Exam 1
6. The nurse on an inpatient rheumatology unit receives a hand -off report on a patient
with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported
laboratory value requires the nurse to assess the patient further?
Platelet count: 50,000/mm3
7. A patient is treated at a clinic with an injection of long-acting penicillin for a
streptococcal throat infection. Her history reveals that she had received penicillin once
before with no allergic response. When the penicillin injection is administered, the nurse
should inform the patient which of the following?
Even though she had taken penicillin once without problems, she must be observed
immediately after with this dose.
8. A patient with systemic lupus erythematosus (SLE) was recently discharged from the
hospital after an acute exacerbation. The patient is in the clinic for a follow-up visit and
as the nurse you know to assess for all of the following EXCEPT which one?
The mouth for leukoplakia
9. The patient diagnosed with an acute exacerbation of Lupus is prescribed high-dose
steroids. Which statement best explains the scientific rationale for using high-dose
steroids in treating SLE?
The steroids will suppress tissue inflammation, thereby reducing damage to organs.
Rationale: The main function of steroid medications is to suppress the inflammatory response of
the body.https://quizlet.com/95806122/n344-hiv-sle-flash-cards/
10. The nurse is caring for a patient with the following arterial blood gases:
pH = 7.31; PaCO2 = 32 mm Hg; HCO3- = 18 mEq/L; PaO2 = 94 mm Hg; SaO2 =
98%. The nurse interprets these blood gases as which of the following?
Partially compensated metabolic acidosis
11. A patient arrives in the emergency department after being in a car crash with
fatalities. The patient has a nearly amputated leg that is bleeding. What action by the
nurse takes priority?
Ensure the patient has a patent airway.
Rationale: Airway is the priority, followed by breathing and circulation (IVs and direct
pressure). Obtaining consent is done by the physician.
https://quizlet.com/265793062/chapter-37-care-of-patients-with-shock-flash-cards/
12. D. D. Is brought to the hospital and is diagnosed with Diabetic Ketoacidosis. Which
of the following assessments would the nurse be most likely to make?
Increased respiratory rate
13. Which of these arterial blood gas values would indicate partially compensated
metabolic acidosis?
pH 7.32, HCO3- 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg
14. DISCREPANCY: A nurse is caring for a client after surgery. The client's respiratory rate
has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min
since they were last assessed 4 hours ago. What action by the nurse is best?
a. Ask if the client needs pain medication.
b. Assess the client's tissue perfusion further.
c. Document the findings in the client's chart.
d. Increase the rate of the client's IV infusion.
ANS: B
Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate,
respiratory rate, or blood pressure. Even though these readings are not out of the normal range,
the nurse should conduct a thorough assessment of the client, focusing on indicators of
perfusion. The client may need pain medication, but this is not the priority at this time.
Documentation should be done thoroughly but is not the priority either. The nurse should not
increase the rate of the IV infusion without an order.
https://quizlet.com/265793062/chapter-37-care-of-patients-with-shock-flash-cards/
A nurse is caring for a patient after surgery. The patient's respiratory rate has increased from 12
to 22 breaths/min and the pulse rate increased from 86 to 108 beats/min since they were last
assessed 4 hours ago. What action by the nurse is best?
Ask if the patient needs more pain medication.
15. The nurse gets the hand-off report on four patients. Which patient should the nurse assess
first?
Patient with a blood pressure change of 128/74 to 110/88 mm Hg
Rationale: This client has a falling systolic blood pressure, rising diastolic blood pressure, and
narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The
nurse should assess this client first. The client with the unchanged oxygen saturation is stable at
this point. Although the client with a change in pulse has a slower rate, it is not an indicator of
shock since the pulse is still within the normal range; it may indicate the client's pain or anxiety
has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly
above the normal range, which is 30 mL/hr.
https://quizlet.com/265793062/chapter-37-care-of-patients-with-shock-flash-cards/
16. Your patient has a compensated respiratory acidosis. You can expect his blood gas to
look like the following:
pH 7.36 pCO2 52 HCO3 32
17. A patient receiving a blood transfusion develops anxiety and low back pain. After
stopping the transfusion, what action by the nurse is most important?
Double checking the patient and blood product identification
https://quizlet.com/546594650/40-med-surg-flash-cards/
18. The nurse monitors all seriously ill patients for the development of acute
disseminated intravascular coagulation (DIC), based on the knowledge that which of the
following is true?
DIC is a bleeding disorder occurring as a result of depletion of platelets and clotting
factors used in a diffuse intravascular thrombosis.
19. The nurse is assessing a patient with full-thickness, circumferential burn around the
arm. It would be most important for the nurse to assess further for which of the
following?
A radial pulse
20. The nurse is admitting a patient who has sustained an electrical burn with an entrance
wound in the hand and an exit wound on the sole of the foot. Nursing interventions are
based on the understanding that electrical burn injuries are characterized by all of the
following EXCEPT which one?
The extensive skin grafting required
Reference:https://www.google.com/search?q=do+electrical+Burns+require+extensive+skin+graf
ting&gs_ivs=1#tts=0
21. The emergency department nurse is admitting a patient with burns sustained in
a house fire. The burns involve the entire front of the trunk, the right arm, and the
perineum. The nurse estimates the percentage of body surface area burned as which of
the following?
28%
22. The nurse is caring for patients in the medical-surgical unit. What action by the nurse
will help prevent a patient from having a type II hypersensitivity reaction?
Correctly identifying the patient prior to a blood transfusion
Rationale: A classic example of a type II hypersensitivity reaction is a blood transfusion
reaction. These can be prevented by correctly identifying the client and cross-checking the unit
of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the
cornerstone of treatment for a type IV hypersensitivity. Latex allergies are a type I
https://quizlet.com/87875496/chapter-20-care-of-patients-with-immune-function-excesshypersensitivity-allergy-and-autoimmunity-flash-cards/
23. A nurse reviews the following data in the chart of a patient with burn injuries. Based
on the data provided, how should the nurse categorize as patients injuries?
ADMISSION NOTES
-36 year old female patient with
bilateral leg Burns
-NKDA
-Health history: asthma
WOUND ASSESSMENT
-Bilateral leg wounds present with a white / black
and leather like appearance.
-No blisters are bleeding present.
-Patient rights pain at “2” on a 1-10 scale.
Full thickness
https://quizlet.com/367166688/iggy-chapter-26-care-of-patients-with-burns-flash-cards/
24. The nurse is planning care for a newly admitted burn patient with full-thickness burns
over 40% of their body surface. The nurse understands that care for this patient may
include which of the following?
-Infusion of lactated Ringer's crystalloid solution and administration of packed red blood
cells.
-Restriction of crystalloid solution and auto grafting procedures as soon as patient
stabilized
-Infusion of colloid Solutions based on hourly outputs and IV morphine as needed
???
-Aggressive fluid resuscitation with crystalloid solution, temporary grafting and
escharotomies as needed.
25. An emergency room nurse assesses a client who was rescued from a home fire. The
client suddenly develops a loud, brassy cough. Which action should the nurse take first?
a.Apply oxygen and continuous pulse oximetry.
b. Provide small quantities of ice chips and sips of water.
c.Request a prescription for an antitussive medication.
d.Ask the respiratory therapist to provide humidified air.
https://quizlet.com/367166688/iggy-chapter-26-care-of-patients-with-burns-flash-cards/
26. A nurse cares for a patient who has burn injuries. The patient's wife asks, “When will
his high risk for infection decrease?” How should the nurse respond?
a."When the antibiotic therapy is complete."
b."As soon as his albumin levels return to normal."
c."Once we complete the fluid resuscitation process."
d."When all of his burn wounds have closed."
https://quizlet.com/367166688/iggy-chapter-26-care-of-patients-with-burns-flash-cards/
https://quizlet.com/493284086/iggy-chapter-26-care-of-patients-with-burns-flash-cards/
27. A 200 lb patient has a TBSA of 47%. What is the flow rate of fluids during the first 8
hours post burn using 4ml in your equation?
1068 ml/hour
The Parkland formula for the total fluid requirement in 24 hours is as follows:
4ml x TBSA (%) x body weight (kg);
50% given in first eight hours;
50% given in next 16 hours.
https://www.nursingtimes.net/clinical-archive/accident-and-emergency/parkland-formula-fluidresuscitation-in-burns-patients-1-using-formulas-03-04-2008/
Good for study: https://quizlet.com/463089295/parkland-formula-questions-for-burns-fluidresuscitation-with-rule-of-nine-flash-cards/
4ml x kg x BSA = ANSWER/2= ANSWER/8= FINAL ANSWER
28. A patient has a platelet count of 9800/mm3. What action by the nurse is most appropriate?
Instruct the patient to call for help to get out of bed.
https://quizlet.com/347263303/med-surg-final-oncology-flash-cards/
And in Iggy TB Ch 22
https://quizlet.com/280773485/exam-4-flash-cards/
29. An important part of the admission interview is for the nurse to obtain the patient’s pre-brun
weight due to which of the following?
The information is used to determine fluid replacement needs
To calculate the fluid rates
To calculate the nutritional needs
To administer optimal drug doses
https://quizlet.com/510764703/med-surg-chapter-26-care-of-patients-with-burns-flash-cards/
PLEASE REVIEW!
30. M.T. has experienced severe burns and has begun treatment with fluids. The nurse assesses
the patient and hears stridor, and dyspnea. What is the nurse’s best action?
a. Raise the head of the bed.
b. Administer a bronchodilator
c. Prepare to get an arterial blood gas.
d. Prepare for intubation
CAN NOT FIND.
31. The patient with a new burn injury asks the nurse why he is receiving intravenous cimetidine
(Tagamet). What is the nurse’s best response?
a. "Tagamet will stimulate intestinal movement."
b. "Tagamet can help prevent hypovolemic shock."
c. "This will help prevent stomach ulcers."
d. "This drug will help prevent kidney damage."
Rationale: Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn
as a result of increased hydrochloric acid production and decreased mucosal barrier. This
process occurs because of the sympathetic nervous system stress response. Cimetidine inhibits
the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement,
prevent hypovolemic shock, or prevent kidney damage.
https://quizlet.com/73579893/burns-flash-cards/
32. A client recovering from hepatitis A asks whether he should take the vaccine to avoid
contracting the disease again. What does the nurse say?
a. "Yes, because now you are more susceptible to this infection."
b. "Yes, because the hepatitis A virus changes from year to year."
c. "No, your liver and immune system are too impaired at this time."
d. "No, having the infection has done the same thing a vaccination would."
https://quizlet.com/42337979/med-surg-chapter-19-flash-cards/
33. The nursing instructor explaining infection tells students that which factor is the best and
most important barrier to infection?
Skin and mucous membranes
Rationale: The skin and mucous membranes are the most important barrier against infection.
https://quizlet.com/311547416/med-surg-chapter-23-care-of-patients-with-infection-2-flashcards/
34. Which type of immunity does the hepatitis B immune globulin provide?
Artificial Passive (per exam review 1)
https://quizlet.com/42337979/med-surg-chapter-19-flash-cards/
https://quizlet.com/85719927/medsurg-chap-19-flash-cards/
35. The nurse reviews the laboratory results of a client and finds that the white blood cell (WBC)
count is 1500/mm3. What is the priority action of the nurse?
a. Have the client wear a mask at all times.
b. Obtain a urine sample for culture and sensitivity.
c. Administer two units of fresh-frozen plasma.
d. Institute reverse isolation precautions.
https://quizlet.com/42337979/med-surg-chapter-19-flash-cards/
36. Your patient has just been admitted for a burn injury on over 36% of his total body surface
area. You can expect care at this time to include all EXCEPT which of the following?
a. Administration of IV Solumedrol to reduce inflammation
b. Two large bore IVs with fluid replacement according to the Parkland Formula
c. Pain management with IV hydromorphone
d. A tetanus toxoid vaccine
CAN’T FIND IT
37. The intensive care nurse is educating the spouse of a client who is being treated for shock.
The spouse states, "The doctor said she has shock. What is that?" What is the nurse's best
response?
"Shock occurs when oxygen to the body's tissues and organs is impaired."
Rationale: Any problem that impairs oxygen delivery to tissues and organs can start the
syndrome of shock and lead to a life-threatening emergency. Shock represents the "whole-body
response," affecting all organs in a predictable sequence. Compensation mechanisms attempt to
maintain homeostasis and deliver necessary oxygen to organs but eventually will fail without
reversal of the cause of shock, resulting in death.
38. The nurse is evaluating the lab panel of a patient admitted from a house fire seven hours ago
that suffered superficial and deep partial thickness burns on over 30% of their total body surface
area. Which lab values do you anticipate for this patient? (Select all that apply)
a. calcium 7.0 mg/dl
b. Hematocrit 52%
c. carboxyhemoglobin elevated
d. K+- 5.1 meq/L
e. Blood Sugar 100 mg/dl
CAN’T FIND
39. A nurse is assessing a client with anemia. Which clinical manifestations does the nurse
expect to see?
Tachycardia
https://quizlet.com/160579026/ch-42-flash-cards/
40. Care for a patient receiving total parenteral nutrition (TPN) includes all of the following
EXCEPT?
a. Accucheck blood sugars every 6 hours.
b. Daily Evaluation of their CBC and electrolyte panel.
c. Maintaining the TPN bag in the refrigerator until it is hung.
d. The checking of the TPN orders with another RN colleague.
Can’t find
41. The nurse is evaluating a lab panel of a patient with disseminated intravascular coagulation.
Which lab values are consistent with this condition? (select all that apply)
a. increased fibrinogen
b. Decreased Platelets
c. Elevated D-Dimer
d. Decrease PT/INR
e. Elevated Fibrin Split Products.
SORT OF THE RIGHT ANSWERS PLEASE REVIEW
https://quizlet.com/459613787/dic-mylab-nclex-questions-16-51-flash-cards/
https://quizlet.com/494205914/disseminated-intravascular-coagulation-flash-cards/
https://quizlet.com/95727125/h476-flash-cards/
41a. The nurse is evaluating a lab panel of a patient with disseminated intravascular coagulation.
Which lab values are consistent with this condition?
Decrease platelets, elevated PT / INR and decreased D-dimer
Decrease platelets, decreased prothrombin and decreased fibrin split products
Decreased fibrinogen, decreased PT / INR and elevated fibrin split products
Decrease platelets, decrease prothrombin and elevated fibrin split products
42. A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a
respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which
action should the nurse take next?
Place the client in an upright position.
https://quizlet.com/367166688/iggy-chapter-26-care-of-patients-with-burns-flash-cards/
43. A patient has an arterial blood gas PH of 7.48. How does the nurse interpret this patient’s
acid-base status?
a.
An unknown acid-base balance status
b.
A normal blood hydrogen ion concentration
c.
A deficit in blood hydrogen ion concentration
d.
An excess in blood hydrogen ion concentration
Rationale: The pH is the negative log of the hydrogen ion concentration. The normal pH of
arterial blood ranges between 7.35 and 7.45. A pH of 7.48 indicates a decrease in the hydrogen
ion concentration (alkalosis).
https://quizlet.com/117791699/assessment-and-care-of-patients-with-acid-base-imbalancesflash-cards/
44. The nurse interprets which arterial blood gas values as uncompensated metabolic acidosis?
pH 7.28, HCO3- 19 mEq/L, PCO2 48 mm Hg, PO2 96 mm Hg
45. The nurse correlates which condition with the following arterial blood gas values: pH 7.48,
HCO3- 24 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg?
Diarrhea and vomiting for 36 hours
Anxiety-induced hyperventilation
Chronic obstructive pulmonary disease
Diabetic ketoacidosis and emphysema
https://quizlet.com/272960640/abg-interpretation-quiz-n291-flash-cards/
46. A patient has a compensated respiratory acidosis when the following blood gas is revealed.
pH 7.35, HCO3 - 34 mEq/L, PCO2 65 mm hg, PO2 78mm Hg
47. A client is being discharged from the emergency department with several broken ribs. For
which acid-base imbalance does the nurse provide discharge teaching?
a. Respiratory alkalosis from anxiety and hyperventilation
b. Respiratory acidosis from inadequate ventilation
c. Metabolic acidosis from calcium loss from broken bones
d. Metabolic alkalosis from taking base-containing analgesics
https://quizlet.com/372334098/ch14-medsurg-acid-base-flash-cards/
48. A client is being discharged and continues to be at risk for developing metabolic alkalosis.
Which statement by the client indicates to the nurse that teaching has been effective?
"I will avoid excess use of antacids."
https://quizlet.com/372334098/ch14-medsurg-acid-base-flash-cards/
49. A nurse in a hematology clinic is working with four clients who have polycythemia vera.
Which client should the nurse see first?
a. Client with a blood pressure of 180/98 mm Hg
b. Client who reports shortness of breath
c. Client who reports calf tenderness and swelling
d. Client with a swollen and painful left great toe
Rationale: Clients with polycythemia vera often have clotting abnormalities due to the
hyperviscous blood with sluggish flow. The client reporting shortness of breath may have a
pulmonary embolism and should be seen first. The client with a swollen calf may have a deep
vein thrombosis and should be seen next. High blood pressure and gout symptoms are common
findings with this disorder.
https://quizlet.com/448612223/chapter-40-care-of-patients-with-hematologic-problems-nursingschool-test-banks-flash-cards/
50. A client presents to the emergency department in sickle cell crisis. What intervention by the
nurse takes priority?
a. Administer oxygen.
b. Apply an oximetry probe.
c. Give pain medication.
d. Talk to concerned family
https://quizlet.com/414952185/chapter-40-care-of-patients-with-hematologic-problems-flashcards/
51. Initial volume replacement for a patient with severe GI bleeding?
Two liters of D5W over half an hour
150 ml of normal saline (NS) per hour for 5 hours
500 mL of 0.45% normal saline (1/2 NS) over half an hour
A liter of Ringer’s lactate (RL) over 15 minutes
52. Client in septic shock, deteriorating. Infusing IV fluids and giving medication. What type of
medications are you most likely to give to this client?
Hormone antagonist drugs
Adrenergic drugs
Antimetabolite drugs
Anticholinergic drugs
53. The client has experienced an electrical injury of the lower extremities. Which are the
priority assessment data to obtain from this client?
a. Current range of motion in all extremities
b. Heart rate and rhythm
c. Respiratory rate and pulse oximetry reading
d. Orientation to time, place, and person
Rationale: The airway is not at any particular risk with this injury. Therefore, respiratory rate
and pulse oximetry are not priority assessments. Electric current travels through the body from
the entrance site to the exit site and can seriously damage all tissues between the two sites. Early
cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes.
Range of motion and neurologic assessments are important. However the priority is to make sure
that the heart rate and rhythm are adequate to support perfusion to the brain and other vital
organs.
https://quizlet.com/370382763/burns-moodle-quiz-flash-cards/
54. A client who is admitted after a thermal burn injury has the following vital signs: blood
pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is
difficult to find pedal pulses. Which action will the nurse take first?
a. Begin intravenous fluids.
b. Check the pulses with a Doppler device.
c. Obtain a complete blood count (CBC).
d. Obtain an electrocardiogram (ECG).
Rationale: Hypovolemic shock is a common cause of death in the emergent phase of clients with
serious injuries. Fluids can treat this problem. An ECG and CBC will be taken to ascertain if a
cardiac or bleeding problem is causing these vital signs. However these are not actions that the
nurse would take immediately. Checking pulses would indicate perfusion to the periphery but
this is not an immediate nursing action.
https://quizlet.com/370382763/burns-moodle-quiz-flash-cards/
55. When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of
the following physiological functions?
A. Bleeding tendencies
B. Intake and output
C. Peripheral sensation
D. Bowel function
Rationale: Aplastic anemia decreases the bone marrow production of RBCs, WBCs, and
platelets. The client is at risk for bruising and bleeding tendencies. A change in the intake and
output is important, but assessment for the potential for bleeding takes priority. Change in the
peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency.
Change in bowel function is not associated with aplastic anemia.
56. What will the nurse identify as symptoms of hypovolemic shock in a patient?
Select all that apply.
1. Temperature of 97.6°F (36.4°C)
2. Restlessness
3. Decrease in blood pressure of 20 mm Hg when the patient sits up
4. Capillary refill time greater than 3 seconds
5. Sinus bradycardia of 55 beats per minute
https://quizlet.com/128436625/nclex-questions-for-shock-critical-care-flash-cards/
57. … coming into the health clinic 1 year after undergoing a (resection) gastric bypass
complaining of weakness, shortness of breath, and a sore tongue. … statement indicates a need
for intervention and client teaching?
“I have been drinking plenty of fluids.”
“I take a vitamin B12 tablet every day.”
“I have 3 to 4 loose stools per day.”
“I have been gargling with warm salt water for my sore tongue.”
Exam 2
5. The client diagnosed with rule-out myocardial infarction is experiencing chest pain while
walking to the bathroom. Which action should the nurse implement first
Have the client sit down immediately
6. It is important that the nurse be knowledgeable about cardiac output in order to do which of the
following?
Evaluate blood flow to the peripheral tissues
7. A client I swearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees
no ECG complexes on the screen. The first action of the nurse is to do which of the following?
Check the client status and lead placement
8. The nurse administers IV nitroglycerin to a patient with chest pain rule out MI. In evaluating
the therapeutic effect of this intervention, the nurse looks for which of the following?
Relief of Pain
9. The nurse is administering a calcium channel blocker to the client diagnosed with a MI. Which
assessment data would cause the nurse to question this medication?