NURSING 1020 MEDSERGE 2 FLASHCARDS

NURSING 1020 MEDSERGE 2 FLASHCARDS A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increase hematocrit E. Increased temperature Increased heart rate B. Increased blood pressure C. Increased respiratory rate A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin? prothrombin time .A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? stop the infusion of blood .A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? hemolytic A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? hemorrhagic stroke A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock increase heart rate ftom 88 to 110/min A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? 0.45% sodium chloride A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? different apical and radial pulses A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take assess the apical pulse for a full minute A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity? Anorexia Rationale:Anorexia, vomiting, confusion, headache, and vision changes are manifestations of digoxin toxicity .A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? systolic BP is increaed A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make? a headache is an expected adverse effect of this medication A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include? eat foods that contain potassium loop diuretics lose potassium! A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take? administer another nitroglycerin tablet A nurse is caring for a client who is at 6 weeks of gestation and has pneumonia. While the nurse is obtaining the client's history, the client tells the nurse that she takes the herb feverfew for migraine headaches. Which of the following actions should the nurse take? explain to the client that she should not take this herb while pregnant A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following dysrhythmias A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time place the client on his left side in trendelenburg position Upgrade to remove ads Only $3/month A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? oliguria A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? Blood pressure 115/68 mmHg Rationale:The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock. A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? A fib A nurse is among the first responders to a mass-casualty incident and does not know what type of personal protective equipment (PPE) is needed. Which of the following actions should the nurse take choose highest level of protection equipment available A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client? a private room A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? Abnormally prominent U wave Rationale:Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression. A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider? dyspnea .A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply.) hypotension weak pulses murmur A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission? auscultating the rate and characteristics of the childs heart sounds A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? the clients bladder becomes distended severe hyperkalemia.. widedned P wave before QRS A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? "DIC is caused by abnormal coagulation involving fibrinogen." A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect? excessive thrombosis and bleeding A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? assess apical pulse for a full minute A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect? lab values are prolonged A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers? the left second intercostal space aortic area right second intercostal space tricuspid area left fifth intercostal space mitral area (point of maximal impulse) left fifth intercostal space at midclavicular line A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? shivering A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction? client report low back pain A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia? shallow respirations .A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload? dyspnea A nurse is assessing an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration? edema in the palm of the hand A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG? reduction of T wave amplitude A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.5 tablets A nurse is preparing to administer amoxicillin 30 mg/kg/day divided equally every 12 hr to a toddler who weighs 32 lb (14.5 kg). Available is amoxicillin 200 mg/5 mL suspension. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 5.5 mL A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products? recombinant A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first? Measure the circumference of both upper arms. Rationale:The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture. A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects? dysrhythmias A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? take clients vitals A nurse is reviewing data for four children. Which of the following children should the nurse assess first? 10-year old child who has sickle cell anemia who reports severe chest pain A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? antiplatelet aggregate A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give? heparin does not dissolve clots. it stops new clots from forming .A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? two arteries one vein A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select? median vein the in forearm A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication? hypotension A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication? decreased BP A nurse on an oncology unit is preparing to administer doxorubicin to a client who has breast cancer. Prior to beginning the infusion, the nurse verifies the client's current cumulative lifetime dose of the medication. For which of the following reasons is this verification necessary? An excess amount of doxorubicin can lead to cardiomyopathy A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication? I feel nasueated and have no appetite While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? impaired tissue perfusion .A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching? I will take my medication at the first sign of an attack A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? these tests help determine the degree of damage to the heart tissue Another Flashcard A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Nursing care of this client should include which of the following nursing actions? Taking daily weights Addison's disease is an endocrine disorder that occurs in all age groups and affects men and women equally. The disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin in both exposed and unexposed parts of the body. Daily weight will alert the nurse that dehydration is occurring, which could indicate an impending crisis. A nurse is caring for a client after a craniotomy for pituitary tumor who has developed diabetes insipidus. The client is receiving vasopressin (Pitressin). The desired response to the medication is evident when the nurse observes which of the following findings? A decrease in urine output. The major manifestations of diabetes insipidus are excessive urination and extreme thirst. Pitressin is used to control frequent urination, increased thirst, and loss of water associated with diabetes insipidus. A decreased urine output is the desired response. A nurse is preparing teaching for a female client who smokes, is obese, and has hypertension. In establishing health promotion goals for the client, the nurse should recognize that which of the following is an inappropriate recommendation for the client? Eliminate sodium from the diet. A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.) *Diaphoresis is correct. Acromegaly is a chronic metabolic disorder caused by an excess of growth hormone after normal growth of the skeleton and other organs is complete. The physical manifestations associated with acromegaly include enlarged sebaceous glands with excessive sweating. *Coarse facial features is correct. The physical manifestations associated with acromegaly include enlarged facial bones with thickening of the skin, leading to coarse facial features. *Enlarged distal extremities is correct. The physical manifestations associated with acromegaly include enlarged hands and feet with thickening of the skin. *Muscle weakness is correct. The physical manifestations associated with acromegaly include fatigue and muscle weakness. A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? Shivering The hypothermia (cooling) blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption. A nurse is caring for a client who is suspected of having diabetes insipidus and is scheduled for a water deprivation test. During the test, the nurse should know to frequently assess the client for the development of hypotension. A client who has diabetes insipidus will continue to excrete urine even though there is no intake. Hypovolemia, with resulting hypotension, is possible. Upgrade to remove ads Only $3/month A nurse is caring for a client who sustained a basal skull fracture. On assessment, the nurse notices a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? Test the drainage for glucose. This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming from the client's nostril is CSF. A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? Regular (Humulin R) Regular insulin is classified as a short-acting insulin. It can be given intravenously with an onset of action of less than 30 min. This is the insulin that is most appropriate in emergency situations of hyperglycemia. A nurse is caring for a client admitted with end-stage cirrhosis of the liver. Which of the following interventions should the nurse anticipate taking to decrease the client's serum ammonia level? Start the client on a low-protein, high-calorie diet. A low-protein, high-calorie diet will reduce the source of ammonia and provide adequate carbohydrates for energy requirements while sparing protein from breakdown for energy. A nurse is caring for a client admitted with a diagnosis of hyperthyroidism. The client reports a weight loss of 5.4 kg (12 lb) in the last 2 months despite increased appetite. Additional symptoms reported include increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following measures should the nurse include in the client's plan of care to prevent a thyroid crisis? Provide a quiet, low-stimulus environment. Thyroid crisis can occur in response to a stressor, so the client should not be exposed to other clients who have active infections or an environment that is noisy and stimulating. A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize which of the following as manifestations of Cushing's syndrome? (Select all that apply.) Cushing's syndrome have hirsutism, excessive body hair, rather than alopecia, hair loss. Tremors are not a common finding in Cushing's syndrome. *Moon face is correct. Moon face, manifested by a round, red, full face, is common in Cushing's syndrome. *Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts are a common manifestation in Cushing's syndrome. Obese extremities is incorrect. Clients who have Cushing's syndrome have truncal obesity (a protuberant abdomen) with thin extremities. *Buffalo hump is correct. Buffalo hump, a collection of fat between the shoulder blades, is a common manifestation in Cushing's syndrome. A nurse is caring for a client admitted with a severe burn injury who is receiving intravenous fluid replacement therapy. The nurse evaluates the therapy to be inadequate if the client developed an increase in heart rate. The client's increased heart rate is likely to be caused by hypovolemia, which indicates inadequate fluid replacement. A nurse is caring for a client whose blood work indicates that the client has hyperthyroidism. The nurse should expect the client to report frequent mood changes. Hyperthyroidism develops when the thyroid gland produces an excess of the thyroid hormones that regulates metabolic rate. Nervousness; frequent mood changes; hand tremors; a rapid, pounding, irregular heartbeat; heat intolerance; diarrhea; and weight loss are common manifestations of hyperthyroidism. The client will have increased peristalsis and may experience diarrhea Hyperthyroidism causes an increased rate of body metabolism, so the client may experience heat intolerance Hyperthyroidism causes an increased rate of body metabolism, so the client may experience weight loss A nurse in a clinic is reviewing the laboratory values obtained from a client being seen for suspected hypothyroidism. If this diagnosis is accurate, the nurse should expect to see an elevated thyroid stimulating hormone (TSH). In hypothyroidism, the nonfunctioning thyroid gland is unable to respond to the TSH, and no endogenous thyroid hormones, such as T3, T4, and free thyroxine, are released. Low levels of T3 and T4 are the underlying stimuli for the release of TSH from the anterior pituitary. This results in an elevation of the TSH level as the anterior pituitary continues to release TSH to stimulate the thyroid gland to release the thyroid hormones T3 and T4. A nurse is caring for a client whose total parenteral nutrition (TPN) was stopped for an hour by mistake. After restarting the infusion pump, the nurse should watch the client carefully for the development of shakiness and diaphoresis. When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia. A nurse is performing teaching with a client who has newly diagnosed type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following manifestations of hypoglycemia? (Select all that apply.) Manifestations of hyperglycemia include polyuria (excessive urination). *Vertigo is correct. Manifestations of hypoglycemia include vertigo (dizziness). Manifestations of hyperglycemia include polydipsia (excessive thirst).