From what stage of sleep are people typically most difficult to arouse?
NREM, sleep spindles
NREM, delta waves
NREM, alpha waves
A patient’s vital signs prior to a blood transfusion were: T = 97.6°F (36.4°C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the patient began complaining of feeling “itchy and hot.” The nurse discovered a rash on the patient’s trunk. Vital signs were: T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention?
Administer an antihistamine (anti-allergenic) medication.
Flush the blood tubing with D5W immediately.
Stop the blood transfusion immediately.
Prepare for emergency resuscitation
Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?
You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113, and respiratory rate is 30. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take?
Notify the physician of the patient's signs of fluid overload
Provide endotracheal suctioning
Provide tracheostomy care
Call the respiratory therapist to check the ventilator settings
Patency is the condition of being open, expanded, or unobstructed.
A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient’s pain?
A patient who underwent a left above-the-knee amputation complains of pain in his left foot. The nurse should document this finding as what type of pain?
The passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration is called which of the following?
When a patient has metabolic acidosis, which body system influences the acid–base imbalance to produce the compensatory changes in the arterial blood gases?
What is the rationale for wrapping petroleum gauze around a chest tube insertion site?
Prevents air from leaking around the site
Prevents infection at the insertion site
Prevents the tube from becoming dislodged
Absorbs drainage from the insertion site
You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient?
Partial rebreather mask
Which pain management task can be safely delegated to nursing assistive personnel?
Assessing the quality and intensity of the pt's pain
Evaluating the effectiveness of pain medication
Administering oral dose of acetaminophen
Providing a therapeutic back massage
Which aspect of restraint use can the nurse delegate to the nursing assistive personnel?
Applying and removing the restraints
Assessing the pt's status
Evaluating the pt's response to restraints
Determining the need for restraint
A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication?
Which process requires energy to maintain the unique composition of extracellular and intracellular compartments?
A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action should the nurse take first?
Encourage a family member to stay with the patient.
Administer lorazepam (an antianxiety medication).
Keep all four of the patient’s bed side rails up.
While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest drainage system (CDU). Which action should the nurse take immediately?
Set up a new drainage system, and connect it to the chest tube.
Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU.
Clamp the chest tube close to the insertion site.
Place the disconnected end nearest the patient into a bottle of sterile water.
Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis?
Risk for Suffocation (drowning)
Risk for Ineffective Airway Clearance (choking)
Risk for Poisoning
Risk for Falls
Which electrolyte is the primary regulator of fluid volume?
What is typically the most reliable indicator of pain?
Past medical Hx
Description by caregiver(s)
You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient’s respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?