You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient?

Which serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours?

You receive a physician’s order to change a patient’s IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change?

You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as

You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results?

You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy?

You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the health care provider?

You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention?

When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume?

Which nursing intervention is most appropriate when caring for a patient with dehydration?

When planning the care of a patient with dehydration, what urine output would the nurse instruct the unlicensed assistive personnel to report?

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit?

When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is

A patient is admitted with metabolic acidosis. Which system is not functioning normally?

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse’s priority action?

A patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. Which IV solution may be used to pull fluid into the intravascular space after the paracentesis?

A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question?

The nurse is caring for a 76-yr-old woman admitted to the medical unit with hypernatremia and dehydration after prolonged fever. The best beverage to offer the patient is

The nurse on a medical-surgical unit identifies which patient as having the highest risk for metabolic alkalosis?

A 22-yr-old man is admitted to the emergency department with a stab wound to the abdomen. The patient’s vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/min, respirations 28 breaths/min, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question?

Which action is most important for the nurse to take when caring for a patient with a subclavian triple-lumen catheter?

You are caring for a patient admitted with diabetes mellitus, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply.)?

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient (select all that apply.)?

While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply.)?

A dehydrated patient is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions (select all that apply.)?

A nurse is performing triage in the emergency department. Which patient should the nurse see first?

A 71-yr-old woman arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask?

Students are having an end of the semester party, which includes drinking alcohol, having snacks, and swimming. A student was found floating in the pool. Which action by first responders is most important?

A 47-yr-old man who was lost in the mountains for 2 days is admitted to the emergency department with cold exposure and a core body temperature of 86.6ºF (30.3ºC). Which nursing action is most important?

A nurse teaches the emergency department staff about their roles during a mass casualty incident. Which primary responsibility is expected of all licensed and unlicensed health care staff?

Which assessment parameter will the nurse address during the secondary survey of a patient in triage?

An 18-yr-old young woman has been admitted to the emergency department after ingesting an entire bottle of chewable multivitamins in a suicide attempt. The nurse should anticipate which intervention?

Which guideline for the assessment of intimate partner violence (IPV) should the emergency nurse follow?

A mass casualty incident was identified on a nearby freeway. Which patient would likely be designated “red” during triage at the site?

An 18-yr-old man who fell through the ice on a pond near his farm was admitted to the emergency department with somnolence. Vital signs are blood pressure of 82 mm Hg systolic with Doppler, respirations of 9 breaths/min, and core temperature of 90°F (32.2°C). The nurse should anticipate which intervention?

Three days after experiencing a series of tick bites, a patient presents to the emergency department. Which manifestation would indicate the patient is experiencing tick paralysis?

A nurse in the emergency department is working triage. Which patient assessment findings would indicate immediate care is required?

A male patient is brought into the emergency department with multiple stab wounds to the legs, one stab wound to the left abdomen, and gang tattoos on both arms. He refused to identify his attacker and then loses consciousness. Police identify him as the assailant in the fatal stabbing of another man. What is the nurse’s priority?

In reviewing the chart, which patient assessment is likely to have the greatest impact on this patient’s risk of death from the accident?Tab 1 Tab2 Tab3 Background ED assessment Current assessment  Male  Found floating face down after surfing accident  CPR done by rescuers  Sinus tachycardia with frequent premature ventricular contractions (PVCs)  Mechanical ventilation  Left pupil size 10 cm, not reactive to light  Pulmonary artery wedge pressure (PAWP)16 mm Hg  PaO2 108 mm Hg, FIO2 50%, PEEP 5 cm  Cool extremities, weak peripheral pulses

The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas with temperatures near 100°F (37.7°C) for the past 2 weeks. When assessing the patient, the nurse finds hypotension, body temperature of 104°F (40°C), dry and ashen skin, and neurologic symptoms. What treatments should the nurse anticipate (select all that apply.)?

During an assessment of a 45-yr-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change?

A 45-yr-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which clinical manifestation might be present as an early manifestation during an exacerbation of asthma?

The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. What is the primary reason for the nurse to carefully inspect the chest wall of this patient?

Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation?

The nurse is caring for a patient with an acute exacerbation of asthma. After initial treatment, what finding indicates to the nurse that the patient’s respiratory status is improving?

The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. In patients with asthma, the nurse assesses for which etiologic factor for this nursing diagnosis?

The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a â-adrenergic bronchodilator and supplemental oxygen. If the patient’s condition does not improve, the nurse should anticipate what as the most likely next step in treatment?

A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use?

While teaching a patient with asthma about the appropriate use of a peak flow meter, what should the nurse instruct the patient to do?

The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions should the nurse provide?

The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone after what occurs?

The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit?

Which test result identifies that a patient with asthma is responding to treatment?

The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign?

The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack?

The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring for which patient parameters?

The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every 6 hours. What should the nurse explain as the best way to prevent oral infection while taking this medication?

The nurse is evaluating if a patient understands how to safely determine whether a metered-dose inhaler (MDI) is empty. The nurse interprets that the patient understands this important information to prevent medication under dosing when the patient describes which method to check the inhaler?

When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands that what causes the manifestations of the disease?

A male patient with chronic obstructive pulmonary disease (COPD) becomes dyspneic at rest. His baseline blood gas results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse’s priority intervention?

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with chronic obstructive pulmonary disease (COPD) are successful based on which finding?

When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this patient?

The nurse teaches pursed-lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism?

Nursing assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)?

A patient has been receiving oxygen per nasal cannula while hospitalized for chronic obstructive pulmonary disease (COPD). The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse?

Before discharge, the nurse discusses activity levels with a 61-yr-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia. Which exercise goal is most appropriate once the patient is fully recovered from this episode of illness?

The nurse evaluates that a patient is experiencing the expected beneficial effects of ipratropium after noting which assessment finding?

The nurse is teaching a patient how to self-administer ipratropium via a metered-dose inhaler (MDI). Which instruction given by the nurse is most appropriate to help the patient learn the proper inhalation technique?

Which statement made by the patient with chronic obstructive pulmonary disease (COPD) indicates a need for further teaching regarding the use of an ipratropium inhaler?

When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included related to the effects of smoking on the lungs and the increased incidence of pulmonary infections?

When teaching the patient with cystic fibrosis about the diet and medications, what is the priority information to be included in the discussion?

When teaching the patient with bronchiectasis about manifestations to report to the health care provider, which manifestation should be included?

The nurse teaches a 53-yr-old male patient with chronic obstructive pulmonary disease (COPD) how to administer fluticasone by metered-dose inhaler (MDI). Which statement by the patient to the nurse indicates correct understanding of the instructions?

The nurse supervises a team including another registered nurse (RN), a licensed practical/vocational nurse (LPN/LVN), and unlicensed assistive personnel (UAP) on a medical unit. The team is caring for many patients with respiratory problems. In what situation should the nurse intervene with teaching for a team member?

The nurse is caring for a 48-yr-old male patient admitted for exacerbation of chronic obstructive pulmonary disease. The patient develops severe dyspnea at rest, with a change in respiratory rate from 26 breaths/min to 44 breaths/min. Which action by the nurse would be the most appropriate?

Although a diagnosis of cystic fibrosis (CF) is most often made before age 2 years, an 18-yr-old patient at the student health center with a history of frequent lung and sinus infections has clinical manifestations consistent with undiagnosed CF. Which information would be accurate for the nurse to include when teaching the patient about a scheduled sweat chloride test?

When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for what potential triggers (select all that apply.)?

The nurse is evaluating a patient diagnosed with type 2 diabetes mellitus. Which symptom reported by the patient correlates with the diagnosis?

A patient, admitted with diabetes mellitus, has a glucose level of 380 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find?

The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin’s peak action?

A patient with type 2 diabetes has a urinary tract infection (UTI), is difficult to arouse, and has a blood glucose of 642 mg/dL. When the nurse assesses the urine, there are no ketones present. What nursing action is appropriate at this time?

Which patient with type 1 diabetes mellitus would be at the highest risk for developing hypoglycemic unawareness?

A patient is admitted with diabetes mellitus, malnutrition cellulitis, and a potassium level of 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result (select all that apply.)?

When computing a heart rate from the electrocardiography (ECG) tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. What does the nurse calculate the patient’s heart rate to be?

Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the electrocardiogram (ECG)?

The nurse obtains a 6-second rhythm strip and charts the following analysis: Atrial data Ventricular data Additional data Rate: 70, regular Rate: 40, regular QRS: 0.04 sec Variable PR interval Isolated escape beats P wave and QRS complexes Independent beats unrelated What is the correct interpretation of this rhythm strip?

The nurse is caring for a patient who is 24 hours post pacemaker insertion. Which nursing intervention is most appropriate at this time?

The nurse observes no P waves on the patients monitor strip. There are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. What does the nurse determine the rhythm to be?

A patient informs the nurse of experiencing syncope. Which nursing action should the nurse prioritize in the patient’s subsequent diagnostic workup?

The nurse prepares to defibrillate a patient. For which dysrhythmia has the nurse observed in this patient?

The nurse observes a flat line on the patient’s monitor and the patient is unresponsive without pulse. What medications does the nurse prepare to administer?

The nurse observes ventricular tachycardia (VT) on the patient’s monitor. What evaluation made by the nurse led to this interpretation?

The patient has atrial fibrillation with a rapid ventricular response. What electrical treatment option does the nurse prepare the patient for?

The nurse is doing discharge teaching with the patient who received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates to the nurse that further teaching is required?

The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates?

The nurse determines there is artifact on the patient’s telemetry monitor. Which factor should the nurse assess for that could correct this issue?

The patient has a potassium level of 2.9 mEq/L, and the nurse obtains the following measurements on the rhythm strip: Heart rate of 86 with a regular rhythm, the P wave is 0.06 seconds (sec) and normal shape, the PR interval is 0.24 sec, and the QRS is 0.09 sec. How should the nurse document this rhythm?

A patient reports dizziness and shortness of breath and is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole?

The nurse is monitoring the electrocardiograms of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all of the patients are observed to be sitting up and talking with visitors. Which patient’s rhythm would require the nurse to take immediate action?

Cardioversion is attempted for a patient with atrial flutter and a rapid ventricular response. After the delivering 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately?

The nurse performs discharge teaching for a patient with an implantable cardioverter-defibrillator (ICD). Which statement by the patient indicates to the nurse that further teaching is needed?

A patient develops third-degree heart block and reports feeling chest pressure and shortness of breath. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing?

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation?

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation?

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement?

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question?

A patient is admitted to the burn unit with second- and third-degree burns covering the face, entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being?

An older adult patient is moving into an independent living facility. What teaching will prevent this patient from being accidently burned in the new home?

A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect?

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed?

The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase?

A patient with type 2 diabetes mellitus is in the acute phase of burn care with electrical burns on the left side of the body and a serum glucose level of 485 mg/dL. What is the nurse’s priority intervention for this patient?

A patient with a burn inhalation injury is receiving albuterol for the treatment of bronchospasm. What is the most important adverse effect of this medication for the nurse to monitor?

The patient in the emergent phase of a burn injury is being treated for severe pain. What medication should the nurse anticipate administering to the patient?

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient?

The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse?

The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn?

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the patient 30 minutes before the scheduled dressing change?

Which patient should the nurse prepare to transfer to a regional burn center?

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient’s care (select all that apply.)?

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury (select all that apply.)?

When teaching the patient in the rehabilitation phase of a severe burn about the use of range-of-motion (ROM), what explanations should the nurse give to the patient (select all that apply.)?

The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation (select all that apply.)?