Fundamentals Midterm

A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching?

"I can have 1-2 alcoholic beverages a week."

A nurse is reinforcing teaching about methods to decrease nausea to a client who is receiving chemotherapy. Which of the following statements by the client indicates a need for further teaching?

"I should eat low carbohydrate foods." "I should eat low carbohydrate foods" is correct. Clients who are experiencing nausea should eat foods high in carbohydrates, such as crackers, yogurt, toast, bananas, and sherbet. This is not an appropriate statement by the client and indicates a need for further teaching.

A nurse working in a provider's office is reinforcing teaching with a client who is 36 weeks of gestation and has experienced a premature rupture of membranes. Which of the following statements by the client indicates a need for additional teaching?

"I will have my husband should wear a condom during intercourse." NO SEX with PROM

A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching?

"It is the responsibility of the provider to obtain express consent."

A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate?

"Let's discuss some strategies you can use when this happens again."

While performing a cardiovascular assessment, you might encounter a variety of pulsations and sounds. Which of the following findings is considered normal?

A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line This is where you would inspect and palpate for the point of maximal impulse. Also called an apical pulsation, it occurs as the apex of the heart bumps against the chest wall with each heartbeat. The apical impulse is not always visible but can be felt as a brief thump. This is a normal and expected finding when you are preparing to auscultate an apical pulse.

A nurse is reviewing the laboratory results of four clients. Which of the following should be immediately reported to the provider?

A client who is prescribed digoxin (Lanoxin) and furosemide (Lasix) with a potassium of 3.1 mEq/L A client who is prescribed digoxin and furosemide with a potassium of 3.1 mEq/L is correct. This value is clearly abnormal and indicates that the client has hypokalemia, or decreased potassium. This is a common complication with the use of loop diuretics, such as furosemide. The nurse should also note that the client receives digoxin. Hypokalemia places the client at increased risk for digoxin toxicity, so this is the client who is at immediate risk for injury and whose laboratory findings should be reported to the provider.

Assigning staff members on each shift the same password for accessing medical records

A nurse administrator is reviewing policies and procedures of the facility she works in to ensure confidentiality requirements are being met. Which of the following indicates that intervention is needed to prevent the release of confidential client information? A. Requiring that client information be sent to providers using pre-saved numbers on the speed dial of the fax machiene. B.Assigning staff members on each shift the same password for accessing medical records C.Allowing nurses to complete electronic documentation on a client while at the clients bedside D. discussing a clients financial hardship at an interdisaplinary team meeting

NG tube to suction

A nurse is assigned to care for four clients. The client with which of the following drainage tubes is at an increased risk for hypokalemia? A. Nephrostomy tube to drainage bag B. Indwelling catheter to gravity C. Chest tube to water seal D. NG tube to suction

"What part of your mothers care concerns you?"

A nurse is caring for a client who has a new colostomy. The client is being discharged and plans to live with her daughter. Which of the following responses by the nurse is appropriate when the daughter states that she doesn't know how she is going to care for her mother's colostomy? A. "Its quite simple, ill make sure colostomy bag is clean before she leaves and you should have no problems" B."Is the colostomy care the only reason your mother is going to be living with you?" C. "A home health nurse will be stopping by tomorrow. If you have any questions you can ask her." D. "What part of your mothers care concerns you?"

A written prescription from the provider

A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and has requested no resuscitative measures be taken in the event of respiratory or cardiac arrest. Which of the following is necessary to legally change the client's code status to do-not-resuscitate (DNR)? a. a written prescription from the provider b. signed documentation from the client c. family support of the decision d. admission to hospice for palliative care

0.75 mEq/L

A nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium (Lithane). Which of the following serum lithium levels indicates the client's dosage is appropriate for maintenance therapy? A.0.25 mEq/L B.0.75 mEq/L C.1.5 mEq/L D. 2.25 mEq/L

Sputum culture of acid fast bacillus

A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have active pulmonary tuberculosis. Which of the following tests is used to confirm this diagnosis? A. Tuberculin test B. Chest X-Ray C. ELISA test D. Sputum culture of acid fast bacillus

Assist the client to a side laying position

A nurse is caring for a client who is postoperative following a wedge resection of a lung and has a chest tube with a water seal chest tube drainage system. The client reports a burning pain in his chest. Which of the following actions by the nurse is appropriate? A. Assist the client to a side laying position B. Remove 10mL from the sunction control chamber C. Apply a padded clamp on the tubing for 1-2 min D. Move the drainage system above the level of the clients heart

25-35lbs

A nurse is caring for a client who is pregnant with a single fetus and has a body mass index (BMI) of 23. When asked by the client how much weight she should gain during the pregnancy, which of the following responses by the nurse is appropriate? A. 10-15lbs B.15-20lbs C.25-35 lbs D.35-45lbs

Headaches

A nurse is caring for a client who is scheduled for a lumbar puncture. The nurse should teach the client that which of the following is a post-procedure complication? A. Hypothermia B. Polyuria C. Headaches D. Seizures

2.5 mL

A nurse is caring for a client who weighs 132 lb and has been prescribed gentamicin (Garamycin) 5mg/kg/day by IV bolus in three equal doses. Available on hand is 40 mg/mL that is to be added to 50 mL 0.9% sodium chloride. How many mL should the nurse add to the solution per dose?

Slurred speech

A nurse is caring for a school-age client who was diagnosed with sickle cell anemia and has been admitted for a vaso-occlusive crisis. Which of the following findings has the highest priority? A. Hematocrit 32% B. WBC 16/mm3 C. Slurred speech D. Yellow Sclerae

Warm refrigerated drops to room temperature prior to instillation

A nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine (Americaine) ear drops for pain relief. Which of the following actions by the nurse is appropriate when administering the ear drops? A. Place the child on the effected side for several minutes upon completion of instillation B. Warm refrigerated drops to room temperature prior to instillation C. Pull the pinna of the ear upward and back during instillation D. Massage the area posterior to the ear after instillation

WBC 2,800/mm3

A nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine (Clozaril). Which of the following findings indicates the client is experiencing an adverse effect of the medication? A. Weight loss B. WBC 2,800/mm3 C. HR 54/min D. Insomnia

Abdominal Distension

A nurse is collecting data on a newborn who was delivered 30 min ago at the gestational age of 37 weeks. Which of the following findings requires further intervention? A. Vesicular rash B. RR 54/min C. Abdominal Distension D. HR 142/min

A client who is recovering from cardiac catheterization

A nurse is planning to obtain blood pressure on four clients. On which of the following clients should the nurse perform an electronic blood pressure measurement? A. A client who is recovering from cardiac catheterization B. A client who is in stage 4 of Parkinsons disease C. A client who has anorexia and hypotension D. A client who has a temperature of (39.1 C) 102.4F and is shivering

Dark urine

A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. The nurse should teach the parent that which of the following is a clinical manifestation associated with the illness? A. Rapid weight gain B. Tar-colored stools C. Lethargy D. Dark urine

"I will use my chromoly inhaler before using my albuterol inhaler"

A nurse is reinforcing teaching about a new prescription for cromolyn sodium (Intal) metered-dose inhaler (MDI) to a school-age child who has asthma. Which of the following statements should indicate to the nurse that the child needs further teaching? A " I be be sure to rinse my mouth out after using my cromolyn inhaler" B. " I can't use my cromlyn inhaler for sudden asthma attacks" C. "its will be several weeks before I notice an improvement in my asthma" D. "I will use my chromoly inhaler before using my albuterol inhaler"

Toast with peanut butter

A nurse is reinforcing teaching about the diet for dumping syndrome to a client who is postoperative following a gastrectomy. Which of the following food selections by the client indicates the teaching was effective? A.Toast with peanut butter B.Apple juice C. Yogurt with fruit D. Beef broth

A client who has rubella

A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precautions? A. A client who has rubella B. A client who has measles C. A client who has hepatitis A D. A client who has rocky mountain spotted fever

Advocacy

A school nurse has requested the school board remove a piece of playground equipment due to a documented increase in injuries that can be linked back to it. The nurse's actions are an example of which of the following? A. Deontology B. Morality C. Principlism D. Advocacy

A nurse is caring for a patient just transferred from the PACU following an abdominal hysterectomy. The patient receiving PCA with IV morphine sulfate 2 mg every 15 min with a 30mg/4hr lockout. One hour after the patient has returned to the unit, the patient tells the nurse that her pain is still unbearable. The nurse checks the PCA monitor and determines that the patient has made six attempts within the last hour. Which of the following actions should the nurse take after performing a pain assessment? A. Check the IV site and PCA pump for proper functioning. B. Teach the patient proper use of the PCA system. C. Ask the provider to increase the morphine dose and shorten the interval between doses. D. Encourage family members to "push the pain button" when the patient is in too much pain to do it herself.

A. Check the IV site and PCA pump for proper functioning. The PCA delivery system should be assessed to determine if there is any malfunction in the delivery of the medication.

A patient who has been experiencing frequent, severe migraine headaches tells the nurse she has heard that biofeedback is effective in treating migraines. The patient asks the nurse to describe how this pain-relief method works. The nurse should reply that biofeedback involves A. measuring skin tension and using learned techniques to relieve pain. B. relating soothing visual images identified by the patient to promote relaxation. C. listening to an increasing volume of music until the pain subsides. D. stimulating the skin with a mild electric current when pain occurs.

A. measuring skin tension and using learned techniques to relieve pain This describes biofeedback, which gradually helps the patient to identify physiological responses that can control migraines and other types of pain.

A nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. In which of the following roles is the nurse functioning?

Advocate Advocate is correct. A nurse advocate acts as a liaison between clients and providers in order to improve or maintain the quality of care that clients receive. The nurse is functioning in the role of the nurse advocate for the clients during the prenatal period.

A nurse is about to transfer to a chair a pt who has a weak left leg. Which of the following actions by the nurse demonstrates correct transfer technique?

Aligning the nurse's knees with the pt's knees just before the transfer. This is a correct strategy that helps the nurse safely the patient while moving to a standing position.

Nursing students interact with which of the following health care staff members?

All of the above

Students need to be familiar with

All of the above

Which of the following hygiene practices are recommended?

All of the above

A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin?

Allow the child to manipulate the medical equipment

A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril?

Aspirin (Bayer) To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). Question: The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril? Person of Focus: The nurse who is reinforcing teaching about captopril Key Words: captopril, reduce, antihypertensive effects So, the question is asking which of the medications should be reinforced to the client as having the potential to reduce the antihypertensive effect of captopril. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Aspirin is correct. Aspirin and other NSAIDS can reduce the antihypertensive effects of captopril, which is an ACE inhibitor. The nurse should reinforce to the client that aspirin has the potential to reduce the antihypertensive effect of captopril and should be avoided.

A nurse is caring for two patients of different cultural backgrounds. Both patients returned from the same type of surgery 2 hr ago. Which of the following should the nurse expect to be the same for both patients? A. Patient perception of the intensity of postoperative pain B. Class of medication used to treat acute postoperative pain C. Goal of pain management for each patient D. Level of pain indicated by each patient on a numeric pain scale

B. Class of medication used to treat acute postoperative pain Opioid analgesics are the class of medication used to treat acute postoperative pain; this is true regardless of the patient's cultural background.

A nurse is caring for a patient admitted to the emergency department with severe pain following a fall from a ladder. The initial assessment reveals long-term use of opioids for chronic pain. Which of the following provider prescriptions for initial pain relief should the nurse question? A. Morphine sulfate B. Pentazocine (Talwin) C. Meperidine (Demerol) D. Hydromorphone (Dilaudid)

B. Pentazocine (Talwin) Pentazocine is an opioid agonist/antagonist agent. This is not an appropriate medication for this patient because it may cause opioid withdrawal in a patient who is physically dependent on opioids.

Studies show that artificial nails contain which of the following contaminates?

Bacteria

While performing a head-to-toe assessment, you perform the Romberg test. You do this to test the patient's

Balance The most common test of balance is the Romberg test. Ask the patient to stand about 2 feet in front of you, with her feet together, toes pointed forward, and her hands at her sides. While you extend your hands so that one is on either side of the patient, ask her to close her eyes. Watch to see how well she can maintain balance in that position. A minimum of swaying is normal, but if the patient sways more than a couple of inches, stop the test and document that the patient demonstrated difficulty maintaining balance on Romberg testing.

A nurse in a long-term care facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Which of the following sites should be included in the teaching? (Select all that apply.)

Blood stream, Urinary tract , Surgical wound, Respiratory tract Urinary tract is correct. Health care associated infections are caused from health care delivery in a health care facility. These result from prescribed antibiotic administration, presence of multi-medication resistant organisms, breeches in infection control practices, and invasive procedures. The urinary tract is a common site for health care associated infections. Surgical wound is correct. Surgical wounds are a common site for health care associated infections. Musculoskeletal system is incorrect. While injuries can occur in the health care setting that affect the musculoskeletal system, this is not a common site for health care associated infections. Respiratory tract is correct. The respiratory tract is a common site for health care associated infections. Blood stream is correct. The blood stream is common site for health care associated infections.

During a pain assessment, a nurse asks questions about the quality of an adult patient's pain. Which of the following statements by the patient refers to pain quality? A. "The pain in my abdomen began last night and has gotten worse and worse." B. "My pain is at a 9 on a scale of 0 to 10." C. "My pain feels like I'm being stabbed by a knife." D. "The pain is worse when I bend over at my waist."

C. "My pain feels like I'm being stabbed by a knife." This statement describes the quality of the patient's pain.

A nurse is about to use the Wong-Baker FACES pain scale to assist a patient in assessing his pain level. Which of the following should the nurse know in order to use this pain scale? A. Face #10 is chosen when the patient is crying because of severe pain. B. Face #0 is chosen when the patient "hurts a little bit." C. This scale is useful for adult patients who have cognitive impairments. D. The nurse matches a face on the scale with that of the patient's face when he is in pain.

C. This scale is useful for adult patients who have cognitive impairments. This pain scale is used for young children as well as for adult patients who have cognitive impairments that create difficulty with descriptive and numeric pain scales.

On the first day of clinical, it is most important for a student to

Come prepared and on time

A nurse is planning to administer a dose of intravenous morphine sulfate for a postoperative patient. Which of the following is a pain management protocol that should be used by the nurse in this situation? A. Withhold this medication for a respiratory rate of less than 14/min. B. Perform the intravenous injection over 1 min. C. Avoid administering opioid agonists on a fixed schedule. D. Have an opioid antagonist available during the administration.

D. Have an opioid antagonist available during the administration. The nurse should assure that an opioid antagonist, such as naloxone (Narcan), is available, as well as equipment for providing respiratory support.

A nurse is caring for a client who has a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take?

Determine respiratory status

A nurse is caring for a client who is diabetic and is being discharged home following an above-the-knee amputation. Which of the following health care professionals should be involved in the client's interdisciplinary team meeting? (Select all that apply.)

Dietitian Physical therapist Social Work

nurse in a pediatric provider's office is conducting telephone triage and receives a call from a client regarding her 4-day-old newborn who was circumcised 2 days ago. Listen to the audio clip and determine which of the following responses by the nurse is appropriate. (Click on the audio button to listen to the telephone conversation.)

Do not attempt to remove it." "Do not attempt to remove it" is correct. Yellow exudate covers the penis 24 hr after the circumcision and will persist for 2 to 3 days. This is an expected finding and should not be removed. The nurse should provide teaching to the client regarding circumcision care.

When assessing peripheral vascular status of the lower extremities, you place your fingertips on the top of your patient's foot between the extensor tendons of the great toe and those of the toe next to it. Which pulse are you palpating?

Dorsalis pedis In the lower extremities, the most common pulse tested is the dorsalis pedis pulse, found on the dorsum of the foot between the extensor tendons to the great toe and the toe next to it.

A nurse is collecting data on a child who is diagnosed with bacterial epiglottitis. Which of the following clinical findings are associated with the illness? (Select all that apply.)

Drooling is correct. Drooling is a clinical finding associated with epiglottitis. Stridor is correct. Stridor is a clinical finding associated with epiglottitis. Difficulty swallowing is correct. Difficulty swallowing is a clinical finding associated with epiglottitis. Croupy cough is incorrect. Croupy cough is a clinical finding associated with acute spasmodic laryngitis, and acute tracheitis, but it is not a clinical finding associated with epiglottitis. High-grade fever is correct. High-grade fever is a clinical finding associated with epiglottitis.

A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis?

Elevated temperature

A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication?

Excessive vomiting

A nurse ambulates an unsteady patient, the pt becomes light-headed and begins to fall. Which of the following interventions by the nurse is appropriate in this situation?

Extend one leg and allow the pt to slide down it. This is a correct procedure that prevents injury to the patient. As the patient gets close to the floor, the nurse bends both legs, continuing to support the patient.

A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following?

Facial edema

Jewelry is only restricted in certain clinical settings.

False

Passwords may be shared with other members of the health care team.

False

When first starting clinical, students meet the health care professional they work with on their first day.

False

A nurse is caring for a hospitalized patient who is performing active range of motion exercises. Which of the following body movements should indicate the nurse that the patient has full range of motion in the shoulder?

Flexing the shoulder by raising the arm from a side position to a 180 degree angle. The demonstrates full range of motion of the shoulder. The patients fingers would be pointing directly upward.

As part of your general patient survey, you find that your patient has a body mass index (BMI) of 23. From this finding, you can conclude that your patient

Has body mass index within normal limits BMI is a measurement of an adult's body fat based on height and weight. Generally, a BMI between 18.5 and 24.9 reflects a normal weight with a normal amount of body fat. A patient with a BMI below 18.5 is considered underweight; a patient with a BMI of 25 or above is considered overweight; and one with a BMI of 30 or above is considered obese.

A nurse in the emergency department is caring for a pt who has a knee injury. The pt will be discharged and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include when discharging this pt?

Hold the cruthces on the unaffected side when preparing to sit in a chair. The crutches should be held on the unaffected side when preparing to sit in a chair.

A nurse is caring for a neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). Because of the administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects?

Hypoglycemia

While examining your patient's head and face, you determine that cranial nerve I is intact when the patient follows your instructions and successfully

Identifies a minty scent Cranial nerve I, the olfactory nerve, controls the sense of smell. To test this nerve's function, ask the patient to identify a nonirritating aroma, such as mint or coffee.

A nurse is caring for a client who is from a culture different than his own. Which of the following actions by the nurse is most important in the provision of culturally competent care?

Identify one's own beliefs and values. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is from a culture different than his own. Question: Which of the following actions by the nurse is most important in the provision of culturally competent care? Person of Focus: The nurse caring for client who is from a different culture Key Words: culture, different, actions, most important, culturally competent care So, the question is asking which of the actions is most important for the nurse to take in the provision of culturally competent care. This is a positively worded, multiple choice item. The key word "most" in the question indicates this is a priority setting item, which means all four actions are important in the provision of culturally competent care, but one action is the most important. Next you should review each option and determine which should be performed first. Identify one's own beliefs and values is correct. To provide culturally competent care, it is essential to identify one's own cultural background, values, and beliefs, especially those that are related to health and health care. This is the most important action by the nurse.

When using and maintaining your stethoscope, it is important to

Insert the earpieces at an angle toward your nose Angling the earpieces toward your nose helps ensure that sounds are effectively transmitted to your eardrums.

When performing a complete, head-to-toe physical examination, which physical-assessment technique should you perform first?

Inspection Inspection is the process of observation. You will first inspect the body systematically, observing for normal as well as abnormal physical signs. When assessing most body systems, the recommended order is inspection, palpation, percussion, and auscultation. Abdominal assessment is an exception, since any manipulation of or pressure on the abdomen may stimulate peristalsis, the waves of contraction that propel contents through the gastrointestinal tract, and thus alter the patient's bowel sounds. So, when assessing the abdomen, inspection is still first, but auscultation comes before percussion and palpation.

Students in clinical sites must always wear the following EXCEPT

Jewelry

You are performing a physical examination of the spine for an older adult. Which of the following findings is common with aging?

Kyphosis Kyphosis, a pronounced "hunchback" curvature of the spine, is an abnormal angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging. This pronounced convexity of the thoracic spine is also common in older patients who have had vertebral fractures.

A nurse is observing an assistive personnel (AP) who is using a mech lift with a hammock sling to transfer a pt from the bed to a chair. The nurse should intervene if the AP

Leaves the bed in the lowest position throughout the procedure. The bed should be raised to its highest position in order to prevent injury to nursing staff and to properly position the lift under the patients bed.

A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)?

Lethargy

A nurse stands facing a pt to demonstrate AROM exercises. which of the following should the nurse do when demonstrating hyperextension of the hip?

Move the leg behind the body. The movement demonstrates hyperextension of the hip.

A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings indicates the client could be experiencing an anastomotic leak?

Oliguria Oliguria is correct. When a gastric bypass is performed, the stomach, duodenum, and part of the jejunum are bypassed by surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death. Oliguria, or decreased urine production, is a finding consistent with peritonitis and can indicate the client is experiencing an anastomotic leak.

A nurse at a long-term care facility is participating in a quality improvement project to reduce the occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile?

Outcome audit

HIPAA regulations are designed to protect

Patients' privacy

A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action by the nurse?

Place client in knee-chest position. Place client in knee-chest position is correct. Placing the client in a knee-chest position will aid in keeping the pressure of the presenting part of the fetus off the cord. Using the ABC priority setting framework, the greatest risk is the cessation of circulation to the fetus; therefore, this is the priority action the nurse should take.

Urinary Catheterization Skill Check-off

Rebound tenderness This procedure elicits rebound tenderness - an increase in pain when deep palpation over a tender area is released. Rebound tenderness in the right lower quadrant at McBurney's point (one third the distance from the anterior iliac crest to the umbilicus) is a sign of acute appendicitis.

A nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. Which of the following should the client experience as a result of the transfusion?

Reduced bleeding time

Over which abdominal quadrant are bowel sounds most active and therefore easiest to auscultate?

Right lower quadrant Over which abdominal quadrant are bowel sounds most active and therefore easiest to auscultate?

A nurse caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the client's total parenteral nutrition (TPN) is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. The nurse should monitor the client for which of the following manifestations?

Shakiness and diaphoresis Shakiness and diaphoresis is correct. The nurse should observe the client for shakiness and diaphoresis. These are manifestations of hypoglycemia, which can occur if there is a sudden interruption in the delivery of TPN, resulting in the client receiving below the prescribed amount.

A nurse is caring for a client who is prescribed lithium (Eskalith). Which of the following clinical findings should be immediately reported to the provider?

Slurred speech Slurred speech is an early clinical finding associated with lithium toxicity and can precipitate the onset of seizures or coma. Using the safety and risk reduction priority setting framework, this finding jeopardizes the immediate physiological safety of the client and should be reported to the provider immediately. Fine hand tremors, Mild thirst, Weight gain are an expected side effect of lithium that may or may not subside during the treatment.

A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of the following should be included in the teaching?

Soybeans To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching regarding foods containing complete protein to a client. Question: Which of the following should be included in the teaching? Person of Focus: The nurse who is reinforcing teaching about complete proteins Key Words: teaching, complete protein, foods, included So, the question is asking which of the foods are complete sources of protein and should be included in the teaching. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determined if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Soybeans is correct. Food sources of complete proteins contain sufficient quantities of all nine essential amino acids to support body growth and maintenance. Soybeans are a source of complete protein and should be included in the teaching.

A nurse is caring for a client who is admitted with acute alcohol withdrawal. Which of the following findings should the nurse report to the provider?

Tachycardia Tachycardia is correct. Symptoms of acute alcohol withdrawal include tachycardia, hypertension, diaphoresis, disorientation, and hand tremors. These can progress to visual or tactile hallucinations, paranoid delusions, agitation, hyperthermia, and grand mal seizures. Acute alcohol is a medical emergency and can cause death if not treated with the appropriate interventions. Tachycardia indicates the client is in acute alcohol withdrawal and should be reported to the provider.

A nurse has assigned four tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first?

Take an ABG specimen to laboratory

A nurse in a rehabilitation center is caring for a client who has just had a cerebrovascular accident. Based on a review of the client's medical record, which of the following findings should be immediately reported to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.)

Temperature 37.6º C (99.8º F) Temperature 37.6° C (99.8° F) is correct. Sore throat, malaise, mouth sores, and fever are clinical findings associated with agranulocytosis, a potentially dangerous blood dyscrasia that is an adverse effect of clozapine. Using the urgent versus nonurgent priority setting framework, this is the priority finding and should be reported immediately to the provider. Blood glucose level 144 mg/dL is incorrect. Hyperglycemia is a potential adverse effect of clozapine, and a blood glucose level of 144 mg/dL is above the expected reference range. While the provider should be made aware of this level, there is another finding that poses a greater risk to the client and should be reported immediately. Headache is incorrect. Headache is a potential adverse effect of nitroglycerin ointment. While the provider should be made aware of this finding, there is another finding that poses a greater risk to the client and should be reported immediately. Dry mouth is incorrect. Dry mouth is a potential adverse effect of clozapine. While the provider should be made aware of this finding, there is another finding that poses a greater risk to the client and should be reported immediately.

A nurse is caring for an infant who has been prescribed a one-time dose of ceftriaxone (Rocephin) 50 mg/kg IM. The infant weighs 17.6 lb. Available is 500 mg/mL. How many mL should the nurse administer?

The nurse should administer 0.8 mL ceftriaxone IM. STEP 1: Determine the infant's weight in kg: 2.2 lb / x kg = weight in lb / 1 kg; 2.2 lb / x kg = 17.6 lb / 1 kg. Cross multiply and x = 8 kg STEP 2: Find total of one-time dose: Amount prescribed x kg weight (mg x kg) = total daily dose; 50 mg x 8 kg = 400 mg STEP 3: What is the dose needed? Dose needed = Desired; Desired = 400 mg STEP 4: What is the dose available? Dose available = Have; Have = 500 mg STEP 5: Do the units of measure need to be converted? No (mg = mg) STEP 6: What is the quantity of the dose available? Quantity = 1 mL STEP 7: Set up an equation using knowledge about basic equivalents. Desired x Quantity / Have = Amount to be given; 400 mg x 1 mL / 500 mg = x mL; 400 x 1 = 400 ÷ 500 = 0.8 mL STEP 8: Reassess to determine if the amount to be given seems plausible. If there are 500 mg in 1 mL and the prescribed dose is 400 mg, it makes sense to administer 0.8 mL. The nurse should administer 0.8 mL ceftriaxone IM.

A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Which of the following statements by the parent indicates a need for further teaching?

This illness will not recur because my child has now had it." "This illness will not recur because my child has now had it" is correct. It is possible for rheumatic fever to recur, so prophylactic treatment with monthly IM injections of benzathine penicillin G, or daily oral doses of penicillin or sulfadiazine, will be needed. This statement by the parent is not appropriate and indicates a need for further teaching.

A nurse is collecting data on a client who has appendicitis. Identify the site the nurse should palpate to determine the presence of tenderness at McBurney's point. (Selectable areas, or "Hot Spots," can be found by moving the cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds with your answer.)

To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is collecting data on a client who has appendicitis. Question: Identify the site the nurse should palpate to determine the presence of tenderness at McBurney's point. Person of Focus: The nurse who is palpating for tenderness at McBurney's point Key Words: appendicitis, site, palpate, tenderness at McBurney's point So, the question is asking the location the nurse should palpate to determine the presence of tenderness at McBurney's point. This is a Hot Spot item, which means an image is provided with clickable "Hot Spots" in various locations on the image Next you should roll the cursor over the image to locate all Hot Spots and determine if each is probably correct, possibly correct, or probably incorrect. Then, you had to click on one of the Hot Spots to select it as the correct option. This is the site the nurse should palpate. McBurney's point is located in the lower right quadrant midway between the anterior iliac crest and the umbilicus. Pressure over this point will elicit pain in the later stages of appendicitis. Remember, the screen is not a mirror image; you had to identify the client's right side. (A)

What is your primary goal in performing a comprehensive physical assessment?

To develop a plan of care Remember the nursing process: assessment, diagnosis, planning, implementation, evaluation. Assessment is the first part of the process. It generates the database from which you will make nursing decisions. Your objective in interacting with patients is to identify their needs and concerns and help find solutions. That is the nursing process in action - and your map is the nursing care plan you establish for each patient. Analyzing and synthesizing data will provide the basis for each nursing diagnosis and for the selection of nursing interventions to manage actual or potential health problems.

An important factor to remember about preparing for an assignment is to follow all facility policies and procedures.

True

Client condition is protected under HIPAA.

True

If a clinical site feels that a student is unprepared to care for a client/patient, the clinical site can ask the student to leave the clinical site.

True

Most allied health programs have specific colors that students must wear while in the clinical setting.

True

Universal precautions are designed to keep the students and clients safe.

True

A nurse is a caring for a client who has borderline personality disorder. Which of the following is a manifestation of the disorder?

Unstable interpersonal relationships So, the question is asking which manifestation is a characteristic of borderline personality disorder. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Unstable interpersonal relationships is correct. Borderline personality disorder is characterized by unstable interpersonal relationships, emotional instability, impulsivity, unstable mood, and self image distortions.Test: Testing and Remediation Advanced Test

A nurse is reviewing the electronic fetal heart rate tracing of a client who is in labor. Which of the following images exhibits variable decelerations?

Variable decelerations are caused from cord compression.

A charge nurse on the pediatric unit is making assignments for a nurse who has floated from the labor and delivery unit. Which of the following clients is appropriate for the charge nurse to assign?

an adolescent who is 2 days post operative following an appendectomy

When performing a respiratory assessment, you auscultate wet, popping sounds at the inspiratory phase of each respiratory cycle. These sounds are best identified as

crackles Crackles, which are sometimes called rales, are wet, popping sounds created by air moving through liquid or by collapsed alveoli snapping open on inspiration. They are most common at the end of inspiration.

A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching?

cue client by providing cards that portray common needs

A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling his family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advice?

discuss risks associated with leaving

A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first?

stop the infusion

A nurse is caring for a child who is 24 hr postoperative following a supratentorial craniotomy. The nurse should maintain the child in which of the following positions?

supine with head of the bed (HOB) elevated to 30 degrees