Blog

A nurse is caring for a client admitted with acute pancreatitis. Which nursing action is most appropriate for a client with this diagnosis?

A health care provider orders lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor:

A nurse is caring for a patient diagnosed with disseminated intravascular coagulation (DIC) following sepsis. The patient is experiencing widespread bleeding and has an elevated D-dimer level. What interventions will the nurse complete?  Select all that apply.

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS) with likely progression to the irreversible stage. The nurse’s plan of care should include which intervention?

A nurse is caring for a patient admitted with dehydration and hypotension. The healthcare provider has ordered an infusion of 0.9% sodium chloride (normal saline) at 150 mL/hr. Which assessment finding would indicate that the fluid therapy is effective?

A triage nurse is helping to sort patients during a natural disaster. Which of the following patients would be categorized in the “immediate” or red level?

A nurses is working with a client with anemia. What findings would the nurse expect on assessment? Select all that apply.

A nurse is caring for a 55-year-old patient with Addison’s disease who presents to the emergency department with complaints of nausea, abdominal pain, and weakness. Upon assessment, the nurse notes a blood pressure of 85/60 mmHg, heart rate of 110 bpm, and hyperpigmentation of the skin. Laboratory results show hyponatremia and hyperkalemia. Which intervention should the nurse implement first?

A patient that had a central line placed 3 hours ago develops hypotension, tachycardia, decreased breath sounds on one side, and tracheal deviation. Which type of shock is suspected? 

A nurse is assessing a patient with chronic glomerulonephritis who reports fatigue, swelling in the legs, and decreased urine output. The nurse notes the following findings: blood pressure 168/96 mmHg, heart rate 88 bpm, respiratory rate 22 breaths/min, bilateral pitting edema in the lower extremities, and crackles in the lung bases. Laboratory results include a BUN of 38 mg/dL (normal range 7-20), creatinine of 3.2 mg/dL (normal range 0.7 – 1.3 mg/dL), and serum potassium of 6.2 mEq/L (normal range 3.5 – 5.0 mEq/L). Which assessment finding is the priority for the nurse to address?