33 terms

Exam #2

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The nurse is educating the patient on starting oral furosemide. Which of the following statements signifies that the teaching was successful?
A. I must count my pulse before taking the medication each morning.
B. I need to rinse my mouth after taking this drug.
C. I need to get up slowly from a sitting or lying position.
D. I need to avoid eating cheese and red wine with this medication.
C.

Diuretics can precipitate volume depletion and orthostatic blood pressure changes. Diuretics do not decrease heart rate. Diuretics do not cause Candida as steroids would. Patients do not need to avoid tyramine (which is in cheese and red wine) while taking diuretics.
The patient in renal failure has experienced a severe hypotensive event, and the ratio of BUN to creatinine is 15:1. The nurse is aware that this is an example of:
A. prerenal failure.
B. intrarenal failure.
C. postrenal failure.
D. chronic renal failure.
A.

Prerenal failure occurs before kidney failure, such as in a severe hypotensive episode. Intrarenal failure occurs because of a problem in the kidney such as glomerular nephritis and maintains a 10:1 BUN:creatinine ratio. Postrenal failure is caused by some type of blockage preventing the urine from leaving the kidney. Chronic renal failure can be a result of many things that cause acute renal failure.
The patient has a serum sodium level of 145 and potassium of 3.7. What is the approximate serum osmolality?
A. 293.7 mOsm/L
B. 290 mOsm/L
C. 141 mOsm/L
D. 153 mOsm/L
B.

Serum osmolality is roughly twice the sodium level. Thus, it would be 145 × 2, which is 290 mOsm/L.
The patient has a blood sugar level of 350 and an anion gap of 17. The nurse is aware that this is indicative of:
A. respiratory acidosis.
B. metabolic alkalosis.
C. respiratory alkalosis.
D. metabolic acidosis.
D.

A normal anion gap is 1 to 12 mEq/L and should not exceed 14 mEq/L. An increased anion gap level reflects overproduction or decreased excretion of acid products and indicates metabolic acidosis; a decreased anion gap indicates metabolic alkalosis. DKA is a cause of metabolic acidosis. Respiratory acidosis and respiratory alkalosis are due to problems with CO2 excretion (too little or too much).
Which of the following patient statements needs to be explored further regarding kidney function? (Select all that apply.)
A. These are the only shoes I could wear today.
B. I had to use three pillows to sleep last night.
C. I have this funny metallic taste in my mouth all the time.
D. I have been drinking 8 glasses of water each day.
E. I have been taking ibuprofen twice a day for the past month.
A, B, C, E

Answer A implies swelling in the feet. Answer B implies paroxysmal nocturnal dyspnea. Answer C could be related to uremia. Nonsteroidal antiinflammatory drugs such as ibuprofen can lead to renal impairment. Drinking 8 or more glasses of water per day is a preventive measure for kidney disease.
Which statement by a patient with chronic kidney disease (CKD) indicates an understanding of the purpose of sevelamer (Renagel) with meals?
A. I need this drug to prevent indigestion.
B. I need this drug to keep my body from absorbing too much phosphorus from food.
C. I need to take this drug to improve my thyroid function.
D. I need to take this drug with meals to avoid constipation.
B

Sevelamer (Renagel)is a third-generation phosphate binder. It is not ordered for indigestion or constipation, and it will not affect thyroid function.
Which of the following meals is the best choice for a patient with chronic kidney disease (CKD) to eat for lunch?
A. Tomato soup, grilled low-fat cheese sandwich, and diet soda
B. Tuna salad on lettuce with low-salt crackers and iced tea
C. Cheeseburger with french fries, a side salad, and a milkshake
D. Ham and cheese sandwich on whole-grain bread with pickle, potato chips, and milk
B

Tuna salad on lettuce with low-salt crackers and iced tea is the best choice. It includes a high biological protein source and is low in sodium, potassium, dairy, and phosphorus. A meal of tomato soup, grilled low-fat cheese sandwich, and diet soda is high in sodium, phosphorus, and fluid. A meal of a cheeseburger with french fries, a side salad, and a milkshake is high in salt, fat, sugar, and dairy. A ham and cheese sandwich on whole-grain bread with pickle, potato chips, and milk is high in salt and phosphorus.
A nurse is assessing a patient with end-stage kidney disease (ESKD) and notices that the patient's left cheek is twitching, the patient's gums are bleeding, and the patient is irritable. Which of the following electrolyte disturbances should the nurse suspect?
A. Hypernatremia
B. Hyperkalemia
C. Hypocalcemia
D. Hypermagnesemia
C

The patient is displaying signs of hypocalcemia. A patient with hypernatremia would be thirsty with sticky mucous membranes and an altered level of consciousness. A patient with hyperkalemia would be anxious with nausea, vomiting, and cramps and tingling in the fingers with electrocardiogram changes. A patient with hypermagnesemia would have respiratory depression, lethargy, and bradycardia.
Which of the following nursing actions is important in the management of a patient with an arteriovenous (AV) fistula? (Select all that apply.)
A. Auscultate the bruit.
B. Palpate the thrill.
C. Draw all laboratory work from the fistula.
D. Avoid constrictive clothing on the limb containing the access.
E. Take BP measurements in the fistula arm.
A, B, D

Auscultate the bruit, palpate the thrill, and avoid constricting clothing on the access limb. Laboratory work should not be drawn from the fistula, and the BP measurements should not be taken in the arm with the fistula.
The priority nursing diagnosis for the patient in shock regardless of the phase or type is:
A. deficient fluid volume.
B. ineffective breathing pattern.
C. ineffective tissue perfusion.
D. imbalanced nutrition: less than body requirements.
C

Ineffective tissue perfusion is the priority nursing diagnosis for a patient in shock. Deficient fluid volume is important in hypovolemic shock. Ineffective breathing pattern and imbalanced nutrition are also important but are not the priority diagnosis.
A postoperative patient has a heart rate of 110 beats/min and blood pressure (BP) of 110/80 mm Hg (previously 130/60 mm Hg). Urine output has been 20 mL/hr for the past 3 hours, capillary filling time is 5 seconds, the skin is cool, the neck veins are flattened, and the patient is complaining of thirst. The nurse suspects:
A. the patient is experiencing hypovolemic shock.
B. the patient has a cardiac tamponade.
C. the patient is in cardiogenic shock.
D. the patient is having an allergic reaction.
A

The patient is experiencing hypovolemic shock as evidenced by decreased urine output, tachycardia, and increased capillary filling time. In cardiac tamponade, heart tones would be muffled and neck veins would be distended. In cardiogenic shock, the BP would be elevated and the neck veins would be distended. With an allergic reaction, there would be signs of allergic response, such as urticaria, anxiety, and respiratory distress.
The nurse notes that the patient's arterial blood gases reflect hypoxia, respiratory alkalosis, scattered crackles, and distended jugular veins. Heart tones are distant, but an S3 and S4 are noted despite scant amounts of concentrated urine output. The nurse anticipates the administration of which of the following intravenous pharmacologic or parenteral therapies?
A. Isotonic saline
B. Amiodarone
C. Furosemide
D. Sodium bicarbonate
The patient is experiencing cardiogenic shock. Administration of fluids (isotonic saline) and sodium bicarbonate would be contraindicated at this time. Amiodarone would only be indicated if the patient was having dysrhythmias
A nurse is working on a spinal cord injury unit and has just finished a report. Which of the following patients should be seen first?
A. 24-year-old man who has not had a bowel movement since yesterday
B. 28-year-old woman who is complaining of being cold
C. 32-year-old man whose blood pressure is 84/40 mm Hg and heart rate is 60 beats/min
D. 18-year-old woman whose dose of low-molecular-weight heparin is due
C

The 32-year-old man is in danger of neurogenic shock and needs to be evaluated. Constipation is an issue, but a patient who has had it for 1 day is not the priority patient. The patient complaining of cold and the patient who needs low-molecular-weight heparin are important, but the hypotension coupled with the bradycardia signifies a problem with sympathetic nervous system integrity.
A nurse is consulting with a multidisciplinary team regarding renal impairment from sepsis. Which of the following statements regarding renal dysfunction is true?
A. An increased creatinine level is the earliest sign of renal impairment.
B. Elevated peak levels of antibiotics can lead to renal impairment.
C. Hypotensive episodes do not affect renal function.
D. Increased production of erythropoietin may result in renal impairment.
B

The frequent use of nephrotoxic drugs (e.g., antibiotics) during critical illness intensifies the risk of progressive renal impairment. Elevated serum creatinine level is usually a late sign, but it is typically accepted as the index for renal dysfunction. Early oliguria is likely caused by decreases in renal perfusion related to shock-like states (with hypotension). Additional signs of renal impairment may include decreased erythropoietin-induced anemia, vitamin D malabsorption, and altered fluid and electrolyte balance.
The nurse is performing an abdominal assessment on a newly admitted patient and notes a bluish discoloration around the umbilicus. The nurse suspects the patient may have a(n):
A. intraperitoneal bleed.
B. metabolic disorder.
C. bleeding disorder.
D. malabsorption syndrome.
A

A bluish discoloration around the umbilicus (Cullen's sign) indicates intraperitoneal bleeding. The other disorders listed do not cause this type of symptom.
The nurse is auscultating bowel sounds and notes high-pitched gurgling sounds every 10 seconds. What intervention should the nurse take?
A. Notify the health care provider (HCP).
B. Document the normal finding.
C. Prepare to administer an enema.
D. Insert a nasogastric (NG) tube and connect to low constant suction.
B

This is a normal finding, and there is no need to contact the HCP. An NG tube or an enema are not warranted at this time.
The nurse is performing an abdominal assessment on a patient who was just admitted to the unit. In what order should the patient's abdomen be assessed?
A. Auscultation, percussion, palpation, and inspection
B. Palpation, inspection, auscultation, and percussion
C. Inspection, percussion, palpation, and auscultation
D. Inspection, auscultation, percussion, and palpation
D

To prevent stimulation of GI activity, the order for the assessment should be inspection, auscultation, percussion, and palpation. The other answers listed are incorrect.
Which of the following endoscopy procedures is the most helpful when evaluating problems with the pancreas?
A. Colonoscopy
B. Esophagogastroduodenoscopy (EGD)
C. Endoscopic retrograde cholangiopancreatography (ERCP)
D. Enteroscopy
C

ERCP provides information on the hepatobiliary system. Colonoscopy provides information on the lower gastrointestinal (GI) system from the rectum to the distal ileum. EGD provides information on the upper GI system to the duodenum. Enteroscopy provides information on the small bowel
A patient in liver failure questions a nurse about why he has to keep taking this laxative (lactulose) because he has diarrhea. What is the appropriate response by the nurse?
A. I will get the doctor to stop the drug.
B. I will get the doctor to order you something to stop the diarrhea.
C. This drug is given to decrease bacteria in your gut and help your liver.
D. This drug is a liver supplement.
C

Lactulose is given to decrease the bacteria growth in the gut and decrease the ammonia level. Asking the health care provider to stop the medication would be inappropriate. Diarrhea is an expected result of the drug, and giving an antidiarrheal medication would counteract the effects of the drug. Lactulose is not a liver supplement.
The patient recovering from gastric bypass surgery is complaining of abdominal pain (8 of 10 on the pain scale), has a temperature of 103° F, has a heart rate of 120 beats/min, and is becoming increasingly restless and anxious. What is the priority intervention?
A. Notify the health care provider.
B. Feed the patient lunch.
C. Administer a beta-blocker to decrease the heart rate.
D. Insert a nasogastric tube (NG) and connect it to low constant suction.
A

The patient could be experiencing an anastomotic leak as evidenced by the pain, fever, tachycardia, anxiety, and restlessness. The priority intervention is to notify the health care provider. The patient should be given nothing by mouth (NPO). Treating the heart rate without further evaluation is dangerous. The nurse should not insert an NG tube on this patient without an order because of the surgical intervention.
A patient is vomiting bright red blood with a hemoglobin of 13 mg/dL and a hematocrit of 40 mg/dL. This indicates to the nurse that the bleed is: (Select all that apply.)
A. an upper gastrointestinal (GI) bleed.
B. a new-onset bleed.
C. an acute problem.
D. mixed with a large amount of gastric secretions.
melena.
A, B, C

Vomiting bright red blood indicates that this is an acute upper GI bleed. The hematocrit has not dropped yet, which would indicate that it is a new problem. Blood with gastric secretions would be coffee ground colored, and melena is dark maroon stool.
A patient with pancreatitis is complaining of pain that is a 9 on a scale of 10. Which of the following interventions should the nurse anticipate? (Select all that apply.)
A. Morphine
B. Meperidine (Demerol)
C. Relaxation techniques
D. Repositioning (knee chest position)
E. Aspirin
A, B, C, D

Morphine or meperidine can be used for pain management. Previously, morphine was thought to cause spasms in the sphincter of Oddi, but evidence has shown that morphine may be more effective with fewer side effects than meperidine. Relaxation techniques (e.g., deep breathing) as well as repositioning may help pain. Aspirin is not indicated for this level of pain.
A patient is complaining of blurred vision, fatigue, and nausea. The nurse notes that the patient's face is flushed, and he has a heart rate of 125 beats/min and blood pressure of 80/40 mm Hg. Which of the following is the appropriate intervention?
A. Offer the patient some orange juice.
B. Check a capillary blood glucose level.
C. Administer glucagon intramuscularly.
D. Start the patient on oxygen at 2 L/min.
B

The patient is exhibiting signs of hyperglycemia, so the first action is to check the blood sugar to determine treatment. Orange juice would increase the blood sugar. Glucagon would increase the blood sugar, and oxygen would not address the hypoglycemia.
The patient has a glycosylated hemoglobin of 8. The nurse understands that this represents an average blood sugar of _______________.
A. 207 for the past 120 days
B. 275 for the past week
C. 170 for the past 30 days
D. 120 for the past week
A

HgbA1C represents the average blood sugar level for the life of the red blood cells, which is 120 days. The other answers are not the correct correlation or time frame (120 days) to represent HgbA1C.
A postoperative craniotomy patient has a serum osmolality of 260 mOsm/kg/H2O and a urine osmolality of 1500 mOsm/kg. The nurse suspects that the patient is experiencing:
A. diabetes insipidus.
B. syndrome of inappropriate ADH secretion.
C. diabetes mellitus.
D. diabetic ketoacidosis (DKA).
B

The patient has a low serum osmolality with a high urine osmolality. In diabetes insipidus, the patient has a high serum osmolality with a low urine osmolality. Diabetes mellitus is an insulin problem, and DKA involves hyperglycemia.
A nurse is teaching the diabetic patient about insulin therapy. Which of the following statements by the patient indicates the teaching was effective?
A. I will take my long-acting insulin before a meal.
B. I will monitor my blood sugar weekly.
C. If I am not going to eat right away, it is okay to take my short-acting insulin anyway.
D. I need to rotate the site I use to obtain blood for glucose monitoring.
D

Sites should be rotated to avoid trauma and bruising. Long-acting insulin is administered once or twice daily. Blood sugar should be monitored at least daily in the diabetic patient and probably more often depending on therapy. Short-acting insulin should be taken before a meal.
Which of the following patients with a fasting blood sugar of 110 mg/dL has the highest risk for development of metabolic syndrome?
A. African American woman with a 40-inch waist, blood pressure of 140/90 mm Hg, triglycerides of 180, and HDL of 25
B. Asian American man with a 30-inch waist, blood pressure of 130/60 mm Hg, triglycerides of 140, HDL of 45
C. Native American man with a 28-inch waist, blood pressure of 120/50 mm Hg, triglycerides of 130, HDL of 50
D. Hispanic American woman with a 34-inch waist, blood pressure of 130/50 mm Hg, triglycerides of 145, HDL of 40
A

Although all of the patients have some risk factors for metabolic syndrome, the African American woman has the highest number of risk factors (waist greater than 40 inches in men and greater than 35 inches in women, triglycerides greater than 150, HDL less than 40 for men and less than 35 for women). All of the patients have a genetic risk factor and high fasting blood sugar.
The postoperative craniotomy patient has a serum osmolality of 320 mOsm/L and urine output of 400 mL/hr for the past 3 hours with a urine specific gravity of 1.003. The nurse anticipates which of the following treatments?
A. 0.9 NaCl at 150 mL/hr intravenously
B. 1.5 mcg desmopressin acetate (DDAVP) subcutaneously every 12 hours
C. Insulin drip at 7 units/hr
D. Oral vasopressin 5 units every 12 hours
B

The patient has diabetes insipidus (DI), and DDVAP is the appropriate treatment. Hypotonic saline (not isotonic) is normally used for DI. Insulin is not indicated for DI, and vasopressin is not an oral medication.
The nurse and the patient's daughter are aware that the patient has a do-not-resuscitate (DNR) order, but when he stops breathing, the daughter screams, Save my daddy! This is an example of a conflict between which two ethical principles?
A. Beneficence and veracity
B. Beneficence and nonmaleficence
C. Nonmaleficence and veracity
D. Nonmaleficence and justice
B

Resuscitation is saving a life, which is usually a good thing (beneficence) unless the patient does not want to suffer any longer; then it is considered doing harm (nonmaleficence). It is not an issue of honesty (veracity) because everyone knows what is happening. It is also not an issue of treating everyone the same (justice).
A nurse is making assignments for the oncoming shift. Which assignment would be appropriate for the patient who is actively dying?
A. Assign the dying patient to a float nurse so the family will not associate the death experience with unit personnel.
B. Assign the nurse with the dying patient to an unstable patient so the nurse will not have to spend time with the dying patient's family.
C. Assign the dying patient to a nurse with whom the family has built a relationship and assign the nurse to a stable patient as well.
D. Assign the dying patient to a nurse who has been off work for 2 or more days so he or she will have the energy to care for the patient's and family's needs and assign the nurse to a stable patient as well.
C

It is best for a dying patient to have a nurse who has built a relationship with the patient's family. Ideally, the nurse would not have another patient, but that is not always possible, so a stable patient is the best option. A float nurse would be a stranger and could cause distress for the family; it would also be a difficult situation for the nurse. Giving the nurse an unstable patient could cause distress to the nurse as well as to both patients, who each have different demanding and possibly time-sensitive needs. The nurse just back from time off may not have a relationship with the family or be familiar with the events that have transpired during that time.
A patient with end-stage renal disease is refusing any further treatments. Which response is appropriate for the nurse to make?
A. Why do you want to stop treatment? Don't you realize you will die?
B. Are you giving up? What will your family say?
C. You want to stop dialysis? Is there something about it that is bothering you?
D This is your decision. I will get the paperwork.
C

Asking the patient if something is bothering him or her opens up the dialogue for the patient to discuss his or her feelings and attitudes. Saying things like:Why do you want to stop treatment? Don't you realize you will die? Or Are you giving up? What will your family say? Will it make the patient feel guilty? This is your decision. I will get the paperwork dismisses any discussion concerning the patient's wishes.
Nurses in the intensive care unit are having a high incidence of burnout after a period in which several long-term patients died in the unit despite having received aggressive care. Which strategies can the nurse manager implement to help the staff deal with these issues? (Select all that apply.)
A. A meeting regarding cardiopulmonary resuscitation (CPR) performance
B. An educational program on futility of care and withdrawal of support
C. A program on stress management and burnout
D. Developing clear polices and guidelines concerning end-of-life care
E. Implementing a reward or bonus program for the staff
B, C, D

An understanding of futile care and withdrawal of support would help the staff deal with patient and family issues. Education on stress management and burnout would help the staff deal with this particular episode. Clear policies and guidelines will help the staff deal with issues as they arise. A meeting on CPR will not assist the nursing staff, and a reward or bonus program will not address the issues of burnout.
A patient with end-stage chronic airflow limitation is receiving palliative care. The nurse notes increase in respiratory rate, use of accessory muscles to breathe, and distress on the patient's face. What interventions should the nurse implement? (Select all that apply.)
A. Increase the morphine drip.
B. Assess the oxygen connections and liter flow.
C. Elevate the head of the bed.
D. Administer naloxone IV
E. Administer an ordered benzodiazepine
A, B, C, E

Increasing the morphine drip, assessing the oxygen connections and liter flow, elevating the head of the bed, and administering an ordered benzodiazepine are all appropriate action for controlling dyspnea in a patient during active dying. Administering IV naloxone would be harmful to the patient.