk for developing retinal detachment

d. retinal detachment occurs most commonly in children with vision problems

e. retinal detachment can occur after eye surgeries, such as cataract surgery

a, b, c, e

a nurse on the neurology floor admits a client who sustained a traumatic brain injury from a skiing accident.

which of the following findings is the nurse most concerned about?

a. client vomited three times in the past hour

b. client has ecchymosis over the mastoid process

c. client shields the eyes when the lights are turned on in the room

d. client reports bloody nasal drainage showing yellow rings on a tissue

client reports bloody nasal drainage showing yellow rings on a tissue

what can a traumatic brain injury CAUSE?

sensitivity to noise or light, headaches, nausea, vomiting, facial ecchymosis, irritability, forgetfulness

what are COMPLICATIONS of a traumatic brain injury?

csf leak, cognitive impairment, increased intracranial pressure, seizures

where can csf leak from?

ears, nose

SATA: the nurse is caring for a client with a history of dysphagia from a stroke who was admitted for pneumonia in the right lower lobe.

which of the following interventions should the nurse include in the plan of care?

a. request an order for continuous IV normal saline

b. provide the client with thickened liquids and pureed foods

c. reposition the client every 2 hours, trying to keep the right lung down

d. instruct the client to rinse the mouth before providing a sputum sample

e. review the client’s basic metabolic panel before administering IV vancomycin

a, b, d, e

the nurse is assessing a client with addison disease who is experiencing an adrenal crisis.

which of the following assessment findings should the nurse address first?

a. BP 88/58

b. confusion

c. severe leg pain

d. potassium 5.1

BP 88/58

the nurse is caring for a client with suspected multiple myeloma.

which of the following findings would support a diagnosis of multiple myeloma?

a. excessive bleeding and bruising

b. bone pain and pathological fractures

c. severe joint pain and morning stiffness

d. enlarged lymph nodes and night sweats

bone pain and pathological fractures