Saunders Comprehensive Review for the NCLEX: Ch 69 Complex Care

Saunders Comprehensive Review for the NCLEX: Ch 69 Complex Care

gissetrom Save Saunders Shock Questions 13 terms metoprolol11Preview Gastrointestinal 50 terms bw154212Preview Unit 3 Practice Questions 45 terms mmchale12Preview Urinary 30 terms ann 856. A client had a 100 mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous bag (IV) has 400 mL remaining. The nurse should take which action FIRST?

• Slow the IV infusion
• Sit the client up in bed
• Remove the IV catheter
• Call the primary health care provider (PHCP)

Answer: 1

Rationale: the client's symptoms are compatible with circulatory overload. This may be verified by noting that 600mL has been infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may be followed in rapid sequence. The nurse may elevate the head of the bed to aid in the client's breathing if necessary. The nurse also notifies the PCHP. the IV catheter is not removed; it may be needed for the administration of medications to resolve the complication.

• Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g/dL (76 mol/L) and a

hematocrit level of 30% (0.30). The nurse takes the client's temperature before the blood transfusion and records 100.6 degrees Fahrenheit (38.1 degrees Celsius) orally. Which action should the nurse take?

• Begin the transfusion as prescribed
• Administer an antihistamine and begin the transfusion
• Administer 2 tablets of acetaminophen
• Delay hanging the blood and notify the primary health care provider (PHCP)

Answer: 4

Rationale: If the client has a temperature higher than 100 degrees F, the unit of blood should not be hung until the PHCP is notified and has the opportunity to give further instructions. The PHCP will likely prescribe that the blood be administered regardless of the temperature or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs a PHCPs prescription to administer medication to the client.

• The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority problem

should the nurse assign to this client?

• deficient fluid volume related to acute blood loss
• risk for aspiration related to acute bleeding in the GI tract
• risk for infection related to acute disease process and medications
• Imbalanced nutrition, less than body requirements, related to lack of nutrients and increased metabolism

Answer 1 Rationale: the priority problem for the client with a cute gastrointestinal bleeding among these options is deficient fluid volume related to acute blood loss. This state can result in decreased cardiac output and hypovolemic shock. Although nutrition is a problem, fluid volume deficit is more of a priority. The client is at risk for aspiration and infection, but these are not actual problems at this point in time.

• The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery

room following a thoracotomy with wedge resection. SELECT ALL THAT APPLY

• Excessive Bubbling in the water seal chamber
• Vigorous bubbling in the suction control chamber
• Drainage system maintained below the client's chest
• 50mL of drainage in the drainage collection chamber
• Occlusive dressing in place over the chest tube insertion site
• Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

Answer: 3,4,5,6

Rationale: the bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure; it may occur during exhalation, coughing, or sneezing.Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube of water in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has re-expanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client retuning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hr is considered excessive and requires notification of the surgeon. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural system

• A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car

fire. The nurse should implement which nursing actions for this client? SELECT ALL THAT APPLY

• Restrict fluids

2.Assess for airway patency 3.Administer oxygen as prescribed 4.Place a cooling blanket on the client 5.Elevate extremities if no fractures are present 6.Prepare to give oral pain medication as prescribed

Answer: 2,3,5

Rationale: The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated tp assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured extremities. The client is kept warm, because the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the watered gastrointestinal function that occurs as a result of a burn injury

• A client is admitted to a hospital with a diagnosis of diabetic keto acidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mol/L). A

continous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 250 mg/dL (13.37 mml/L). The nurse would next prepare to administer which medication?

• an ampule of 50% dextrose
• NPH insulin subcutaneously
• IV fluids containing dextrose
• Phenytoin for the prevention of seizures

Answer: 3

Rationale: emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema can occur. During management of DKA, when the blood glucose level falls to 250-300 mg/dL, the infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL or until the client recovers from ketosis.

• The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should

assess for which earliest sign of ARDS?

• bilateral wheezing
• inspiratory crackles
• intercostal retractions
• increased respiratory rate

Answer: 4

Rationale: The earliest detectable sign of ARDS is an increased respiratory rate, which begins from 1 to 96 hours after the initial insult to the body.This is followed by dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

• A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on the elevated

troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication?Time: 11:00am. 11:15 am. 11:30 am. 11:45 am

Pulse: 92 bpm. 96 bpm. 104 bpm. 118 bpm

Resp: 24 breaths. 26 breaths. 28 breaths. 32 breaths

per min. per min. per min. per min

BP: 140/88 128/82 104/68 88/58

• Cardiogenic shock
• cardiac tamponade
• pulmonary embolism
• dissecting thoracic aortic aneurysm

Answer: 1

Rationale: cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension, a paid pulse that becomes weaker; decreased urine output and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissection aortic aneurysm usually are accompanied by back pain.

• The nurse is caring for a client with chronic kidney disease on continuous replacement renal therapy (CRRT) without the use of a

hemodialysis machine. The nurse determines that which parameters is most important in ensuring success of this treatment?

• Mean arterial pressure (MAP)
• Systolic blood pressure (SBP)
• Diastolic blood pressure (DBP)
• Central venous pressure (CVP)

Answer: 1

Rationale: CRRT provides continuous ultrafiltration of extracellular fluid and clearance of urinary toxins over a period of 8 to 24 hours; it is used primarily for clients with AKI or critical ill patients with CKD who cannot tolerate hemodialysis. Water, electrolytes and other solutes are removed as the client's blood passes through a hemofilter. If CRRT does not require a hemodialysis machine, the client's MAP needs to be maintained above 60 mmHg and arterial and venous access sites are necessary.

• The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. The nurse would note which trend in vital signs

if the intracranial pressure is rising?

• increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
• Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
• Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
• Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

Answer: 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure Rationale:A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. respiratory irregularities may occur.

• A client develops an anaphylactic reactions after receiving morphine. The nurse should plan to institute which actions? SATA
• administer oxygen
• quickly assess the clients respiratory status
• document the event, interventions and client's response
• keep the client supine regardless of the blood pressure readings
• leave the client briefly to contact a primary health care provider
• start an IV infusion of D5W and administer a 500 mL bolus

Answer: 1,2,3

Rationale: an anaphylactic section requires immediate actions, starting with quickly assessing the client's respiratory status. Although the PHCP and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV normal saline is started and infused per PHCP prescription. Documentation of the event, actions taken, and client outcomes needs to be done. The head of the bed should be elevated if the client's blood pressure is normal.

• A client in shock develops a central venous pressure of 2mmHg and a mean arterial pressure of 60 mmHg. Which prescribed intervention

should the nurse implement first?

• increase the rate of O2 flow

2.obtain arterial gas results

• insert an indwelling urinary catheter
• increase the rate of IV fluids

Answer: 4

Rationale: the MAP and CVP are both low for this patient, indicating a state of shock. Shock is the result of inadequate perfusion. Fluid volume should be immediately restored first to provide adequate perfusion for the client in a shock state.