MED SURG evolve hesi EXAM

The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? A Serum PTT of 10 s ...

The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? A Serum PTT of 10 seconds. B Serum calcium of 5 mg/dl. Correct C Oxygen saturation of 90%. D Hemoglobin of 10 g/dl.
TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. A serum calcium level of 5 (B), which is low, is an indicator of possible tumor lysis syndrome. (A, C, and D) are not particularly related to TLS. Awarded 0.0 points out of 1.0 possible points.
2.ID: 6974889585A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? A Lower left quadrant pain and a low-grade fever. Correct B Severe pain at McBurney's point and nausea. C Abdominal pain and intermittent tenesmus. D Exacerbations of severe diarrhea.
Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area for diverticula, and the inflammation of diverticula causes a lowgrade fever (A). (B) would be indicative of appendicitis. (C and D) are symptoms exhibited with ulcerative colitis. Awarded 0.0 points out of 1.0 possible points.
3.ID: 6974891763During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first? A Use a laryngoscope to check for a foreign body lodged in the esophagus. B Reposition the head to validate that the head is in the proper position to open the airway. Correct C Turn the client to the side and administer three back blows. D Perform a finger sweep of the mouth to remove any vomitus.
The most frequent cause of inadequate aeration of the client's lungs during CPR is improper positioning of the head resulting in occlusion of the airway (B). A foreign body can occlude the airway, but this is not common unless choking preceded the cardiac emergency, and (A, C and D) should not be the nurse's first action. Awarded 0.0 points out of 1.0 possible points.
4.ID: 6974891794A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because A they occur in the lower lobe alveoli which are more sensitive to infection. B gram-negative organisms are more resistant to antibiotic therapy. Correct C they occur in healthy young adults who have recently been debilitated by an upper respiratory infection. D gram-negative pneumonias usually affect infants and small children.
The gram-negative organisms are resistant to drug therapy (B) which makes recovery very difficult. Gramnegative pneumonias affect all lobes of the lung (A). The mean age for contracting this type of pneumonia is 50 years (C and D), and it usually strikes debilitated persons such as alcoholics, diabetics, and those with chronic lung diseases. Awarded 0.0 points out of 1.0 possible points.
5.ID: 6974891705A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed. What is the priority nursing diagnosis for this client? A Impaired communication related to paralysis of skeletal muscles. Correct B High risk for infection related to increased intracranial pressure. C Potential for injury related to impaired lung expansion. D Social isolation related to inability to communicate.
To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a skeletal-muscle relaxant, such as vecuronium, is usually prescribed. Impaired communication (A) is a serious outcome because the client cannot communicate his/her needs due to intubation and diaphragmatic paralysis caused by the drug. Although this client might also experience (D), it is not a priority when compared to (A). Infection is not related to increased intracranial pressure (B). The mechanical venilator provides consistent lung expansion (C). Awarded 0.0 points out of 1.0 possible points.
6.ID: 6974890435When preparing a client who has had a total laryngectomy for discharge, what instruction is most important for the nurse to include in the discharge teaching? A Recommend that the client carry suction equipment at all times. B Instruct the client to have writing materials with him at all times. C Tell the client to carry a medic alert card stating that he is a total neck breather. Correct D Tell the client not to travel alone.
It is imperative that total neck breathers carry