Capstone exam -2 Questions and Answers

Capstone exam -2 Questions and Answers The nurse cares for a client who is at 39 weeks gestation. The healthcare provider orders a biophysical profile (BPP). The nurse should understand that an abnormal biophysical profile (BPP) indicates that labor needs to be induced The nurse cares for a client with Celiac disease who is receiving supplemental magnesium in their IV fluids. Which symptom would alert the nurse that the client's magnesium level has become too high? Diminished deep tendon reflexes A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? Fluid and electrolyte imbalance The nurse cares for a client who had a cholecystectomy 24 hours ago. The nurse notes that the T-tube has drained 750 mL of brownish-green drainage since the surgery. Which nursing intervention is most appropriate? Document the findings in the chart electrical burn? Color or urine, skin turgor, amount of urine. In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share? Saturated fats are found mostly in animal sources. A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GERD is needed? "I eat small meals and have a bedtime snack." The nurse cares for a client who had a parathyroidectomy 2 days ago. The client now appears irritable, and complains of tingling/numbness in the face and ears. Laboratory results show: Potassium 3.2 mEq/L, Sodium 138 mEq/L, Calcium 8.2 mg/dL. Which lunch tray is most appropriate for this client? Grilled cheese sandwich, collard greens and yogurt The nurse cares for a client with end-stage renal failure who is exhibiting extreme thirst, confusion, and dry flushed skin. The client's laboratory results show the following: Potassium 3.4 mEq/L, Sodium 155 mEq/L, Calcium 9.5 mg/dL. The nurse would expect to implement which intervention? Restrict sodium intake The nurse cares for a client who was admitted for chest pain. The nurse notes the following rhythm on the monitor. Which intervention is most appropriate? Evaluate client condition The nursing assistant informs the nurse that a client with chronic renal failure has "white crystals" and dry, itchy skin. What instruction should the nurse give to the nursing assistant? Prepare a tepid-water bath for the client 9 units Heparin infusion? 17.3 bolus of 1 liter normal saline over 3 hours? 333 insulin drip of 13 units per hour? 6 insulin drip of 12 units per hour? 5 14 units Heparin infusion? 26.8 dopamine at 8 mcg, supplied an 800mg in 250mL D5W? 20 dopamine at 8 mcg, supplied as 1200mg in 250mL D5W? 13 peritoneal dialysis? Check for obstruction, turn patient, and call doctor. The nurse is providing discharge teaching to a patient who was hospitalized for the treatment of a kidney stone. The type of kidney stone the patient experienced was a uric acid type stone. What type of foods will you educate the patient to avoid ? [select all that apply] Liver Scallops Pork The nurse cares for a client 24 hours after surgery to repair a traumatic right leg injury due to shark attack. The client's vital signs at 0700 are: BP 102/72, HR 88, Temp 98.2, Resp 12, 02 saturation 96% on 2L NC. At 1200, the client's vital signs are: 86/58, HR 126, Temp 98.0, Resp 20, 02 saturation 90% on 2L NC. The nurse notes that the client is restless and agitated, with cool, pale skin. Which interventions are appropriate for this client? Select all that apply. One, some, or all may be correct. Initiate 1L normal saline IV fluid bolus Give 2 units packed RBC's The nurse is caring for a client with a known cardiac disease. The primary care physician had prescribed Isosorbide mononitrate (Imdur) 30 mg PO prn for symptoms of angina pectoris. Past medical history indicates a traumatic head trauma 1 year ago due to dizziness. What does the nurse do first? Perform orthostatic blood pressure A client with osteoporosis, is prescribed to take Calcitonin. Which assessment finding below is a possible adverse reaction of this medication and requires you notify the physician immediately? Carpopedal spasm while assessing the patient's blood pressure A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication? White blood cell count, 3000 mm3 The serum ammonia level of a client with cirrhosis is elevated. As a priority, a nurse should plan to: observe for increasing confusion. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? Blood pressure is 90/40 mm Hg. The nurse cares for a client who underwent colon resection surgery yesterday. The client's vital signs at 0800 are: BP 135/88, HR 92, Temp 98.8, Resp 16, 02 saturation 94%/2L NC. The nurse collects the client's vital signs at 1000. Which vital sign is most important for the nurse to address? BP 102/66 The healthcare provider orders an EMG for a client in the hospital setting. The client asks the nurse what this test will examine. The nurse's best response is: This test measures the electrical activity in your muscles." nurse is caring for a client with the following lab values. Which value would most concern the nurse? Platelet 128 uL The nurse is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse anticipate? Hgb 10g/dl The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign or symptom of this oncological emergency? Electrocardiographic changes The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply. One, some, or all may be correct. Facial edema in the morning Serum calcium level of 12 mg/dL (3.0 mmol/L) Numbness and tingling of the lower extremities A patient has sustained head and chest injuries from a motor vehicle accident. What clinical manifestations indicate that they are ready to transfer to a critical care unit after responding well to medical treatments? Stabilized vital signs and complaints of pain A patient becomes cyanotic during a generalized tonic-clinic seizure. Which is the most appropriate action by the nurse? Continuing to observe the seizure Hypertension is also common because of hypervolemia secondary to kidney dysfunction. The nurse assesses a client suspected of having meningitis for meningeal irritation and notices a positive Brudzinski's sign. Which finding did the nurse observe? The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. The nurse assesses a client on the neurovascular unit. When the nurse entered the room, the client was resting in bed with their eyes closed. As the nurse clicked on the lights, the client opened their eyes. The client was able to move their hands and feet on request. The client correctly reported their name, the year and date, but stated that they are in a shopping mall. According to the Glasgow Coma Scale (see below), the nurse would report what value? 14 After a 5 year old undergoes a craniotomy, the nurse performs a neurological assessment that includes the level of consciousness, pupillary activity, and reflex activity. Which would the nurse include in the assessment? Motor function The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next? Give the patient 4 to 6 oz more orange juice. The nurse cares for a hospitalized client who was admitted for left-sided heart failure. Which nursing assessment is most appropriate for this client? Listening to lung sounds The nurse cares for a client admitted with pericarditis. Which symptom should the nurse communicate to the healthcare provider immediately? Jugular venous distention The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which would the nurse check first? . Baseline fetal heart rate Which of these clients are most likely to develop fluid (circulatory) overload? Select al that apply. One, some, or all may be correct. A. A premature infant B. A 101-year-old man C . A client with heart fallure E. A client receiving renal dialysis The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? A platelet count of 50,000 mm3 (50 × 109/L) The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom would the nurse expect to note in this client? an increase in blood pressure A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.3 mmol/L). The nurse would next prepare to administer which medication? C. IV fluids containing dextrose The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse would tell the client that which food item is least likely to contain calcium? butter Decerebrate posturing position of an unconscious person where the upper extremities and lower extremities are extended and the wrists are flexed Positive Kernig's Sign neck pain when flexing the leg at the (Meningitis) Negative Babinski's sign Toes curl downward. (normal) Decorticate posturing arms flexed inward and bent in toward the body and the legs are extended Hypercalcemia shortened QT interval Hypocalcemia lengthened QT interval Hypokalemia widened T wave Hyperkalemia Pointed T wave coronary angiogram? a change in rhythm or tachycardia Heart failure? improved exercise tolerance and decreased dyspnea sepsis? decreasing systolic blood pressure sign of septic shock ! vital signs for a client post-operative? An increasing heart rate. it could be pain, anxiety, a complication heart rate from 80 to 100 Hyperkalemia (Potassium 4.5? Administer calcium gluconate. Hypernatremia (Sodium 145) Encourage fluids. The nurse is teaching parents of an infant with newly diagnosed heart failure how to care for the infant at home. The infant is on diuretic therapy. The nurse should suggest which most appropriate method to assess strict urine output? Weighing diapers Fluid balance post-op? Edema, crackles, weight gain MAP = multiply diastolic pressure by 2 + systolic pressure / 3 (should be at least 60 mm/Hg) Myasthenia Gravis? Circulatory tingle (unrelated tingle)