Acute Midterm 2 Review.docx

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  Acute Practice Questions Lab Values:    BUN: 3.6-7.1 mmol/L    Creatinine: 44-133    Hb A1C: 4%-6%    Random glucose: 3.6-5.7    Hematocrit: 0.36-0.49    Platelets: 150-350    PT: 11-13 seconds    PTT: 25-35 seconds    INR: 0.81-1.2    Total cholesterol: <5.19     Na+: 135-145    Potassium: 3.5-5.0    Calcium: 2.2-2.58    Magnesium: 0.65-1.05    Chloride: 95-105    Phosphate: 0.97-1.45 1.   You are caring for a patient who is admitted with community acquired pneumonia. You are aware that this patient would be at highest risk for what type of shock?    Septic shock    Rationale: septic shock can start from bacteria that leads to infection 2.   The type of shock that develops when blood volume is pooled in the peripheral vessels is defined as?    Circulatory shock    Rationale: low blood volume causes circulatory shock 3.   The nurse assesses the client and notes their blood pressure is within normal limits, however HR is 130 BPM and skin is cool and clammy. The client also has hypoactive bowel sounds and decreased urine output. Which stage of shock would the nurse suspect?    Compensatory stage    Rationale: symptoms of compensatory stage of shock are: o   Tachycardia  Acute Practice Questions o   Pallor, clammy skin, cool o   Oliguria o   Hypoactive bowel sounds o   Blood shunted to vital organs o   Increased glucose levels o   Increased RR (resp alkalosis) 4.   You are working on a burn unit. One of your client is exhibiting S/S of third spacing, which occurs when fluid moves out of the intravascular but not into the intracellular space. Based upon fluid shift what would you expect the client to demonstrate    Hypovolemia    Third spacing is due to fluids leaving the vascular space and going into interstitial space, so there would be a drop in volume in the vessels causing hypovolemia 5.   The nurse is caring for a client hx of CHF. The primary care provider prescribes daily weights. The nurse weighs the client and notes a gain of 1kg. What volume of retained fluid would correspond with this increase?    1L    1L = 1kg 6.   The nurse is caring for a client with dementia who requires total care including feeding. The nurse would recognize the client is at risk for which electrolyte imbalance related to the inability to perceive, respond to or communicate their thirst?    Hypernatremia    Low water volume would cause hypernatremia 7.   The nurse is caring for a client admitted with AKI. The clients UO is 15mL/hr and their serum K+ levels is 3.2 mmol/L. The primary care provider prescribes IV fluid 0.9% NaCl with 40 mmol/KCl at 100 mL/hr. The nurse’s priority action is?      Call physician and question order    The patients renal function is compromised and infusing that much K+ would cause hyperkalemia 8.   You are caring for a client with a bowel obstruction. The client has a NG tube inserted to suction gastric contents. You recognize the nurse is at risk for which acid-base imbalance related to this treatment?    Metabolic alkalosis     NG suction or vomiting can generate metabolic acidosis by the loss of gastric secretions, which are rich in HCl 9.   You are caring for a client with COPD who is a known CO2 retainer. What acid-base imbalance will this client be at an increased risk for if high concentrations of oxygen are administered?    Respiratory acidosis    Resp acidosis occurs when lungs cannot remove enough CO2  Acute Practice Questions 10.   You are caring for a client with chronic renal failure who is post-op from cardiac surgery. The client has a post-op of 60 mmol/L Hgb and the doctor has prescribed 2 units of packed RBCs. In the order, it is specified that these units must be fresh blood. What is the rationale for this specification?    Risk of hyperkalemia    Due to decreased renal failure 11.   You are caring for a client who is receiving a blood transfusion. The client rings their call bell and informs you that they are flank pain, pain at the IV site and you note they are shaking. The urine in their foley is reddened. What type of reaction is this?    Acute hemolytic transfusion reaction    Symptoms of acute hemolytic transfusion reaction: o   Chills o   Pain at IV site, flank, back and chest o   Dark urine o   Dizzy o   Fever o   SOB 12.   You are caring for a client who is post-op day 1 following abdominal surgery. There is an order to ambulate as tolerated, however the client verbally refused to ambulate. Based upon this information, what assessment should you perform?    Pain 13.   Inadequate pain management in the post-op period can lead the client to resist deep breathing and coughing. This increases their risk for which potential complication?    Atelectasis    Reduced airway expansion and subsequent accumulation of pulmonary secretions will lead to actelectis 14.   Identify the pathophysiological cause of Volkmann’s contracture    Obstructed arterial blood flow to forearm 15.   Which type of traction would be the most appropriate for a client with a fractured proximal femur?    Bucks extension traction (applied to distal end of a lower fractured limb)    Femur is distal lower limb and bucks is indicated for this type of fracture    Russells traction is used for lower leg    Dunlops is used to upper extremities for elbows and humerous    Cervical head halters are used to stabilize the neck 16.   While assessing a client who has had a knee replacement surgery, the nurse notes a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the most  priority nursing diagnosis for this client?    Risk of peripheral neurovascular dysfunction    The hematoma may cause an interruption of tissue perfusion  Acute Practice Questions 17.   A client post total hip replacement is being routinely turned. What should the other caregivers do to prevent dislocation of the new prosthesis?    Prevent internal rotation of affected leg    After receiving hip prosthesis, the affected leg should be kept abducted, adduction and rotation should be avoided to prevent dislocation 18.   What complication is common in fractures of the neck of the femur?    Avascular necrosis (death of bone tissue due to interruption of the blood supply) 19.   The client is being prepared for discharge following a total hip replacement. What statement  by the client would indicate the need for further teaching?    I will need my husband to assist me with getting off the low toilet seat    Hips must not bend down to low toilet seats and must use raised toilet seats 20.   You are assigned to a client with an arm cast for a fractured radius. Upon assessment, the client reports pain in the limb and you note their fingertips are pale and the client cannot move their finger. What complication would you expect?    Compartment syndrome (pressure within the muscles and decreases blood flow which prevents nourishment from reaching nerve and muscle cells)    Symptoms of compartment syndrome: o   Weakness in limb o   Pallor o   Paralysis o   Pain 21.   A client comes to the clinic complaining of pain at the site of a hip replacement. The client reports that they have had a hip replacement surgery 3 years ago. On assessment, the nurse notes the area around the surgical scar is erythematous and edematous. What would the nurse suspect?    Infection at surgical site that has spread from another site in the body    Infections occurring more than 2 years after surgery are attributed to the spread of infection through the blood stream 22.   Orthopedic surgery can be used to correct a variety of ortho conditions. What conditions can  be corrected by orthopedic surgery?    Joint disease     Necrotic tissue    Tumors    Unstabilized fractures 23.   Clients with orthopedic injury are at increased risk for DVT, what signs and symptoms would the nurse assess for when assessing for DVT?    Unilateral calf tenderness    Increase warmth of calf
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