The nurse knows that lab values sometimes vary for the older client. Which data would
the nurse expect to find when reviewing laboratory values of an 80-year-old male?
A. Increased WBC, decreased RBC.
B. Increased serum bilirubin, slightly increased liver enzymes.
C. Increased protein in the urine, slightly increased serum glucose levels.
D. Decreased serum sodium, an increased urine specific gravity.
C. Increased protein in the urine, slightly increased serum glucose levels.
Rationale: As older adults age, the protein found in urine slightly rises as a
result of kidney changes, and the serum glucose increases slightly, also due to
changes in the kidney.
,The health care provider has determined that a client has irreversible brain damage with
subsequent brain death. Organ donation is discussed with the family. Which action
should the nurse take prior to contacting the organ procurement organization (OPO)?
A. Obtain informed consent.
B. Disconnect the ventilator.
C. Remove all jewelry.
D. Contact the medical examiner.
A. Obtain informed consent.
Rationale: When brain death has been determined by the healthcare provider,
the organ donation process may be initiated. The nurse should obtain signed
informed consent from the family prior to contacting the organ procurement
organization (OPO).
A client reports shortness of breath and chest pressure radiating down the left arm. The
client is receiving 2 liters of oxygen via nasal cannula and has two saline lock intravenous
catheters. The nurse performs a 12 lead electrocardiogram (ECG) that shows ST segment
elevation in leads II, III, aVF, and V4R. Which action should the nurse implement first?
A. Give 0.3 mg nitroglycerin sublingual. Incorrect
B. Administer4 mg IV morphine sulfate.
C. Measure the ST segment height.
D. Infuse 0.9% sodium chloride bolus.
D. Infuse 0.9% sodium chloride bolus.
Rationale: This 12 lead electrocardiogram (ECG) myocardial injury is in the
inferior and right ventricular portion of the heart muscle and requires an
, intravenous (IV) fluid bolus to fill the right ventricle for the heart to pump.
Medications such as morphine sulfate and nitroglycerin will cause profound
hypotension due to vasodilation if fluids are not given first.
A client falls off a ladder approximately 15 feet high and is admitted to the ICU for
observation due to a small intracranial bleed noted in the left occipital area of the brain
as observed on the CT Scan done in the emergency department. The client has been
stable for the past 12 hours. The client reports to the nurse a new onset of pain in the left
shoulder. Which action should the nurse do next?
A. Contact the healthcare provider.
B. Perform an abdominal assessment.
C. Observe the client's pupillary response.
D. Examine the left shoulder's range of motion.
B. Perform an abdominal assessment.
Rationale: Injury to the spleen, especially an encapsulated splenic
hemorrhage may be difficult to diagnose initially because the signs of
bleeding do not become evident immediately. The fact the client fell
approximately 15 feet resulting in a fractured skull and now reports a new
onset of left shoulder pain may be indicative of a splenic rupture. The referred
shoulder pain is called "Kehr's sign". The nurse should initially assess the
abdomen for signs of an abdominal injury. The nurse needs to assess the
abdomen for distention, guarding, rebound tenderness, and rigidity. The nurse
also needs to closely monitor the client's hemodynamic status for signs of
hypovolemic depletion due to the splenic hemorrhage.
In preparing to administer intravenous albumin to a client following surgery, which are
the priority nursing interventions? (Select all that apply.)
A. Set the infusion pump to infuse the albumin within four hours.
the nurse expect to find when reviewing laboratory values of an 80-year-old male?
A. Increased WBC, decreased RBC.
B. Increased serum bilirubin, slightly increased liver enzymes.
C. Increased protein in the urine, slightly increased serum glucose levels.
D. Decreased serum sodium, an increased urine specific gravity.
C. Increased protein in the urine, slightly increased serum glucose levels.
Rationale: As older adults age, the protein found in urine slightly rises as a
result of kidney changes, and the serum glucose increases slightly, also due to
changes in the kidney.
,The health care provider has determined that a client has irreversible brain damage with
subsequent brain death. Organ donation is discussed with the family. Which action
should the nurse take prior to contacting the organ procurement organization (OPO)?
A. Obtain informed consent.
B. Disconnect the ventilator.
C. Remove all jewelry.
D. Contact the medical examiner.
A. Obtain informed consent.
Rationale: When brain death has been determined by the healthcare provider,
the organ donation process may be initiated. The nurse should obtain signed
informed consent from the family prior to contacting the organ procurement
organization (OPO).
A client reports shortness of breath and chest pressure radiating down the left arm. The
client is receiving 2 liters of oxygen via nasal cannula and has two saline lock intravenous
catheters. The nurse performs a 12 lead electrocardiogram (ECG) that shows ST segment
elevation in leads II, III, aVF, and V4R. Which action should the nurse implement first?
A. Give 0.3 mg nitroglycerin sublingual. Incorrect
B. Administer4 mg IV morphine sulfate.
C. Measure the ST segment height.
D. Infuse 0.9% sodium chloride bolus.
D. Infuse 0.9% sodium chloride bolus.
Rationale: This 12 lead electrocardiogram (ECG) myocardial injury is in the
inferior and right ventricular portion of the heart muscle and requires an
, intravenous (IV) fluid bolus to fill the right ventricle for the heart to pump.
Medications such as morphine sulfate and nitroglycerin will cause profound
hypotension due to vasodilation if fluids are not given first.
A client falls off a ladder approximately 15 feet high and is admitted to the ICU for
observation due to a small intracranial bleed noted in the left occipital area of the brain
as observed on the CT Scan done in the emergency department. The client has been
stable for the past 12 hours. The client reports to the nurse a new onset of pain in the left
shoulder. Which action should the nurse do next?
A. Contact the healthcare provider.
B. Perform an abdominal assessment.
C. Observe the client's pupillary response.
D. Examine the left shoulder's range of motion.
B. Perform an abdominal assessment.
Rationale: Injury to the spleen, especially an encapsulated splenic
hemorrhage may be difficult to diagnose initially because the signs of
bleeding do not become evident immediately. The fact the client fell
approximately 15 feet resulting in a fractured skull and now reports a new
onset of left shoulder pain may be indicative of a splenic rupture. The referred
shoulder pain is called "Kehr's sign". The nurse should initially assess the
abdomen for signs of an abdominal injury. The nurse needs to assess the
abdomen for distention, guarding, rebound tenderness, and rigidity. The nurse
also needs to closely monitor the client's hemodynamic status for signs of
hypovolemic depletion due to the splenic hemorrhage.
In preparing to administer intravenous albumin to a client following surgery, which are
the priority nursing interventions? (Select all that apply.)
A. Set the infusion pump to infuse the albumin within four hours.
