The nurse has completed evaluating the cranial nerves of a patient. The nurse
documents impairment of the right cranial nerves (CN IX and CN X). Based on these
findings, the nurse will instruct the patient to complete which of the following?
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"Refrain from eating or drinking for now."
Which assessment would be the most important for a patient who is receiving a loop
diuretic (Lasix/Furosemide) for the management of CHF?
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Monitor for orthostatic hypotension and HR
,Which of the following types of posturing is exhibited by abnormal flexion of the
upper extremities and plantar flexion of the feet?
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Decorticate.
The nurse is caring for a patient with extensive burn injuries (more than 20% of total
body surface area). The nurse would assess which of the following to determine if the
patient is receiving adequate fluid resuscitation?
(Select all that apply)
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Monitoring mean arterial pressure (MAP) trends
Monitoring urine specific gravity
Auscultating for adventitious lung sounds
Monitoring blood pressure trends
Monitoring heart rate trends
Monitoring hourly urine output
A patient is being admitted to the neurologic ICU following an acute head injury that
has resulted in cerebral edema. When planning this patient's care, the nurse would
expect to administer what priority medication?
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, Mannitol (Osmitrol).
A patient exhibiting an altered level of consciousness due to blunt-force trauma to the
head is admitted to the ED. The provider determines the patient's injury is causing
increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the
results of what diagnostic tool?
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GCS
What goal of care should a gerontologic nurse prioritize when working with the
elderly?
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Helping older adults use their strengths to optimize independence.
What electrolyte imbalance is present when the nurse observes a positive Chvostek's
sign?
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Hypocalcemia
, A patient with possible bacterial meningitis is admitted to the ICU.What assessment
finding would the nurse expect for a patient with this diagnosis?
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Neck flexion produces flexion of knees and hips.
During a pulmonary assessment, the nurse observes the chest for symmetry. The nurse
identifies the findings as normal. Which of the following would be consistent with a
normal assessment?
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Lateral diameter greater than anteroposterior diameter
When planning the care of a patient with a fluid imbalance, the nurse understands that
in the human body, water and electrolytes move from the arterial capillary bed to the
interstitial fluid. What causes this to occur?
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Hydrostatic pressure resulting from the pumping action of the heart
A nurse is developing a care plan for a patient with a partial-thickness burn, and
determines that an appropriate goal is to maintain frequent repositioning. What is the
best rationale for this intervention?
Give this one a try later!
documents impairment of the right cranial nerves (CN IX and CN X). Based on these
findings, the nurse will instruct the patient to complete which of the following?
Give this one a try later!
"Refrain from eating or drinking for now."
Which assessment would be the most important for a patient who is receiving a loop
diuretic (Lasix/Furosemide) for the management of CHF?
Give this one a try later!
Monitor for orthostatic hypotension and HR
,Which of the following types of posturing is exhibited by abnormal flexion of the
upper extremities and plantar flexion of the feet?
Give this one a try later!
Decorticate.
The nurse is caring for a patient with extensive burn injuries (more than 20% of total
body surface area). The nurse would assess which of the following to determine if the
patient is receiving adequate fluid resuscitation?
(Select all that apply)
Give this one a try later!
Monitoring mean arterial pressure (MAP) trends
Monitoring urine specific gravity
Auscultating for adventitious lung sounds
Monitoring blood pressure trends
Monitoring heart rate trends
Monitoring hourly urine output
A patient is being admitted to the neurologic ICU following an acute head injury that
has resulted in cerebral edema. When planning this patient's care, the nurse would
expect to administer what priority medication?
Give this one a try later!
, Mannitol (Osmitrol).
A patient exhibiting an altered level of consciousness due to blunt-force trauma to the
head is admitted to the ED. The provider determines the patient's injury is causing
increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the
results of what diagnostic tool?
Give this one a try later!
GCS
What goal of care should a gerontologic nurse prioritize when working with the
elderly?
Give this one a try later!
Helping older adults use their strengths to optimize independence.
What electrolyte imbalance is present when the nurse observes a positive Chvostek's
sign?
Give this one a try later!
Hypocalcemia
, A patient with possible bacterial meningitis is admitted to the ICU.What assessment
finding would the nurse expect for a patient with this diagnosis?
Give this one a try later!
Neck flexion produces flexion of knees and hips.
During a pulmonary assessment, the nurse observes the chest for symmetry. The nurse
identifies the findings as normal. Which of the following would be consistent with a
normal assessment?
Give this one a try later!
Lateral diameter greater than anteroposterior diameter
When planning the care of a patient with a fluid imbalance, the nurse understands that
in the human body, water and electrolytes move from the arterial capillary bed to the
interstitial fluid. What causes this to occur?
Give this one a try later!
Hydrostatic pressure resulting from the pumping action of the heart
A nurse is developing a care plan for a patient with a partial-thickness burn, and
determines that an appropriate goal is to maintain frequent repositioning. What is the
best rationale for this intervention?
Give this one a try later!
