Full review NCLEX

Prior to taking necessary supplies into a surgical suite where the surgery case may involve blood, the nurse will don which attire?

-A hair covering is donned first to prevent hair from falling on fresh surgical scrubs. -A mask is worn to prevent dispelling droplets into the sterile field. -Surgical scrubs are worn to prevent shedding. Scrub pants and tops are preferred over dresses to protect shedding from the perineum, which contaminates the sterile field. -Shoe covers are worn when there are cases that may involve blood.

What does a Durable Power of Attorney for Health Care as a legal document provide?

-Direction about treatment choices in certain circumstances such as an advance directive -A surrogate decision-maker in the event the client becomes incapacitated or unable to make informed health care decisions. -A permanent part of the client's medical record.

The nurse is caring for a client with acute renal failure. The morning assessment findings indicate the client has become confused and irritable. What may cause this behavior?

-Elevated blood urea nitrogen levels can cause confusion as urea is neurotoxic. - Clients with renal failure retain fluid and are at risk for dilutional hyponatremia. Increased or decreased levels sodium levels can cause confusion, but this client is not at risk for hypernatremia.

After the nurse administers ear drops to an adult client, it is important for the nurse to implement which action?

-Gently massage the tragus of the ear. Is a correct nursing measure that will facilitate the flow of medication in the auditory canal. -The client can remain on his side for 5 to 10 minutes with the affected ear up to help distribute the medication and prevent the medication from escaping the ear canal. - The cotten ball is placed loosely at the opening of the auditory canal for 15 minutes to prevent the medication from escaping the canal when the client changes positions.

A client has Type 2 diabetes and is brought to the emergency department in an unresponsive state. A diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse prepares for the administration of which initial therapy? -GIve O2 or IV NSS

-IV NSS

18 mo - 3 years needs

-Important to let child do tasks alone -Finger foods -provide emotional support when necessary

Which prescriptions would necessitate the nurse to seek clarification from the primary healthcare provider?

-Lasix 20.0 mg p.o. daily -Benadryl 25 mg p.o. hour of sleep for three nights -Folic acid 1 mg daily -Heparin 1000 IU subcutaneously daily It is inappropriate to have a trailing zero after a decimal point for doses expressed in whole numbers. It can be mistaken as 200 if the decimal point is not seen and read appropriately. The Folic acid order lacks a route, thus needs clarification. This order should be written as Heparin 1,000 units subcutaneously daily. Use commas for dosing units at or above 1,000 or use words such as one thousand to improve readability. Use units rather than IU (International units) as it can be mistaken as IV or 10.

acid-fast bacilli (AFB) precautions?

Airborne precautions

Can pts on MAOI's eat bananas and avocados

Bananas and avocados cannot be eaten while taking the medication. (Tyramine especially if ripe)

Which symptom is the client who overdosed on barbiturates most likely to exhibit?

Barbiturates are central nervous system (CNS) depressants. They will slow the respiratory and heart rate.

Benztropin

Benztropin is used to treat parkinsonism of various causes and drug-induced extrapyramidal reactions seen with chlorpromazine.

Which medications below are used to help decrease tremors for clients with hyperthyroidism?

Beta blockers help anxiety and tremors.

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation?

Clear urine Correct: The irrigation is regulated so that the urine is free of clots and slightly pink tinged.

Akathesia

Complaints of restlessness, inability to sit still, and nervous energy indicate akathesia

What symptoms does the nurse expect to see in a client with bulimia nervosa?

Diagnostic criteria for bulimia nervosa are recurrent episodes of binge eating; recurrent inappropriate compensatory behavior to prevent weight gain such as laxative, diuretic, or enema use, induced vomiting, fasting, and excessive exercise; and feeling of self-worth unduly influenced by weight. Amenorrhea is found in anorexia nervosa.

Which personal protective equipment should the nurse wear while holding a client to prevent jerking as a primary healthcare provider drains a client's large abscess at the bedside?

During drainage of an abscess, there is the possibility of bodily fluids spraying the nurse. The nurse needs the protection of a gown, mask, and face shield. Gloves are worn to prevent touching contaminated material. Donning sterile items is not necessary as the nurse is not assisting with the procedure, but holding the client instead.

DM Ct. is it safer to file or cut nails?

File - less likely to cut or irritate

The nurse is evaluating the outcomes of nursing interventions for the client on the long-term care unit. The nurse has determined that the goal was partially met. What should the first nursing action be at this point to maintain quality of care?

First, the nurse will want to determine if the interventions were performed. If they were not carried out, the goal could not be achieved.

Indomethacin

For Pain, inflammation, fever

Removing PPE

Gloves, Goggles/Shield, Gown, Mask

A client diagnosed with Diabetic Ketoacidosis (DKA) is on an insulin drip. What is most appropriate for the nurse monitor?

Insulin brings glucose and Potassium into the cell leaving the client hypokalemia and at risk for arrhythmias

Can you use petroleum jelly with O2 therapy

Petroleum jelly is a combustible substance. It should not be used with oxygen therapy.

To reduce the risk of developing a hematoma following balloon angioplasty, the nurse should implement which of these measures?

Prevent flexion of the affected leg -DO NOT WALK

SSRI SE

The drug causes temperature dysregulation, with increased sweating in some clients; therefore, the client's comment indicates understanding of the teaching.

Earliest EKG sign of hypokalemia

The earliest EKG change is often premature ventricular contractions (PVCs), which can deteriorate into ventricular tachycardia or fibrillation (VT/VF) without appropriate potassium replacement.

A mother tells the clinic nurse that her child has just been diagnosed with attention-deficit/hyperactivity disorder (ADHD) and asks the nurse what will be done to help her child. How should the nurse respond to the mother?

The standard of care for children includes central nervous system stimulants along with behavior and family therapy.

Wernicke-Korsakoff Syndrome treatment

Thiamine 50 - 100 mg IV or IM is indicated bid for clients with this syndrome. It is usually given for several days, followed by 10-20 mg once a day until a therapeutic response is obtained.

Which postpartum client must have a private room? 1)A client who has antibodies for Hepatitis 2) A client who is rubella non-immune. 3) A client who is rubella immune. 4) A client who has lupus antibodies.

- 1. This client should be in a private room for her protection and the protection of other postpartum women. The presence of antibodies for Hepatitis C indicates HCV infection and possibly impaired immune function due to liver damage. In addition, Hepatitis C is transmitted by contact with body fluids and it is likely that lochia will be found on toilet surfaces. It is also common for postpartum women to have some kind of wound (perineal laceration or episiotomy) and they will be at increased risk of HCV contaminated lochia coming into contact with their wound. 2. Incorrect: Rubella non-immunity carries risks only to an unborn fetus. 3. Incorrect: Rubella immune woman has no risks.

A school nurse is planning a session on the effects of cannabis use for a high school health class. Which information does the nurse need to include?

-Cannabis ingestion can cause tachycardia. I-nhaled cannabis produces a greater amount of tar than tobacco. -Cannabis smoke contains more carcinogens than tobacco smoke. -Orthostatic hypotension can be caused by cannabis injections. -It is possible to overdose on cannabis. Symptoms include fatigue, paranoia, delusions, hallucinations, and possible psychosis.

A nurse works in the operating room (OR) as a circulator with a focus on decreasing surgical-site infections. Which actions should the nurse perform to help prevent surgical-site infections?

-Close the OR doors at all times during a surgical case. -Minimize traffic in the OR. -Monitor the sterile field at all times. -Immediately discard any object that becomes contaminated. -Incorrect: Laminar flow has not been proven to prevent surgical-site infections.

The client in the emergency department is suspected of having a lesion caused by anthrax. What assessment question is most important?

-Cutaneous anthrax may be contracted by working with contaminated animal skin products. Anthrax is found in nature and commonly infects wild and domestic hoofed animals. - Cutaneous anthrax is contracted by spores entering cuts or abrasions in the skin.

What is the best way for the nurse to keep the airway open for an alert, but very drowsy client complaining of chest pain with no evidence of trauma?

-Nasopharyngeal airway: Nasal airway is used on alert clients to keep the airway open. 1. Incorrect: Oropharyngeal airway, Oral airway is not recommended to open the airway of an alert client. The oral airway may cause gagging.

A client is admitted to the critical care unit after suffering from a massive cerebral vascular accident. The client's vital signs include BP 160/110, HR42, Cheyne-Stokes respirations. Based on this assessment the nurse anticipates the client to be in which acid base balance?

-Respiratory acidosis Causes of Respiratory acidosis include any causes of decreased respiratory drive such as due to drugs (narcotics) or central nervous system disorders.

A client with heart failure and pulmonary edema is given furosemide intravenously. Which assessment indicates the furosemide has achieved the desired effect?

-The client's lungs have fewer rales on auscultation. The goal for diuretic therapy in this client is to prevent/relieve fluid accumulation in the lungs. This answer addresses the most life threatening sequelae with HF. The number one thing to worry about in clients with HF is pulmonary edema because this is what can kill the client. -Increased urinary output is an expected finding, but treatment of pulmonary edema is the primary goal.

Autism

2) Twisting 3) Preoccupation with objects 4) A personal language -All are behaviors seen in children with autistic disorder. They do not form interpersonal relationships with others. Do not play with others.

ºOn the third postoperative day a client develops a fever of 103.3ºF/39.6ºC and is shivering. The primary healthcare provider writes these prscriptions. Which should the nurse do first?

Blood cultures MUST be drawn immediately to identify the causative bacteria. Once the organism is identified the primary healthcare provider will order organism specific antibiotics. Always draw blood cultures before administering the antibiotic. If antibiotics are given before the blood cultures are draw, the culture will be inaccurate, and the client cannot be treated appropriately.

The nurse is caring for a client in labor. While performing a vaginal examination the labor nurse feels soft squishy tissue instead of a head. What assessment would the nurse make?

Breech presentation

Buspirone lag time

Buspirone has a lag time between start of therapy and subsiding of symptoms of 10-14 days. The client must take the medication regularly, as ordered, so that it has sufficient time to take effect.

Which are risk factors for post-influenza complications?

Clients who are over the age of 65, have diabetes, have renal disease, or who reside in a nursing home are all at risk for post-influenza complications.

A client with Crohn's disease develops a fever and symptoms of an infection. The nurse recognizes this complication may occur as a result of which finding?

Clients who suffer from Crohn's disease are at risk for developing fistulas, and an abscess can result from the fistula.

The son of an elderly diabetic client complains that his mother is frequently having low blood sugar. What should the nurse teach this family member about symptoms of hypoglycemia in the elderly?

Elders may not recognize early symptoms of hypoglycemia. Blood sugar levels should be checked frequently. Some oral medications are more likely to cause hypoglycemia episodes. If the client has frequent episodes, perhaps a medication change is warranted. The elderly must maintain regular schedules and adequate food intake. These may present challenges for the elder who lives alone. If an elder develops unsteady gait, loss of concentration, lightheadedness, the blood glucose levels should be checked. These symptoms are typical in a hypoglycemic episode.

A client is taking NSAIDs for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts you to the possibility that the client is chronically losing small amounts of blood?

Elevated reticulocyte count indicates increased production of RBCs is occurring. If a client is chronically losing blood, the body's response is to increase RBC production so the retic count would increase.

The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials?

Empty vials and sharps such as needles and syringes used in delivering chemotherapy agents should be disposed of in a chemotherapy sharps container. These waste containers are designed to protect workers from injuries and are disposed of by incineration at regulated medical waste facilities.

too much fludrocortisone replacement

Fludrocortisone is a mineralocorticoid which causes the client to retain sodium and water. Retaining sodium and water will cause the client's weight to increase. Remember any sudden gain of weight is due to water retention.

Which signs and symptoms will the nurse include when teaching a client about the signs and symptoms of recurrent nephrotic syndrome?

Foamy urine, which may be caused by excess protein in the urine, is seen with nephrotic syndrome. Swelling (edema), particularly around the eyes (periorbital) and in the ankles and feet are symptoms of nephrotic syndrome. -Weight gain is seen with renal disorders due to poor renal function and increased fluid volume.

A visitor is going into the room of a client who is on droplet precautions. Which instruction would the nurse give the visitor?

For a client on droplet precautions, a clean gown and gloves are worn when there will be any contact with the client or with any contaminated items in the client's room. Also a mask and eye protection is worn when the visitor will be within 3 feet of the client.

The nurse is monitoring the healing of a full-thickness wound to the right thigh. The wound has a small amount of blood during the wet to dry dressing change. The nurse should know that this is the result of or evidence of?

Good blood flow, chart and continue

Donning PPE

Gown, Mask, Respirator, Goggles/shield, Gloves

A client's membranes spontaneously rupture at 10 cm dilation and -2 station. The nurse notes that the fluid is colored green. What client preparation is the priority nursing action?

Green stained fluid indicates fetal passage of meconium. The fetus must be suctioned by the health care provider when the head is still on the perineum and before the baby takes its first breath. This will remove any particulate matter from the meconium that may cause aspiration.

A client admitted with biliary atresia has just arrived on the pediatric unit. The unit is very busy and the other RNs are busy with other clients at this moment. What action by the charge nurse would be most appropriate?

Have an LPN perform an initial assessment until an RN can verify the findings and complete the admission assessment. -The best answer is to have the LPN initiate the assessment and let the RN complete the assessment once he/she has completed the present task. Assessment on the new client should be completed by a RN within eight hours of arriving on the unit. It is acceptable to let the LPN initiate the process. It would be best if a licensed person did a brief initial assessment on the child instead of the NA. The RN will verify the data.

The nurse is caring for a client with a closed head injury. Which of these would increase intracranial pressure?

Hypoventilation leads to vasodilation and increased intracranial pressure.

Which comment made by a client scheduled for a lumbar laminectomy and diskectomy indicate the need for futher teaching?

I can turn myself: The client must log roll with assistance. The spine must be kept in proper alignment to allow the area time to rest and heal. The nurse should reinforce this information with the client.

A client diagnosed with Arachnophobia is prescribed alprazolam 0.5 mg tid. The nurse knows that teaching about this medication is successful when the client makes what statement?

I should not stop taking alprazolam suddenly. -This is a true statement. Doing this could produce serious withdrawal symptoms, such as depression, insomnia, anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium.

The nurse prepares to give an injection to a client. When the nurse aspirates prior to injecting, a small amount of blood is noted in the syringe. Which action is most appropriate for the nurse to take?

If blood is noted with aspiration after the needle has been inserted, the needle and medication should be discarded. The nurse needs to restart the process with new equipment and medication.

The nurse has been trained to work in a decontamination station for hazardous exposure victims. What should the nurse tell this victim about the process?

If the victim can remove his/her own clothing, then instructions should be given to do so and dispose of in hazardous material container. The person will wash for several minutes, beginning with a minute or so of full body rinsing with water to remove any visible contaminants, followed by soap, and final rinse. Times vary with institution and known contaminants. Using soap with good surfactant qualities is important. Generally, the victim is instructed to rinse with tepid water, apply soap from head to toe, and then rinse again with copious amounts of water.

A child is admitted to the hospital with a temp of 102.2ºF/ 39.0ºC, lethargic, and no urinary output in 6 hours. Which prescription would be priority for this child?

Immediate blood cultures should be obtained on a child, as sepsis is suspected with any temperature this high.

The emergency department called the LDR to give report on a 24 year old primigravida at term and having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate?

Instruct the LPN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse. -Obtaining vital signs and placing clients on electronic fetal monitors are within the scope of practice of LPNs.

postpartum and complaining of intense perineal pain

Intense perineal pain is a symptom of a perineal hematoma, which is a medical emergency.

Which room assignment by the charge nurse would be most appropriate for a nine year old child with ADHD? 1)Rooming with a ten year old with Crohn's disease. 2) Rooming with an eight year old with a history of seizures. 3)Rooming with a six year old admitted with asthma. 4) Rooming with a seven year old with a urinary tract infection.

It would be best to pair this child with the child with a urinary tract infection. They are close to the same age and this child's condition does not require a quiet environment that could be interrupted by a hyperactive child.

A client is admitted to the emergency department in diabetic ketoacidosis (DKA). Which central venous pressure (CVP) reading would the nurse anticipate?

LOW -2mmgs ex. This is a CVP reading that would indicate fluid volume deficit. A client in DKA will have polyuria.

A Mexican immigrant family lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be most important for the home health nurse?

Lead may be found in the soil around rusted cars. Old paint contains lead. Chips of paint may be consumed by young teething children. Old run down apartments may also have pipes which contain lead. Consuming even small amounts of lead can be harmful.

Elderly receiving IV fluids check

Lung sounds frequently, high risk for FVE

A client at 36 weeks gestation is receiving Magnesium Sulfate for treatment of pre-eclampsia. Which finding requires immediate action?

Magnesium Sulfate is a potent central nervous system depressant that is excreted through the kidneys. Adequate kidney function is vital to prevent Magnesium toxicity. The urinary output must average at least 30cc/hr.

The high school nurse is teaching her students about proper food storage and preparation. What instructions should be given in the teaching plan to prevent exposure to the potentially fatal botulism pathogen?

Make sure that you heat food or drink to 212 degrees Fahrenheit for 10 minutes. (Boiling inactivates it)

Malnourished Ct. findings

Malnourished clients appear pale due to anemia. Anemia is related to folate deficiency. Serum prealbumin, albumin, protein levels are decreased in malnourished individuals.

A client with Type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What instruction would the nurse give the client?

Morning hyperglycemia may be the result of dawn's phenomenon or the somogyi effect. The client must take their blood sugar between two and three o'clock in the morning for several days to determine the cause of morning hyperglycemia. If the client has decreased blood sugar between two and three o'clock in the morning, suspect somogyi effect.

A client diagnosed with major depression is admitted to the psychiatric unit for electroconvulsive therapy. She asks the nurse, how many of these treatments do you think I will need? What should be the nurse's reply?

Most clients require an average of 6 to 12 treatments, but some may require up to 20 treatments.

Which ethical principle is involved in reporting a medication error to the primary healthcare provider?

Nonmaleficence is best illustrated with the nurse's action, as the goal is to do no harm to the client. With timely reporting of an error, further complications may be prevented.

Should the hospital develop a response plan for each potential distaster?

One good response plan should be developed rather than multiple plans. This will ensure adequate understanding of the plan and decrease confusion of roles that could occur with multiple plans.

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) STAT. The client has a non-tunneled central venous catheter with an open tip in place. Which procedure would the nurse use when administering the medication through the catheter?

Open tip central venous catheters require heparin flush to keep the lumen patent. The correct procedure is saline, medication, saline, and then heparin. The medication and the heparin should not come in contact thus flush with saline before the medicine to clear the central line lumen of herapin and after to clear the lumen of medication.

A primipara is admitted to the LDR at term in active labor and with rupture of membranes. Her last vaginal exam one hour ago revealed that she was dilated to 6 centimeters, 100% effaced, and at -1 station. The client calls out "My belly really hurts; I feel like I have to have a bowel movement!" Which action should the nurse perform first?

Perform a sterile vaginal exam -Labor can progress rapidly even in a primipara. As the fetal presenting part descends, pressure is placed on the rectum and many women report that it feels like they need to have a bowel movement. The symptoms described indicate that the client has fully dilated and is a 1+ or better station and delivery may be imminent.

Proper cane walking

Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client stands with the body weight divided between the two legs. The weaker leg is then advanced to the cane, with the body weight divided between the good leg and the cane. Finally the stronger leg is advanced past the cane and the weaker leg, with the body weight divided between the cane and the weaker leg.

That other types of food contain gluten

Processed meats

A client was prescribed thioridazine hcl five days ago and presents to the emergency department with a shuffling gate, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication is suspected?

Pseudoparkinsonism may appear 1 to 5 days following initiation of antipsychotic medications: occurs most often in women, the elderly, and dehydrated clients. Symptoms include tremor, shuffling gait, drooling, and rigidity.

The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. What would the nurse unfamiliar with formalin do?

READ MSDS All hazardous materials come with a MSDS—material safety data sheet—which includes the identity of the chemical, the physical and chemical characteristics, the physical and health hazards, primary routes of entry, exposure limits, precautions for safe handling, controls to limit exposure, emergency and first-aid procedures, and the name of the manufacturer or distributor.

External radiation Effects

Radiation may cause fatigue, loss of appetite, erythema, skin problems and pancytopenia. NO EDEMA

What is the best position for a client immediately following a bilateral salpingo-oophorectomy?

Side lying, We want to position for comfort with the knees flexed and on the side for airway.

S/S UTI

Signs and symptoms of UTI include burning on urination, nocturia, incontinence, suprapubic or pelvic pain, hematuria, and back pain.

When assessing a client with a brain injury the nurse will monitor for which sign of increased intracranial pressure (ICP)?

Signs of increased intracranial pressure include papilledema, elevated systolic pressure, wide pulse pressure, decreased pulse, and slow respirations.

Post THyroidectomy diet

Soft diet to prevent damage

The nurse delegated feeding of an elderly client to the unlicensed assistive personnel (UAP). Two hours after other trays were picked up from the rooms, the nurse notes that the client's tray is still at the bedside. What should the nurse do first? -Speak to the UAP -Give snack to patient

Speak to UAP -Communication is important in delegation, as is follow-up. There may be a good reason that the tray was not served.

Do not take with SSRI

St. John's Wort in combination with a selective serotonin reuptake inhibitor could cause serotonin syndrome which can be fatal.

Full thickness burn, what do you use to irrigate the wound?

Sterile saline

A nurse is teaching a renal transplant client about self care after discharge. As part of the information about transplant rejection, the nurse cautions the client to notify the primary healthcare provider of which occurrence?

Tenderness over the kidney indicates a problem with the kidney and the primary healthcare provider should be notified immediately. Other s/s of an acute rejection are fever, increased BUN/CR, weight gain, decreased urine output and increased BP.

What task by the RN should be performed first? -Give scheduled antibiotics or Assess new admit

The admit assessment should be done first. It is important to initiate the assessment and physical within one hour of being on a general acute unit. Completion of the assessment and establishing a plan of care should be completed by 8 hours of admission.

While preparing a fact sheet for a client diagnosed with a vancomycin-resistant enterococcus (VRE) urinary tract infection, the home health nurse should include which instructions?

The bathroom and kitchen should be cleaned with warm water and bleach to decrease contamination. The client should wash hands after using the bathroom and before preparing food. -Not HOT water, can cause drying of skin/crackin

The nurse is teaching the client about benzodiazepines. Which comments by the client indicates adequate understanding of the drug effects/side effects?

The benzodiazepines slow reaction time and may affect general alertness. -The client should not operate machinery until effects of the medication are observed, and it is determined that the client can drive safely. -Benzodiazepines affect the central nervous system and slow reaction time. - Benzodiazepines medications are usually prescribed for short periods of time. -The benzodiazepines are frequently abused. Clients develop tolerance and dependence on the drugs.

Which prevention strategy should be considered when developing the health promotion plan for new parents concerning sudden infant death syndrome (SIDS)?

The child should be placed in the supine position when being put to bed for naps or for the night. This position has helped to reduce the incidence of SIDS by as much as 50% since the 1990s.

A client is scheduled for surgery today. As you prepare the pre-op medication, the client says, I have changed my mind. I don't want to go through with the surgery. What should the nurse do first?

The client has the right to make decisions, and to change his mind. The primary healthcare provider should be notified.

Serotonin Syndrome s/s

The client is likely to have a fever and may also experience shivering. The client is usually agitated. Increased heart rate and blood pressure are expected.

The client is receiving a prostaglandin agonist for the treatment of glaucoma. Which comment by the client indicates a lack of understanding of the treatment regimen?

The color of the iris may darken in the eye being treated; however, it is important that the client understand that drops should not be placed in the unaffected eye. To do so may result in a subnormal intraocular pressure. -Eye lashes will be longer in treated eye

After artificial rupture of membranes, the baseline fetal heart rate tracking begins to show sharp decreases with a rapid recovery with and between contractions. Which of the following actions by the RN has priority?

The fetal heart pattern is that of repetitive deep variable decelerations. This pattern is likely due to a prolapsed umbilical cord after AROM. The priority intervention is to relieve the pressure on the cord from being trapped between the presenting part and the pelvis. This can be accomplished by manual pressure on the presenting part, placing the client in Trendelenberg position, or placing her in the knee-chest position.

The nurse is working on a health promotion plan for a young family whose child has severe allergies and asthma symptoms. Which interventions would be important to include in the health promotion plan?

The frequent washing in hot water removes dust mites. Adequate venting lessens the likelihood of fungal/mold spores. Carpet harbors dust and other allergens. The floors and upholstered furniture may harbor dust, pollen from clothing, and other irritants. -Humid air may contribute to mold or fungal spores in the house. Less humidity is appropriate.

Gallbladder disease eating a high fat meal

The gallbladder assists in digestion of fat. When foods high in fat are ingested bile is released from the gallbladder to assist in digestion. If gallstones are formed in the gallbladder or blocking the outlet to the gallbladder, the client may experience epigastric discomfort after a meal high in fat.

Conscious sedation goal

The goals and effects of conscious sedation include alteration of mood, maintenance of consciousness, cooperation, elevation of pain threshold, minor variation of vital signs, and some degree of amnesia.

A client who needs a peak blood level drawn because the antibiotic just finished infusing.

The most urgent task is the peak medication level that needs to be drawn. If the level is not drawn at the appropriate time, the results may not give an accurate report of what is needed to determine if the medication is at the appropriate dosage or not, and if the dosage is safe.

A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly. The newborn weighs 6 pounds. The dispensed dose is 25,000 units per 1 mL. What should the nurse do?

The nurse must consult with the pharmacy to receive further instructions. The dose is greater than the allowed volume to be given intramuscularly, which warrants clarification by the pharmacy.

What essential assessment must be performed for clients with implanted dialysis access devices?

The nurse palpitates the thrill and listens for the bruit to ensure patency of the access device.

A male client was admitted to the psychiatric unit with delusions and a history of auditory hallucinations. The client reports that the FBI has been watching his house and he thinks that they are going to raid the house and arrest him. How should the nurse respond?

The nurse should empathize with the feelings of the client, and she should not validate the belief itself. -I believe that your thoughts are very disturbing to you.

The circulating nurse prepares the sterile field in the operating room (OR). Fifteen minutes later, the nurse is informed the surgery will be delayed for 20 minutes because the surgeon is working at another hospital. Which is the best action for the nurse to take?

The nurse should monitor the sterile field while awaiting the surgeon -The nurse should not cover the sterile field because of the possibility of contamination during removal of the drape. -It is not necessary to take down sterile field because delay in minimal

A prescription is written to give MSO4 8 mg intramuscularly now. What should the nurse do?

The nurse should notify the primary healthcare provider, because MSO4 is an abbreviation that is on the Joint Commission's do not use list. MSO4 can mean morphine sulfate or magnesium sulfate. Notifying the primary healthcare provider to clarify the prescription will prevent a medication error from occurring

The nurse should plan to evaluate the earliest onset of effectiveness of nitroglycerin sublingual within what time frame?

The onset of action for Nitroglycerin sublingual is 1 to 3 minutes. So the effectiveness can be assessed 3 minutes after the drug is administered.

A male client presents to the mental health unit following a brutal beating by his wife. He has numerous bruises on his face, chest, and back. He has one laceration where she "came at me" with a knife. At this time, what is most likely to be the mood of the perpetrator in this situation?

The perpetrator has completed the acute battering phase and has now likely entered the honeymoon phase with extreme kindness and acts of love. She is now calm after the tension has been released.

The platelet count is 10,000/mm3

The platelet level is at the "panic" level. The client is at risk for a cerebral hemorrhage. Assessing the LOC takes priority because this is the answer that is most life threatening.

The case management nurse focuses on overseeing and organizing client care. What are the goals of the case management model of client care?

The primary goals of the case management model of interdisciplinary client care are to provide high-quality, appropriate, and cost-effective care to each client in a timely manner.

Virchow's triad risk factors for DVT and Pul. Embolism

The risk factors known as Virchow's triad include venous stasis, injury to the vessel wall, and hypercoagulability.

After shift report, which client should be seen first? 1) An eight year old that is in skeletal traction. 2) A six year old that had an appendectomy 6 hours ago. 3) An unattended two year old admitted for a sleep study. 4) A four year old cerebral palsy child with a tracheostomy admitted for UTI.

The unattended child should be checked first to make sure he/she is safe and having no complications. A child this age is entirely dependent on someone else.

A migrant farmer worker comes into the clinic complaining of headache, dizziness and muscle twitching after working in the fields. The nurse recognizes that the person is exhibiting signs of which condition?

These are symptoms of Pesticide exposure when combined with the details given of coming from the fields. Other symptoms include memory loss, difficulty concentrating, mood changes, abdominal pain, n/v, malaise, skin rashes, and eye irritation. Death can result from severe acute pesticide poisoning.

Which client should the nurse assign to the LPN rather than the RN? Choose one answer. 1) Client being admitted to unit. 2) Client going into surgery. 3) Client being discharged. 4) Client returning from surgery.

This client has the least amount of assessing or teaching and most predictable.

A client delivered a term male infant four hours ago. The infant was stillborn. Which room assignment would be most appropriate for this client?

This client needs a private room so she can feel free to grieve and other family members can stay with her for support. She should be transferred to a GYN (NOT POSTPARTUM UNIT) unit so the sights and sounds of the maternity unit do not contribute to her pain.

A nurse orienting to the ICU is inserting a nosogastric (NG) tube. Is Auscultates over the epigastric area with NS to check tube placement OK?

This is an incorrect intervention and the nurse precepting would need to intervene. If the NG is not in the correct place, the NS would go into the lung.

Which prescriptions are appropriate for newborn infants?

This vaccine will decrease incidence of hepatits B virus recommended at birth. Mandatory prophylactic agent applied in NB's eyes as precaution against ophthalmia neonatorium. Vitamin K (Aquamephyton) routine injection to prevent hemorrhagic disease of NB. PKU-Screening for phenylketonuria not reliable until NB has ingested an ample amount of the amino acid phenylalemine, a constituent of both human and cow's milk. Nurse must document initial ingestion of milk and perform test at least 24 hours after that time.

sentinel event?

Unexpected occurrence causing death or serious injury -A client scheduled for knee replacement surgery had an above the knee amputation performed.

UAP, Sterile urine sample from from foley or V/S 12 hours post partum?

V/S , Foley = invasive procedure

Are verbal orders of antineoplastic agents allowed?

Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety.

What is most important for the nurse to do prior to initiating peritoneal dialysis? Warm the solution or Have ct void.

Warm- we want to promote vasodilation for good exchange so warm the fluids. Voiding un-necessary before

A client has been admitted to the psychiatric unit with a diagnosis of schizophrenia. Which client behaviors does the nurse anticipate?

Waxy flexibility describes a condition in which the client allows body parts to be placed in bizarre or uncomfortable positions for long periods of time. Grandiosity and agitated behavior are signs and symptoms of schizophrenia. -)(NO anxiety or slumped posture)

What is the diet of choice, for client's on hemodialysis?

we need to restrict the protein to restrict the waste build up, they only get dialyzed every other day, so restrict the fluid, and restrict the sodium and potassium.

Common side effect of SSRI

Sweating

MMR contraindication

Allergy to eggs

INH do not eat?

Foods high in tyramine

Restlessness think?

Hypoxia

Small pox

-Droplet and Contact - Not all exposed will get it -10-30% fatal -Isolated for 18 days after exposure until scabs fall off

When does alcohol withdrawal delirium begin?

48-72 hrs after last drink

botulism risk

Have you eaten any home-canned foods recently

Inhalants do what to the heart?

Make it beat rapidly

Suicide precautions

-Clients should not be left alone for long periods of time. It is best not to place in a private room. Be sure to place close to the nurse's station. - Make rounds at frequent, irregular intervals to avoid predictability.

-Salmonella -Shigella -Escherichia Coli (E. Coli) -Clostridium Difficile

-Salmonella is a gram negative bacillus found in animal sources such as chicken products, eggs, turkey, and some beef. - Shigella infection is a gram negative organism that invades the lumen of the intestine and causes disease and severe runny, bloody diarrhea. Spread through the fecal oral route. Improper hygiene is most likely cause. - Escherichia coli is the most common aerobic organism colonizing the large bowel. Often linked to ingestion of undercooked contaminated beef and vegetables that have been contaminated by animal waste water. - Clostridium Difficile is a spore-forming bacterium usually preceded by antibiotics that disrupt normal intestinal flora and allow the C. Difficile spores to proliferate within the intestine.

Correct answer .5 or 0.5

0.5

The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue?

Cumulative Index for Nursing and Allied Health Literature (CINAHL)

After report, the nurse is assigned to care for 4 clients. Which client should the nurse see first? 1) Adult admitted 3 hours ago post appendectomy. 2) Adult with early onset of Alzheimer's disease and is confused. 3) Adult with Steinman pins to traction after internal fixation of the femur. 4) Adult with dehydration, who has been picking at her bedding and IV tubing all night.

4 Being restless is an early sign of hypoxia. Oxygen may be necessary. Remember the ABCs.

Booster seat age?

4-7 before that car seat

A client is being discharged from the hospital. The client has an unsteady gait and has weakness in the right leg. What assistive device would be most appropriate for the client?

A walker, with four wide, sturdy legs, would provide the most stable assistive device for a client with an unsteady gait.

The nurse is working with a committee at the local school to develop an emergency preparedness plan for tornados. What should be included in the plan?

: Everyone should be aware of safe zones within the school. Personnel should be given this information and signs posted in safe zones. There must be systems in place to accurately determine number of people in the building at any given time. There must be a system in place to alert personnel and students of tornado warnings. Regular practice prepares everyone for an actual event. 4. Incorrect: Gymnasiums are not considered safe places due to wide expanse of roof. Safe zones should be on interior walls, no windows, strong concrete floor if possible.

Parents brought their 5 year old child to the emergency room for pain and swelling in the left arm. An x-ray of the arm confirmed a fracture. The parents give conflicting stories about the "accident". What action by the nurse is most appropriate? Consult social services to rule out child abuse. OR Obtain a history as to how the accident happened.

COnsult Social Services to rule out child abuse

plateletpheresis

Can donate every 14 days

Special car restraints need until?

Children should use special car restraints until 4 feet, 9 inches in height or 8-12 years old.

A newborn with circumoral cyanosis.

Circurmoral cyanosis is bluish discoloration of and around the lips. It is an indicator of cyanotic heart defect.

Hypothyroid, Increase fluids or fiber?

Fiber, to prevent constipation from hypothyroidism

T/F: If chest compressions are being given with enough force and depth, a pulse will be felt with each compression.

True

Is Four year old admitted for developmental studies ok for LPN to care for?

Yes

Prozac 40 mg

if doses are greater than 20 mg it should be divided into two doses, not 40 mg for one dose.

What does HIPAA do

The HIPAA legislation of 1996 provides, in part, more widespread access to health insurance and the protection and privacy of health information, and legal requirements for appropriate sharing of client's information.

The nurse is caring for a client 28 weeks pregnant that reports swollen hands and feet. Which symptom below would cause the greatest concern?

muscle spasms-watch for seizure.

The client is admitted with a period of unobserved loss of consciousness and now has an EEG scheduled this am. What intervention should the nurse implement?

prior to an EEG we want the client to eat so the blood sugar does not drop and take medications, except sedatives, prior to the EEG. -give all meds including anticovulsants, unless specifically ordered.

Hypermagnesemia can be caused?

renal insufficiency or iatrogenic overtreatment.

How would the nurse determine the best size oropharyngeal airway for a client?

An airway of proper size will extend from the corner of the client's mouth to the tip of the earlobe on the same side of the client's face.

After a retropubic prostatectomy for treatment of benign prostatic hyperplasia, a client enters the post-anesthesia care unit with a three way Foley catheter that has a continuous irrigation of normal saline infusing. On the initial assessment of the urine in the Foley catheter bag, the nurse notes that the drainage is dark red. Which action should the nurse take?

An expected urine color would be dark red. The nurse would need to increase the irrigation rate until the urine becomes light pink. There is nothing here to indicate that the client is hemorrhaging.

Which client is at greatest risk for hemorrhage? 1) C-section delivery 2) Vaginal delivery of twins 3) Vaginal delivery of premature baby 4) Precipitous delivery of gravida 5

-1. Correct: The surgical opening of the abdomen and uterus makes this the highest risk Incorrect: The precipitous could make you think tear, but Gravida 5 makes you think easy opening.

Which assessment finding would best indicate a positive Mantoux tuberculin skin test?

-A central area of induration surrounded by erythema -The basis of reading the skin test is the presence or absence of induration, which is a hard, dense, raised formation. This is the area that is measured. Sometimes the site has erythema, a reddening of the skin that can also have swelling. The erythema should NOT be measured. Reactions to the skin test will vary. Measure only the induration.

What information should be included in the health promotion plan for parents of toddlers and the promotion of adequate bowel elimination in toddlers?

- Fiber is important for achieving adequate bowel elimination. -Fruits and whole grains may help. - Water intake is important, coupled with adequate fiber. -Distractions at toileting times may result in poor elimination results. ( No distractions) - The toddler should be taken to the bathroom after meals and at bedtime to encourage adequate elimination. (Not a random 3 x a day) -Do not be punitive if unsucessful

The nurse is caring for a client diagnosed with major depression post electroconvulsive therapy. What nursing interventions should be included in this post treatment period?

- Positioning on the side will prevent aspiration. Stay with the client until he/she is fully awake, oriented, and able to perform self-care activities without assistance. -Pulse, respirations, and blood pressure should be monitored every 15 minutes for the first hour. -Structured routine to prevent confusion

A physical assessment of a client on the second day after a thoracotomy reveals: oral temperature 100º F/37.8ºC; heart rate 92 and regular, BP 130/80; respirations 24 and shallow; and bilateral crackles in lower bases. The client reports incisional pain. Because of these findings, what should the nurse do first? Value 1) Cough and deep breathe the client. 2) Give prescribed acetaminophen (Tylenol) to reduce the client's fever. 3) Medicate the client for pain. 4) Assist the client to ambulate.

- The client described in this question is post thoracotomy, With ANY post-op client the number one concern, especially as a brand new nurse, is preventing pneumonia. A thoracotomy is very painful and the client is unlikely to breathe deep unless the pain is relieved. Temperature of 100º F/37.8ºC, HR 92, Respirations 24, bilateral crackles (indicating atelectasis) all reveal this client is heading for pneumonia. -Coughing and deep breathing IS exactly what the client needs, but the client will not cough and deep breathe if it hurts.

The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy? Which assessments by the nurse suggests that the client is developing this complication?

1) Asterixis 1 2) Lethargy 1 3) Amnesia 1 4) Behavioral changes 1 NO Kussmaul respirations

A child has sustained a severe burn. Which answer would be the correct order of what would be done for this child when the medical team arrives on the scene?

Airway, IV, pain, foley

A client is transported via ambulance to the Emergency Department with severe, crushing chest pain radiating up the left jaw. The client is diaphoretic with a blood pressure of 136/88, HR 102, R 24, T98.6ºF/37.0ºC. The primary healthcare provider prescribes Oxygen at 2 liters/nasal cannula, Morphine 2 mg IVP, Aspirin 81 mg, and Nitroglycerin 0.4 mg SL. What instruction will the nurse give the client when administering the aspirin?

Aspirin has been shown to decrease mortality and reinfarction rates after MI. Use clopidogrel (Plavix) in case of aspirin allergy. The fastest way to get the aspirin into the circulatory system is to have the client chew the aspirin prior to swallowing.

Which group of symptoms would it be important for the nurse to report to the primary healthcare provider for a client taking benazepril?

Correct: Is sign and symptoms of adverse effects of ACE inhibitor use. Weight gain would be a sign of fluid retention. Fluid volume should be reduced with an ACE inhibitor. The potassium level is high. Hyperkalemia is an adverse effect of an ACE inhibitor. Both of these need to be reported to the primary healthcare provider.

A client who was hospitalized with a diagnosis of schizophrenia tells the nurse, my veins have turned to stone and my heart is solid! How would the nurse identify this statement?

Depersonalization, which is the unstable self-identity of an individual with schizophrenia may lead to feelings of unreality (the feeling that one's parts have changed or a sense of seeing oneself from a distance).

Respiratory alkalosis s/s Metabolic acidosis s/s

Respiratory alkalosis includes hyperventilation and tachypnea. Metabolic acidosis includes tachypnea with deep respirations.

Does anorexia happen in left or right sided hear failure?

Right

A child was diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) in the clinic one week ago. Today the child's mother calls the clinic to tell the nurse, "Ever since my child has been on methyphenidate he has not been able to sleep." What is the best response for the nurse to make?

To prevent insomnia, give him the last daily dose at least 6 hours before bedtime. -If the medication is sustained-released, administer the dose in the morning.

A client with a history of adrenal insufficiency is placed on fludrocortisone. Which one is most important to monitor?

Weight gain to determine the right dose

Amitripyline

When taking tricyclic antidepressants, such as amitriptyline, the skin may be sensitive to sunburn. Use sunscreens and wear protective clothing, and sunglasses.

What should the nurse do when taking a telephone prescription from a primary healthcare provider?

Whenever a verbal or telephone prescription is given, the nurse is to transcribe the prescription, and then read it back to the ordering primary healthcare provider at the time the prescription is given. If the prescription is received and repeated back to the primary healthcare provider without transcribing the prescription first, an error may occur.

The nurse is caring for a preschool child who is being treated in the hospital for respiratory syncytial virus (RSV). In planning the client's care, the nurse should recognize that the child is likely to view this illness as?

Yes the preschool child views illness as punishment. -Disturbance to body image is for adolescents

IRON IM injection best location

ventrogluteal using z-trach