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NUR 213 Final 1
- A client has an AV fistula in the right upper arm for hemodialysis treatments. When planning
- Take blood pressures only on the right side to ensure accuracy
- Use the fistula for all venipunctures and IV infusions
- Ensure that small clamps are attached to the fistula dressing at all times
- Assess the fistula for the presence of a bruit and a thrill every 4 hours
care for this client, which measure should the nurse implement to promote client safety?
Answer
- Assess the fistula for the presence of a bruit and a thrill every 4 hours
- A client is scheduled for hydrotherapy for a burn dressing change. Which action should the
- Ensure the client has a robe and slippers
- Administer an analgesic 20 mins before therapy
- Send dressing supplies with the client to hydrotherapy
- Administer an IV antibiotic 30 mins prior to therapy
nurse take to ensure that the procedure is most tolerable for the client?
Answer
- Administer an anal- gesic 20 mins before therapy
- A client with Myasthenia Gravis is admitted to the hospital, and the nursing history reveals
- Mouth ulcers
- Muscle cramps
- Feelings of depression
- Unexplained weight gain
that the client is taking pyridostigmine. When assessing the client for the side effects of this medication, the nurse should ask the client about the presence of which occurance?
Answer
- Muscle Cramps
Rationale
Answer Pyridostigmine is an anticholinesterase inhibitor used to treat myasthenia gravis. Muscle cramps and small muscle contractions are common side effects and occur as a result of overstimulation of neuromuscular receptors.
- The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor.
Which action should the nurse take? 1 / 4
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- Prepare for defibrillation
- Continue to monitor the rhythm
- Notify the HCP
- Prepare to administer lidocaine hydrochloride
Answer
- Continue to monitor the rhythm
Rationale
Answer As an isolated occurance, a PVC is not life threatening. The nurse should continue to monitor the patients rhythm. Frequent PVCs, however, maybe precursors of a more life-threatening rhythm such as vtach or vfib.
- A client was admitted to the hospital 24 hours ago after sustaining blunt force trauma to the
- Cyanosis and pallor
- Diffuse crackles and rhonchi on chest auscultation
- Increase in respiratory rate from 18 to 30 breaths per minute
- Haziness or "white out" appearance of lungs on chest X-ray
chest. Which earliest clinical manifestations of acute respiratory distress syndrome (ARDS) should the nurse monitor for?
Answer
- Increase in respiratory rate from 18 to 30 breaths per minute
Rationale
Answer ARDS usually develops within 24-48 hrs after an initiating event, such as chest trauma. In most cases tachypnea and dyspnea are the earliest clinical manifestations as the body compensates for mild hypoxemia through hyperventilia- tion. Cyanosis and pallor are usually late signs of severe hypoxemia. In ARDS lung sounds are initially clear but progress to crackles and rhonchi as pulmonary edema occurs. Xrays will shouw a "white out" appearance much later in the progression of ARDS.
- A client has developed atrial fibrillation and has a ventricular rate of 150 beats per minute.
- flat neck veins
- nausea and vomiting
- hypotension and dizziness
- hypertension and headache
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The nurse should assess the client for which effects of this cardiac occurrence?
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Answer
- hypotension and dizziness
- The home care nurse is making a follow-up visit to a client after a renal transplant. The
- hypotension, graft tenderness, and anemia
- hypertension, oliguria, thirst, and hypothermia
- fever, hypertension, graft tenderness, and malaise
- fever, vomiting, hypotension, and copious amounts of dilute urine output-
nurse should assess the client for which manifestations of acute graft rejection?
Answer
- fever, hypertension, graft tenderness, and malaise
- A client with a burn injury recieves a prescription for a regular diet. Which is the best meal for
- peanut butter & jelly sandwich, apple, tea
- chicken breast, broccoli, strawberries, milk
- veal chop, boiled potatoes, jell-o, orange juice
- pasta with tomato sauce, garlic bread, ginger ale
the nurse to provide to the client to promote wound healing?
Answer
- chicken breast, broccoli, strawberries, milk
Rationale
Answer the meal with the best potential to promote wound healing includes nutrient-rich food choices including protein, such as chicken and milk, and vitamin c, such as strawberries and broccoli. The remaining food options include one or more items with low nutritional value, especially the jell- o, tea, jelly, and ginger ale.
- An adult client arrives in the emergency department with burns to both entire legs and the
perineal area. Using the rule of nines, the nurse could determine that approximately what percentage of the clients body surface area has been burned?
Answer 37% Rationale
Answer Each leg is 18% and the perineum is 1% (18+18+1 = 37) 3 / 4
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- A client who is unresponsive and pulseless and has a possible neck injury is brought into the
- Insert an oropharyngeal airway
- Tilt the head and lift the chin
- Place in the recovery position
- Stabilize the skull and push up the jaw
emergency department after a motor vehicle crash. What should the nurse do to open the clients airway?
Answer
- Stabilize the skull and push up the jaw
Rationale
Answer the healthcare team uses the jaw thrust maneuver to open the airway until an xray confirms that the cervical spine is stable in order to prevent potential aggravation of the cervical spine injury.
- The nurse assesses the water seal chamber of a closed chest drainage sys- tem and notes
- The tubing is kinked
- An air leak is present
- The lung has reexpanded
- The system is functioning as expected
fluctuations in the chamber. What does this finding indicate?
Answer
- The system is functioning as
expected Rationale
Answer Fluctuations (tidaling) in the water seal chamber is normal during inhala- tion and exhalation.
- The nurse plans care for the client diagnosed with end stage renal disease (ESRD). Which
findings does the nurse expect to find in the clients medical record? Select all that apply
Answer
- Edema
- Anemia
- Polyuria
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