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Nursing Care Essentials
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1
Question
In which type of shock should the nurse anticipate the use of afterload reducing agents?
Page 4
Answer
Cardiogenic shock
2
Question
A client reports pain in the jaw, back, shoulder, shortness of breath, and nausea. What action should the nurse take?
Page 4
Answer
Obtain an ECG
3
Question
In the care plan for a patient 2 hours post-surgery, what intervention decreases the risk of pulmonary emboli?
Page 4
Answer
Early ambulation
4
Question
For a client with stroke and residual dysphagia, what should the nurse avoid when initiating the diet?
Page 4
Answer
Giving the client thin liquids
5
Question
Potential complication of brain tumor: pituitary dysfunction
Page 4
Answer
Yes
6
Question
Potential complication of brain tumor: cerebral edema
Page 4
Answer
Yes
7
Question
Potential complication of brain tumor: vision loss
Page 4
Answer
Yes
8
Question
Potential complication of brain tumor: focal neurologic deficits
Page 4
Answer
Yes
9
Question
Definition of a primary brain tumor
Page 5
Answer
Originated from a single cell that is genetically different from nearby cells
10
Question
In a trauma patient who hit the windshield with forehead in a car crash, contrecoup brain injury affects which area?
Page 4
Answer
Occipital
11
Question
Priority assessment after alteplase (Activase) administration
Page 5
Answer
Bleeding
12
Question
Complication of pulmonary embolism
Page 5
Answer
Right-sided heart failure
13
Question
Priority action for client with suspected brain tumor and diabetes insipidus
Page 5
Answer
Obtain blood pressure
14
Question
Patient 60 kg receiving norepinephrine 50 mL/hr from 1 mg/250 mL NS. Dose in mcg/min?
Page 5
Answer
3 mcg/min
15
Question
Doll's eyes (oculocephalic reflex) absent indicates?
Page 5
Answer
Disruption in normal brainstem processing
16
Question
Doll's eyes present in opposite direction to head turn indicates?
Page 5
Answer
Intact reflex
17
Question
Presence of cervical injuries related to doll's eyes test?
Page 5
Answer
Contraindication
18
Question
Key information for parents of 6YO with redness and conjunctivitis
Page 5
Answer
Handwashing can prevent spread to others
19
Question
Early indications of increased ICP in traumatic brain injury
Page 5
Answer
Restlessness, confusion, LOC
20
Question
Post-CABG patient with low BP, narrow pulse pressure, tachycardia, muffled heart sounds likely has?
Page 7
Answer
Cardiac tamponade
21
Question
Intervention to help MS client avoid urinary incontinence
Page 7
Answer
Establish a regular voiding schedule
22
Question
Basilar skull fracture may cause?
Page 7
Answer
Cerebral spinal fluid leaks from nose or ears
23
Question
Early sign of hypoxemia
Page 7
Answer
Restlessness
24
Question
Condition where mitral valve orifice narrowed and blood flow obstructed during diastole
Page 7
Answer
Mitral valve stenosis
25
Question
Clinical manifestations of autonomic dysreflexia
Page 7
Answer
Bradycardia and hypertension
26
Question
Nursing interventions for patient with renal failure vascular graft (select all)
Page 7
Answer
Palpate for thrill
27
Question
Nursing interventions for patient with renal failure vascular graft
Page 7
Answer
Palpate for bruit
28
Question
Nursing interventions for patient with renal failure vascular graft
Page 7
Answer
Don't take BP on that arm
29
Question
Primary cause of anemia in chronic renal failure
Page 7
Answer
Decreased renal production of erythropoietin
30
Question
Chest tube and drainage system: fluid fluctuating in water-seal compartment/bottle indicates?
Page 7
Answer
Assess for leaks