Comp Jeporady

The UAP reports to the nurse a patient seems very anxious with respiratory rate 38 breaths/min. Which acid-base imbalance should the nurse suspect?

RESP ALKALOSIS Hyperventilation, PE, mechanical ventilation, and anxiety are often causes of respiratory alkalosis. The hyperventilation is associated with blowing off carbon dioxide. This decrease in carbon dioxide will lead to an increase in pH and cause respiratory alkalosis

While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by the nurse is the most appropriate?

Reconnect the tube to the water seal.

The RN in a clinic is providing teaching for a patient with a UTI. The provider has ordered ciprofloxacin (Cipro) 250 mg twice a day for 3 days. Which of the following responses are appropriate for teaching about this medication?

"This medication may cause dizziness. Use caution driving" "Report any tendon pain, ruptured tendons are a side effect of the medication". "This medication may cause photosensitivity, implement sun protection measures"

Which information should the nurse teach the client post-barium enema procedure?

"You need a mild laxative to help expel the barium"4.

How to calculate the expected date of delivery?

Add 9 months and 7 days to first day of last period

What populations are considered at higher risk for committing suicide?

Caucasians, especially older adults and teens, have the highest suicide rates. Other high-risk groups include adolescent and young adult Alaskan Native and Native American males. Having access to a gun or individuals with major depression also increases the risk of suicide.

The nurse, working on a pediatric unit is caring for an 18 month old toddler. The child's mother says, "I have been working so hard to toilet train her but she keeps having accidents. When will she learn to control her bowels?" What is the nurse's best response.

Children normally attain control by age 2 ½ so it is normal for an 18 month old to have accidents.

The nurse in the cardiovascular clinic receives telephone calls from four clients. Which client should be scheduled to be seen as a priority?

Client with atrial fibrillation who reports episodes of lightheadedness and syncope.

What foods would you recommend a client with anemia consume?

Eggs, red meat, turkey, broccoli, chicken, shellfish, spinach, legumes, dark chocolate, pumpkin seeds

What are critical pathways and why are they important when planning patient care?

Critical pathways, also known as care maps, are multidisciplinary plans detailing best practices for addressing specific diseases. These pathways support the coordination and delivery of high-quality care.

What is Cushing's Triad?

Cushing's triad indicates imminent death and is a late sign of increased ICP manifesting as: severe hypertension widened pulse pressure bradycardia

What are best practice guidelines for administering potassium IV to patients with hypokalemia?

Never IV push or bolus potassium. Usually ordered as a 10-20mEq/dose, always diluted. Infused slowly at a rate up to 10meq/hr. Do not exceed 20meq/hr when infusing K.

What is considered a normal heartrate for a 3 year-old toddler?

Normal HR for toddlers is 80-140.

What medications are prescribed for patients with Diabetes Insipidus?

DDAVP is the preferred drug - Desmopressin acetate

What would you teach males regarding health screening guidelines for testicular cancer?

Examine testicles monthly after a shower or bath. Look and feel for any lumps, smooth, rounded masses, or any change in the size, shape, or consistency of the testes

When teaching a group of older adults about preventing disease, what teaching points should be included on primary disease prevention?

Examples of primary prevention strategies include avoiding tobacco and red meat, and receiving vaccines per recommendations. Primary prevention is focused on modifying associated factors (avoidance of known or potential carcinogens), vaccines, and removal of at-risk tissues.

What are the nursing priorities when caring for a patient with suicidal ideations?

Find out if the patient has a plan to harm self. Then find out if the patient has signed a no-harm contract

Why is it important for nurses to advocate for clients?

Nurses are expected to advocate for patients. This includes patients that do not have family members or significant others to advocate for them. Advocacy responsibilities include acting in the role of an advocate, utilizing advocacy resources, and respecting client decisions regarding treatment and care options.

A client is beginning to exhibit seizure activity. UAP are in the room to provide assistance. Which safety measure may the nurse assign to the UAP?

Obtain blankets or other linens with which to pad the side rails

What are priority nursing interventions when caring for patients with bulimia?

Patients must eat/rest in view of staff and cannot go to bathroom unsupervised for a period of time after ingesting food. Therapy is indicated to help resolve personal issues contributing to the eating disorder

has the fastest rate of absorption. What lab value is important to monitor for patients prescribed an ACE-I?

Patients on ACE Inhibitors can develop hyperkalemia. Monitor potassium levels. K sparing diuretics are contraindicated with ACE-I due to the increase in potassium level.

What patients are appropriate for interdisciplinary conferences?

Patients with repeat hospitalizations, multiple therapies or services, and those with an unstable diagnosis.

What teaching is appropriate for parents regarding prevention of SIDS?

Place baby on back for sleeping, firm mattress, no soft objects or blankets in bed. Breastfeeding reduces incidence of SIDS. Room sharing reduces the risk of SIDS, not in adult bed.

What are droplet precautions?

Private room if available. Wear mask when working within 3 feet of patient. Surgical mask required if patient is transported out of the room

What therapeutic interventions would you implement for a child with end-stage cancer?

Quiet room, only necessary nursing care

The nurse is caring for a client with continuous IV infusion of 5% dextrose in water with 40 mEq of potassium chloride added to each liter. During a routine check of the infusion the nurse discovers that 4 hours of fluids has infused in the past 1 hour. What would be the nurses first action?

Reduce the infusion rate

What are therapeutic communication responses?

Restating Reflecting Summarizing

What dietary restrictions are appropriate for patients with CKD?

Restriction of fluids, proteins, and electrolytes is important. Waste products from protein breakdown lead to uremia. Educate the patient to limit protein intake and fluids. Also, restrict potassium, sodium, and phosphorus intake.

Why would the fundus be soft and boggy three hours after postpartum?

Retained placental tissue

What teaching points for insulin dependent diabetics are important regarding administration sites?

Rotate injection sites in the abdomen, which is the preferred site for administration as it has the fastest rate of absorption.

What are priority concerns when caring for a patient with schizophrenia experiencing command hallucinations?

Safety is always a priority concern for patients experiencing active psychosis. Increased supervision is required as the patient may harm self or others. Protect the patient and others from injury.

The nurse is planning a community center presentation about prevention of Lyme Disease. Which of the following information should the nurse include?

Wear long sleeved shirts and pants hiking or in wooded areas. Remove any ticks from body with tweezers (not fingers) by grasping the tick and gently pulling straight out.

The nurse is developing a health promotion teaching plan for a community group of middle aged adults over 50. Information about which immunizations should be included?

influenza, pneumococcal

The nurse is caring for a client with a pneumothorax that has a chest tube. Which assessment finding should be reported immediately

160 ml of drainage in collection system in the past hour.

What age-appropriate language skills are expected for a four-year old child?

4-year-old children can form 4 - 5 word sentences and should have a vocabulary of approximately 1500 words.

If the agency has both a rapid response team and a code blue team, for which of the following clients would the nurse request the rapid response team's immediate intervention?

A client c/o chest pain, hypotension, and shortness of breath

What is considered normal resting heartrate for a newborn (neonate)?

110-170 is a normal heartrate for a newborn

What is considered normal urine output for a child weighing less than 30kg?

1-3 mL/kg/hr is normal urine output for children that weigh less than 30kg (66lbs)

The nurse is caring for a client undergoing a lumbar puncture. Which actions by the nurse are appropriate? Select all that apply.

1. Encourage normal breathing and relaxation with the client. 2. Reassure the client by explaining what is happening. 3. Have the client empty the bladder prior to the procedure 5. Apply a sterile dressing over puncture site and monitor for CSF leakage.

What is the SCIP Measure for administering a prophylactic antibiotic prior to surgery?

All patients should have received a prophylactic antibiotic within one hour before surgical incision

Which problem is a primary concern for a client diagnosed with Rheumatoid Arthritis?

Alteration in comfort

What manifestations might you expect to see in a patient in the manic state of bipolar disorder?

Alteration in thought processes and speech patterns, flight of ideas, clang associations, and grandiosity. Extreme drive and energy, inflated sense of self-importance, reduced sleep needs, excessive talking with pressured speech, racing thoughts, and dangerous activities such as indiscriminate spending, reckless sexual encounters, or risky investments. Help these patients focus and direct them toward relaxing activities in a calm environment.

What medications are administered for patients experiencing ventricular tachycardia?

Amiodarone Lidocaine Epinephrine

The nurse is caring for a client requiring mechanical ventilation. The client has decreasing oxygen sat. increasing respiratory acidosis and restlessness. What is the nurse's priority action?

Assess the placement of the ET tube and breath sounds

What would you teach patients with diabetes regarding activity, insulin, and glucose levels?

Avoid exercise if glucose is below 80 or above 250, if there are ketones in urine, during times insulin peaks or within 1 hr of insulin injection. Keep a simple sugar snack available during exercise in case of hypoglycemia.

The nurse is caring for a client who is confused and disoriented, has pulled out the urinary catheter twice and now has hematuria. The PCP orders restraints. What type of restraint would the nurse choose initially?

Mitt

A nursing student is preparing to administer insulin to a client with diabetes. Indicate the correct order of the following steps for the administration of this medication.

Mix the insulins Assess the skin for the injection Cleanse the site with alcohol. Pinch the skin lightly Insert the needle quickly into the sub-q tissue Inject the medication Count to five Remove the syringe.

The nurse is caring for a client receiving an antineoplastic medication IV. The nurse discovers the IV site is red, edematous, and painful. Knowing that antineoplastic medications are vesicants, the nurse uses which word to document what the client experienced?

Extravasation

t is the correct order to remove Personal Protective Equipment (PPE)?

Gloves Eyewear Gown Mask

What teaching would you provide to a client regarding foods high in calcium?

Good sources for Calcium include cheese, yogurt, strawberries, broccoli, citrus fruits, almonds, leafy greens, & tomatoes.

What foods would you teach patients experiencing an acute episode of diverticulitis to avoid?

High fiber foods should be avoided during an acute attack of diverticulitis

The nurse teaches the UAP about using a safety razor to shave facial hair. Which action by the UAP indicates successful teaching by the nurse?

Holds the skin taut to prevent cutting the skin

What are the causes of respiratory alkalosis?

Hyperventilation (from anxiety or PE) Mechanical Ventilation

What are the manifestations associated with Addisonian crisis?

Hypotension, Tachycardia, Hyponatremia, Hyperkalemia, Hypoglycemia, Dehydration, fever, weakness, confusion

What are best practices for the trach ties when performing tracheostomy care?

Secure new ties before removing soiled ones. There should be space for one finger between the tie and the neck.

What immunization is indicated during pregnancy?

Tdap

The client made the following statement to the nurse, "My doctor just told me that he cannot save my leg and that I need to have a AKA." Which response by the nurse is the most appropriate

Tell me more. . .

What is the purpose of the HPV vaccine?

The HPV vaccine may prevent some types of cervical cancer. This vaccine does not prevent ovarian cancer

During a physical examination a 24 month old child clings to the parent and cries every time the nurse attempts to touch her. From knowledge of psychosocial development, the nurse makes which conclusion about the child?

The child is displaying normal toddler development.

Metabolic alkalosis

associated with NG suctioning, prolonged vomiting, or the use of antacids.

Respiratory acidosis

associated with a decreased respiratory rate (respiratory depression) from overdose or anesthesia. Respiratory acidosis may also be caused by ARDS, pneumonia, and COPD.

Metabolic acidosis

associated with salicylate intoxication, DKA, dehydration, diarrhea, liver failure, and Kussmaul respirations.

At what age is it recommended for girls to receive the HPV vaccine?

between 9-26 years old

A client is HIV positive, taking antiviral medication as ordered and has no HIV-related problems. The client is being admitted for an appendectomy. What type of precautions would be required when caring for this client?

standard

Although the client refused the procedure, the nurse insisted and inserted a NGT in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following?

Battery

Administration of what medications cannot be delegated?

Do not delegate: Administration of medications, including blood, via IV or central lines.

What patients are considered appropriate for a temporary emergency admission?

A client who is a current danger to self or others is a candidate for a temporary emergency admission.

What are best practices to teach patients for prevention of DVT/VTE?

Leg exercises Compression stockings Avoid crossing legs or sitting for long periods of time

Which components should the nurse include under the assessment of the client's history of present illness? Select all that apply.

1. When the symptoms started 2. How often the problem occurs 4. What treatments the client has tried 5. Factors that aggravate the problem

A 34 year old female is having a yearly checkup with her PCP. Which of the following is an appropriate breast health guideline for a woman this age?

A clinical breast exam by a health professional every 3 years

A nurse manager is explaining the use of incident reports to a group of nurses in an orientation program. Which of the following information should the nurse manager include?

A description of the incident should be documented in the chart. Incident reports include a description of the incident and actions taken. The risk management department investigates the incident.

Which nursing action supports the nurse's intervention to align and support a client in Sims' position?

A pillow to support the head, maintaining it in good alignment

The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client?

A positive reading means exposure to TB bacilli"

A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse responds by saying that the corticosteroids will do which of the following?

Decrease inflammation in the airways

The nurse is administering one unit of packed red blood cells as ordered by the PCP. While the nurse is measuring the vitals 15 mins after starting the transfusion, the client complains of chills and back pain. What should the nurse do first.

Disconnect the blood tubing from the catheter, replacing it with an infusion of normal saline.

A 24-year old gravida 1, para 0 patient, receiving oxytocin, is in labor at 41 weeks gestation. Which of the following are appropriate nursing actions in the presence of late fetal heart rate decelerations?

Discontinue the oxytocin. Administer oxygen to the mother by mask. Notify the healthcare provider.

What are teaching points for patients prescribed a transdermal medication patch?

Do not cut patch. Apply to hairless skin. Can shower with patch on, no need to cover patch.

The nurse at change of shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused is trying to get out of bed and had pulled out the IV line, which has subsequently reinserted. Which actions by the nurse is appropriate?

Document the behavior that require continued use of the restraints. Provide range-of-motion exercises when the restraints are removed. Orient the client Assess the tightness of the restraints.

What teaching is appropriate for patients prescribed phenytoin (Dilantin)?

Don't discontinue abruptly. Diabetics monitor glucose. Urine may turn harmless pinkish red/brown color. Thrombocytopenia and gingival hyperplasia are adverse reactions.

What are age appropriate toys for a preschool child?

Dress-up clothes, coloring books/crayons, dolls, housekeeping toys, dollhouses, play store toys, telephones, farm animals and equipment, village sets, trains, trucks, cars, hand puppets, and medical kits provide hours of self-expression for preschool children.

What are expected manifestations in patients experiencing panic level anxiety?

During a panic attack, the person is completely distracted, unable to function, and may lose touch with reality. Have staff help protect and remove other patients. Speak calmly providing simple directions.

What is best practice for a client who has Meniere's disease and is experiencing an acute attack of vertigo?

During an acute attack, it is best for the client to lie down in a darkened, quiet room and avoid position changes. Fluids are administered IV to prevent dehydration.

The nurse assesses a post-op client who has a rapid weak pulse, urine output less than 30ml/hr, and decreased blood pressure. The client's skin is cool and clammy. What complication should the nurse suspect?

Hypovolemic shock

A client comes in to the clinic and is diagnosed with otitis media. Which statement indicates the clients understands the correct management for this disease?

I can apply hot packs to the ear for pain relief"

What are complications associated with administration of TPN?

Increased temperature indicates infection Excess fluid volume Hyperglycemia Hyperkalemia

What is informed consent?

Informed consent is when patients are informed of proposed care, risks and benefits, likelihood of achieving goal, and alternatives by the provider. The client signs the consent form confirming understanding what the provider explained.

What is thyroid storm?

Life-threatening disorder associated with uncontrolled hyperthyroidism. Manifests as a high fever and severe HTN. Monitor and report any temperature increase, palpitations, chest pain, dyspnea, vertigo.

What vaccines are contraindicated for children who are immunosuppressed?

Live attenuated vaccines

What lab values require monitoring for patients taking a statin medication?

Liver Enzymes

What are expected manifestations for a child with glomerulonephritis?

Low urine output, Periorbital edema, Cola-colored urine, HTN

What is the expected outcome of administering magnesium sulfate to a patient in preterm labor?

Magnesium Sulfate is a smooth muscle relaxant used to slow or stop contractions

What patient manifestations indicate the nurse needs to prioritize for follow-up?

Major change in VS Abnormal Lab values Fatal Cardiac Rhythms Complaints of Dizziness Difficulty Swallowing

Which phase in the cycle of violence prevents an abuse victim from leaving their abuser?

The honeymoon stage is when the abuser exhibits loving behaviors toward the abused spouse.

The nurse is transcribing the PCP's orders and finds the following medication order on a client's chart: morphine 8 mg prn every 2 hours. Which of the rights of medication administration would the nurse need to clarify?

The nurse needs to clarify the right route because this is not indicated in the question.

What interventions are appropriate for a patient with a retinal detachment experiencing bright flashes of light, floating dark spots, and sensation of a curtain pulled over part of the visual field?

To prevent further injury limit mobility. Following repair of a detached retina, cool or warm compresses may be applied. Teach to avoid lying face down, stooping, or bending preoperatively

What education would you provide for patients being discharged after ileostomy surgery?

Use a skin barrier. Empty if 1/3 - 1/2 full Change pouch during inactive times (before meals, before bedtime, early am, or 2-4 hours after eating).

What are the nursing priorities when caring for a patient in restraints?

Use quickrelease knot to tie to bed frame. Ensure loose enough for ROM and 2 fingers fit between restraints and client. Formal assessment at frequent intervals for ROM of each limb, repositioning, and nutrition/elimination needs. Document per policy.

What medications are appropriate for patients with SIADH?

Vasopressin antagonists to promote water excretion without causing Na loss. Tolvaptan po or conivaptan IV.

When would the nurse administer RhIg?

When the mother is Rh-negative and the father is Rh -positive. If Rh - negative female is not sensitized may receive RhIg the 28th week of pregnancy to prevent sensitization for the rest of pregnancy. If the baby is Rh -positive the mother receives another dose of RhIg.

When inserting a Foley catheter in a female, the nurse should complete which action?

Wipe far labial fold, near labial fold, and directly over center of urethral meatus Lubricate the tip of the catheter prior to insertion