Comp 1, Comp 8, Comp 7, Comp 6, Comp 5, Comp 4, Comp 3, Comp 2

Diverticulosis

High fiber diet

Peritonitis-

N/V

Patient on met Forman going for CT

Notify HCP

Patient scheduled for CT has creatinine of 1.8

Notify HCP

No honey before

1year old

Emergent

See now (lung collapse, MI)

Dysphasia follow up wrong answer

Tuck chin when swalllowing

PUD

Type and cross

Send home during mass disaster

Ulcerative colitis taking prednisone

DI

Urine goes from 500 to 125ml

Sanguineous to serosanguinours drainage =

Wound healing

Lateral violence

Wrong answer sexual

Domestic violence (neg stem)

Abusers have low self-stem and think of themselves as not important

A nurse working on a medical surgical unit has just received a hand off report on the following clients, the nurse should first plan to assess the client who has:

Acute pancreatitis and is reporting the development of pain on deep inspiration Rationale - acute could burst (septic)

Patient to see first

Acute pancreatitis with onset of pain

The primary health care provider has prescribed ampicillin 150 mg 3 times a day to a doodler the weighs 22lbs the drug available is ampicillin suspension that is 250mg/5ml. Which action should the nurse take

Administer 3ml (do the math)

The nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with severity of 6 out of 10. The nuse administers 1 sublingual nitroglycerin tablet, after 5 minutes the client states the pain is a severity level of 3 which of the following actions should the nurse be prepared to do next?

Administer another nitro sublingual tablet

Alcohol withdrawal and hard to arouse

Administer flumazenil

The nurse is caring for a client who has developed hypovolemic shock and has a heart rate of 160BPM and is receiving oxygen @ 2L via nasal cannula, which of the following actions would be a priority for the nurse to perform?

Administer the prescribed NS @150ml/hr

The nurse is caring for a 4yr old child at an outpatient clinic. The client is being seen for an excellent checkup after beginning amoxicillin 3 days prior for otitis media. The primary prescribes the following vaccinations varicella, MMR, deactivated polio & Dtap for the client which of the following actions by the nurse would be correct

Administer the vaccines as prescribed

Phototherapy

Adverse affect is gray baby

Incident reports

Adverse reaction to I medication is an insider t report: patient with phlebitis while on antibiotics

Furosemide

Adverse reaction to watch for tinnitus

Colonoscopy

Age 50, the Q 10yr, prostate Q1yrs with digital exam

Here's zoster

Airborne

Disseminated Zoster

Airborne precautions

Correctly charted in progress notes

Ambulated to the door without assistance

TBI

BP increases, high BP (autonomic dysreflexia)

DM

BS less than 100 patient should not be exercising Teach them to eat a carb snack before exercising

Which is concerning

Baby that has tripled weight @ 6months

Interdisciplinary

Baby withdrawing w/ rhinorrhea, hyperreflexia, and mother on drugs

Chest tube

Bad if drainage is >100ml

Cefriaxone

Be cautions when someone has severe PCN allergy

Lithium

Be sure to stay hydrated

Rinse mouth-asthma steroid med

Beclomethasone

Follow up or see fist

Bleeding gums with phenytoin or metoprolol prescribed for patient with HR 60

What to report to MD

Bloody ruptured membranes

Dig toxicity

Blurred vision and anorexia

Clononscopy

Bowel prep

Secondary prevention

Breast exam

Thoracentesis

Breath sounds (RR)

A nurse caring for a patient who had hypothyroidism which would the nurse expect to assess

Brittle nails Dry skin Menorrhagia (abnormal heavy bleeding when menstruating)

Cancer patient diet

Broil chicken and cottage cheese ( do not choose toast)

Lateral violence means

Bulling where other person gets offended

Only MD can remove

Chest tube

Chemo diet

Chicken, green beans, cottage cheese

Abnormal vital signs

Child with HR 160 and walking in hallway

Barium enema-

Clay colored stool

Patient with anxiety

Clear and simple sentences

Spontaneous birth

Clear nasopharyngeal

Peritoneal dialysis

Cloudy = infection

Discard used needles in

Coffee can or glass jar

Who to see first

Colonoscopy w/BP change, "I can't take this anymore", 2yr old 68 HR while playing w/ toys, burn 75%or CP, creatinine 2.7

5 yr old child

Coloring book( do not choose bike)

Dusky and dry call MD

Colostomy

Dying kid

Comfortable measures

GI bleed w/ black tarry stool

Common cause H. Pylori ulcer w/ GI bleeding

Left side CVA

Communication

Medication wasting

Complete with another nurse and waste first before giving

Urgent

Compound fracture with +1 edema or 30% burns to body (burns)

Which patient sent to hospital in disaster

Compound fracture with chest pain.

The nurse is assessing the client who has a suspected retinal detachment of the left eye which of the following client statements would be consistent with this diagnosis?

I see floating dark spots in my left eye

The nurse is caring for a pregnant client whose last menstrual period began on October 21st using the naegel's rule which of he following dates would be the due date?

July 28

Due date ( and 7 days and subtract 3 months )

July 28th

Priority patient with

K+ 2.4

Photo of cardiac strip

K+ is the answer

No ace inhibitors with

K+ sparing diuretics

Which prescribed medication should be given first

K+ to patient with low K+

Fidelity

Keep commitments

Internal radiation

Keep lead lined box, supplies, or lead apron in room

Which patient to discharge

Kid tonsillectomy 18hours ago

Metabolic alkalosis

Know ABGs

MOM W.FHR 180

LAY ON LEFT SIDE (NORMAL FHR 110-160)

Further teaching for fiscally responsibility

Letting family help (not a part of fiscally responsibility )

Ulcerative colitis

Liquid bloody stool 10-20 days is expected If it is less than 3-4 days send them home on prednisone

The nurse is caring for a client who has been prescribed a statin for TX hyperlipidemia. Which should the nurse check

Liver enzymes

Meniere's

Low Na diet

Blood transfusion reaction s/s

Low back pain, impending doom 1st stop transfusion 2nd disconnect and pull back 3rd new tube 4th normal saline

Diverticulitis

Low fiber diet

SIADH

Low sodium, bounding pulses

Enema cramp

Lower bag

Patient complaining of abdominal cramping during soap suds enema

Lower bag

A nurse is administering a soap suds enema to a client, the client reports abdominal cramping shortly after what actions should the nurse take

Lower the bag (slow it down)

Below the knee amputee

Risk for sepsis or Hypovolemia

The nurse is caring for a 2month old infant that is post operative following a surgical repair of a cleft lip and is crying

Rock the baby

PEG tube

Rotate 360 degrees, x1day

Mag sulfate

S/E response rate of 10

Suicide

S/s in teens-breakups, extreme weight loss, getting rid of personal belongings

A newly hired nurse has prepared a client for a transport to a surgical suite which of the following would require follow up

Shaving the clients operative side with shaving cream and a razor.

Liver enzymes

Shock statin use (give statins @night)

Mom loses baby

Sign no harm contract

Patient with depression

Sign safety contract

Needs additional teaching about informed consent

Signed by nurse to indicate patient understanding

The nurse attending a conference on informed consent it would indicate the need for additional teaching if the nurse states that informed consent

Signed by nurse to state patient understands procedure.

The nurse is planning care for a newly admitted client who has major depressive disorder following the death of her newborn 2 weeks ago, which of the following goals should the nurse identify as the priority?

Signing a no harm

Assessment for bucks traction

Skin breakdown

RH shot wrong answer

Something about placental lining

Pt. Angry and gets out of chair

Speak calm

Latex allergy

Spina big idea or multiple surgeries

Latex allergy includes

Spina big idea/ multiple surgeries

Fragile skin

Use wash cloth under tourniquet—-put over gown

Hearing aid follow up

Using alcohol swabs to clean

Veal chop

V- Variable C- Cord Comphression E- Early Decels H- Head Compression A- Accelerations O - OK L-Late Decels P - Placenta

Cardiac strips identify

V-tach

45% burns follow up

V/O 145 ml/8hr (4ML x% X kg)

Airborne

Varicella (M.T.V)

Slander

Verbal

Assault

Verbal abuse

Internal radiation see first

Visitor in room for 2hrs

Vitamin deficiency related to alcohol

Vit B6

UAP

Vital signs 2 hours post op

No vaccine for child w/

WBC 3.9

Pt who needs private room

WBC of 2,300

Small laceration—head

Wade when asleep

MD inhaler

Wait 2 minutes between each puff

The nurse working in the psychiatric inpatient unit is caring for a client who has bipolar disorder and is in the manic phase the client states to the nurse " I am bored" which of the following activities is appropriate for the nurse to suggest to the client?

Waking with the nurse in the courtyard

Bipolar patient in manic phase

Walk around with nurse

Continuous bubbling in chest tube

Wall suction container

Scabies (SATA)

Wash/dry hot water Ointment neck down -leave on 8-14hrs.

Prefilled injectable

Waste 1ml w/ witness before administering

Patient took whole bottle of amitriptyline

We're you trying to krill yourself?

A nurse is caring for a client who has a sealed radiation implant, which of the following precautions should the nurse implement?

Wear the lead shield while providing client care.

Buck traction

Weight free hanging, private room, skeletal pin care

Child follow up-

Weight triples at 6 months

Avoid decongestants

With BPH

Libel (defamaiton)

Writing something bad about someone on social media

Colostomy diet

Yogurt

The nurse has instructed the client who has a UTI about prescribed drug ciprofloxacin—which of the following instructions should the nurse give the client?

You should report the development of tendon pain while taking this medication, since tendon rupture is a potential complication

Blood can be hung max of

4hrs

Priority

4y/o kid with laceration and falling asleep

Math

54%

IM injections

5mL is too much for gluteal

See first

Acute pancreatitis with pain of 7 after medication

Pt. Suspected of flu

Droplet precautions —-gown, gloves, mask

Fluid volume depletion

Decreased pulse pressure or check creatinine?

Cirrhosis

Decreased sodium

LPN

Delegation -can obtain past medical history NOT assessment

Delirium is reversible,

Dementia is not

Seat alarm for

Dementia patient

Pertussis precautions include

Droplet, wear mask within 3ft of pt. Pt. Wears mask outside the room

Signs of hypothyroidism

Dry skin Menorrhagia Brittle nails

Hypothyroid (select all that apply)

Dry skin, brittle mails, menorrhagia

Increase protein, lay down after meals, no fluids while eating

Dumping syndrome

The nurse has provided dietary teaching to a client who recently had a surgical colostomy placed, which of the following statement made by the client indicates a correct understanding of the instructions?

Eating yogurt can help decrease the amount of gas that I have

Vent alarm

Either assess patient or bag them

Ileostomy

Empty 30 min after eating

The nurse working at a rehab center is managing care for a client with left sided stroke 3 weeks ago which is the goal

Establish communication ethically

left CVA

Establish means of communication

Blood reaction

Everything stopped and removed then run NS

Follow up at health fair

Ex-smoker of 2 months with BP greater than 140/90

Prevent PE

Exercise legs

Insulin

Fastest absorbed through abdomen

HPV vaccine

Female 9-26

OT

Fine motor skills

Evisceration

Call, cover, splint-client should be placed in a semi folders position, this reduces pressure on the abdominal wall. Moist dressing prevents drying of the organs.

Pacemaker

Can use electronic devices, but have to be used on the opposite side of the pacemaker (right side)

Urgent (multiple fx, 1+pedal pulses)

Can wait

Private room

Cancer patient, immune compromised, neutropenia, glove, gown, mask

Place on strong side, move with weak

Cane

Cane follow up

Carry on affected side

MAG

Check potassium

Beclomethasone

Rinse mouth

Patient with INR of 3.5 wants to leave AMA

Risk for bleeding

Priority teaching for thrombocytopenia

Risk for bleeding

Anxiety attack

Tell patient i will stay with you

LPN cannot give medication through

Central line

Macular degeneration

Central vision loss

When does the 2nd stage of labor start

Cervix is completely dilated and baby at - 1 station

BP

Change by 20 either way is priority

TPN/lipids

Change dressing

Foot drop with high top sneakers

Check every 2hrs

CFS

Check for halo, notify HCP

Statins

Check liver enzymes

Sexual assault

Check patient first

If you give patient wrong med

Check patient first, then call MD

Med error

Check patient of allergic reaction

PVC

Check peripheral pulses

Rhythm strip with 3 PVC's

Check postassium

A charge nurse is planning to admit several clients in the medical unit, it would be necessary for the nurse to admit which client to a private room?

Has a fever of unknown origin

The nurse is caring for a client who had lumbar spinal surgery 8hrs. Ago. It would be a priority for the nurse to notify the surgeon if

Has a numerate amount of clear drainage on the surgical dressing

Cleft lip

Have family rock baby

Fiscal barrier follow up

Having family get involved

A nurse is teaching a female client about positive signs of pregnancy which of the following client statements would indicate a correct understanding of the teaching?

Heartbeat (lung sounds)

A nurse is reviewing the lab results of a male client who is scheduled to have a cardiac catheter in one hour which of the following should the nurse immediately report to the HCP

Hematocrit of 32%

AKI

Hemoglobin 33

Priority decreased urine output (480ml in a 24 hr. Period)

Hepatic encephalopathy

Ethical issues

Hospice patient goes home w/ pick line

Testicular exam after

Hot bath/shower

The nurse is talking with a client who has MS what would need follow-up by the nurse

Hot showers

A nurse is caring for a client who has developed tumor lysis syndrome. What should the nurse expect?

Hyperkalemia

Tumor lysis

Hyperkalemia: cloudy urine

Addison's disease

Hyperkalemia: hyponatremia, and decreased blood glucose (hypoglycemic)

Respiratory alkalosis for

Hyperventilation

Respiratory alkalosis

Hyperventilation, panic attack

Below the knee amputation (BKA)

Hypovolemic shock

Thoracentesis with elevated HR (90-110)

Hypovolemic shock

The nurse working in the PACU is assessing the client who had a below-the-knee amputation the nurse should give priority to assessing the client for?

Hypovolemic shock —possible bleeding

Prostatectomy Foley catheter wrong answer

I CAN'T SHOWER FOR 2 WEEKS

Hearing aid wrong answer

I can clean with alcohol

Hepatic encephalopathy

Increased ammonia levels build up toxins causing confusion and slurred speech.

Dumping syndrome

Increased protein and lay down after meals

Spina bifida and multiple surgeries

Increased risk for latex allergy

Answer -patient with ——put in droplet precautions

Influenza

Emphysema-

Inhaler before exercise

A nurse is caring for a patient who has metastatic colon cancer who is undergoing chemotherapy the client has been admitted the acute care medical center due to prolonged Messi and assessment findings include HR 120, BP 80/48, RR 14, AND ABG'S OF pH 7.46,CO2 45, BICARBONATE 29, which of the following prescriptions would the nurse give first?

Initiate D5

The nurse working in the ED has received the following prescriptions for a newly admitted client, which prescriptions should the nurse implement first?

Initiate IV sodium and potassium for a client admitted with diarrhea and dehydration who has a serum potassium level of 2.9

Coumadin DVT and a-fib

Ink 2-3 Antidote vit k

The nurse is caring for a client who is currently prescribed bed rest which of the following actions should the nurse take to help prevent the development of pulmonary embolism?

Instruct the client to perform leg exercises (prevent DVT)

The nurse is teaching a group of clients about insulin administration which of the following informations should the nurse include?

Insulin absorption is fastest when injected into the abdomen

NG tube (SATA)

Irrigate w/ sterile water, reposition q2h, tun off suction to listen to bowel sounds.

Declomethasone is a corticosteroid

It is a daily use inhaler to prevent asthma flare ups, it is not a rescue inhaler. It can increase the risk of oral thrush, therefore, you need to rinse your mouth after each use.

Right side heart failure

JVD

Glomerulonephritis

JVD, crackles, increased fluid r/t kidney not working properly infection

Pancarditis

JVD, lwan forward if pain: pain on inspiration

Intussusception

Jelly like stool: knee to chest position

Delegation

LPN to get blood sugar

APGAR @

1 min and 5 min

3yr old speaks

3-4 word sentences

ABG

DKA (metabolic acidosis

TURP

Flow to keep the urine pink tinged Hang NS and keep flushing

Tumor lysis syndrome

Hyperkalemia

Wrong answer

I will work out at insulin peak

PT

Mobility

Battery

Nurse grabs pts arm when leaving

Kidney transplant-

Temp change

GERD

Use wedge pillow

IM injection

Z track method (iron)

LPN NO

central lines

The nurse is prioritizing patient care after a change of shift report and nurse should first plan to see the patient who:

-had an endoscopic retrograde cholangiopancreatography 30 min. Ago and is reporting difficulty swallowing

Deltoid muscle needle size

1-1 1/2

Skin to skin

1-2 hrs

Laceration

10 inch gash that is gushing blood —priority apply pressure then obtain IV access

TPN

10 ml syringe (do not pick 3ml syringe)

Umbilical cord fall off

10-15 days < 5problem

CPR

100 compressions

Follow up-

11 yr old sitting in front seat

Further seat belt safety teaching

11 yrs old sitting in front seat

Infant HR

110-160

Lipids IV

12 hrs

Snippy cup

12 months (14 months is concerning)

Chest tube follow up

175 ml/hr

70/30

70 NPH, 30 regular insulin salt, sex

Smile

2-3 months

Smallest needle for blood is

20 gauge

Suicide risk

20 yr old alcoholic and gun

A nurse is caring for a client who has a potassium level of 2.4 which of the following prescriptions should the nurse question?

20MEqL KCL IV/15 minutes (running to fast)

Increased risk for cervical cancer

24y/o African American female with history of HPV

Appropriate IM needle gauge and size

25 gauge 1' needle

Aortic

2nd intercostal space right eternal border

A nurse is auscultation the client's aortic valve it would be the correct technique if the nurses placed the stethoscope on the

2nd intercostal space, right eternal border

Auscultation aortic

2nd space right of the eternal border

A nurse is working on a pediatric cardiac unit is reviewing the telemetry monitors for assigned clients, which client should the nurse initially plan to assess?

2yr old toddler who is walking in the hallway and has a HR of 160 BPM (abnormal HR)

Priority setting

2yr old walking hall with HR 160

Give self-great exam

7days after period

Breast feed main form of nutrition

8-12x

COPD 02 sat

89% is normal

Child follow up

9 months stand up

Med math

325 burn answer

Catch lab

33% HCT is bad: 37 normal

Rotate peg tube

360 degrees

Expected urine output for a baby

3ml/hr

Hold vaccines for 2 weeks

4 yr old on ABX

Male prostate high risk

40-49y/o

CT contrast cannot receive meteor in within

48hrs.

The nurse working on a pediatric unit is caring for the following children who have been admitted in the past 12 hrs. It would be a priority goal for the nurse to initiate an interdisciplinary conference for the child who:

5yrs old with diagnosed cystic fibrosis at birth and has been hospitalized 4 times in the past 2 months.

Cholesterol

65 y/o on low cholesterol with high LDL -send to PCP there is a problem

A nurse is working in a community health clinic is assessing clients who are waiting to be seen, which client should the nurse have the primary health care provider see first?

A 57 yrs old with Graves' disease with a team. 100.5 (thyroid issue)

The nurse is assessing a client who has developed an Addisonian crisis which of the following finding is consistent with this diagnosis?

A blood glucose of less than 60

Question about an 11yr old in the front seat what are the teachings for that?

A child should not be allowed in the front seat until 12 yrs. Old

The nurse is monitoring a client following at Horace tests it would be a priority for the nurse to notify the primary health care provider if the client develops

A heart rate that has increased from 95 to 110BPM

The nurse working on the mom/baby unit has become aware of the following client situation, which of he following clients should the nurse initially assess?

A neonate who is 4hr. Old, whose resting HE is 95BPM NormalHR 120-140

The nurse is caring for a client who is receiving prescribed magnesium sulfate IV which of the following client finding s would indicate the client is experiencing a side effect of that medication?

A respiratory rate of 10 breaths per minute

A nurse is caring for a male client who has a deep partial thickness and a full thickness burn 45%of the lower body, it would be a priority for the nurse to notify the primary health care physician if the client has:

A urinary output of 45ml over the past two hours (normal 30ml/hr)

Cardiac strip

A-fib give heparin

Perform ADLs in

AM for rheumatoid arthritis

Cirrhosis of the liver

AST, ALT increased Teach no alcohol, proper diet, transplant

Insulin teaching

Abdomen absorbs faster

Peg tube

Abdominal wall- stomach- annotate swallow comatose or stroke patient

Flumazenil

Antidote for benzodiazepines

Profuse bleeding

Apply pressure then start IV

Delegation order

Asses, plan, communicate, surveillance, evaluate, feedback

Order of action

Assess Plan Communicate Surveillance/supervise Evaluate/feedback

Colostomy

Assess bowel sounds ?

Foot drop patient in high top shoes

Assess pressure points

The nurse is delegating tasks to staff members on the unit, which of the following is the appropriate offer of action for delegating tasks?

Assess, plan, communication, survey, supervise, evaluate, give feedback

The nurse working on a medical surgical unit is delegating tasks to unlicensed personnel which of delegated task would require follow up by the charge nurse?

Assisting a client who had a paracentesis 2 hours ago to get out of bed for the first time. -RN needs to do the first

New RN should get what patient

Asthma patient getting discharged or ETOH patient with protocols

2nd space right of eternal border

Auscultation aortic

Bronchovesicular

Auscultation between scapulae

Sickle cell

Avoid high altitiudes

A-fib

CCB like dilitazem (very neat drugs)

Reduces spread of MRSA

CNA give CHG bath

Cardiac strip—asystole

CPR

After spinal surgery

Call DR moderate clear drainage

Stoma pink and dry

Call HCP

ETOH cart

Call MD

Child becomes Hypovolemic with HR of 116

Call help or give fluids? (Most people said to give fluids)

Surgery on femur and restless

Call rapid response (could be fat emboli)

A nurse is assessing a patient who had a colostomy created 6 hrs. Ago. The stoma appears dark red dry and flaccid with a small amount of mucous drained in the bag. Which action would be a priority for the nurse?

Call the doctor

The nurse is caring for a 3yr. Old who has had 160ml of urine output over the past 8hrs. The child weighs 33lbs which of the following actions should the nurse take?

Continue to monitor

V/s on child

Continue to monitor

Water seal at 2cm

Continue to monitor

End stage renal

Creatinine 2.7 is expected Normal levels 0.6-1.2

Interdisciplinary patient

Cystic fibrosis

Multidisciplinary question

Cystic fibrosis kid

The nurse working on the med/surg unit has been made aware of situation, who would she assess first?

DM type 2, premeal BG 85, and now has a post meal BG of

Novice nurse gets

DVT waiting for ultrasound

Retinal detachment

Dark floating spots (pay attention to the eye they are asking)

High iron foods

Dark green leafy vegetables, beans

Detached retinal of right eye

Dark spots in right eye

Math-

Decrease 15ml

Cirrhosis and acute ascites

Decrease Na

Yogurt w/ colostomy to

Decrease gas

The nurse has received the handoff report for the client who has a prescription for dobutamine to ensure at 5mcg/kg/min. The client is receiving 500mg in 250mg in 250ml dextrose at 18ml/hr. What action should the nurse take?

Decrease the infusion rate to 15ml/hr

Magnesium toxicity

Decrease urine output

Cardiac tamponade are

Decreased BP, JVD, muffled heart sounds with clear lungs

A nurse is caring for a client who has acute kidney injury and is at risk for volume depletion which of the following findings would indicate the client is developing this complication

Decreased pulse pressure

The nurse is preparing to administer prescribed medication to the following client it would be essential for the nurse to follow up the primary health care provider for the client who has?

Diabetes mellitus, just had a CT scan with IV contrast and has been prescribed met for in.

Correct technique

Diaphragm of stethoscope to hear bronchovesicular sounds

Myasthenia Gravis priority

Difficulty swallowing and muscle weakness

Schizophrenic with command hallucinations yelling " i will do it!"

Distract them

Restraints—2 fingers

Distracted with music

low fiber

Diverticulitis

High fiber

Diverticulosis

Question with vital signs and low K+

Do EKG first

Patient with insomnia

Do activities in AM

Old patient having trouble steeping

Do activities when patient is awake

Pt. With o+ blood receiving B+ blood

Do not assess patient (o universal donor , AB+ universal receiver)

Diet for patient on Coumadin

Do not change

PRBC

Do not flush with D5W

Patient with potassium 2.4

Do not get patient OOB

Glargine

Do not mix

Kid with (what seems to be low but isn't) urinary output

Document and continue to monitor Kid urinary output=15ml/hr Adult=30ml/hr

RhoGam is given for the mom so that she

Does not develop antibodies toward an A+ baby. RhoGam is given once per pregnancy

Informed consent

Does not indicate the patient understands the procedures -neg stem

ERCP

Does not need bowel prep Priority if patient is still having difficulty swallowing 1 hr after

Fever of unknown origin (neg stem)

Does not need private room

A nurse is teaching another of five tear old child about age appropriate toys which of the following toys would be appropriate for the nurse to recommend?

Doll and coloring book (do not pick the 100 piece puzzle)

Clean catch urine

Dominant hand holds cup

Restraints

Don't attach to movable part

DYSPHAGIA (NEG SEM QUESTION)

Don't ignore cough I will not tilt head down when swallowing

Isolation precaution for inhalation anthrax

Droplet precautions

Droplet precautions

Flu Gown, gloves, mask

PICC line or triple lumen

Flush with 10ml NS

Post thoracenteses

Follow up —HR increase form 99 to 110

Administering eye gel

From nose outward

Digoxin-neg stem question

Further education if patient states " i need to avoid food high in vit k including avocado, potatoes, and bananas"

Sit up after eating, no caffeine, carbonated, spicy, smoking-wedge pillow

GERD

Why would HDL be high if patient is on correct diet

Genetics

Suspect abuse

Get detailed hx

Delegate to LPN

Get patient history

Negative titles to measles and pregnant

Gets MMR after delivery (only give immunizations that aren't live: no nasal influenza)

Chest pain reduced after one nitro tab

Give 2nd dose

Medication math answer for child 22 lbs

Give 3ml

Septic shock

Give LR @ 30 mg/kg but BP still low —administer vasopressin to increase BP

HPV

Give ages from 9-26

4 yr old on ABX

Give all vacccines

MI pain went from 6-3

Give another nitro

HHS

Give fluids

Hypovolemic shock

Give fluids then O2

Kawasaki

Give immunoglobulins

Rubella titer negative

Give vaccine after delivery

Patient with colostomy

Give yogurt

Take off PPE-

Gloves

Sequence for doffing (removing )PPE

Gloves Goggles Gown Mask

PPE used with MRSA

Gloves and gown (contact)

Take off PPE

Gloves, gown, goggles, mask,

Addison's

Glucose less than 60

Addisonian crisis

Glucose of 60

Celiac disease

Gluten allergy

NG

Gold standard x-ray of KUB and pH

Second prevention

Great exam

Polycystic kidney disease

Gross hematuria

Metabolic alkalosis No ketones

HHS

The nurse has provided medication instruction to a patient who has asthma and been prescribed beclomethasone which of the following client statements indicates a correct understanding of this instruction?

I should rinse my mouth out after this medication

The nurse has instructed a female client who recently received hearing aids. Which of the following client statements indicates the need for additional teaching?

I will clean them with alcohol wipes

Digoxin wrong answer

I will decrease the amount of potassium in my diet

The nurse has provided discharge teaching to a client who had an open radical prostatectomy and has been discharged home with a urinary catheter which of the following statements made by the patient would require follow up by the nurse.

I will not be able to take a shower for the next 2 weeks

The nurse has instructed a client who regularly menstruates about performing self-breast examinations at home which of he following client statements indicates correct understanding of eh teaching?

I will perform myself breast examination 7 days after my period ends-you do it 7 days post as the hormones have decreased and any natural lumps will disappear, and breast will not be at tender and sore.

The nurse has instructed a client who must ambulate with a cane which of the following client statements indicates a correct understanding of the teaching?

I will place the cane on the side of the unaffected lib and walk with the weaker leg first.

The nurse is working on a crisis hotline speaking with a client who states " I just took an entire bottle of amitriptyline" which of the following responses should the nurse initially make to the client?

I'm glad you called, and I want to sen an ambulance to help you

Crisis hotline

I'm glad you called: I'd like to send help

Warfarin-

INR 2-3

Warfarin check

INR of 2

Follow up

IV K+ 20mEq

Kidney transplant 1 week ago

If BP decreases=good

Heimlich maneuver

If someone is showing the shocking sign do abdominal thrusts

Sexual harassment is not lateral violence

In the work place

Lost dentures

Incident report

Incorrect note

Incident reports do not get charted

Digoxin

Increase K+ and decrease calcium, green leafy veggies, bananas, and sweet potatoes

Allopurinol

Increase fluids

Patients aPTT while on heparin is 30 sec

Increase heparin

Bacterial meningitis

Mask when outside the room

Soaked pad

Massage fundus

HCP orders 150mg to be given TID Give 3ml TID

Math

Tube feed

Max 24 hours

Antimboloism stockings

Measure calf circumference and width

GCS

Measures eye, verbal, and motor responses (15= the best outcome: 3=worst outcome)

Vaccine for 18yrs

Meningitis

The nurse is caring for a client that has acute kidney injury which of the following arterial blood gas results would the nurse expect to find?

Metabolic acidosis

ABG-AKI

Metabolic acidosis (identify it by pH and bicarbonate)

AKI-

Metabolic alkalosis

Eternal radiation

Mild soap and water, do not rub, leave on tattoos/ markings. No washcloth

Following bronchoscope

Monitor for any hemoptysis

Addison disease

Monitor v/s BP

Activity for mother that lost child 2 weeks ago

Mourning

Digoxin toxicity

N/V, blurred vision Check level-greater than 2 is toxic 1st check v/s

Peritonitis

N/v

Atherosclerosis

NO EGGS

Barium enema

NPO

Peptic ulcer disease

NPO and NG tube (coffee ground eyes is-GI bleed)

GI bleed

NPO until HCP clears

SIADH-

Na 120

Spontaneous delivery

Nasopharynx suction

Suicide risk-

Native American with gun permits OUR test- old man whose wife died

Command hallucinations

Needs more supervision (worst hallucinations)

Priority patient in mon/baby unit

Neonate with HR of 95

Hearing aid care

No alcohol, mild soap/water only Use a hearing aid on the lowest setting

External radiation

No direct sunlight for one year

SCIP

No disposable razors (use electric razor & start ABX 1hr before surgery)

Neutropenia

No fruits/flowers in room

Multiple sclerosis

No hot baths

Brace maker—set between 60-70

No lifting arms above head for 4 weeks Magnet to reset

IBS

No loperamide (ain't diarrhea drug)

Abruptly placenta

No oxygen, painful

Ace

No potassium sparing diuretics

Lateral violence means bullying

No sexual harassment

Patient with pericarditis

No vesicular breath sounds

8hrs post delivery with moderate bleeding

Normal

Dawn phenomenon

Normal to have high BG in AM

The nurse is teaching a class on health promotion and illness prevention which of the following actions by the nurse is an example of secondary prevention?

Performing monthly self-breast examinations.

The nurse is caring for a patient who has paranoid schizophrenia and a history auditory hallucinations the client is yelling and pacing in the day room " I will do it" what of the following actions will the nurse take?

Obtaining increased supervision for the client

HIT

On heparin > one week

Cane

On unaffected side and forward with weak leg

Testicular exam

Once a month after shower

Emphysema

One activity at a time like walking and talking

Restraints for violent behavior

One to one monitoring

Lispro

Onset in 15-30 min

Sterile dressing change Which requires to follow up

Opening towards self first

Phenytoin

Oral hygiene to prevent gingival hyperplasia

Bronchiole lungs sounds

Over trachea

Delegate

PCA to check v/s after biopsy

Stop novice nurse if starting 22gIV-needs to be 20g or larger

PRBC

DVT prevention

PROM

Health fair

PSA testing

The nurse is caring for a client that develops the following cardiac rhythm

PVC check potassium —-peripheral pulses

The patient is having an anxiety attack and is hyperventilating which ABG results would be consistent with the findings?

PaCO2 of 98

Assess first

Pacemaker and dizzy

Post-op priority

Pacemaker feeling dizzy

Interdisciplinary care

Parkinson's and cystic fibrosis

Stroke

Patient becomes restless see first

Identification

Patient form PACU first thing we do is identify the patient

Put patient in room first for DR to see

Patient who had TB test 48 hr ago

Novice nurse

Patient with asthma and d/c

Increased temp

Patient with temp greater than 101.5 get them out of the waiting room and into a private room

Denial

Patient with terminal cancer wants 2nd opinion

Draw trough before

Peak

The nurse is discussing health screening guidelines with a group of men it would be appropriate for the nurse to state

Perform monthly testicular exams immediately after a bath or shower

I pro

Report tendon

Chest not moving

Resp acidosis

Circumcision

Petroleum jelly, no wipes, warm water, loose diaper

The charge nurse in the ED is reviewing the care provided for recently admitted clients: which of the following reflects implementation of an accepted standard of care?

Placing the client who has suspected hemophilia influenza on droplets precautions.

Which would be a concern while on anti-coagulants

Platelet <100,000

Heparin drip -adverse reaction

Platelet less than 100,000- normal 150-400K

Heparin —bleeding concern

Platelets 90,000 LOW Antidote protamine sulfate

Priority-

Post ERCP can't swallow after 30min

Priority patient 2hr.

Post lumbar puncture reports headache

Arm laceration

Pressure, insert new IV, clean, suture

Child with asthma using rescue inhaler Q2HR while awake

Priority

Patent with BP 92/58

Priority

Patient with internal radiation has visitor >2hrs

Priority

Cardiac strip of V-fib

Priority -defibrillator

Lithium toxicity

Priority does not need to limit sodium

Paranoid schizophrenia

Priority is patient yelling don't make me do it

6y/o 130 @ rest

Priority see first

Sodium 125

Priority see first Normal levels 135-145

Burns on chest

Priority see first.

Pyloric stenosis

Projectile vomiting infants

Who to see first?

Pt. Who is supposed to be getting 100 ml/hr and has received 400 ml in 2hr.

Enoxaparin

Retain air bubble

Hypothermia

Rewarm trunk before extremities

9 months

Pull up

Hypovolemic shock-

Pulse increase HT from 80-100

Wrong sterile

Put on gloves before opening packages

Alcohol based rub before

Putting gloves for standard precautions

A preceptor is working with a newly hired nurse who is preparing to perform a sterile dressing change,which of the following actions by the newly hired nurse would require intervention by the preceptor?

Putting on sterile gloves prior to opening the outer packaging.

When transferring patient —-after endoscopy

RN assess to see if they can bear weight

Restraints priority

ROM every 2hrs

Mag side effects

RR 10

Mask photo

RSV if it says child

Further education

Radiation materials have to stay in room (such as v/s machine) decimeter stays -measures radiation

Post op VP shunt

Raise HOB 30 degrees

Infant car seat anchored in middle of seat

Rear for 2years

LPN can

Recheck liver biopsy vital signs

LPN-

Recheck vitals

Histrionic personality disorder

Redirect/ don't let interrupt group

Transcribing telephone order

Repeat back

Teach care

Replace with new ties before remove the old ones

Kidney transplant

Report temp change of 1 degree

Grave's disease and thyroid storm

Report temp increase of 1 degree

Ciprofloxacin

Spontaneous tendon rupture

Outside agency

Stage 3 pressure ulcer on adult patient should be reported.

Hepatitis B

Standard precautions

Itching, wheezing during transfusion

Stop disconnecting get another bad, new tube-return to the blood bank-do not flush

Oxytocin

Stop w/contractions over 2.5

Community program for primary prevention

Stress management

70 yr old who lost his wife

Suicide risk

Evisceration (protruding organ)

Supine position Wet gauze Notify Physician

Spontaneous abortion

Support group (sorry for your loss)

Teach ties —not secured (moving in and out while coughing)

Supposed to be one finger under ties

Crying baby w/ cleft palate

Swaddle, hold close and rock

Crying baby with cleft palate

Swaddle, hold close and rock

Endoscopic retrograde cholangiopancreatography (ERCP

Swallowing irritability

24hrs-feeling fullness-stop feed, check residual, check the tubing for kinks

TPN

Always have 2 nurse check order, change tubing q24hr

TPN

Always have 2 nurses check order: change tubing Q24hrs

TPN check

Psych with manic bipolar

Take for a walk

MS painted should not

Take hot bath

MS wrong answer

Take hot bath

Postmortem neg-stem

Take lines out before autopsy

Carpal tunnel

Take v/s first

PACU following regional anesthesia

Take vitals

TURP-

Teach kegels

TPN watch for

Temp increase

Invading privacy of famous patient

Terminate

HIPPA breach

Terminate employees

Teaching men group

Testicular checks after shower

Amitriptyline OD

Thanks for calling I'm sending an ambulance

The nurse is assessing clients at the scene of a mass casualty disaster and is prioritizing care based on the disaster triage tag system which of the following clients should be transported to the health care facility first?

The client who has multiple compound fractures and is reporting chest pain

Desmopressin

Therapeutic effect would be ruin output going from 2500m; to 1200ml

Therapeutic communication

This is a rough time for you

A nurse is teaching a client who had a spontaneous abortion about the need to receive a RhoGam shot, which of the following client statements indicates a need for further teaching?

This medication will allow my body to fully remove the placenta lining -false statement

Medications should be given

Through a central line

Temperature 100 degrees indicates

Thyroid storm

Medication treatment for open angle glaucoma

Timolol (hold for HR <60)

D/C for disease

Tonsillectomy

Rhythm strip is V-tach

Treat with valsalva's maneuver or lidocaine

Blood transfusion reaction

Tubing and blood has to get sent back to the blood bank

The nurse is caring for a client who had abdominal surgery and has developed an evisceration after calling for assistance which of the following actions would the nurse take next?

Use a moist ABD to cover the abdomen

Carbamazepine

Use condom with birth control because it deactivates it

Someone w/ cast

Use crutches up with good, down with bad and resume normal activity

Adrenal Glands

corticosteroids, catecholamines

Chart pic

d5 fluid

Child dying

essential activities only

ABG—respiratory alkalosis

hyperventilation

Follow up before surgery

nurse uses disposable razor

Late decelerations

poor placental perfusion (POOF, LION)

TORB

telephone order read back