Nursing Practice Questions: Heart Failure, ABG Analysis

 Question 1 1 out of 1 points Based on the etiology and main cause of heart failure, the nurse knows that which client has the greatest need for health promotion measures to prevent heart failure? Selected B. Answer:...

 Question 1 1 out of 1 points Based on the etiology and main cause of heart failure, the nurse knows that which client has the greatest need for health promotion measures to prevent heart failure? Selected B. Answer: A 65-year-old woman with hypertension Answers: A. A 32-year-old man with colorectal cancer. B. A 65-year-old woman with hypertension C. An 86-year-old man with a history of asthma. D. A 53-year-old with Parkinson disease Response Heart failure (HF) is caused by systemic hyper-tension in Feedback: most cases. Some clients experienc-ing myocardial infarction (MI, “heart attack”) also develop HF. The next most common cause is structural heart changes, such as valvular dysfunction, particularly pulmonic or aortic stenosis, which leads to pressure or volume overload on the heart.  Question 2 1 out of 1 points  What assessment data is needed prior to the administration of sublingual nitro (Nitro SL)? Selected C. Answer: Blood pressure Answers: A. Respiratory status B. EKG results C. Blood pressure D. Heart rate Response Nitro is given for chest pain and a BP needs be assessed Feedback: prior to administration as nitro is a strong vasodialater. Nitro does not affect HR or oxygenation status. It is given for chest pain and not dependent on EKG results.  Question 3 1 out of 1 points Match each medication on the left with its primary purpose on the right. o Question Correct Match Selected Match Nitroglycer D. D. in Relieve chest pain by Relieve chest pain by dilating vessels. dilating vessels.  Aspirin A. A. (ASA) Prevent platelet Prevent platelet aggregation. aggregation. Clopidogre B. B. l Prevent clot formation Prevent clot formation after stents. after stents. Atorvastati C. C. n Reduce cholesterol Reduce cholesterol levels. levels. o All Answer Choices A. Prevent platelet aggregation. B. Prevent clot formation after stents. C. Reduce cholesterol levels. D. Relieve chest pain by dilating vessels. o Response Nitroglycerin - Relieve chest pain by dilating vessels Feedback: Aspirin (ASA) - Prevent platelet aggregation Clopidogrel - Prevent clot formation after stents Atorvastatin - Reduce cholesterol levels  Question 4 1 out of 1 points Which of the following is a hallmark sign of left-sided heart failure? Selected Answer: Pulmonary congestion Answers: Peripheral edema Pulmonary congestion Ascites Jugular vein distension Response Pulmonary congestion, including crackles and Feedback: dyspnea, is a characteristic symptom of left-sided heart failure  Question 5 1 out of 1 points Which client statement should alert the nurse to suspect left-sided heart failure (HF)? Selected A. Answer: “I must stop halfway up the stairs to catch my breath.” Answers: A. “I must stop halfway up the stairs to catch my breath.”  B. “I have experienced blurred vision on several occasions.” C. “I am awakened by the need to urinate at night.” D. “I have been drinking more water than usual.” Response Clients with left-sided heart failure report weakness or Feedback: fatigue while performing normal activities of daily living, as well as difficulty breathing or “catching their breath.” This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.  Question 6 1 out of 1 points You are a nurse on the medical floor and you are doing rounds. You notice a call light and enter the patients room. The patient is stating that he is having chest pain. You take the patients vitals: B/P 154/88 p 110 r 22 T 98.7f What would be your next steps? Selected Answer: Place 02 on the patient and start a nitro trial Answers: Administer acetamophen for the  chest pain. Give a beta-blocker Place 02 on the patient and start a nitro trial Perform immediate PCI  Question 7 1 out of 1 points 1. Ordered: hydroxyzine pamoate 75mg po daily. Available: Patient weight: 264 pounds How many capsules are you going to give this patient? Type in your numerical and unit answer. Selected 3 Answer: capsules Correct Answer: Evaluation Method Correct Answer Case Sen Exact Match 3 tabs Exact Match 3tabs Exact Match 3Tabs Exact Match 3 Tabs  Exact Match 3 Caps Exact Match 3Caps  Question 8 1 out of 1 points The physician orders Ampicillin 500 mg in 90 mL NS IVPB to infuse over 40 minutes. The drop factor is 10 gtt/mL. How many drops per minute (gtt/min) should the nurse infuse? Type in your numerical and unit answers Selected 23 Answer: gtt/min Correct Answer: Evaluation Method Correct Answer Case Sen Exact Match 23 gtt/min Exact Match 23gtt/min Exact Match 23 gtts/min Exact Match 23gtts/min Response Answer: 23gtt/min; 90 mL x 10gtt/mL divided by 40 minutes = Feedback: rounded to 23 gtt/min  Question 9 1 out of 1 points A nurse cares for a client with right-sided heart failure (HF). The client asks, “Why do I need to weigh myself every day?” Which is the correct nursing response? Selected A. Answer:  "Weighing daily provides the best indication of fluid gains and losses." Answers: A. "Weighing daily provides the best indication of fluid gains and losses." B. "The hospital requires that all clients be weighed daily." C. “Daily weights will help us ensure that you’re eating properly.” D. “You need to lose weight to decrease the incidence of heart failure.” Response Daily weight provides the best indication of fluid volume Feedback: balance; they are needed to document fluid retention or loss. One liter of fluid equals 2.2 lb (1 kg) equals 1000 mL. Therefore, weight changes are the most reliable indicator of fluid loss or gain. The other responses do not address the importance of monitoring fluid retention or loss.  Question 10 1 out of 1 points The nurse completes discharge teaching about sublingual nitroglycerin (Nitrostat). Which client statement indicates that teaching has been effective? Selected A. Answer: "This medication may cause headaches and  dizziness." Answers: A. "This medication may cause headaches and dizziness." B. "This medication may increase the frequency of my chest pain." C. "I will take three tablets at once every time I have chest pain." D. "I will take this medication with food or meals." Response Nitroglycerin may cause headaches and dizziness Feedback: secondary to its vasodilatory effects. Nitro has a therapeutic effect in decreasing (not increasing) the frequency of chest pain. The client's statement about taking three tablets at once every time chest pain occurs indicates that the teaching has been ineffective; the client does not client not understand how and when to take Nitro correctly; (take the first tab and wait for 5- minutes to see if angina subsides; repeat this step up to three times). Three rounds of Nitro may not be needed.  Question 1 1 out of 1 points A patient's most recent arterial blood gas (ABG) report indicates that they are experiencing Respiratory Alkalosis. Which ABG result matches this acid-base imbalance? Selected C. Answer:  pH 7.60, CO2 32 mm Hg, HCO3 25 mEq/L Answers: A. pH 7.45, CO2 38 mm Hg, HCO3 24 mEq/L B. pH 7.22, CO2 49 mm Hg, HCO3 26 mEq/L; C. pH 7.60, CO2 32 mm Hg, HCO3 25 mEq/L D. pH 7.26, CO2 60 mm Hg, HCO3 24 mEq/L; Response Correct Answer: pH 7.60 = Alkalosis, CO2 32 = Feedback: Alkalosis, HCO3 25 - STABLE; which reflects Respiratory Alkalosis.  Question 2 1 out of 1 points The nurse is caring for a patient whose most recent ABG results reveal: pH 7.24, CO2 54, HCO3 26. Which acid-base imbalance is the patient exhibiting and which are the most significant etiological factors (causes) of this imbalance? Selected D. Answer: Respiratory acidosis; CNS depression, pulmonary edema, and airway obstruction. Answers: A.  Metabolic acidosis; diabetic ketoacidosis (DKA), renal failure, and diarrhea. B. Metabolic acidosis; vomiting, excess diuretic use, and hyperaldosteronism. C. Respiratory acidosis; elevated body temperature and methamphetamine use. D. Respiratory acidosis; CNS depression, pulmonary edema, and airway obstruction. Response Respiratory acidosis; CNS depression, pulmonary edema, Feedback: and airway obstruction. ABG interpretation; pH 7.24 = ACID, CO2 54 = ACID, HCO3 25 = STABLE. Causes of respiratory acidosis are related to hypoventalation such as narcotics overdose, respiratory arrest, CNS depression, pulmonary edema, airway obstruction, and ches trauma.  Question 3 1 out of 1 points The nurse is caring for a patient whose most recent ABG results reveal: pH 7.49, CO2, 29, HCO3 26. Which acid-base imbalance is the patient exhibiting, and which interventions/orders should the nurse anticipate to help manage this imbalance effectively? Selected B. Answer: Respiratory alkalosis; administer a sedative and rebreather mask utilization. Answers: A.  Respiratory alkalosis; administer a buffer, increase respiratory rate, and treat the underlying cause once identified. B. Respiratory alkalosis; administer a sedative and rebreather mask utilization. C. Respiratory acidosis; decrease respiratory rate and treat causes such as diabetic ketoacidosis ( DKA). D. Respiratory acidosis; position the patient in high fowler's and maintain a patent airway. Response Respiratory alkalosis; administer a sedative and Feedback: rebreather mask utilization. ABG Interpretation: pH 7.49 = Alkalosis, CO2 29 = Alkalosis, and HCO3 26 = STABLE = Respiratory alkalosis. The nurse should anticipate interventions and orders such as administering sedatives, applying a rebreather mask (to rebreathe their CO2 that is low). pr ,ecjamoca; vemto;atopm amd sedation. All of those shich will help decrease the patient's tachy respiratory rate (hyperventilation), which is resulting in a loss (blowing off) of CO2.  Question 4 1 out of 1 points A patient's most recent arterial blood gas (ABG) report indicates they are experiencing Metabolic Acidosis. Which ABG result matches this acid-base imbalance, and is the correct associated cause? Selected D. Answer: pH 7.32, CO2 37 mm Hg, HCO3 20 mEq/L; Diabetic Ketoacidosis (DKA).  Answers: A. pH 7.55, CO 2 30 mm Hg, HCO3 24 mEq/L; Opioid overdose. B. pH 7.55, CO2 38 mm Hg, HCO3 40 mEq/L; Chest Trauma C. pH 7.26, CO2 60 mm Hg, HCO3 25 mEq/L; Asthma attack. D. pH 7.32, CO2 37 mm Hg, HCO3 20 mEq/L; Diabetic Ketoacidosis (DKA). Response Metabolic acidosis is demonstrated via pH 7.32 = ACID, Feedback: CO2 37 = STABLE, and HCO3 20 = ACID. Associated causes of Metabolic Acidosis ae as follows; acid gain secondary to starvation, diabetic ketoacidosis, renal failure, lactic acidosis, shock, sepsis, bicarbonate loss, severe diarrhea or bile drainage, an overdose of Salicylates (Aspirin (ASA) ), or ethanol (alcohol ETOH).  Question 5 1 out of 1 points Which client's arterial blood gas results would the nurse interpret as within normal limits? Selected C. Answer: pH 7.45, CO2 41, HCO3 25 Answers: A. pH 7.30, CO2 66,  HCO3 38 B. pH 7.35, CO2 24, HCO3 15 C. pH 7.45, CO2 41, HCO3 25 D. pH 7.28, CO2 24, HCO3 15 Response pH 7.45 = STABLE Normal values - Feedback: pH 7.35-7.45 CO2 41 = STABLE CO2 35-45 HCO3 25 = STABLE HCO3 21-28  Question 6 1 out of 1 points Your patient is exhibiting Metabolic Acidosis. Which ABG result matches this acid-base imbalance? Selected D. Answer: pH is 7.26 - CO2 35 - HCO3 18. Answers: A. pH is 7.35 - CO2 45 - HCO3 22  B. pH is 7.26 - CO2 60 - HCO3 25 C. pH is 7.55 - CO2 38 - HCO3 40 D. pH is 7.26 - CO2 35 - HCO3 18. Response Metabolic Acidosis is demonstrated with the following: Feedback: pH 7.26 = ACID, CO2 35 = STABLE, HCO3 18 = ACID  Question 7 1 out of 1 points Order: Pepcid 20mg o.o. daily. Available: 400mg of famotidine (Pepcid) of oral suspension reconstituted to 50 mL. After reconstitution, each 5 mL contains 40mg of medication. The nurse will give 2.5mL. Selected Answer: True Answers: True Fals e Response 20 mg/40 mg = 5 mL X 0.5 = Feedback: 2.5 mL.  Question 8 1 out of 1 points  Which specific type of medication reported as taken daily by an older client will cause a nurse to assess for indications of an acid-base imbalance? Selected A. Answer: Diuretics Answers: A. Diuretics B. Antidysrhythmi c C. Antilipidemic D. Hormonal therapy Response Diuretics can cause an acid-base imbalance by depleting Feedback: electrolytes. Depending upon the site and mode of action, some diuretics increase excretion of potassium, choloride, calcium, bicarbonate, or magnesium.  Question 9 1 out of 1 points Which client will the nurse remain most alert for the possibility to develop Respiratory Alkalosis? Selected B. Answer: Client who is anxious and breathing rapidly Answers: A.  Client with multiple rib fractures B. Client who is anxious and breathing rapidly C. Client with slow shallow respirations and lethargic D. Client with diarrhea Response Patient's that are anxious or breathing rapidly from a Feedback: medical event can go into Respiratory Alkalosis due to the rapid respirations and blowing off too much CO2. The treatment is to give pt a rebreather mask, sedation if required, stay with them and assure a calm and quiet environment if possible. Also in the field or at home you can always have them breathe into a paper bag. For additional feedback please refer to the panapto and class content for Week 5.  Question 10 1 out of 1 points Your patient ABG results are pH 7.25, CO2 55, HCO3 26. Which acid- base imbalance is your patient exhibiting? Selected D. Answer: Respiratory Acidosis Answers: A. Metabolic  Alkalosis B. Metabolic Acidosis C. Respiratory Alkalosis D. Respiratory Acidosis Response pH - 7.25 = ACID Feedback: CO2 - 55 = ACID HCO3 - STABLE Resulting in Respiratory Acidosis  Question 1 1 out of 1 points Which action by a nurse using informatics technology would violate patient confidentiality? Response Great job! Correct Answer: C) Taking a photo of a patient’s Feedback: condition and posting it on social media. Patient confidentiality is a fundamental ethical and legal obligation in healthcare. Sharing patient information, including images, on social media without explicit consent is a violation of privacy and HIPAA regulations.  Question 2 1 out of 1 points  Which answer options contain correct information about informatics? Select all that apply. Response Outstanding! All the answers are correct! The use of Feedback: informatics helps to reduce medication errors. The use of informatics helps to make nursing care more efficient and effective. The failure to use informatics constitutes a deficiency in patient care. A significant purpose of informatics is to retrieve data for evidence-based practice and quality improvement. When using informatics to research evidence- based practice, all data sources must be evaluated for their credibility and reliability.  Question 3 1 out of 1 points A student nurse asks the nursing instructor how nurses use informatics when they practice nursing. What is the best response by the nurse instructor? Response Great Job! The correct answer is, "Nursing informatics is an Feedback: important science used daily in the care of clients." Rationale: Nursing informatics is the science of using computers in the practice of nursing, from daily assessments to nursing research. Medication administration is only one aspect of computer use by nurses. Nurses do need to become proficient in the use of computers. All medical disciplines use informatics in the care of clients.  Question 4 1 out of 1 points Which is a new aspect of the informatics system that helps facilitate safe client care? Response Excellent! The correct answer is that an intranet that has Feedback: access to medical and nursing information. Rationale: Intranets within a system offer nurses access to information about treatment and disease, enabling them to  become more informed about client conditions. Looking up the client's phone number is familiar and helpful when delivering care. E-mails from the manager have more to do with unit policies and changes than with client care. The intranets offer a wide range of medical and nursing information, which is helpful for newer nurses when dealing with rare conditions. Passwords do not help the nurse to provide better care other than ensuring the protection of the client's privacy.  Question 1 0.5 out of 0.5 points These medications are ordered for the client with Mobility concerns or chronic illness. Match the medication to their action/classification. o Question Correct Match Selected Match Enoxaparin 40 C. C. mg subcut. Anticoagulant, anti- Anticoagulant, anti- daily thrombotic, heparin thrombotic, heparin low molecular weight low molecular weight pregabalin 150 A. A. mg bid GABA analogue, GABA analogue, treats nerve and treats nerve and muscle pain, muscle pain, including including fibromyalgia, and fibromyalgia, and seizures. seizures. Cyclobenzaprin B. B. e 10mg PO TID Muscle relaxer - Muscle relaxer - relieves pain and relieves pain and discomfort caused by discomfort caused by strains, sprains, and strains, sprains, and  other muscle injuries other muscle injuries o All Answer Choices A. GABA analogue, treats nerve and muscle pain, including fibromyalgia, and seizures. B. Muscle relaxer - relieves pain and discomfort caused by strains, sprains, and other muscle injuries C. Anticoagulant, anti-thrombotic, heparin low molecular weight o Response Enoxaparin 40 mg subcut. daily: Anticoagulant, anti- Feedback: thrombotic, heparin low molecular weight pregabalin 150 mg bid: GABA analogue, treats nerve and muscle pain, including fibromyalgia, and seizures. Cyclobenzaprine 10mg PO TID: Muscle relaxer - relieves pain and discomfort caused by strains, sprains, and other muscle injuries  Question 2 0.5 out of 0.5 points The nurse on the medical–surgical unit is providing care for a client with a cervical spinal cord injury (SCI) from an accident several years ago. The client reports a headache and their blood pressure is 200/112 mmHg and heart rate 50. Which intervention(s) should the nurse provide? (Select all that apply) Selected 2. Answers:  Assess the client for bowel obstruction. 4. Check the client's bladder. 5. Remove the compression stockings. Answers: 1. Recheck the blood pressure and heart rate in 2 hours. 2. Assess the client for bowel obstruction. 3. Administer pain medication as ordered. 4. Check the client's bladder. 5. Remove the compression stockings. Response Rationale: The client has manifestations of autonomic Feedback: dysreflexia. This is a medical emergency. A distended urinary bladder can cause autonomic dysreflexia. If the bladder is causing the problem, the nurse can relieve manifestations by draining the client's bladder. A distended bowel can cause autonomic dysreflexia. If the bowel is the problem, the nurse can relieve the manifestations by removing the impaction. The compression stockings can contribute to autonomic dysreflexia by creating an irritation that causes the manifestations. The stockings also elevate blood pressure by increasing venous return to the heart. The BP and HR should be reassessed more frequently (in continuance to look for the cause [assessing]) rather  than rechecking them in 2 hours. If the cause is not found, the client’s blood pressure will continue to increase and heart rate will decrease = LIFE THREATENING. Administering pain medication would not address the manifestations of autonomic dysreflexia.  Question 3 0.5 out of 0.5 points A client with permanent paralysis of the trunk, arms, and legs is experiencing which condition? Selected 4. Answer: Quadriplegia Answers: 1. Paraplegia 2. Complete spinal cord injury (SCI) 3. Spinal shock 4. Quadriplegia Response Quadriplegia is paralysis of the upper and lower limbs Feedback: and trunk. Paraplegia is paralysis of all or part of the trunk, legs, and pelvic organs. Spinal shock is a temporary condition characterized by spinal cord swelling; decreased blood flow and blood pressure; and complete loss of motor function, spinal reflexes, and autonomic function below the level of injury. Complete SCIs involve a total loss of all sensory and motor function  below the level of the injury. Depending on its location, a complete SCI could results in either quadriplegia or paraplegia.  Question 4 0.5 out of 0.5 points Upon admission to the ER, a patient with a compression fracture at C5 can move their head, only, and has flaccid paralysis of all extremities. The patient asks if the paralysis is permanent. What is the nurse's most appropriate response? Selected 1. Answer: "It is too early to tell. When the inflammation around your injury decreases and spinal shock subsides, we will know more." Answers: 1. "It is too early to tell. When the inflammation around your injury decreases and spinal shock subsides, we will know more." 2. "I am so sorry, but yes. Unfortunately, there is a strong likelihood that your paralysis is probably permanent." 3. "No. There should be marked recovery of function in a few days." 4. "You should talk to your doctor about things of that nature." Response Spinal shock due to swelling may last from a few days  Feedback: to weeks to months (and in some instances, years) thus clouding the issue of the true extent of the injury.  Question 5 0.5 out of 0.5 points The nurse is planning care for a client who is experiencing an alteration in mobility. Which would the nurse include as an independent nursing intervention? Selected 4. Answer: Instructing on the importance of proper nutrition and an active lifestyle Answers: 1. Prescribing a skeletal muscle relaxant 2. Identifying necessary modifications to the home environment 3. Administering a prescribed nonsteroidal anti- inflammatory drug (NSAID) 4. Instructing on the importance of proper nutrition and an active lifestyle Response An appropriate independent nursing intervention for a Feedback: client who is experiencing an alteration in mobility is providing instruction on the importance of proper nutrition and an active lifestyle. Administering a prescribed NSAID is an example of a collaborative intervention that the nurse can implement. Identifying necessary modifications for the home environment is a  collaborative intervention often implemented by the occupational therapist. Although it is appropriate for the nurse to administer a skeletal muscle relaxant, it is outside the scope of nursing practice to prescribe this medication.  Question 6 0.5 out of 0.5 points What complications should the nurse anticipate for client's with spinal injuries? (Select all that apply) Selected 1. Answers: Autonomic dysreflexia. 3. Anxiety. 4. Atelectasis and/or pneumonia. 5. Skin breakdown, pressure injuries at the bony prominences. 6. Deep vein thrombosis (DVT). 7. Depression. Answers: 1. Autonomic dysreflexia. 2. Nutrition more than body requirements.  3. Anxiety. 4. Atelectasis and/or pneumonia. 5. Skin breakdown, pressure injuries at the bony prominences. 6. Deep vein thrombosis (DVT). 7. Depression. Response All of the answers are correct except nutrition greater Feedback: than body requirement. Often clients with spinal cord injuries do not eat enough to meet their body requirements. Often the cause of the spinal cord injury is trauma and/or a traumatic event like a MVA or gunshot. These clients require more nutrition intake because of the body's hyper-metabolic state from the trauma insult to the body.  Question 7 0.5 out of 0.5 points Which clinical manifestations are related to the client with a spinal cord injury? (Select All That Apply) Selected 1. Answers: Muscle spasticity 2. Loss of bladder and bowel  control 3. Pain 4. Paralysis 5. Difficulty breathing Answers: 1. Muscle spasticity 2. Loss of bladder and bowel control 3. Pain 4. Paralysis 5. Difficulty breathing 6. Feeling of happiness Response All of the answers are correct except the feeling of Feedback: happiness. The manifestation of weakness or numbness below the injury level. The nurse should assess the client's ability to feel touch by softly touching the client's skin a soft cotton tip stick, starting from the client's face. The nurse touches the client's face and ask if they can feel it. Then moves down the neck to the shoulder, then on to fingers on both sides. The nurse will ask the client  to move their head side to side; lift shoulders, raise both arms, and grips. Then continue to lower extremities. The nurse is assessing the client level of injury. The level of injury picture can provide guidance to which level the client may loose sensory and motor ability based on the site of the spinal injury. The client with a spinal cord injury have experienced a traumatic event which may include feelings of sadness, anxiety, and may lead to depression.  Question 8 0.5 out of 0.5 points Which priority assessment should the nurse complete in caring for a client with a spinal cord injury? Selected 4. Answer: Assess the client's sensory and motor movements of the client extremities during the initial assessment and repeat through out the shift. Answers: 1. Assess the client's peripheral pulses and capillary refill every 2 hours. 2. Daily weights and monitor trends. 3. Measure Intake and output every shift and evaluate the 24 hour trends. 4. Assess the client's sensory and motor movements of the client extremities during the initial assessment and repeat through out the shift.  Response Clients with spinal cord injury have weakness and/or Feedback: numbness below the level of their spinal injury. Review the "Dermatome" man to review what each spinal level injury innervates with nerve and motor connections. The nurse would assess pulses and cap refill every 2 hours when a client has a perfusion problem; I&O totals for a 24 hour period would provide the client's fluid status; Daily weight provides an accurate status of the clients fluid status, for example: Heart failure clients are usually placed on daily weights to monitor their fluid status.  Question 9 0.5 out of 0.5 points The nurse is evaluating the effectiveness of interventions to address a client's bowel and bladder dysfunction as a result of a spinal cord injury. Which finding would indicate that these interventions have been successful? Selected 4. Answer: The client is improving in ability to perform self-urinary catheterization. Answers: 1. The client has an indwelling urinary catheter and is provided with stool softeners every morning. 2. The client is limiting fluids to reduce need to void. 3. The client had two episodes of impacted stool over the last week.  4. The client is improving in ability to perform self-urinary catheterization. Response An ideal outcome for the client with bowel and bladder Feedback: dysfunction as a result of a spinal cord injury would be for the client to attain appropriate bowel and bladder elimination habits. If the client's ability to perform self- urinary catheterization is improving, the interventions can be considered successful. A client with an indwelling urinary catheter who is receiving stool softeners every morning is not progressing toward appropriate bowel and bladder elimination habits. A client who had two episodes of impacted stool over the last week is not progressing in bowel elimination habits. A client who is limiting fluids to reduce the need to void is possibly hindering his health in order to avoid having to perform self-urinary catheterization.  Question 10 0.5 out of 0.5 points These medications are ordered for the client with a spinal cord injury. Match the medication to their action/classification. o Question Correct Match Selected Match Methylprednisolon C. C. e 40 mg IVP BID Corticosteroid - help Corticosteroid - help relieve swelling, relieve swelling, redness, itching, and redness, itching, and allergic reactions allergic reactions Pantoprazole 40 B. B. mg IVP bid  Proton-pump Proton-pump inhibitor- treat high inhibitor- treat high levels of stomach levels of stomach acid caused by acid caused by stress stress docusate 100 mg A. A. capsule PO bid Laxative, Bowel Laxative, Bowel softener, bowel prep softener, bowel prep o All Answer Choices A. Laxative, Bowel softener, bowel prep B. Proton-pump inhibitor- treat high levels of stomach acid caused by stress C. Corticosteroid - help relieve swelling, redness, itching, and allergic reactions o Respons Be sure to know why these medications are ordered for the e client with a spinal cord injury Feedbac Methylprednisolone 40 mg IVP BID: Corticosteroid - help k: relieve swelling, redness, itching, and allergic reactions Pantoprazole 40 mg IVP bid: Proton-pump inhibitor- treat high levels of stomach acid caused by stress docusate 100 mg capsule PO bid: Laxative, Bowel softener, bowel prep  Question 1 1 out of 1 points Which medication would the nurse expect to administer to a patient with a history of asthma that develops shortness of breath and stridor and becomes hypotensive during allergy skin testing? Selected A. Answer: Epinephrine Answers: A. Epinephrine B. Zileuton C. Fexofenadine D. Cromolyn sodium Response The patient is experiencing an Feedback anaphylactic reaction, and epinephrine : is a first-line sympathomimetic used to treat anaphylaxis. Zileuton is a leukotriene antagonist; it is also used to prevent symptoms of allergic rhinitis, but is it not useful during an acute episode. Fexofenadine is a non- sedating antihistamine and is not a first-line drug to treat anaphylaxis. Cromolyn sodium is a mast-cell- stabilizing drug; it is used to prevent symptoms of allergic rhinitis it is not  useful during an acute episode.  Question 2 1 out of 1 points Which intervention is most important to implement when caring for a patient with a hypersensitivity reaction? Selected C. Answer: The allergen should be withdrawn immediately Answers: A. Perform a physical examination the patient B. Take the patient's vital signs every 5 minutes C. The allergen should be withdrawn immediately D. Obtain a list of the patient's home medications Response To stop the hypersensitivity Feedback: reaction you MUST remove what is the cause  Question 3 1 out of 1 points  You are the nurse on the surgical floor. You have a patient that is a 69 y/o F who just came back from the OR who just had an arthrocentesis done. Which priority action would the nurse consider when taking care of this patient. Selected A. Answer: Monitoring the insertion site for bleeding or leakage of synovial fluid Answers: A. Monitoring the insertion site for bleeding or leakage of synovial fluid B. Assessing for return of the client’s gag reflex C. Assessing for postprocedural pain to ensure optimal pain relief D. Placing the patient in a prone position and elevating the extremity Response The first priority is assessing the Feedback insertion site for bleeding or leakage. : The procedure is performed under local anesthesia and the client’s gag reflex is not affected. Often the client’s pain after the procedure is reduced as the pressure of the effu-sion is decreased when fluid is removed.  Question 4 1 out of 1 points Which nursing response is most likely to cause harm to a client who has anaphylaxis? Selected C. Answer: Delaying the administration of epinephrine Answers: A. Using a nonrebreather mask to administer oxygen B. Increasing the IV saline flow rate C. Delaying the administration of epinephrine D. Failing to inform the family about a change in the client’s condition Response According to the Centers for Disease Feedback Control and Prevention, the single : most harmful action during anaphylaxis is delaying the administra- tion of epinephrine. It is safer to give the drug when it is not needed than it is to not give it when it is needed. When oxygen is applied, the recommendation is to use a nonrebreather mask to increase oxygen delivery. Increasing the IV flow rate (when the IV is not the source of anaphylaxis) can help support  circulation and blood pressure. Informing the family, al-though a good action, is not the priority action during management of anaphylaxis  Question 5 1 out of 1 points A nurse assesses a group of clients who have rheumatoid arthritis (RA). Which client would the nurse see first? Selected C. Answer: Client with a red, hot, swollen right wrist Answers: A. Client with a worse joint deformity since the last visit B. Client who has a puffy-looking area behind the knee C. Client with a red, hot, swollen right wrist D. Client who reports jaw pain when eating Response The presence of only one hot, Feedback: swollen, painful joint (out of proportion to the other joints) is considered infected until proven  otherwise. The condition requires immediate assessment  Question 6 1 out of 1 points The nurse is performing an assessment on a paitnet with a new diagnosis of rheumatoid artritis (RA). THe nurse expects to note which early manifestations of the disease? Selected Answers: Anorexia Joint inflammation Weakness Fatigue Low-grade fever Answers: Joint deformities High fever Anorexia Joint inflammation  Weakness Fatigue No pulse in extremities Bleeding Asymmetrical Joint Low-grade fever Response RA is a chronic, progressive systemic Feedback inflammatory autoimmune disease : process that primarily affects the synovial joints. It also affects other joints and body tissues. Early manifestations include fatigue, anorexia, weakness, joint inflammation, low-grade fever and paresthesia. Joint deformities are late manifestations. The inflammation with RA is symetrical so if the joints are asymetrical then they should be investigated. Bleeding is an issue and dose not have anything to do with RA.  Question 7 1 out of 1 points The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) Selected A. Answers: Edema  C. Decreased function D. Redness Answers: A. Edema B. Pallor C. Decreased function D. Redness E. Pulselessness Response the five cardinal symptoms of Feedback: inflammation (warmth, redness, swelling, pain, and decreased function) caused by capillary leak, nasal and conjunctival mucus secretion, and pruritus (itching), often occurring with redness (erythema).  Question 8 1 out of 1 points Which vasoactive amine is most responsible for the initial symptoms of inflammation during an allergic response?  Selected C. Answer: Histamine Answers: A. Bradykinin B. Prostaglandi ns C. Histamine D. Leukotriene Response The initial inflammatory response is Feedback: triggered by histamine, often within 10 minutes of exposure to an allergen. It is also a very prevalent vasoac-tive amine. The other amines are secreted later, causing the secondary phase and prolonging the allergic reaction  Question 9 1 out of 1 points Which clinical symptom(s) will the nurse expect to find in a client who is experiencing the release of histamine? Selected D. Answer: Swelling and edema Answers: A.  Diarrhea and abdominal cramping B. Foul-smelling urine C. Excessive bleeding D. Swelling and edema Response Histamines and kinins cause capillary Feedback: leak syn-drome by increasing the size of the capillary pores, which causes fluid to leave the capillaries and collect in the interstitial space with edema and swelling.  Question 10 1 out of 1 points A clinic nurse is working with an older client. What action is most important for preventing infections in this client? Selected D. Answer: Assessing vaccination records for booster shot needs Answers: A. Teaching the patient how and when to take daily vitamins B.  Encouraging the client to eat a nutritious diet C. Instructing the client to wash minor wounds carefully D. Assessing vaccination records for booster shot needs Response Older adults may have insufficient Feedback antibodies that have already been : produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.