The nurse is caring for a client with an injury to the occipital lobe the nurse would monitor which parameter as the priority

Vision

An emergency room nurse assesses a patient who was rescued from a home fire. The patient suddenly develops a loud, brassy cough and hoarseness. Which of the following is an appropriate action taken by the nurse?

Oxygen

The nurse performs his initial assessment of Mr.G. How would the nurse document the percentage of the patient's total body surface area that sustained burns ?(rule of 9)

• 45%

Attached is a picture of Mr.G’s leg. The remainder of her burns have a similar appearance. How would you characterize this degree of burn injury?

Superficial (first degree) burn -

Based on clinical developments over the past two hours the nurse's priority concern is that the patient may be developing ___the nurse anticipates the provider will order ___

• Heart failure due to fluid overload hypovolemic shock secondary to intravascular fluid loss respiratory distress secondary to smoke inhalation
• Furosemide 40 mg IV push increased rate of isotonic intravenous fluids initiate hypotonic intravenous fluids mechanical ventilation

A nurse is assessing patients in a medical-surgical unit. Which patient would the nurse identify as being at greatest risk for atrial fibrillation?

• A 50-year-old with stage 3 congestive heart failure.

Immediately after a percutaneous coronary intervention (PCI) and stent placement, the client is admitted to the nursing unit. Which are indications of a complication specific to this procedure?

• Hypokalemia

After teaching a patient who is recovering from an endoscopic transnasal hypophysectomy, the nurse assesses the patient’s understanding. Which statement made by the patient indicates a correct understanding of the teaching?

• I’ll keep food on upper shelves so i do not have to bend over

A client is taking levothyroxine for treatment of primary hypothyroidism. The nurse knows that thyroid hormones have which effects?

• Stimulate the heart

A nurse cares for a patient who is recovering from a parathyroidectomy when taking the patients blood pressure the nurse notes that the patient's hand has gone into flexion contractions which laboratory result does the nurse correlate with this condition

• Serum calcium 6.9 mg/dl

The nurse creates a plan of care for a client with a new diagnosis of graves disease the nurse would include which intervention in the plan of care

• Keep the room temperature cool

A hospitalized client with type 1 diabetes mellitus tells the nurse that he feels as if he is having a hypoglycemic reaction the nurse would complete which action first

Obtain a blood glucose reading

A nurse teaches a patient with type 2 diabetes mellitus who is prescribed metformin which statement by the patient demonstrates that they understand the nurses teaching

• I may experience some GI discomfort when taking this medication

A nurse assesses a patient who is being treated for hyperglycemic - hyperosmolar state (HHS) which clinical manifestation indicates to the nurse that the therapy needs to be adjusted

• Glascow coma scale score is unchanged

The RN is assigned to provide care for four hospitalized patients in private rooms on the medical surgical unit which patient is most appropriate for the RN to delegate to the licensed practical nurse LPN

• A 72 year old woman admitted 3 days ago for new onset atrial fibrillation has a history of diabetes mellitus type 2 (insulin controlled)hypertension osteoarthritis currently on a beta blocker in normal sinus rhythm preparing for discharge

The nurse prepares to administer adenosine to the patient in . __The expected therapeutic response to this intervention is for the patient to exhibit____ .

• supraventricular tachycardia
• short period of asystole

Mr A is a 62 year old man who is post op day 2 following coronary bypass graft surgery (CABG). He becomes unconscious, pulseless and his EKG demonstrates the rhythm shown. What is an appropriate intervention for this? EKG PIC

• Defibrillation

A nurse evaluates prescriptions for a patient with chronic atrial fibrillation. Which medication would the nurse expect to find on this patient’s medication administration record to prevent a common complication of this condition?

• Warfarin (coumadin)

Which symptom would suggest a potential serious complication of atrial fibrillation?

• Aphasia

A nurse cares for a patient who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy?Select three that apply.

• Urine output is decreased.
• Specific gravity is increased.
• Urine osmolality is increased.

A client is on the telemetry unit for medication adjustments. The client's rhythm shows sinus tachycardia with a rateof 128 beats/min. The nurse realizes that which factors may be causes for this rhythm? (Select four that apply).

• Fear
• Fever
• Stress
• Hypoxemia

A patient admitted with an acute MI has a heart rate of 56 beats/minute. Based on this finding, which area of the heart is most likely serving as the pacemaker?

• atrioventricular (AV) node

The nurse enters a patient's room to discover the patient has experienced a cardiac arrest. The patient is nonresponsive, peripheral pulses are absent, and there is no heartbeat. The patient's telemetry leads demonstrate that the patient is in normal sinus rhythm. What is one possible cause of this patient presentation?

• Hypoglycemia

A patient with secondary adrenal insufficiency would be expected to have____ ACTH levels and ____cortisol levels.

High

Low

A 29 year old transmale (female to male transgender) patient is being prescribed testosterone therapy. The patient asks, "How will I know this is even working?" The nurse educates the patient that an intended effect of testosterone therapy is:

• growth of facial and body hair

Below is a list of symptoms/ assessment findings which may be found in patients with diabetes insipidus (DI) and syndrome of inappropriate anti-diuretic hormone (SIADH). Drag THREE the assessment findings seen in SIADH from the "possible answers" column to the "findings in SIADH" column. Select 3 that apply.

• increased urine osmolarity

• weight gain
• hyponatremia

Please review the attached case study. Given this patient's clinical presentation and laboratory results, what is the most appropriate treatment for him?

• hydrocortisone

Please review the attached case study. What is the diabetic complication that this patient is experiencing?

• diabetic ketoacidosis (DKA)

1. A seasoned nurse is orienting a new graduate nurse to the unit. Together, they are caring for Mr W, a 51 year old man who developed a GI bleed and is now in a state of hypovolemic shock. The new graduate is uncertain about the course of shock and how best to care for this patient. The seasoned nurse explains the adaptive responses and events during hypovolemia shock to the new grad, but it's been 20 years since nursing school and her textbook knowledge is a little rusty. Which are the accurate statements made by the seasoned nurse? Select 4 that apply.

• The refractory stage of shock is characterized by SpO2 below 70% and the development of multiple organ dysfunction syndrome.
• Tissue hypoxia begins in nonvital organs such as the skin and GI tract, and later in shock may affect vital organs as well.
• A slight increase in diastolic blood pressure, tachypnea and tachycardia may be the only symptoms present in the initial stage of hypovolemic shock.
• The body tries to compensate for drop in blood pressure first through vasoconstriction and tachycardia, and later through activation of the renin angiotensin, aldosterone system.

A client who is mechanically ventilated is receiving synchronized intermittent mandatory ventilation (SIMV). The nurse understands that this ventilator setting entails:

• The ventilator delivers breaths to the patient at a set respiratory rate, but between the breaths, the patient can breathe naturally on their own.

The nurse assesses a client's ECG and notes that there are 8 QRS complexes on a 6-second rhythm strip. What is the client's ventricular rate?

• 80 beats per min

Mr M is a 24 year old man who is experiencing anaphylactic shock secondary to peanut allergen exposure. What assessment findings would the nurse anticipate observing in this patient? Select 3 that apply.

• decreased urine output
• capillary refill greater than 3 seconds
• tachycardia

Which of the following is an appropriate nursing intervention in caring for the patient with hypovolemic shock?.

• Elevate the patient's feet with the head of the bed flat or elevated to less than 30 degrees.

Which laboratory values must the nurse be cognizant of prior to administering lactated Ringer's solution to a patient in shock?

• potassium and lactate

Why is norepinephrine an effective medication in treating patients with shock?

• It improves mean arterial pressure by increasing cardiac contractility,increasing venous return and increasing peripheral resistance

Which patient is at highest risk for developing sepsis?

• A 66 year old female patient with AIDS currently hospitalized with Salmonella infection, receiving IV antibiotics and TPN infection,

1. The nurse manager on the medical surgical floor noticed that rates of sepsis on the unit increases from 10% to 15% in the past month. What is one potential topic she may educate her staff on in order to reduce the rate of sepsis on the floor?

• Continuous review of the need for Foley catheters and prompt removal once the catheter is no longer needed catheter is no longer needed catheter is no longer needed

Ms P suffered a massive brain stem stroke 30 minutes ago. The nurse assesses him and notes that the client fails to open his eyes, even to pressure. He is mumbling incoherent sounds and exhibits decerebrate posturing in response to pain. What is the client's Glasgow Coma Scale (GCS) score?

• 5

The nurse is caring for five patients on the stroke unit. For each of the five patients, match the area of their brain affected by the stroke with the corresponding defect.

• Temporal lobe → difficulties with auditory processing
• Cerebellum → impaired balance and coordination
• Frontal lobe → motor dysfunction
• Occipital lobe → visual impairment

A seasoned nurse is orienting a new nurse on the stroke unit. Which action taken by the new nurse would cause the seasoned nurse to intervene?

• The nurse prepares to administer a dose of tPa (IV alteplase) to a client with a hemorrhagic stroke

The nurse is caring for a client treated with tPa (IV alteplase) following a stroke. Which assessment finding is the highest priority highest priority highest priority for the nurse to report to the primary health care provider?

• The client's blood pressure is 194/122 mmHg

A new nursing graduate from St Paul's started his first nursing job on the neurology floor at Jamaica Hospital. He is preparing tPa for the first time. His preceptor would intervene if the new graduate nurse takes which action?

• Tells the patient scheduled to receive tPa that he would be inserting a foley catheter right after the tPa infusion is complete.

Ms D is a 41 year old female with atrial fibrilation being discharged with a prescription for clopidogrel 75 mg daily.What information should the nurse's discharge education include pertaining to this medication?

• "Wear gloves when you use sharp objects such as scissors, knives and gardening tools."

Mrs C-W is a 37 year old female with hydrocephalus. She underwent placement of a ventriculoperitoneal (VP) shunt for treatment of this condition. She asks the nurse, "How can I be sure that my shunt is working once I'm out of the hospital?" The nurse most appropriately responds:

• "You should report any headache, nausea, vomiting, or behavior changes promptly to your neurologist as these symptoms could suggest shunt malfunction."

1. Mrs Z is a 61 year old female who underwent kidney transplant for treatment of end stage renal failure. On post-operative day 5, she develops increasing flank pain. Her vitals are BP 120/80 mmHg, HR 118, T 102.3 F, RR 18,SpO2 98%. Her labs demonstrate elevated BUN and creatinine and she is oliguric. She has gained 1 kg overnight.The nurse recognizes that Mrs Z is likely experiencing which post-operative complication associated with renal transplantation?

• acute graft rejection

Fill in the blank with the appropriate word. A MELD score is used to determine a patient's position on the ____transplant list.

• Liver

Which of the following patients would be a candidate for a cardiac transplant?

• A 40 year old male with T2DM, rheumatoid arthritis, hypertension, and New York Heart Association Class 4 heart failure due to severe dilated cardiomyopathy

Mrs D is a 60 year old female who is taking Celcept (mycophenolate) to prevent rejection of her transplanted lung.What important information should the nurse provide regarding this medication?

• "Make sure you stay up to date with skin checks, mammograms, and other regular cancer screening."

Read the case study provided. Considering this patient's clinical presentation, drag and drop the THREE priority nursing actions from the column of possible answers to the "Three priority nursing actions" column.

• Place the patient in a high Fowler's position
• Apply oxygen 2L/min via nasal cannula
• STAT page the health care provider

Please review updates to the case study. Based on this patient's risk factors, clinical presentation, and test results,what is the most likely explanation for TH's symptoms?

• pulmonary embolism

Which of the following is a risk factor that increases TH's risk for pulmonary embolism?

• recent surgery

The resident wrote the following orders for TH. Some are appropriate and some are inappropriate. Drag 3appropriate orders from the list of possible answers to the column labeled "Three (3) Appropriate orders." *Al1 doses are accurate.*

• Heparin 5000 units IV now, then 20,000 units in 1000 mL/D5W to run at 1000 units hour per hour per hour
• PT/INR and PTT q4 hours
• Warfarin (Coumadin) 7.5 mg PO daily

TH asks why he is being put on warfarin. What is the best response by the nurse?

• "The warfarin will prevent any new blood clots from developing."

The nurse is caring for an elderly patient with pneumonia who is decompensating. The nurse suspects the client may be developing Acute Respiratory Distress Syndrome (ARDS). Which assessment data confirm the diagnosis of ARDS?

• Low arterial oxygen when patient is receiving 100% FiO2 oxygen

Mr A is a 70 year old male patient with chronic kidney disease secondary to type 2 diabetes mellitus. His GFR is currently 70 mL/minute. Given this patient's GFR, what should the nurse focus on when educating this patient?

• Educate about the importance of glycemic control and minimizing exposure to nephrotoxic substances

Ms H is a 66 year old female with end stage renal failure (ESRD). Her GFR is 11 mL/minute and she is anuric. She is suffering from significant edema on the days she does not attend hemodialysis. Which intervention can the nurse recommend to decrease Ms H's edema?

• Place Ms H on a fluid restriction

Patients who take sevelamer should be monitored for which electrolyte abnormality?

• hypercalcemia

The nurse is assessing a patient's arteriovenous (AV) fistula. Which of the following would be an expected finding observed by the nurse?

• The nurse hears a swooshing sound when she auscultates with her stethoscope overthe AV fistula

The nurse is assessing the sternal incision of a patient is is post op day 7 following coronary artery bypass graft (CABG) surgery. Which of the following findings would alert the nurse of a possible sternal wound infection?

• Oral temperature 102.1 degrees Fahrenheit

The PACU nurse is monitoring four patients who have just undergone cardiac catheterization (PCI) via femoral artery. Which patient is experiencing an emergent post-procedure complication? Select 3 that apply.

• A 77-year old man complaining of shortness of breath, coughing up pink, froth sputum with SpO2 89% sputum
• A 32-year old man who previously had 2+ pulses in both femoral arteries but now has 2+ pulse in the right femoral artery and no palpable pulse in the left femoral artery.
• A 40-year old man reporting chest pain whose EKG strip demonstrates sinus tachycardia with premature ventricular contractions (PVCs)

The nurse is caring for a female client with atypical angina. Which symptom does the nurse anticipate?

• indigestion

Mr E presents to the emergency department with new onset severe chest pain. What is one laboratory test the nurse anticipates will be ordered?

• T troponin

You are caring for a nonverbal patient with a tracheostomy. You monitor for indications to suction, which include (select 2 that apply)

• audible secretions
• respiratory rate 30 breaths per minute

You receive a new admission, Mrs P, a 50 year old female who is in respiratory distress. You are reviewing the orders for this patient in the electronic medical record which read "Apply oxygen 6L/minute continuously." What is the nurse's best action regarding this order?

• Contact the provider to clarify the incomplete order

You are orienting a new nurse to the medical surgical floor. You observe the new nurse performing tracheostomy care. Which action taken by the new nurse causes you to intervene given that it poses a potential risk for infection?

• The nurse does not perform hand hygiene prior to beginning tracheostomy care

The nurse is assuming care of Mr L, a 22 year old man who was just intubated for presumed smoke inhalation injury. Which of the following finding documented in the patient's EHR confirms that the provider verified initial endotracheal tube placement following the intubation procedure?

• End tidal CO2 of 40 mmHg (within normal limits)

JK presents to the primary care office for a routine physical exam. When the nurse is assessing her, she notes the findings pictured below. The patient states, "I was at the beach yesterday and I missed a spot with my sunscreen." How would you characterize this degree of burn injury?

• Partial thickness (second degree) burn

LM's ECG shows supraventricular tachycardia.

• Vital signs reveal the following:
• 1200: HR = 88 BPM; RR = 22 bpm; BP 142/86 mm Hg
• 1215: HR = 92 BPM; RR = 24 bpm; BP 120/82 mm Hg
• 1230: HR = 106 BPM and weak; RR = 28 bpm; BP 100/62 mm Hg
• 1245: HR = 120 BPM and weak; RR = 32 bpm; BP 90/58 mm Hg

The nurse determines that these vital sign findings most likely indicate which complication of supraventricular tachycardia?

• Cardiogenic shock

1. Mr E is a 44 year old male patient with a 30 year history of type 1 diabetes mellitus. On exam, the nurse notes+JVD, 3+ bilateral pedal edema and cyanosis. The nurse identifies that these findings are most consistent with ___, which is a complication___ of diabetes mellitus.__ is one additional finding the nurse may expect to observe in this patient.

• diabetic nephropathy, diabetic neuropathy, heart failure,
• macrovascular, microvascular
• ejection fraction 25%, microalbuminuria, sinus bradycardia

1. A patient in shock has been started on norepinephrine. What assessment finding signifying a side effect of this medication requires the nurse to communicate with the provider immediately?

• Report of chest pain

1. A client has undergone cardiac catheterization using the right femoral artery for access the nurse determines that the client is experiencing a complication of the procedure if which finding is noted

• There is a new ST elevation observed on EKG

1. The nurse is caring for a client with a tracheostomy tube what important intervention is taken by the nurse in order to prevent the client from developing tracheoesophageal fistula

• Maintain normal cuff pressure

1. The nurse notes that the client is taking atenolol which of the following would demonstrate a therapeutic response to this medication

• Decrease in blood pressure from 170/94 mmHg to 126/82 mmHg

1. Mr. E presents to the emergency room with new onset severe chest pain from the choices below which laboratory test is the most important to perform to determine if Mr.E is having a myocardial infarction

• Serum troponin level

1. The nurse enters a patients room to discover the patient has experienced a cardiac arrest the patient is nonresponsive peripheral pulses are absent and there is no heartbeat the patients telemetry leads demonstrate that the patient is in normal sinus rhythm what is one possible cause of this presentation

• Acidosis

1. The nurse is caring for a client with a tracheostomy tube when providing tracheostomy care what is an appropriate action by the nurse

• Use half hydrogen peroxide to clean the non disposable inner cannula

1. A Nurse assesses a patient with diabetes mellitus and notes that the patient is unresponsive and has a capillary blood glucose of 33. What action would the nurse take first?

• Administer 1 mg of IM glucagon

The nurse is caring for Ms.A a 30 year old female with covid 19 who is receiving mechanical ventilation via endotracheal tube the nurse understands that which of the following is an indication for ET tube suctioning

• Patient appears restless