The nurse is reviewing the laboratory results for several clients. Which of the laboratory result indicates a client with partly compensated metabolic
... [Show More] acidosis?
Chloride 100 mEq/L (100 mmol/L)
Sodium 130 mEq/L (130 mmol/L)
Hemoglobin 15 g/dL (150 g//L)
PaCO2 30 mm Hg
PaCO2 30 mm Hg
The client is admitted to an ambulatory surgery center and undergoes a right inguinal orchiectomy. Which option is the priority before the client can be discharged to home?
Able to ambulate in the hallway with assistance
Post-operative pain is managed
Correct response
Able to tolerate a regular diet
Psychological counseling is scheduled
Post-operative pain is managed
A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first?
Test deep tendon reflexes
Check blood calcium level
Check complete blood count (CBC) with differential
Check serum potassium level
Check complete blood count (CBC) with differential
Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ.
The client with a T-2 spinal cord injury reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. What action should the nurse take next?
Place the client into the bed and administer the ordered PRN analgesic
Measure the client's respirations, blood pressure, temperature and pupillary responses
Check the client for bladder distention and the urinary catheter for kinks
Assist client with relaxation techniques
Check the client for bladder distention and the urinary catheter for kinks
These are findings of autonomic dysreflexia, also called hyperreflexia. This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. The stimulus creates an exaggerated response of the sympathetic nervous system and can be a life-threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus.
The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first?
Administer the ordered PRN medication
Reassess the extremity in 15 minutes
Readjust the traction for comfort
Notify the health care provider
Notify the health care provider
Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity.
The nurse is examining a 2 year-old child with a tentative diagnosis of Wilm's tumor. The nurse would be most concerned about which statement by the mother?
"My child has lost three pounds in the last month."
"The child prefers some salty foods more than others."
"All the pants have become tight around the waist."
"Urinary output seems to be less over the past two days."
"Urinary output seems to be less over the past two days."
Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction. Increasing abdominal girth is a common finding in Wilm's tumor, but does not require immediate intervention by the nurse.
A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care?
Compromised host precautions
Airborne precautions
Contact precautions
Droplet precautions
Contact precautions
The resistant bacteria remain alive for up to three days after the client dies. Therefore, contact precautions must still be used. The body should also be labeled as MRSA-contaminated so that the funeral home staff can protect themselves as well. Gown and gloves are required.
The client is diagnosed with cystic fibrosis (CF). The nurse would expect the client to be treated with oral pancreatic enzymes and which type of diet?
Sodium-restricted
Dairy-free
High fat, high-calorie
Gluten-free, low fiber
High fat, high-calorie
CF affects the cells that produce mucus, sweat and digestive juices. Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra fiber to prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are at risk for osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten intolerance, not CF, needs a gluten-free diet.
During assessment of orthostatic vital signs on a client with cardiomyopathy, the nurse finds that the systolic blood pressure (BP) decreased from 145 to 110 mm Hg between the supine and upright positions while the heart rate (HR) rose from 72 to 96 beats per minute. In addition, the client reports feeling lightheaded when standing up. The nurse should implement which of the following actions?
Increase fluids that are high in protein
Instruct the client to increase fluid intake for the next two days
Restrict fluids for the next few hours
Instruct client to increase fluid intake for several hours
Instruct client to increase fluid intake for several hours
This client is experiencing postural hypotension, a decrease in systolic blood pressure 15 mm Hg accompanied by an increase in heart rate 15 to 20 beats above the baseline with a change in position from supine to upright. This is often accompanied by lightheadedness. Fluid replacement is appropriate, but must be instituted very cautiously, as this client with cardiomyopathy will also be very sensitive to changes in fluid status and fluid overload may develop rapidly with aggressive rehydration. After the client increases fluid intake for one to two hours, the client should be reassessed for resolution of the postural hypotension.
The nurse is teaching a client with coronary artery disease about nutrition. What information should the nurse be sure to emphasize?
Add complex carbohydrates to each meal
Avoid large and heavy meals
Limit sodium to 7 grams per day
Eat three balanced meals a day
Avoid large and heavy meals
Eating large, heavy meals can pull blood away from the heart for the digestion process. This may result in angina for clients with coronary artery disease. Sodium for clients with cardiac disease is limited to two grams per day. Three meals a day is a correct approach. However, it does not mention the size of the meal, which is more important.
The nurse is teaching the client with chronic renal failure (CRF) about medications. The client questions the purpose of taking aluminum hydroxide. What is the best explanation for the nurse to give the client about the therapeutic effects of this medication?
It will reduce serum calcium
Amphojel increases urine output
The drug is taken to control gastric acid secretion
It decreases serum phosphate
It decreases serum phosphate
Aluminum binds phosphates that tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel are commonly used to decrease serum phosphate.
The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis (ALS). Which finding would the nurse expect?
Confusion
Shallow respirations
Tonic-clonic seizures
Loss of half of visual field
Shallow respirations
ALS is a chronic progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. In ALS, upper and lower motor neurons degenerate (die) and stop sending messages to muscles; all muscles under voluntary control eventually weaken and atrophy. People eventually lose their ability to speak, eat, move and breathe. However, ALS does not impair a person's mind or intelligence. ALS does not affect a person's ability to see, smell, taste, hear or recognize touch.
The nurse is caring for a client who is in the advanced stage of multiple myeloma. Which action should be included in the plan of care?
Monitor for hyperkalemia
Careful repositioning
Administer diuretics as ordered
Place in protective isolation
Careful repositioning
Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in several bones. This disease may also harm other tissues and organs, especially the kidneys. This type of cancer causes hypercalcemia, renal failure, anemia,and bone damage. Because multiple myeloma can cause erosion of bone mass and fractures, extra care should be taken when moving or positioning a client due to the risk of pathological fractures. [Show Less]