MedSurg Exam 1 - Chapters 1, 2, 4, 6, 13, 15, 34 & 57
Studied by 0 people
Knowt Play
Learn
Practice Test
Spaced Repetition
Match
Flashcards1/132
There's no tags or description
Looks like no tags are added yet.
Name | Mastery | Learn | Test | Matching | Spaced |
|---|
No study sessions yet.
133 Terms
A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new nurse that which is the priority when working as a professional nurse?
A. Attending to holistic client needs.
B. Ensuring client safety.
C. Not making medication errors.
D. Providing client-focused care.
B. Ensuring client safety.
A nurse is orienting a new client and family to the medical-surgical unit. What information does the nurse provide to best help the client promote his or her own safety?
A. Encourage the client and family to be active partners.
B. Have the client monitor hand hygiene in caregivers.
C. Offer the family the opportunity to stay with the client.
D. Tell the client to always wear his or her armband.
A. Encourage the client and family to be active partners.
A nurse is caring for a post-operative client on the surgical unit. The client's blood pressure was 142/76 mmHg 30 minutes ago, and now is 88/50 mmHg. What action would the nurse take first?
A. Call the rapid response team.
B. Document and continue to monitor.
C. Notify the primary health care provider.
D. Repeat the blood pressure in 15 minutes.
A. Call the rapid response team.
A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept?
A. Assesses for cultural influences affecting healthcare.
B. Ensures that all the client's basic needs are met.
C. Tells the client and family about all upcoming tests.
D. Thoroughly orients the client and family to the room.
A. Assesses for cultural influences affecting healthcare.
A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors?
A. Bring a list of all medications and what they are for.
B. Keep the provider's phone number by the telephone.
C. Make sure that all providers wash hands before entering the room.
D. Write down the name of each caregiver who comes in the room.
A. Bring a list of all medications and what they are for.
Which action by the nurse working with a client best demonstrates respect for autonomy?
A. Asks if the client has questions before signing a consent.
B. Gives the client accurate information when questioned.
C. Keeps the promises made to the client and family.
D. Treats the client fairly compared to other clients.
A. Asks if the client has questions before signing a consent.
A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is most accurate?
A. Avoid embarrassing the client by asking questions.
B. Don't make assumptions about his or her health needs.
C. Most LGBTQ people do not want to share information.
D. No differences exist in communicating with this population.
B. Don't make assumptions about his or her health needs.
A nurse is calling the on-call health care provider about a client who had a hysterectomy two days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication?
A. I would like you to order a different pain medication.
B. The client has allergies to morphine and codeine.
C. Dr. Smith doesn't like non-steroidal anti-inflammatory meds.
D. This client had a vaginal hysterectomy two days ago.
D. This client had a vaginal hysterectomy two days ago.
A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive personnel. Four hours later, the nurse notes that the client's blood pressure taken by the AP was much higher than previous readings, and the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?
A. Determining if the AP knew how to take blood pressure.
B. Double-checking the AP by taking another blood pressure.
C. Providing more appropriate supervision of the AP.
D. Taking the blood pressure instead of delegating the task.
C. Providing more appropriate supervision of the AP.
A newly graduated nurse in the hospital states that because of being so new, participation in Quality Improvement, QI, projects is not wise. What response by the precepting nurse is best?
A. All staff nurses are required to participate in Quality Improvement here.
B. Even being new, you can implement activities designed to improve care.
C. It's easy to identify what indicators would be used to measure quality.
D. You should ask to be assigned to the Research and Quality Committee.
B. Even being new, you can implement activities designed to improve care.
A nurse is talking with a co-worker who is moving to a new state and needs to find new employment there. What advice by the nurse is best?
A. Ask the hospitals there about standard nurse-client ratios.
B. Choose the hospital that has the newest technology.
C. Find a hospital that has achieved magnet status.
D. Work in a facility affiliated with a medical or nursing school.
C. Find a hospital that has achieved magnet status.
A nurse manager wishes to ensure that the nurses on the unit are participating at their highest levels of competency. Which areas would the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine report, Health Professions Education: a bridge to quality? Select all that apply.
A. Collaborating with an interprofessional team.
B. Implementing evidence-based care.
C. Providing family-focused care.
D. Routinely using informatics in practice.
E. Using quality improvement in client care.
F. Formalizing systems thinking when implementing care.
A. Collaborating with an interprofessional team.
B. Implementing evidence-based care.
D. Routinely using informatics in practice.
E. Using quality improvement in client care.
A nurse is interested in making interprofessional work a high priority. Which actions by the nurse best demonstrates this skill? Select all that apply.
A. Consults with other disciplines on client care.
B. Coordinates discharge planning for home safety.
C. Participates in comprehensive client rounding.
D. Routinely asks other disciplines about client progress.
E. Shows the nursing care plans to other disciplines.
F. Delegates tasks to unlicensed personnel appropriately.
A. Consults with other disciplines on client care.
B. Coordinates discharge planning for home safety.
C. Participates in comprehensive client rounding.
D. Routinely asks other disciplines about client progress.
F. Delegates tasks to unlicensed personnel appropriately.
The nurse utilizing evidence-based practice considers which factors when planning care. Select all that apply.
A. Cost-saving measures
B. Nurses' expertise
C. Client preferences
D. Research findings
E. Values of the client
F. Plan, do, study, act, model
B. Nurses' expertise
C. Client preferences
D. Research findings
E. Values of the client
A nurse manager wants to improve handoff communication among the staff. What actions by the manager would best help achieve this goal? Select all that apply.
A. Attend handoff rounds to coach and mentor.
B. Create a template of suggested topics to include in report.
C. Encourage staff to ask questions during handoff.
D. Give raises based on compliance with reporting.
E. Provide education on the SBAR method of communication.
A. Attend handoff rounds to coach and mentor.
B. Create a template of suggested topics to include in report.
C. Encourage staff to ask questions during handoff.
E. Provide education on the SBAR method of communication.
A nurse asks the charge nurse to explain the difference between critical thinking and clinical judgment. What statement by the charge nurse is best?
A. Clinical judgment is often clouded by erroneous hypotheses.
B. Clinical judgment is the observable outcome of critical thinking.
C. Critical thinking requires synthesizing interactions within a situation.
D. Critical thinking is the highest level of nursing judgment.
B. Clinical judgment is the observable outcome of critical thinking.
The nurse understands which information regarding patient-centered care.
A. A competency recognizing the client as the source of control of his or her care.
B. A project addressing challenges in implementing patient-centered care.
C. Purposeful, informed, and outcome-focused care of clients or families.
D. The ability to use best evidence and practice when making care-related decisions.
A. A competency recognizing the client as the source of control of his or her care.
A nurse wishes to participate in an activity that will influence health outcomes. What action by the nurse best meets this objective?
A. Creating a transportation system for healthcare appointments.
B. Lobbying with a national organization for healthcare policy.
C. Organizing a food pantry in an impoverished community.
D. Running for election to the County Public Health Board.
B. Lobbying with a national organization for healthcare policy.
What factor best predicts a nurse's willingness to employ critical thinking?
A. Caring
B. Knowledge
C. Presence
D. Skills
A. Caring
To demonstrate clinical reasoning skills, what action does the nurse take?
A. Collaborating with coworkers to buddy up for lunch breaks.
B. Delegating frequent vital signs on a new post-operative patient.
C. Documenting a complete history and physical on an admission.
D. Requesting the provider order medication for a client with high potassium.
D. Requesting the provider order medication for a client with high potassium.
The new nurse asks the preceptor how context affects clinical judgment. What response by the preceptor is best?
A. Context considers the whole of the patient's story and circumstances.
B. It shouldn't only, nursing knowledge would affect clinical judgment.
C. Outside influences, such as environment in which you provide care, influence your decisions.
D. The context of the situation provides an extra layer of complexity to consider.
C. Outside influences, such as environment in which you provide care, influence your decisions.
Once the nurse has considered all possible collaborative and client problems, what action does the nurse take next?
A. Act on the observed cues.
B. Determine desired outcomes.
C. Generate solutions.
D. Prioritize the hypotheses.
D. Prioritize the hypotheses.
A nurse working in a medical home would do which of the following as part of the job?
A. Advocate with insurance companies.
B. Coordinate interprofessional care.
C. Hold monthly team meetings.
D. Provide out-of-network specialty referrals.
B. Coordinate interprofessional care.
A nurse is confused on why systems thinking is important since working on the unit involves caring for a few specific clients. What explanation by the nurse manager is best?
A. It's a good way to conduct root cause analysis.
B. It is important for quality improvement and safety.
C. Systems thinking helps you see the bigger picture.
D. You may enter management one day and need to know this.
B. It is important for quality improvement and safety.
The expert nurse understands that critical thinking requires which elements to be present. Select all that apply.
A. Based on logic, creativity, and intuition.
B. Driven by needs.
C. Focused on safety and quality.
D. Grounded in a specific theory.
E. Guided by standards.
F. Requires forming options about evidence.
A. Based on logic, creativity, and intuition.
B. Driven by needs.
C. Focused on safety and quality.
E. Guided by standards.
The nurse manager is conducting an annual evaluation of a staff nurse and is appraising the nurse's clinical reasoning. What nurse actions does the manager observe to help form this judgment? Select all that apply.
A. Anticipating consequences of actions.
B. Delegating appropriately.
C. Interpreting data.
D. Noticing cues.
E. Setting priorities.
A. Anticipating consequences of actions.
C. Interpreting data.
D. Noticing cues.
E. Setting priorities.
According to WHO, what does primary care involve? Select all that apply.
A. Empowered people and communities.
B. Essential public functions.
C. Multisectoral policy and action.
D. Primary care.
E. Priority consideration of chronic diseases.
F. Elimination of chronic diseases.
A. Empowered people and communities.
B. Essential public functions.
C. Multisectoral policy and action.
D. Primary care.
A nurse wishes to work in a community-based practice setting. Which areas would this nurse explore for employment? Select all that apply.
A. Hospice Facility
B. Minute Clinic
C. Mobile Mammography Unit
D. Small Community Hospital
E. Telehealth
F. Home Health Care
A. Hospice Facility
B. Minute Clinic
C. Mobile Mammography Unit
E. Telehealth
F. Home Health Care
A nurse learns that the fastest-growing subset of the older population is which group?
A. Elite Old
B. Middle Old
C. Old Old
D. Young Old
C. Old Old
A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal?
A. Exercise program to improve physical function.
B. Financial planning seminar series for older adults.
C. Social events such as dances and group dinners.
D. Workshop on prevention from becoming an abuse victim.
A. Exercise program to improve physical function.
A nurse caring for an older client on the medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment would the nurse perform first?
A. Auscultate bowel sounds
B. Check skin turgor
C. Perform an oral assessment
D. Weigh the client
C. Perform an oral assessment
A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review?
A. Barley Soup
B. Black Beans
C. White Rice
D. Whole Wheat Bread
C. White Rice
A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue?
A. Cut some sodium out of your diet.
B. Dehydration can cause incontinence.
C. Have something to drink every one to two hours.
D. Take your diuretic in the morning.
C. Have something to drink every one to two hours.
A home health care nurse is planning an exercise program with an older adult who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult?
A. Building strength and flexibility
B. Improving exercise endurance
C. Increasing aerobic capacity
D. Providing personal training
A. Building strength and flexibility
An older adult recently retired and reports being depressed and lonely. What information would the nurse assess as a priority?
A. History of previous depression
B. Previous stressful events
C. Role of work in the adult's life
D. Usual leisure time activities
C. Role of work in the adult's life
A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for stressful coping?
A. I have had the same best friend for decades.
B. I think I am coping very well on my own.
C. My kids come to see me every weekend.
D. Oh, I have lots of friends at the senior center.
A. I have had the same best friend for decades.
A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps?
A. Have the client use a walker or cane on the steps.
B. Teach the client to hold the handrail when using the steps.
C. Instruct the client to use the garage door instead.
D. Tell the client to use a two-footed gate on the steps.
B. Teach the client to hold the handrail when using the steps.
An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important?
A. Assess for orthostatic hypotension.
B. Determine if there are new medications.
C. Evaluate the client for gait abnormalities.
D. Perform a delirium screening test.
B. Determine if there are new medications.
An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying those are for old people. What action by the nurse would be most helpful?
A. Arrange medications by time in a drawer.
B. Encourage the client to use easy open tops.
C. Put color-coded stickers on the bottle caps.
D. Write a list of when to take each medication.
C. Put color-coded stickers on the bottle caps.
An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client?
A. Keep the light on in the bathroom at night.
B. Order a bedside commode for the client.
C. Put the client on a toileting schedule.
D. Use side rails to keep the client in bed.
A. Keep the light on in the bathroom at night.
An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication would he or she suggest in place of the morphine?
A. Cyclobenzaprine
B. Hydromorphone hydrochloride
C. Ketorlac
D. Meperdine
B. Hydromorphone hydrochloride
A nurse admits an older adult from a home environment. The client lives with an adult son and daughter-in-law. The client has urine burns on the skin, no dentures, and several pressure injuries. What action by the nurse is most appropriate?
A. Ask the family how these problems occurred.
B. Call the police department and file a report.
C. Notify Adult Protective Services.
D. Report the findings as per agency policy.
D. Report the findings as per agency policy.
A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What action by the nurse is best?
A. Call Adult Protective Services
B. Discuss concerns with the health care team
C. Do not allow the client to sign the consent
D. Have the client's family sign the consent
B. Discuss concerns with the health care team
A nurse working in an acute care of the elderly unit learns that frailty in the older population includes which components? Select all that apply.
A. Dementia
B. Exhaustion
C. Slowed physical activity
D. Weakness
E. Weight gain
F. Frequent illness
B. Exhaustion
C. Slowed physical activity
D. Weakness
A home health care nurse assesses an older adult for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adult's kitchen might indicate an adequate intake of these nutrients? Select all that apply.
A. 1% milk,
B. Carrots,
C. Lean ground beef,
D. Oranges,
E. Vitamin D supplements,
F. Cheese sticks
A. 1% milk,
B. Carrots,
D. Oranges,
E. Vitamin D supplements,
A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? Select all that apply.
A. Constipation
B. Dehydration
C. Mania
D. Urinary incontinence
E. Weakness
F. Anorexia
A. Constipation
B. Dehydration
E. Weakness
F. Anorexia
A nurse manager institutes the Fulmer-Spices framework as part of the routine assessment of older adults in the hospital. The nursing staff assesses for which factors. Select all that apply.
A. Confusion.
B. Evidence of abuse.
C. Incontinence.
D. Problems with behavior.
E. Sleep disorders.
A. Confusion.
C. Incontinence.
E. Sleep disorders.
A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last month's visit. What actions would the nurse perform first? Select all that apply.
A. Assess the client's ability to drive or transportation alternatives.
B. Determine if the client has dentures that fit properly.
C. Encourage the client to continue the current exercise plan.
D. Have the client complete a three-day diet recall diary.
E. Teach the client about proper nutrition in the older population.
A. Assess the client's ability to drive or transportation alternatives.
B. Determine if the client has dentures that fit properly.
D. Have the client complete a three-day diet recall diary.
A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse delegate to the assistive personnel? Select all that apply.
A. Assess skin redness when turning.
B. Document Braden scale results.
C. Keep the client's skin dry.
D. Obtain a pressure relieving mattress.
E. Turn the client every two hours.
C. Keep the client's skin dry.
D. Obtain a pressure relieving mattress.
E. Turn the client every two hours.
A nurse admits an older adult to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? Select all that apply.
A. Contact Adult Protective Services or hospital social work.
B. Request the primary health care provider prescribes tube feedings.
C. Perform and document results of a Braden scale assessment.
D. Request a dietary consultation from the health care provider.
E. Suggest a high protein oral supplement between meals.
F. Assess the client's own teeth or the dentures for proper fit.
C. Perform and document results of a Braden scale assessment.
D. Request a dietary consultation from the health care provider.
E. Suggest a high protein oral supplement between meals.
F. Assess the client's own teeth or the dentures for proper fit.
A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration?
A. A 36-year-old who is prescribed long-term steroid therapy.
B. A 55-year-old who recently received intravenous fluids.
C. A 76-year-old who is cognitively impaired.
D. An 83-year-old with congestive heart failure.
C. A 76-year-old who is cognitively impaired.
A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best?
A. Measure intake and output every 4 hours.
B. Assess client further for fall risk.
C. Increase the IV flow rate to 250 mL per hour.
D. Place the client in a high-fowler position.
B. Assess client further for fall risk.
After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching?
A. I must drink a quart (liter) of water or other liquid each day.
B. I will weigh myself each morning before I eat or drink.
C. I will use a salt substitute when making and eating my meals.
D. I will not drink liquids after 6 p.m. so I won't have to get up at night
B. I will weigh myself each morning before I eat or drink.
A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss?
A. Client taking furosemide.
B. Anxious client who has tachypnea.
C. Client who is on fluid restrictions.
D. Client who is constipated with abdominal pain.
B. Anxious client who has tachypnea.
A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?
a. Increased respiratory rate from 12 to 22 breaths per minute
b. Decreased skin turgor on the client's posterior hand and forehead
c. Increased urine-specific gravity from 1.012 to 1.030 g/ML
d. Decreased orthostatic changes when standing
d. Decreased orthostatic changes when standing
After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching?
A. Slices of smoked ham with potato salad.
B. Bowl of tomato soup with a grilled cheese sandwich.
C. Salami and cheese on whole wheat crackers.
D. Grilled chicken breast with glazed carrots.
D. Grilled chicken breast with glazed carrots.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia?
A. A 34-year-old who is NPO and receiving rapid intravenous D5W infusions.
B. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic.
C. A 67-year-old who is experiencing pain and is prescribed ibuprofen.
D. A 73-year-old with tachycardia who is receiving digoxin.
A. A 34-year-old who is NPO and receiving rapid intravenous D5W infusions.
A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching?
A. Have your spouse watch you for irritability and anxiety.
B. Notify the clinic if you notice muscle twitching.
C. Call your primary health care provider for diarrhea.
D. Bake or grill your meat rather than frying it.
C. Call your primary health care provider for diarrhea.
A nurse is caring for a client who has the following laboratory results. Potassium 2.4 mEq/L. Magnesium 1.8 mEq/L Calcium 8.5 mEq/L Sodium 144 mEq/L Which assessment does the nurse complete first?
A. Depth of respirations.
B. Bowel sounds.
C. Grip strength.
D. Electrocardiogram.
A. Depth of respirations.
A nurse cares for a client who has a serum potassium of 6.5 MEq/L and is exhibiting cardiovascular changes. Which intervention will the nurse implement first?
A. Prepare to administer Patiromer by mouth
B. Provide a heart-healthy low-potassium diet
C. Prepare to administer dextrose 20% and 10 units of regular insulin IV push
D. Prepare the client for hemodialysis treatment
C. Prepare to administer dextrose 20% and 10 units of regular insulin IV push
The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?
A. Administer high-ceiling loop diuretics.
B. Assess the client's lung sounds every two hours.
C. Place a pressure-relieving overlay on the mattress.
D. Weigh the client daily at the same time on the same scale.
B. Assess the client's lung sounds every two hours.
A nurse is assessing a client with hypokalemia and notes that the client's hand-grip strength has diminished since the previous assessment one hour ago. What action does the nurse take first?
A. Assess the client's respiratory rate, rhythm, and depth.
B. Measure the client's pulse and blood pressure.
C. Document findings and monitor the client.
D. Call the primary health care provider.
A. Assess the client's respiratory rate, rhythm, and depth.
A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure?
A. Notifies the pharmacy of the IV potassium order.
B. Assesses the client's IV site every hour during infusion.
C. Sets the IV pump to deliver 30 MEq of potassium an hour.
D. Double checks the IV bag against the order with the precepting nurse.
C. Sets the IV pump to deliver 30 MEq of potassium an hour.
A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition?
A. Assesses the client's chvostek and trousseau sign.
B. Keeps the client's room quiet and dimly lit.
C. Moves the client carefully to avoid fracturing bones.
D. Administers bisphosphonates as prescribed.
D. Administers bisphosphonates as prescribed.
A nurse is caring for a client who has a serum calcium level of 14 MgDL. Which primary health care provider order does the nurse implement first?
A. Encourage oral fluid intake.
B. Connect the client to a cardiac monitor.
C. Assess urinary output.
D. Administer oral calcitonin.
B. Connect the client to a cardiac monitor.
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital?
A. Ask family members to speak quietly to keep the client calm.
B. Assess urine color, amount, and specific gravity each day.
C. Encourage the client to drink at least one liter of fluids each shift.
D. Dangle the client on the bedside before ambulating.
D. Dangle the client on the bedside before ambulating.
A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? Select all that apply.
A. Increased Pulse Rate
B. Distended Neck Veins
C. Decreased Blood Pressure
D. Warm and Pink Skin
E. Skeletal Muscle Weakness
F. Visual Disturbances
A. Increased Pulse Rate
B. Distended Neck Veins
E. Skeletal Muscle Weakness
F. Visual Disturbances
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? Select all that apply.
a. Urine output of 25 mL per hour
b. Serum potassium level of 5.4 MEq/L
c. Urine specific gravity of 1.02 g/mL
d. Serum sodium level of 128 MEq/L
e. Blood osmolality of 250 mOsm/Kg
b. Serum potassium level of 5.4 MEq/L
e. Blood osmolality of 250 mOsm/Kg
A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? Select all that apply.
A. Reports of palpitations.
B. Slow, shallow respirations.
C. Orthostatic hypotension.
D. Paralytic ileus.
E. Skeletal muscle weakness.
F. Tall, peaked T waves on ECG.
A. Reports of palpitations.
E. Skeletal muscle weakness.
F. Tall, peaked T waves on ECG.
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? Select all that apply.
A. Hypokalemia - muscle weakness with respiratory depression.
B. Hypermagnesemia - bradycardia and hypotension.
C. Hyponatremia, - decreased level of consciousness.
D. Hypercalcemia - positive Trousseau and Chvostek signs.
E. Hypomagnesemia - hyperactive deep tendon reflexes.
F. Hypernatremia - weak peripheral pulses.
A. Hypokalemia - muscle weakness with respiratory depression.
B. Hypermagnesemia - bradycardia and hypotension.
C. Hyponatremia, - decreased level of consciousness.
E. Hypomagnesemia - hyperactive deep tendon reflexes.
F. Hypernatremia - weak peripheral pulses.
After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? Select all that apply.
A. Respiratory rate of 8 breaths per minute.
B. Absent deep tendon reflexes.
C. Strong productive cough.
D. Active bowel sounds.
E. U-waves present on the electrocardiogram.
C. Strong productive cough.
D. Active bowel sounds.
A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? Select all that apply.
A. Calculate pulse pressure with each blood pressure reading.
B. Assess skin turgor using the back of the client's hand.
C. Assess for pitting edema in dependent body areas.
D. Monitor trends in the client's daily weights.
E. Assist the client to change positions frequently.
F. Teach client and family how to read food labels for sodium.
A. Calculate pulse pressure with each blood pressure reading.
C. Assess for pitting edema in dependent body areas.
D. Monitor trends in the client's daily weights.
E. Assist the client to change positions frequently.
F. Teach client and family how to read food labels for sodium.
A nurse is caring for clients with electrolyte imbalances on a medical surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? Select all that apply.
A. Hypomagnesemia - kidney failure.
B. Hyperkalemia - salt substitutes.
C. Hyponatremia - heart failure.
D. Hypernatremia - hyperaldosteronism.
E. Hypocalcemia - diarrhea.
F. Hypokalemia - loop diuretics.
B. Hyperkalemia - salt substitutes.
C. Hyponatremia - heart failure.
D. Hypernatremia - hyperaldosteronism.
E. Hypocalcemia - diarrhea.
F. Hypokalemia - loop diuretics.
A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? Select all that apply.
A.Sodium, 160 MEq/L, = overhydration.
B. Potassium, 5.4 MEq/L,, = dehydration.
C. Osmolarity, 250 Mosm/L, = overhydration.
D. Hematocrit, 68%, = dehydration.
E. BUN, 39 Mg/DL, = overhydration.
F. Magnesium, 0.8 Mg/DL, = dehydration.
B. Potassium, 5.4 MEq/L,, = dehydration.
C. Osmolarity, 250 Mosm/L, = overhydration.
D. Hematocrit, 68%, = dehydration.
F. Magnesium, 0.8 Mg/DL, = dehydration.
A nurse is caring for a client who has just had a central venous access line inserted. What action will the nurse take next?
A. Begin the prescribed infusion via the new access.
B. Ensure that an x-ray is completed to confirm placement.
C. Check medication calculations with a second RN.
D. Make sure that the solution is appropriate for a central line.
B. Ensure that an x-ray is completed to confirm placement.
A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse complete first?
A. Amount of pressure in fluid container.
B. Date of catheter tubing change.
C. Type of dressing over the site.
D. Skin color and capillary refill.
D. Skin color and capillary refill.
A nurse teaches a client who is being discharged home with a peripherally inserted central catheter, PICC. Which statement will the nurse include in this client's teaching?
A. Avoid carrying your grandchild with the arm that has the central catheter.
B. Be sure to place the arm with the central line catheter in a sling during the day.
C. Flush the peripheral inserted central catheter line with normal saline daily.
D. You can use the arm with the central catheter for most activities of daily living.
A. Avoid carrying your grandchild with the arm that has the central catheter.
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
A. Redness at the catheter insertion site.
B. Report of headache and stiff neck.
C. Temperature of 100.1 degrees Fahrenheit.
D. Pain rating of 8 on a scale of 0 to 10.
B. Report of headache and stiff neck.
A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
A. The catheter has been in place for 20 hours.
B. The client has poor vascular access in the upper extremities.
C. The catheter is placed in the proximal tibia.
D. The client's left lower extremity is cool to the touch.
D. The client's left lower extremity is cool to the touch.
A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripheral inserted central catheter, PICC, requires immediate attention?
A. The initial site dressing is three days old.
B. The PICC was inserted four weeks ago.
C. A securement device is absent.
D. Upper extremity swelling is noted.
D. Upper extremity swelling is noted.
A nurse assesses a client's peripheral IV site and notices edema and tenderness above the site. What action will the nurse take next?
A. Apply cold compresses to the IV site
B. Elevate the extremity on a pillow
C. Flush the catheter with normal saline
D. Stop the infusion of intravenous fluids
D. Stop the infusion of intravenous fluids
While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 1.5-inch or 4-cm venous cord. How will the nurse document this finding?
A. Grade 3 phlebitis at IV site
B. Infection at IV site
C. Thrombosed area at IV site
D. Infiltration at IV site
A. Grade 3 phlebitis at IV site
A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by the new nurse demonstrates the need for more instruction on this technology?
A. I don't need to manually calculate IV infusion rates with smart pumps.
B. Responding to IV pump alarms is a high priority for client safety.
C. The hospital can pre-program the pumps for high alert during limits.
D. These pumps have a system to prevent fluids from free-flowing into the client.
A. I don't need to manually calculate IV infusion rates with smart pumps.
A nurse prepares to insert a peripheral venous catheter in an older adult. What action will the nurse take to protect the client's skin during this procedure?
A. Lower the extremity below the level of the heart.
B. Apply warm compresses to the extremity.
C. Tap the skin lightly and avoid slapping.
D. Place a washcloth between the skin and the tourniquet.
D. Place a washcloth between the skin and the tourniquet.
A nurse delegates care to an assistive personnel. Which statement will the nurse include when delegating hygiene for a client who has a vascular access device?
A. Provide a bed bath instead of letting the client take a shower.
B. Use sterile technique when changing the dressing.
C. Disconnect the intravenous fluid tubing prior to the client's bath.
D. Use a plastic bag to cover the extremity with the device.
D. Use a plastic bag to cover the extremity with the device.
A nurse teaches a client who is prescribed a central vascular access device and is transferring to a skilled facility for long-term treatment. Which statement will the nurse include in this client's teaching?
A. You will need to wear a sling on your arm while the device is in place.
B. There is no risk of infection because sterile technique will be used during insertion.
C. Ask all providers to vigorously clean the connections prior to accessing the device.
D. You will not be able to take a bath with this vascular access device.
C. Ask all providers to vigorously clean the connections prior to accessing the device.
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, what action will the nurse take to relieve pain?
A. Administer topical lidocaine to the site.
B. Place warm compresses on the site.
C. Administer prescribed oral pain medication.
D. Massage the site with scented oil.
B. Place warm compresses on the site.
A nurse assesses a client who was started on intraperitoneal therapy five days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy will the nurse assess the client?
A. Allergic reaction
B. Bowel obstruction
C. Catheter-lumen occlusion
D. Infection
D. Infection
A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention will the nurse suggest to the management team to make the biggest impact on decreasing complications?
A. Initiate a dedicated team to insert access devices.
B. Require additional education for all nurses.
C. Limit the use of peripheral venous access devices.
D. Perform quality control testing on skin preparation products.
A. Initiate a dedicated team to insert access devices.
A nurse prepares to flush a peripherally inserted central catheter, PICC, line with 50 units of heparin. The pharmacy supplies a multidose vial of heparin with a concentration of 100 units per milliliter. Which of the syringes shown below will the nurse use to draw up and administer the heparin?
Always use a 10 milliliter syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC. The PICC line would be accessed with a needleless syringe.
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication and notes it to have been inserted four months ago. The site has no redness, warmth, or swelling and flushes easily. What action does the nurse take?
A. Notify the primary health care provider.
B. Administer the prescribed medication.
C. Discontinue the PICC.
D. Switch the medication to the oral route.
B. Administer the prescribed medication.
A registered nurse RN occasionally delegates client care to licensed practical nurses, LPNs, or technicians. What information does the RN consider when delegating components of IV therapy? Select all that apply.
A. Each state's Nurse Practice Act will regulate who can perform care related to IVs.
B. The nurse would check the facility's policies and procedures manual.
C. The LPN's level of experience primarily guides the decision.
D. Technicians cannot participate in any part of caring for IV infusions.
E. The RN remains accountable for all aspects of IV care and delegated actions.
F. The Infusion Nurses Society has guidelines and standards of IV therapy competency.
A. Each state's Nurse Practice Act will regulate who can perform care related to IVs.
B. The nurse would check the facility's policies and procedures manual.
E. The RN remains accountable for all aspects of IV care and delegated actions.
F. The Infusion Nurses Society has guidelines and standards of IV therapy competency.
A nurse assesses a client who has peripherally inserted central catheter, PICC. For which common complications will the nurse assess? Select all that apply.
A. Phlebitis
B. Pneumothorax
C. Thrombophlebitis
D. Excessive bleeding
E. Extravasation
F. Pneumothorax
G. Infiltration
A. Phlebitis
C. Thrombophlebitis
A nurse prepares to administer a blood transfusion to a client and checks the blood label with a second registered nurse using an International Society of Blood Transfusion, ISBT, universal barcoding system to ensure the right blood for the right client. Which components must be present on the blood label in barcode and in I-readable format? Select all that apply.
A. Unique Facility Identifier
B. Lot Number Related to the Donor
C. Name of the Client Receiving Blood
D. ABO Group and RH Type of the Donor
E. Blood Type of the Client Receiving Blood
F. Signature Line for Two-Person Verification
A. Unique Facility Identifier
B. Lot Number Related to the Donor
D. ABO Group and RH Type of the Donor
A nurse assists with the insertion of a central vascular access device. Which actions will the nurse ensure are completed to prevent a catheter-related bloodstream infection? Select all that apply.
A. Include a review for the need of the device each day in the client's plan of care.
B. Remind the primary health care provider to perform hand hygiene prior to insertion if he or she forgets.
C. Cleanse the preferred site with alcohol and let it dry completely before insertion.
D. Ask everyone in the room to wear a surgical mask during the procedure.
E. Plan to complete a sterile dressing change on the device every day.
F. Minimal client draping and barrier precautions as blood loss are minimal.
A. Include a review for the need of the device each day in the client's plan of care.
B. Remind the primary health care provider to perform hand hygiene prior to insertion if he or she forgets.
D. Ask everyone in the room to wear a surgical mask during the procedure.
A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take to use best practices? Select all that apply.
A. Choose a distal site on the client's non-dominant arm.
B. Verify that the prescription is appropriate for peripheral infusion.
C. Place the venous catheter near an area of joint flexion.
D. Wear a surgical mask during the catheter insertion procedure.
E. Perform hand hygiene before inserting the catheter.
F. Limit unsuccessful attempts by up to three clinicians to one attempt each.
A. Choose a distal site on the client's non-dominant arm.
B. Verify that the prescription is appropriate for peripheral infusion.
E. Perform hand hygiene before inserting the catheter.
A nurse is caring for a client who suffered massive blood loss after trauma. How does the nurse correlate the blood loss with the client's mean arterial pressure, MAP?
A. It causes vasoconstriction and increased MAP.
B. Lower blood volume lowers MAP.
C. There is no direct correlation to MAP.
D. It raises cardiac output and MAP.
B. Lower blood volume lowers MAP.
A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths per minute, and the pulse rate increased from 86 to 98 beats per minute, since the client was last assessed four hours ago. What action by the nurse is best?
A. Ask if the client needs pain medication.
B. Assess using the MEWS score.
C. Document the findings in the client's chart.
D. Increase the rate of the client's IV infusion.
B. Assess using the MEWS score.
The nurse gets the handoff report on four clients. Which client would the nurse assess first?
A. Client with a blood pressure change of 128/74 to 110/88 mmHg.
B. Client with oxygen saturation unchanged at 94 percent.
C. Client with a pulse change of 100 to 88 beats per minute.
D. Client with urine output of 40 milliliters per hour for at least two hours.
A. Client with a blood pressure change of 128/74 to 110/88 mmHg.
A nurse is caring for a client after surgery who is restless and apprehensive. The assistive personnel reports the vital signs and the nurse sees that they are only slightly different from previous readings. What action does the nurse delegate next to the AP?
A. Assess the client for pain or discomfort.
B. Measure urine output from the catheter.
C. Reposition the client to the side.
D. Stay with the client and reassure him or her.
B. Measure urine output from the catheter.