CCN Flashcards
(126 cards)
1
Q
The nurse is discussing complications of chronic pancreatitis with a client diagnosed with the disease. Which complication should the nurse discuss with the client?
Diabetes insipidus.
Crohns disease.
Narcotic addiction.
Peritonitis
A
Narcotic addiction.
2
Q
The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit?
Hematochezia
Left upper abdominal pain
Ascites and peripheral edema
Temperature over 102o F (38.9o C)
A
Left upper abdominal pain
3
Q
The male client diagnosed with chronic pancreatitis calls and reports to the clinic nurse that he has been having a lot of “gas,” along with frothy and very foul-smelling stools. Which action should the nurse take?
Explain that this is common for chronic pancreatitis.
Ask the client to bring in a stool specimen to the clinic
Arrange an appointment with the HCP for today.
Discuss the need to decrease fat in the diet so that this won’t happen.
A
Arrange an appointment with the HCP for today.
4
Q
A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of Cullen’s sign. Which of the following is an appropriate action by the nurse to identify this finding?
Tap lightly at the costovertebral margin on the clients back
Palpate the client’s right lower quadrant
Inspect the skin around the umbilicus
Auscultate the area below the client’s scapula
A
Inspect the skin around the umbilicus
5
Q
A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to be reported to the provider?
A. History of cholelithiasis
B. Serum amylase levels three times greater than the expected value
C. client report of severe pain radiating to the back that is rated at an “8”
D. Hand spasms present when blood pressure is checked
A
D. Hand spasms present when blood pressure is checked
6
Q
Pancreatitis is commonly characterized by:
Edema and inflammation
Pleural effusion.
Sepsis,
Disseminated intravascular coagulopathy.
A
Edema and inflammation
7
Q
Nursing measures for pain relief for pancreatitis include:
A. Encouraging bed rest to decrease metabolic rate,
B. Teaching the patient about the correlation between alcohol intake and pain.
C. Withholding oral feedings to limit the release of secretin.
D. All of the above.
A
D. All of the above.
8
Q
The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient’s plan of care?
A. Immediately start enteral feeding to prevent malnutrition.
B. Insert an NG and maintain NPO status to allow pancreas to rest.
C. Initiate early prophylactic antibiotic therapy to prevent infection.
D. Administer acetaminophen (Tylenol) every 4 hours for pain relief.
A
B. Insert an NG and maintain NPO status to allow pancreas to rest.
9
Q
The client is diagnosed with acute pancreatitis. Which health care provider’s admitting order should the nurse question?
Bed rest with bathroom privileges
Initiate IV therapy at D5W 125 mL/hr.
Weigh client daily.
Low-fat, low-carbohydrate diet.
A
Low-fat, low-carbohydrate diet.
10
Q
A nurse is completing an admission assessment of a lient who has pancreatitis. Which of the following findings should the nurse expect?
Pain in the UG rating to the shoulder
Report of pain being worse when sitting upright
Pain relieved with defecation
Epigastric pain radiating to the left shoulder
A
Epigastric pain radiating to the left shoulder
11
Q
The cllent has just had an endoscopic retrograde cholangiopancreatogram (ERCP). Which post-procedure interyention should the nurse implement?
Assess for rectal bleeding.
Increase fluid intake.
Assess gag reflex
Keep in supine position.
A
Assess gag reflex
12
Q
The client with an acute exacerbation of chronic pancreatitis has a nasogastric tube and is NPO. Which interventions should the nurse implement? Select all that apply.
Monitor the bowel sounds
Weigh the client daily.
Assess the intravenous site.
Provide oral and nasal care.
Monitor the blood glucose
A
Monitor the bowel sounds
Weigh the client daily.
Assess the intravenous site.
Provide oral and nasal care.
Monitor the blood glucose
13
Q
Which of the following diagnostic studies could identify an increase in the diameter of the pancreas?
X-ray.
Hemoglobin and hematocrit levels.
Utrasound.
serum amylase
A
Utrasound
14
Q
.
A
15
Q
.
A
16
Q
A major symptom of pancreatitis that brings the patient to medical care is:
Severe abdominal pain.
Fever.
Jaundice.
Mental agitation.
A
Severe abdominal pain.
17
Q
The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain?
Recommend lying in the prone position with legs extended.
Maintain a tripod position over the bedside table.
Place in side-lying position with knees flexed.
Encourage a supine position with a pillow under the knees.
A
Place in side-lying position with knees flexed
18
Q
The nurse is preparing to administer A.M. medications to the following clients. Which medication should the nurse question before administering?
A. Pancreatic enzymes to the client who has finished breakfast.
B. The pain medication, morphine, to the client who has a respiratory rate of 20.
C. The loop diuretic to the client who has a serum potassium level of 3.9 mEq/L.
D. The beta blocker to the client who has an apical pulse of 68 bpm,
A
A. Pancreatic enzymes to the client who has finished breakfast.
19
Q
The nurse is completing discharge teaching to the client diagnosed with acute pancre- atitis. Which instruction should the nurse discuss with the client?
A. Instruct the client to decrease alcohol intake.
B. Explain the need to avoid all stress.
C. Discuss the importance of stopping smoking
D. Teach the correct way to take pancreatic enzymes.
A
C. Discuss the importance of stopping smoking
20
Q
The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of:
Serum calcium
Serum lipase
Serum bilirubin
Serum amylase.
A
Serum lipase
21
Q
A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient’s increased risk of bleeding. The nurse recognizes that this risk is related to the patient’s inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?
A. Alterations in glucose metabolism
B. Retention of bile salts
C. Inadequate production of albumin by hepatocytes
D. Inability of the liver to use vitamin K
A
D. Inability of the liver to use vitamin K
22
Q
A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient’s liver?
A. Place hand under the right lower abdominal quadrant and press down lightly with the otherhand.
B. Place the left hand over the abdomen and behind the left side at the 11th rib.
C. Place hand under right lower rib cage and press down lightly with the other hand.
D. Hold hand 90 degrees to right side of the abdomen and push down firmly
A
C. Place hand under right lower rib cage and press down lightly with the other hand.
23
Q
.
A
24
Q
.
A
25
.
26
.
27
.
28
W hich of the following is considered a “hallmark” symptom of pancreatitis?
Vomiting
Mid-epigastric pain that radiates to the back
Gradual onset of pain
Alcohol consumption
Mid-epigastric pain that radiates to the back
29
A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings?
Malnutrition
Osteomyelitis
Alcohol abuse
Diabetes mellitus
Alcohol abuse
30
Which of the following can be used in the treatment of acute pancreatitis? Select all that apply.
Parenteral fluids
Nasogastric suctioning
Corticosteroids
H2 receptor antagonists
Narcotics or Demerol
Surgical resection of the pancreas
Parenteral fluids
Nasogastric suctioning
H2 receptor antagonists
Narcotics or Demerol
31
Which lab test result would indicate that Mr. Walker has acute pancreatitis?
Elevated bilirubin levels
Elevated serum lipase and amylase levels
Low white blood cell count
Elevated blood alcohol level
Elevated serum lipase and amylase levels
32
A nurse is completing nutritional teaching for a client who has pancreatitis, Which of the following statements by the client indicates an understanding of the teaching? (SATA)
A. plan to eat small, frequent meals.
B. I will eat easy-to-digest foods with limited spice
C. I will use skim milk when cooking
D. I plan to drink regular cola
E. I will limit alcohol intake to two drinkers per day
A. plan to eat small, frequent meals.
B. I will eat easy-to-digest foods with limited spice
C. I will use skim milk when cooking
33
Nursing management of the patient with acute pancreatitis includes: (SATA)
A. Check for signs of hypocalcemia
B. Provide a diet low in carbohydrates
C. Observing stools for signs of steatorhea
D. Giving insulin based on sliding scale
E. Monitoring fot infection, particularly respiratory tract infection
A. Check for signs of hypocalcemia
E. Monitoring fot infection, particularly respiratory tract infection
34
What client problem has a priority for the client diagnosed with acute pancreatitis?
A. Risk for fluid volume deficient
B. Alteration in comfort
C. Imbalanced nutrition: less than the body requires
D. Knowledge deficient
B. Alteration in comfort
35
The patient with HHS presented with a glucose levetl of 800 mg/dL and is started on IV fluids and insulin. What action do you anticipate when the patient's glucose reaches 250 mg/dL?
A. Administer an intravenous (IV) solution with 5% dextrose.
B Administer sodium polystyrene sulfate (Kayexalate).
C. Slow the IV infusion rate to 40 mL/hour.
D.Assess cardiac monitoring for peaked T waves.
A. Administer an intravenous (IV) solution with 5% dextrose.
36
What is a typical finding of hyperosmolar hyperglycemic syndrome (HHS)?
A. Occurs in type 1 diabetes as the presenting symptom
B. Slow onset resulting in a blood glucose level greater than 600 mg/dL
C. Ketone bodies higher than 4+ in urine
D. Signs and symptoms of diabetes insipidus
B. Slow onset resulting in a blood glucose level greater than 600 mg/dL
37
A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessment of the patient, you suspect DKA rather than HHS based on the finding of
A. polyuria.
B. severe dehydration.
C. rapid, deep respirations.
D. decreased serum potassium.
C. rapid, deep respirations.
38
What is a finding in DKA that is not seen in hyperosmolar hyperglycemic syndrome (HHS)?
A. Glucose level above 400 mg/dL
B. Hyperkalemia
C. Ketones in blood
D. Urine output of 30 mL/hr
C. Ketones in blood
39
Which assessment is the most sensitive indicator that the lV fluid administration may be too rapid when treating a patient with DKA and a history of renal disease?
A. Pedal edema
B. Tachypnea
C. Urine output of 40 mL/hour
D. Change in the level consciousness
D. Change in the level consciousness
40
The patient presents to emergency department with a glucose level of 400 rg/dL, ketone result of 2+, and rapid respirations with fruity odor. What finding do you anticipate?
A. pH below 7.30
B. Urine specific gravity below 1.005
C. High sodium bicarbonate levels
D. Low blood urea nitrogen (BUN) level
A. pH below 7.30
41
The patient in the emergency department is diagnosed with diabetic ketoacidosis. Which laboratory value is essential for you to monitor?
A. Magnesium (Mg)
B. Hemoglobin (H)
C. White blood cells (WBCs)
D. Potassium (K)
D. Potassium (K)
42
The patient with type 1 diabetes arrives in the emergency department with a glucose level of 390 mg/dL and positive result for ketones. Vital signs are 110/70 mm Hg, 120 beats/minute and 28 deep, sighing respirations/minute. What is the priority need for the patient?
A. Oxygen
B. Intravenous (IV) fluids
C. Albuterol (Ventolin)
D. Metformin (Glucophage)
B. Intravenous (IV) fluids
43
The patient has type 1 diabetes mellitus and is found unresponsive with cool and clammy skin. What action is a priority?
A. Obtain a serum glucose level.
B. Give hard candy under the tongue.
C. Administer glucagon per standing order
D. Notify the health care provider.
C. Administer glucagon per standing order
44
The client diagnosed with acute pancreatitis is being discharged home. Which statement by the client indicates the teaching has been effective?
1. "I should decrease my intake of coffee, tea, and cola."
2. "I will eat a low-fat diet and avoid spicy foods."
3. "I will check my amylase and lipase levels daily."
4. "I will return to work tomorrow but take it easy."
2. "I will eat a low-fat diet and avoid spicy foods."
45
The nurse is assessing a client with complaints of vague upper abdominal pain that is worse at night but is relieved by sitting up and leaning forward. Which assessment question should the nurse ask next?
1. "Have you noticed a yellow haze when you look at things?"
2. "Does the pain get worse when you eat a meal or snack?"
3. "Have you had your amylase and lipase checked recently?"
4. "How much weight have you gained since you saw the HCP?"
2. "Does the pain get worse when you eat a meal or snack?"
46
The nurse caring for a client diagnosed with cancer of the pancreas writes the collaborative problem of "altered nutrition." Which intervention should the nurse include in the plan of care?
1. Continuous feedings via PEG tube.
2. Have the family bring in foods from home.
3. Assess for food preferences.
4. Refer to the dietitian.
4. Refer to the dietitian.
47
The client is being admitted to the outpatient department prior to an endoscopic retrograde cholangiopancreatogram (ERCP) to rule out cancer of the pancreas. Which pre-procedure instruction should the nurse teach?
1. Prepare to be admitted to the hospital after the procedure for observation.
2. If something happens during the procedure, then emergency surgery will be done.
3. Do not eat or drink anything after midnight the night before the test.
4. If done correctly, this procedure will correct the blockage of the stomach.
3. Do not eat or drink anything after midnight the night before the test.
48
The client admitted to rule out pancreatic islet tumors complains of feeling weak, shaky, and sweaty. Which should be the first intervention implemented by the nurse?
1. Start an IV with D5W.
2. Notify the health-care provider.
3. Perform a bedside glucose check.
4. Give the client some orange juice.
3. Perform a bedside glucose check.
49
Which client problem is the nurse's priority concern for the client diagnosed with acute pancreatitis?
1. Impaired nutrition.
2. Skin integrity.
3. Anxiety.
4. Pain relief.
4. Pain relief.
50
Which laboratory data indicate the client's pancreatitis is improving?
1. The amylase and lipase serum levels are decreased.
2. The white blood cell count (WBC) is decreased.
3. The conjugated and unconjugated bilirubin levels are decreased.
4. The blood urea nitrogen (BUN) serum level is decreased.
1. The amylase and lipase serum levels are decreased.
51
The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?
1. Deep tendon reflexes.
2. Arterial blood gases.
3. Skin turgor.
4. Capillary refill time.
1. Deep tendon reflexes.
52
Inside the pancreas are special cells that secrete digestive enzymes and hormones. The cells that secrete digestive enzymes are known as ______________ cells.
A. Islet of Langerhans
B. Protease
C. Acinar
D. Amylase
C. Acinar
53
From the pancreas and gallbladder, the common bile duct and pancreatic duct open into the ____________ where digestive enzymes and bile flow into the duodenum via the major duodenal papilla which is surrounded by a muscular valve that controls the release of digestive enzymes known as the ______________.
A. ampulla of vater, sphincter of Oddi
B. papilla of vater, sphincter of Oddi
C. minor duodenal papilla, ampulla of vater
D. jejunum, sphincter of pylori
A. ampulla of vater, sphincter of Oddi
54
Select-ALL-that-apply: In the pancreas, the acinar cells release:
A. Amylase
B. Somatostatin
C. Lipase
D. Protease
A. Amylase
C. Lipase
D. Protease
55
You're caring for a 45 year old patient who is admitted with suspected acute pancreatitis. The patient reports having extreme mid-epigastric pain that radiates to the back. The patient states the pain started last night after eating fast food. As the nurse, you know the two most common causes of acute pancreatitis are:
A. High cholesterol and alcohol abuse
B. History of diabetes and smoking
C. Pancreatic cancer and obesity
D. Gallstones and alcohol abuse
D. Gallstones and alcohol abuse
56
Which patient below is at MOST risk for CHRONIC pancreatitis?
A. A 25 year old female with a family history of gallstones.
B. A 35 year old male who reports social drinking of alcohol.
C. A 15 year old female with cystic fibrosis.
D. A 66 year old female with stomach cancer.
C. A 15 year old female with cystic fibrosis.
57
Your patient with acute pancreatitis is scheduled for a test that will use a scope to assess the pancreas, bile ducts, and gallbladder. The patient asks you, "What is the name of the test I’m going for later today?" You tell the patient it is called:
A. MRCP
B. ERCP
C. CT scan of the abdomen
D. EGD
B. ERCP
58
A patient is admitted to the ER with the following signs and symptoms: very painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, you notice bluish discoloration around the belly button. As the nurse, you know this is called?
A. Grey-Turner's Sign
B. McBurney's Sign
C. Homan's Sign
D. Cullen's Sign
D. Cullen's Sign
59
While assisting a patient with chronic pancreatitis to the bathroom, you note the patient's stool to be oily/greasy in appearance. In your documentation you note this as:
A. Steatorrhea
B. Melena
C. Currant
D. Hematochezia
A. Steatorrhea
60
A patient with acute pancreatitis is reporting excessive thirst, excessive voiding, and blurred vision. As the nurse, it is priority you?
A. Reassure the patient this is normal with pancreatitis
B. Check the patient's blood glucose
C. Assist the patient with drinking a simple sugar drink like orange juice
D. Provide a dark and calm environment
B. Check the patient's blood glucose
61
A patient who received treatment for pancreatitis is being discharged home. You're providing diet teaching to the patient. Which statement by the patient requires immediate re-education about the diet restrictions?
A. "It will be hard but I will eat a diet low in fat and avoid greasy foods."
B. "It is very important I limit my alcohol intake to no more than 2-3 glasses of wine a week."
C. "I will concentrate on eating complex carbohydrates rather than refined carbohydrates."
D. "I will purchase foods that are high in protein."
B. "It is very important I limit my alcohol intake to no more than 2-3 glasses of wine a week."
62
The physician orders a patient with pancreatitis to take a pancreatic enzyme. What assessment finding demonstrates the pancreatic enzymes are working properly?
A. Abdominal girth is decreased
B. Skin turgor is less than 2 seconds
C. Blood glucose is 250
D. Stools appear formed and solid
D. Stools appear formed and solid
63
During a home health visit, you are assessing how a patient takes the prescribed pancreatic enzyme. The patient is unable to swallow the capsule whole, so they open the capsule and mix the beads inside the capsule with food/drink. Which food or drink is safe for the patient to mix the beads with?
A. Pudding
B. Ice cream
C. Milk
D. Applesauce
D. Applesauce
64
Which of the following is not a sign or symptom of Diabetic Ketoacidosis?
Positive Ketones in the urine
Oliguria
Polydipsia
Abdominal Pain
Oliguria
65
A patient is admitted with Diabetic Ketoacidosis. The physician orders intravenous fluids of 0.9% Normal regular insulin N bolus and then 10 Saline and 10 units of intravenous start an insulin drip, per protocol. The, the following. pH labs are Glucose 455, potassium 2.5 5. Which of the following is the most appropriate nursing intervention to perform next?
A. Start the IV fluids and administer the
B. Hold the insulin and notify the doctor of the potassium level of 2. 5.
C. Hold IV fluids and administer insulin as ordered
B. Hold the insulin and notify the doctor of the potassium level of 2. 5.
66
When priming the tubing for, an Insulin infusion it is best practice to waste 50 cc to 100cc of insulin prior to starting the infusion because insulin absorbs into the plastic lining of the tubing.
True
False
True
67
You are providing care to a patient experiencing diabetic ketoacidosis. The patient IS on an insulin drip and their current glucose level is 300. In addition to this, the patient also has 5% Dextrose 0.45% NS infusing in the right antecubital vein. Which of the following patient signs/symptoms causes concern?
A. Patient complains of thirst.
B. Patient has a potassium level of 2 3
C. Patient's skin and mucous membranes are dry.
D. Patient is nauseous.
B. Patient has a potassium level of 2.3
68
What type of insulin do you expect the doctor to order for treatment of DKA?*
A. IV Novolog
B. IV Levemir
C. IVN PH
D. IV Regular Insulin
D. IV Regular Insulin
69
A patient diagnosed with diabetes mellitus is being discharged home and you are teaching them about preventing DKA. What statement by the patient demonstrates they understood your teaching about this condition?*
A. "I should not be alarmed if ketones are present in my urine because this is expected during illness."
B. "It is normal for my blood sugar to be 250-350 mg/dL while I'm sick."
C. "I will hold off taking my insulin while I'm sick."
D. "It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids."
D. "It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids."
70
Which patient is MOST likely to develop Diabetic Ketoacidosis?*
A. A 25 year old female newly diagnosed with Cushing's Disease is taking glucocorticoids.
B. A 36 year old male with diabetes mellitus who has been unable to eat the past 2 days due to a gastrointestinal illness and has been unable to take insulin.
C. A 35 year old female newly diagnosed with Type 2 diabetes.
D. None of the options are correct.
B. A 36 year old male with diabetes mellitus who has been unable to eat the past 2 days due to a gastrointestinal illness and has been unable to take insulin.
71
Which of the following patients are MOST at risk for developing heart failure? Select-all-that-apply:
A. A 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction.
B. A 55 year old female with a health history of asthma and hypoparathyroidism.
C. A 30 year old male with a history of endocarditis and has severe mitral stenosis.
D. A 45 year old female with lung cancer stage 2.
E. A 58 year old female with uncontrolled hypertension and is being treated for influenza.
A. A 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction.
C. A 30 year old male with a history of endocarditis and has severe mitral stenosis.
E. A 58 year old female with uncontrolled hypertension and is being treated for influenza.
72
A patient is being discharged home after hospitalization of left ventricular systolic dysfunction. As the nurse providing discharge teaching to the patient, which statement is NOT a correct statement about this condition?
A. "Signs and symptoms of this type of heart failure can include: dyspnea, persistent cough, difficulty breathing while lying down, and weight gain."
B. "It is important to monitor your daily weights, fluid and salt intake."
C. "Left-sided heart failure can lead to right-sided heart failure, if left untreated."
D. "This type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema."
D. "This type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema."
73
Which of the following are NOT typical signs and symptoms of right-sided heart failure? Select-all-that-apply:
A. Jugular venous distention
B. Persistent cough
C. Weight gain
D. Crackles
E. Nocturia
F. Orthopnea
B. Persistent cough
D. Crackles
F. Orthopnea
74
A patient is diagnosed with left-sided systolic dysfunction heart failure. Which of the following are expected findings with this condition?
A. Echocardiogram shows an ejection fraction of 38%.
B. Heart catheterization shows an ejection fraction of 65%.
C. Patient has frequent episodes of nocturnal paroxysmal dyspnea.
D. Options A and C are both expected findings with left-sided systolic dysfunction heart failure.
D. Options A and C are both expected findings with left-sided systolic dysfunction heart failure.
75
Patients with left-sided diastolic dysfunction heart failure usually have a normal ejection fraction.
True
False
True
76
A patient has a history of heart failure. Which of the following statements by the patient indicates the patient may be experiencing heart failure exacerbation?
A. “I’ve noticed that I’ve gain 6 lbs in one week.”
B. “While I sleep I have to prop myself up with a pillow so I can breathe.”
C. “I haven’t noticed any swelling in my feet or hands lately.”
D. Options B and C are correct.
E. Options A and B are correct.
F. Options A, B, and C are all correct.
E. Options A and B are correct.
77
Patients with heart failure can experience episodes of exacerbation. All of the patients below have a history of heart failure. Which of the following patients are at MOST risk for heart failure exacerbation?
A. A 55 year old female who limits sodium and fluid intake regularly.
B. A 73 year old male who reports not taking Amiodarone for one month and is experiencing atrial fibrillation.
C. A 67 year old female who is being discharged home from heart valve replacement surgery.
D. A 78 year old male who has a health history of eczema and cystic fibrosis.
B. A 73 year old male who reports not taking Amiodarone for one month and is experiencing atrial fibrillation.
78
A 74 year old female presents to the ER with complaints of dyspnea, persistent cough, and unable to sleep at night due to difficulty breathing. On assessment, you note crackles throughout the lung fields, respiratory rate of 25, and an oxygen saturation of 90% on room air. Which of the following lab results confirm your suspicions of heart failure?
A. K+ 5.6
B. BNP 820
C. BUN 9
D. Troponin <0.02
B. BNP 820
79
Which of the following tests/procedures are NOT used to diagnose heart failure?
A. Echocardiogram
B. Brain natriuretic peptide blood test
C. Nuclear stress test
D. Holter monitoring
D. Holter monitoring
80
What type of heart failure does this statement describe? The ventricle is unable to properly fill with blood because it is too stiff. Therefore, blood backs up into the lungs causing the patient to experience shortness of breath.
A. Left ventricular systolic dysfunction
B. Left ventricular ride-sided dysfunction
C. Right ventricular diastolic dysfunction
D. Left ventricular diastolic dysfunction
D. Left ventricular diastolic dysfunction
81
A patient with left-sided heart failure is having difficulty breathing. Which of the following is the most appropriate nursing intervention?
A. Encourage the patient to cough and deep breathe.
B. Place the patient in Semi-Fowler's position.
C. Assist the patient into High Fowler's position.
D. Perform chest percussion therapy.
C. Assist the patient into High Fowler's position
82
You're providing diet discharge teaching to a patient with a history of heart failure. Which of the following statements made by the patient represents they understood the diet teaching?
A. "I will limit my sodium intake to 5-6 grams a day."
B. "I will be sure to incorporate canned vegetables and fish into my diet."
C. "I'm glad I can still eat sandwiches because I love bologna and cheese sandwiches."
D. "I will limit my consumption of frozen meals."
D. "I will limit my consumption of frozen meals."
83
A patient taking Digoxin is experiencing severe bradycardia, nausea, and vomiting. A lab draw shows that their Digoxin level is 4 ng/mL. What medication do you anticipate the physician to order for this patient?
A. Narcan
B. Aminophylline
C. Digibind
No medication because this is a normal Digoxin level.
C. Digibind
84
Which of the following is a late sign of heart failure?
A. Shortness of breath
B. Orthopnea
C. Edema
D. Frothy-blood tinged sputum
D. Frothy-blood tinged sputum
85
These drugs are used as first-line treatment of heart failure. They work by allowing more blood to flow to the heart which decreases the work load of the heart and allows the kidneys to secrete sodium. However, some patients can develop a nagging cough with these types of drugs. This description describes?
A. Beta-blockers
B. Vasodilators
C. Angiotensin II receptor blockers
D. Angiotensin-converting-enzyme inhibitors
D. Angiotensin-converting-enzyme inhibitors
86
A patient with heart failure is taking Losartan and Spironolactone. The patient is having EKG changes that presents with tall peaked T-waves and flat p-waves. Which of the following lab results confirms these findings?
A. Na+ 135
B. BNP 560
C. K+ 8.0
D. K+ 1.5
C. K+ 8.0
87
You are assisting a patient up from the bed to the bathroom. The patient has swelling in the feet and legs. The patient is receiving treatment for heart failure and is taking Hydralazine and Isordil. Which of the following is a nursing priority for this patient while assisting them to the bathroom?
A. Measure and record the urine voided.
B. Assist the patient up slowing and gradually.
C. Place the call light in the patient's reach while in the bathroom.
D. Provide privacy for the patient.
B. Assist the patient up slowing and gradually.
88
A patient is taking Digoxin. Prior to administration you check the patient's apical pulse and find it to be 61 bpm. Morning lab values are the following: K+ 3.3 and Digoxin level of 5 ng/mL. Which of the following is the correct nursing action?
A. Hold this dose and administer the second dose at 1800.
B. Administer the dose as ordered.
C. Hold the dose and notify the physician of the digoxin level.
D. Hold this dose until the patient’s potassium level is normal.
C. Hold the dose and notify the physician of the digoxin level.
89
Which of the following is a common side effect of Spironolactone?
A. Renal failure
B. Hyperkalemia
C. Hypokalemia
D. Dry cough
B. Hyperkalemia
90
The physician’s order says to administered Lasix 40 mg IV twice a day. The patient has the following morning labs: Na+ 148, BNP 900, K+ 2.0, and BUN 10. Which of the following is a nursing priority?
A. Administer the Lasix as ordered
B. Notify the physician of the BNP level
C. Assess the patient for edema
D. Hold the dose and notify the physician about the potassium level
D. Hold the dose and notify the physician about the potassium level
91
A 55-year-old female arrives to the ER with a right leg fracture. An x-ray is performed and shows a closed tibia fracture. A closed reduction is performed and a cast is put in place. The patient is ordered Morphine 2 mg IV every 4-6 hours as needed for pain. The patient calls on the call light to tell you the pain medication is not working and that it even hurts to slightly stretch the leg. What is your response to this statement by the patient? Select all that apply:
A. Reassure the patient that this is normal after a bone fracture, and reposition the cast.
B. Re-adjust the cast to ensure it fits snugly against the fracture.
C. Perform neurovascular checks.
D. Elevate the leg above heart level.
E. Loosen and remove restrictive items.
F. Notify the physician.
C. Perform neurovascular checks.
E. Loosen and remove restrictive items.
F. Notify the physician.
92
A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse's first intervention?
a. Assess pedal pulses.
b. Apply oxygen by nasal cannula.
c. Increase the IV flow rate.
d. Document the finding.
a. Assess pedal pulses.
93
The nurse is caring for a client with a fractured fibula. Which assessment prompts immediate action by the nurse?
a. Reported pain of 4 on a scale of 0 to 10
b. Numbness and tingling in the extremity
c. Swollen extremity where the injury occurred
d. Reports of being cold in bed
b. Numbness and tingling in the extremity
94
A patient with comminuted fractures of the tibia and fibula is treated with open reduction and application of an external fixator. The next day, the patient complains of severe pain in the leg, which is unrelieved by ordered analgesics. The patient's toes are pink, but the patient complains of numbness and tingling. The most appropriate action by the nurse is to
a. Notify the patient's health care provider.
b. Check the patient's blood pressure.
c. Assess the external fixator pins for redness or drainage.
d. Elevate the extremity and apply ice over the wound site.
a. Notify the patient's health care provider.
95
The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse's response is based on the understanding that:
a. A bone fragment has injured the nerve supply in the area
b. An injured artery causes impaired arterial perfusion through the compartment
c. Bleeding and swelling cause increased pressure in an area that cannot expand
d. The fascia expands with injury, causing pressure on underlying nerves and muscles
c. Bleeding and swelling cause increased pressure in an area that cannot expand
96
A client has an arm cast and reports that it feels really tight and the fingers are puffy. What is the nurse's best response?
a. "Elevate your arm on two pillows and apply ice to the cast."
b. "Continue to take ibuprofen (Motrin) until the swelling subsides."
c. "It is normal for a new cast to feel a little tight for the first few days."
d. "Please come to the clinic today to have your arm checked by the health care provider."
d. "Please come to the clinic today to have your arm checked by the health care provider."
97
Which patient below is at MOST risk for developing a condition called autonomic dysreflexia?
A. A 24-year-old male patient with a traumatic brain injury.
B. A 15-year-old female patient with a spinal cord injury at C7.
C. A 35-year-old male patient with a spinal cord injury at L6.
D. A 42-year-old male patient recovering from a hemorrhagic stroke.
B. A 15-year-old female patient with a spinal cord injury at C7.
98
Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action?
A. Perform a bladder scan
B. Perform a rectal digital examination
C. Assess the patient's blood pressure
D. Administer a PRN medication to alleviate pain and provide a dark, calm environment.
C. Assess the patient's blood pressure
99
You're performing a head-to-toe assessment on a patient with a spinal cord injury at T6. The patient is restless, sweaty, and extremely flushed. You assess the patient's blood pressure and heart rate. The patient’s blood pressure is 140/98 and heart rate is 52. You look at the patient's chart and find that their baseline blood pressure is 106/76 and heart rate is 72. What action should the nurse take FIRST?
A. Reassess the patient’s blood pressure.
B. Check the patient's blood glucose.
C. Position the patient at 90 degrees and lower the legs.
D. Provide cooling blankets for the patient.
C. Position the patient at 90 degrees and lower the legs.
100
You’re providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select all the most common causes you will discuss during the in-service:
A. Hypoglycemia
B. Distended bladder
C. Sacral pressure injury
D. Fecal impaction
E. Urinary tract infection
B. Distended bladder
C. Sacral pressure injury
D. Fecal impaction
E. Urinary tract infection
101
After taking all the necessary steps for a patient who has developed autonomic dysreflexia, what should the nurse assess FIRST as a possible cause of this condition?
A. Skin break down
B. Blood glucose
C. Possible bladder irritant
D. Last bowel movement
C. Possible bladder irritant
102
The physician orders Nitropaste for a patient who has developed autonomic dysreflexia. Which finding would require the nurse to hold the ordered dose of Nitropaste and notify the physician?
A. The patient’s blood pressure is 130/80.
B. The patient reports a throbbing headache.
C. The patient’s lower extremities are pale and cool.
D. The patient states they took Sildenafil 12 hours ago.
D. The patient states they took Sildenafil 12 hours ago.
103
A patient is receiving treatment for a complete spinal cord injury at T4. As the nurse you know to educate the patient on the signs and symptoms of autonomic dysreflexia What signs and symptoms will you educate the patient about? Select all that apply:
A. Headache
B. Low blood glucose
C. Sweating
D. Flushed below site of injury
E. Pale and cool above site of injury
F. Hypertension
G. Slow heart rate
H. Stuffy nose
A. Headache
C. Sweating
F. Hypertension
G. Slow heart rate
H. Stuffy nose
104
What is the BEST position for a patient experiencing autonomic dysreflexia?
A. High Fowler's with legs lowered
B. Low Fowler's with legs lowered
C. Semi-Fowler's with legs at heart level
D. Prone
A. High Fowler's with legs lowered
105
In autonomic dysreflexia, the nurse would expect what finding below the site of the spinal cord injury?
A. Flushed lower body
B. Pale and cool lower extremities
C. Low blood pressure
D. Absent reflexes
B. Pale and cool lower extremities
106
Which statements are TRUE about autonomic dysreflexia? Select all that apply:
A. "Autonomic dysreflexia is an exaggerated reflex response by the parasympathetic nervous system that results in severe hypertension due to a spinal cord injury."
B. "Autonomic dysreflexia causes a slow heart rate and severe hypertension."
C. "Autonomic dysreflexia is less likely to occur in a patient who has experienced a lumbar injury."
D. "The first-line of treatment for autonomic dysreflexia is an antihypertensive medication."
B. "Autonomic dysreflexia causes a slow heart rate and severe hypertension."
C. "Autonomic dysreflexia is less likely to occur in a patient who has experienced a lumbar injury."
107
The nurse is about to assess for bowel impaction in a patient who has developed autonomic dysreflexia. The nurse makes it priority to?
A. Avoid using lubricants
B. Stimulate the bowel with rectal manipulation
C. Slowly administer a saline solution prior to assessment
D. Instill an anesthetic jelly prior to assessment
D. Instill an anesthetic jelly prior to assessment
108
Select the main structures below that play a role with altering intracranial pressure:
A. Brain
B. Neurons
C. Cerebrospinal Fluid
D. Blood
E. Periosteum
F. Dura mater
A. Brain
C. Cerebrospinal Fluid
D. Blood
F. Dura mater
109
The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply:
A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord
B. Vasodilation of cerebral vessels
C. Decreasing cerebrospinal fluid production
D. Leaking proteins into the brain barrier
B. Vasodilation of cerebral vessels
D. Leaking proteins into the brain barrier
110
A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing?
A. Coughing
B. Sneezing
C. Talking
D. Valsalva maneuver
E. Vomiting
F. Keeping the head of the bed between 30- 35 degrees
A. Coughing
B. Sneezing
D. Valsalva maneuver
E. Vomiting
111
A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will?
A. cause vasoconstriction and decrease the ICP
B. promote diuresis and decrease the ICP
C. cause vasodilation and increase the ICP
D. cause vasodilation and decrease the ICP
C. cause vasodilation and increase the ICP
112
You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is:
A. 5-15 mmHg
B. 60-100 mmHg
C. 30-45 mmHg
D. >160 mmHg
B. 60-100 mmHg
113
Which patient below is at MOST risk for increased intracranial pressure?
A. A patient who is experiencing severe hypotension.
B. A patient who is admitted with a traumatic brain injury.
C. A patient who recently experienced a myocardial infarction.
D. A patient post-op from eye surgery.
B. A patient who is admitted with a traumatic brain injury.
114
A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would?
A. Administered PRN dose of a vasopressor
B. Administer 2 L of oxygen
C. Remove extra blankets and give the patient a cool bath
D. Perform suctioning
C. Remove extra blankets and give the patient a cool bath
115
A patient has a ventriculostomy. Which finding would you immediately report to the doctor?
A. Temperature 98.4 'F
B. CPP 70 mmHg
C. ICP 24 mmHg
D. PaCO2 35
C. ICP 24 mmHg
116
External ventricular drains monitor ICP and are inserted where?
A. Subarachnoid space
B. Lateral Ventricle
C. Epidural space
D. Right Ventricle
B. Lateral Ventricle
117
Which of the following is contraindicated in a patient with increased ICP?
A. Lumbar puncture
B. Midline position of the head
C. Hyperosmotic diuretics
D. Barbiturates medications
A. Lumbar puncture
118
You're collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature?
A. Rectal
B. Oral
C. Axillary
A. Rectal
119
A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication?
A. Bradycardia
B. Decerebrate posturing
C. Restlessness
D. Unequal pupil size
C. Restlessness
120
You're maintaining an external ventricular drain. The ICP readings should be?
A. 5 to 15 mmHg
B. 20 to 35 mmHg
C. 60 to 100 mmHg
D. 5 to 25 mmHg
A. 5 to 15 mmHg
121
Which patient below with ICP is experiencing Cushing's Triad? A patient with the following:
A. BP 150/112, HR 110, RR 8
B. BP 90/60, HR 80, RR 22
C. BP 200/60, HR 50, RR 8
D. BP 80/40, HR 49, RR 12
C. BP 200/60, HR 50, RR 8
122
The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient's cerebral perfusion pressure, and how do you interpret this as the nurse?
A. 90 mmHg, normal
B. 62 mmHg, abnormal
C. 36 mmHg, abnormal
D. 56 mmHg, normal
A. 90 mmHg, normal
123
During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as:
A. Decorticate posturing
B. Decerebrate posturing
C. Flaccid posturing
B. Decerebrate posturing
124
While positioning a patient in bed with increased ICP, it important to avoid?
A. Midline positioning of the head
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck
D. Flexion of the hips
D. Flexion of the hips
125
During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find?
A. The eyes will roll down as the head is moved side to side.
B. The eyes will move in the opposite direction as the head is moved side to side.
C. The eyes will roll back as the head is moved side to side.
D. The eyes will be in a fixed mid-line position as the head is moved side to side
D. The eyes will be in a fixed mid-line position as the head is moved side to side
126
A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication?
A. Mannitol will remove water from the brain and place it in the blood to be removed from the body.
B. Mannitol will cause water and electrolyte reabsorption in the renal tubules.
C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion.
D. Mannitol is not for patients who are experiencing anuria.
B. Mannitol will cause water and electrolyte reabsorption in the renal tubules.
