H exam help three

Case Study Question (5/6): The ICU nurse has reviewed all nurses' notes and received prescriptions from the primary healthcare provider. Which prescriptions should the nurse perform immediately? SATA

- Initiate Droplet Precautions -Hourly Neuro Checks Utilizing Glasgow Coma Scale -IV NS at 125 mL/hr. -Ceftriaxone 2 g IVPB every 12 hours. -Initiate seizure precautions.

Case Study 6/6: The nurse assesses the client one hour after initiating interventions. Drag the assessment finding to the box on the right that would indicate to the nurse that the client's condition has improved.

- RR 22 -Brown Liquid Stool 30 mL -O2 sat 97% -BP 96/60

What statements by a client diagnosed with a hiatal hernia would indicate to the nurse that the discharge teaching was effective? 1. "I should eat six small meals a day." 2. "Sitting up for an hour after I eat will decrease symptoms." 3. "Eating a grapefruit for breakfast will help digest the rest of my food." 4. "Ten inch blocks need to be placed under the head of my bed." 5. "I will get assistance for lifting heavy objects." 6. "I will avoid using laxatives."

1. "I should eat six small meals a day." 2. "Sitting up for an hour after I eat will decrease symptoms." 4. Ten Inch blocks need to be placed under head of my bed. 5. "I will get assistance for lifting heavy objects."

During an assessment interview with a client, what alternative healing modalities should the nurse inquire about? 1. "Tell me about your use of teas, herbs, and vitamins." 2. "What traditional or folk remedies are used in your family?" 3. "Do you meditate, pray, or use relaxation techniques for healing purposes?" 4. "What prescription medications are you taking?" 5. "What alternative therapies have you used?"

1. "Tell me about your use of teas, herbs, and vitamins." 2. "What traditional or folk remedies are used in your family?" 3. "Do you meditate, pray, or use relaxation techniques for healing purposes?" 5. "What alternative therapies have you used?"

A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response? 1. "The pain you feel is real." 2. "The primary healthcare provider is right. Your pain is not real." 3. "Let me get you an appointment with the psychiatrist." 4. "Don't worry. Everything will be ok."

1. "The pain you feel is real."

The nurse is teaching the parents of a child with impetigo about care. Which statement by the parents indicate further 1. "We will not allow bathing until the scabs are healed." 2. "The skin and crusts will be washed daily with soap and water." 3. "Lotions should not be applied to the lesions, so they remain dry." 4. "We will apply the antibiotic ointment to the lesions after removing the crusts."

1. "We will not allow bathing until the scabs are healed."

A medical surgical nurse has been floated to the pediatric unit to assist during a staffing shortage. Which clients would be most appropriate for the float nurse? 1. A 10 year old in sickle cell crisis. 2. A 6 month old in a croup tent. 3. A 4 month old with bronchiolitis. 4. A 2 year old with cleft palate repair. 5. A 8 year old with Crohn's disease. 6. A 4 year old with acute asthma.

1. A 10 year old in sickle cell crisis. 5. A 8 year old with Crohn's disease. 6. A 4 year old with acute asthma.

The nurse has been caring for a client who is confused. Upon entering the room, the nurse finds the client on the floor. The side rails are up, there is urine on the floor, and an abrasion is noted on the client's forehead. Which information should the nurse include in the incident report? 1. Abrasion on the client's forehead. 2. Client's perspective as to why they fell. 3. Client's confused state. 4. Presence of urine on the floor. 5. Side rails were up.

1. Abrasion on the client's forehead. 3. Client's confused state. 4. Presence of urine on the floor. 5. Side rails were up.

A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual? 1. Attend an activity with the client who is reluctant to go alone. 2. Allow the client to break an insignificant rule. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry.

1. Attend an activity with the client who is reluctant to go alone. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry.

Which client would be appropriate for the RN to assign to the LPN? 1. Client requiring enemas and antibiotics. 2. Newly admitted client with diagnosis of diabetic ketoacidosis (DKA). 3. Client returning from surgery post right upper lobectomy. 4. Client with frequent reports of nausea and vomiting following chemotherapy. 5. Client requiring frequent sterile dressing changes.

1. Client requiring enemas and antibiotics. 4. Client with frequent reports of nausea and vomiting following chemotherapy. 5. Client requiring frequent sterile dressing changes.

A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients from a culture other than the nurse's culture. Which points should the nurse include in the presentation? 1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 2. Follow cultural beliefs when caring for all clients of that particular culture. 3. Ethnocentrism facilitates therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences.

1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences.

What nursing interventions should the nurse initiate in a client who experiences sundowning? 1. Limit naps. 2. Encourage TV watching in the evening. 3. Create a calm, quiet environment. 4. Open window blinds during the day. 5. Leave the lights on at night. 6. Maintain a routine.

1. Limit naps. 3. Create a calm, quiet environment. 4. Open window blinds during the day. 6. Maintain a routine.

A client has just delivered a newborn. Based on the primary healthcare provider's notation, what prescriptions does the nurse anticipate administering to the mother? 1. Measles, mumps and rubella (MMR) vaccine 2. Hepatitis A vaccine 3. Hepatitis B immune globulin 4. RH0(D) immune globulin 5. Tetanus toxoid

1. Measles, mumps and rubella (MMR) vaccine 4. RH0(D) immune globulin

A 9 month old with asthma symptomology has montelukast sodium oral granules prescribed. What is the most appropriate way for the nurse to instruct the parent on how to administer the medication? 1. Mix the granules with a spoonful of baby food such as applesauce. 2. Pour the granules directly on the back of the infant's tongue. 3. Dissolve the granules in an 8 ounce (240 mL)bottle of juice. 4. Administer the medication in the morning mixed in a bowl of rice cereal.

1. Mix the granules with a spoonful of baby food such as applesauce.

What should the nurse include in the post-op care of a client following the removal of the posterior pituitary gland? 1. Monitor intake and output. 2. Restrict fluids to no more than 1500 ml/day. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully.

1. Monitor intake and output. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully.

A client is admitted to the hospital with a platelet count of 132,000 mm3 and a white cell count of 8,495 cells/mcL. What interventions should the nurse implement? 1. Monitor stools for occult blood. 2. Place on fall prevention. 3. Place client in protective isolation. 4. Restrict venipunctures. 5. Limit visitors.

1. Monitor stools for occult blood. 2. Place on fall prevention. 4. Restrict venipunctures.

The charge nurse is delegating assignments on the Alzheimer's unit of a long-term care facility. What task could be assigned to the unlicensed assistive personnel (UAP)? 1. Replace soiled heel protectors on bedfast client. 2. Provide TUMS to client reporting heartburn. 3. Trim fingernails on confused diabetic client. 4. Escort dementia client on an outdoor walk. 5. Assist client to complete the daily menu list.

1. Replace soiled heel protectors on bedfast client. 4. Escort dementia client on an outdoor walk 5. Assist client to complete the daily menu list.

A school nurse is planning a lesson on inhalant abuse for a high school health class. Which information does the nurse need to include? 1. Substances used for inhaling include lighter fluid, spray paint, and airplane glue. 2. Inhalants are absorbed through the lungs and cause central nervous system depression rapidly. 3. Although inhaling can make a person very ill, death is highly unlikely. 4. Inhaling substances can cause abdominal pain, lethargy, and renal failure. 5. Inhalants cause the heart to beat slowly.

1. Substances used for inhaling include lighter fluid, spray paint, and airplane glue. 2. Inhalants are absorbed through the lungs and cause central nervous system depression rapidly. 4. Inhaling substances can cause abdominal pain, lethargy, and renal failure.

Which client could the telemetry charge nurse safely transfer in order to admit a new client? 1. Twenty-four hour post operative carotid endarterectomy. 2. Unstable angina with onset of atrial fibrillation. 3. Status post coronary artery bypass grafting (CABG) with atrial flutter. 4. Myocardial infarction with a history of heart failure.

1. Twenty-four hour post operative carotid endarterectomy.

Which action by a nurse would require the charge nurse to intervene? 1. Walking in the hallway outside the operating room without a hair covering. 2. Putting on a surgical mask, gown and cap shoe cover before entering the operating room (OR). 3. Wearing a surgical mask into the holding area. 4. Wearing scrubs from home into the nursing station.

1. Walking in the hallway outside the operating room without a hair covering.

The nurse is caring for a client receiving peritoneal dialysis. Place the steps for peritoneal dialysis in the correct order.

1. Warm the Dialysate 2. Assess the Tenckhoff Catheter 3. Begin the Dwell Time 4. Complete the exchange 5. Assess effluent

A school nurse is teaching a group of preteens with acne how to care for the skin. What points should the nurse include? 1. Wash face with soap and warm water. 2. Avoid using oily creams. 3. Do not use cosmetics that block sebaceous gland ducts. 4. Do not squeeze lesions. 5. Clean face vigorously with a terrycloth

1. Wash face with soap and warm water. 2. Avoid using oily creams. 3. Do not use cosmetics that block sebaceous gland ducts. 4. Do not squeeze lesions.

What should the nurse include when providing education to a client receiving tetracycline? 1. Wear long sleeves when going outside. 2. Take tetracycline on a full stomach. 3. Wait at least two hours after taking tetracycline prior to taking iron supplements. 4. Tetracycline can decrease the effectiveness of birth control pills. 5. Do not take this medicine after the expiration date on the label has passed

1. Wear long sleeves when going outside. 3. Wait at least two hours after taking tetracycline prior to taking iron supplements. 4. Tetracycline can decrease the effectiveness of birth control pills. 5. Do not take this medicine after the expiration date on the label has passed

The nurse is caring for a client on the surgical unit. The primary healthcare provider prescribed morphine sulfate 20 mg IM one time dose. The nurse has available: morphine sulfate in a 20 mL vial, labeled 15 mg per mL. How many mL should the nurse administer? Record answer using one decimal place.

1.3

The emergency department nurse is assigned to care for four pediatric clients with varying symptoms. Which client should the nurse examine first? 1. 12 year old reporting a severe headache 2. 6 month old with respiratory rate of 68/min while sleeping 3. 2 year old with a broken arm who is crying and appears in pain 4. 8 year old with cellulitis of the left leg and an elevated body temperature

2. 6 month old with respiratory rate of 68/min while sleeping

What action should the nurse take first for the 5 year old client brought to the urgent care clinic with a blistering sunburn? 1. Administer analgesics. 2. Apply cool water soaks. 3. Check immunization status for tetanus. 4. Educate family to avoid greasy lotions or butter on the burn

2. Apply cool water soaks.

The charge nurse is planning the staff assignments for the clients on a neurological unit. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? 1. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. 2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. 3. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. 4. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96.

2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam.

The charge nurse on the Labor and Delivery unit is making morning assignments. What client would be most appropriate for a newly hired licensed practical nurse (LPN)? 1. Assist with bottle feeding newborns in the nursery. 2. Completing perineal care for post-delivery clients. 3. Observing a Cesarean section for co-joined twins. 4. Ambulate client to bathroom following delivery.

2. Completing perineal care for post-delivery clients.

The nurse is preparing to educate a group of clients on how to decrease the risk of developing recurrent renal calculi. What topics should the nurse include? 1. High-purine foods to consume 2. Discuss diuretic use to prevent urinary stasis 3. Straining urine with each void 4. Maintaining a daily water intake of at least 2 liters 5. Foods low in calcium

2. Discuss diuretic use to prevent urinary stasis 4. Maintaining a daily water intake of at least 2 liters 5. Foods low in calcium

The emergency department called the labor and delivery unit to give report on a 24 year old primigravida at term, 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? 1. Request that the emergency department hold the client until one of the RNs is available to do the initial assessment. 2. Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse. 3. Assign an LPN/VN to complete the nursing history and an initial obstetric assessment on this client. 4. Inform one of the RNs that a client is coming from the ED and that a nursing history should be completed as soon as possible.

2. Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse.

What interventions should the nurse include when planning care for a client post heart transplant? 1. Place on airborne precautions. 2. Instruct visitors to wash hands prior to entering the room. 3. Maintain strict aseptic technique. 4. Initiate pulmonary hygiene measures. 5. Provide for early ambulation.

2. Instruct visitors to wash hands prior to entering the room. 3. Maintain strict aseptic technique. 4. Initiate pulmonary hygiene measures. 5. Provide for early ambulation.

Which assessment finding would indicate to a nurse that a client receiving chemotherapy may have difficulty maintaining proper nutrition? 1. Fatigue 2. Mucositis 3. Neutropenia 4. Diarrhea

2. Mucositis

A client has been prescribed chlorpromazine for the treatment of schizophrenia. The nurse makes afternoon rounds and finds the client's temperature to be 104.7º F/40.4º C. The client has extreme muscle rigidity, and the vital signs have been fluctuating for the last four hours. What should the nurse do first? 1. Provide a tepid sponge bath. 2. Notify the primary healthcare provider immediately. 3. Administer an antipyretic immediately. 4. Administer the chlorpromazine as prescribed.

2. Notify the primary healthcare provider immediately.

What interventions should the nurse plan to implement when admitting a client diagnosed with measles? 1. Admit to a semi-private room with a client diagnosed with tuberculosis (TB). 2. Place a surgical mask on the client when transferring to x-ray. 3. Initiate airborne precautions. 4. Wear surgical mask when entering the client's room. 5. Assign a nurse who has received the measles vaccine to take care of this client.

2. Place a surgical mask on the client when transferring to x-ray. 3. Initiate airborne precautions. 5. Assign a nurse who has received the measles vaccine to take care of this client.

After discontinuing a peripherally inserted central line (PICC), it is most important for the nurse to record which information? 1. How the client tolerated the procedure. 2. The length and intactness of the central line catheter. 3. The amount of fluid left in the IV solution container. 4. That a dressing was applied to the insertion site

2. The length and intactness of the central line catheter.

The nurse is teaching a client diagnosed with salmonellosis about how to decrease the transmission to others. Which statement by the nurse would require follow up? 1. "I will wash my hands after feeding pets." 2. "I will use a meat thermometer to cook food to safe temperature." 3. "I will clean my hands with water before handling food." 4. "I will use disposable dishes until infection free."

3. "I will clean my hands with water before handling food."

A home health nurse has taught a client about home dressing changes using a clean technique. Which statement made by a client indicates to the nurse that the client understands this technique? 1. "The wound should be cleaned using a washcloth, soap, and water." 2. "Povidone-iodine should be applied to the wound with each dressing change." 3. "It is important that I wash my hands using soap and water before removing my dressing." 4. "I will use sterile gloves to clean my wound and change the dressings."

3. "It is important that I wash my hands using soap and water before removing my dressing."

A client is admitted with an acute episode of diverticulitis. What symptom would the nurse promptly report to the primary healthcare provider? 1. Midabdominal pain radiating to the shoulder 2. Nausea and vomiting periodically for several hours 3. Abdominal rigidity with pain in the left lower quadrant 4. Elimination pattern of constipation alternating with diarrhea

3. Abdominal rigidity with pain in the left lower quadrant

Based on expected growth and development for a 7 month old infant, what would the nurse anticipate that the mother would report at the infant's well-baby visit? 1. Has slight head lag when pulled to sitting position. 2. Walks holding onto furniture. 3. Able to sit, leaning forward on both hands. 4. Has neat pincer grasp.

3. Able to sit, leaning forward on both hands.

A nurse assesses the 5 minute Apgar on a term, newborn infant. Based on the Apgar score, what should be the nurse's priority intervention? 1. Continue Apgar scoring every five minutes until 20 minutes of life. 2. Transfer newborn to the neonatal intensive care unit ASAP. 3. Administer "blow-by" oxygen while suctioning. 4. Perform cardiopulmonary resuscitation.

3. Administer "blow-by" oxygen while suctioning.

A nurse is caring for a 65 year-old client diagnosed with dehydration. The client has been receiving intravenous normal saline at 150 mL/hour for the past 4 hours. Which finding would the nurse need to notify the primary healthcare provider? 1. Blood pressure 136/84 2. Report of nausea 3. Anxiety 4. Urinary output at 50 mL/hour

3. Anxiety

The nurse is caring for a client with renal failure. The client has a 24 hour intake of 2500 mL and a 24 hour urinary output of 200 mL. What is the priority nursing assessment? 1. Assess for dependent edema. 2. Monitor for cardiac arrhythmias. 3. Auscultate breath sounds. 4. Monitor sodium and potassium levels

3. Auscultate breath sounds.

The nurse is caring for a client taking spironolactone. Which dietary change should the nurse teach the client to make when starting treatment with this medication? 1. Eat extra helpings of bananas. 2. Increase intake of water. 3. Avoid salt substitutes. 4. Increase intake of green leafy vegetables.

3. Avoid salt substitutes.

A teenage client is placed on life-support as a result of a motor vehicle accident (MVA). Following an electroencephalogram (EEG), the client has been declared brain dead. Which action by the nurse would take priority? 1. Call the respiratory department to have the ventilator removed. 2. Notify the facility's pastoral personnel. 3. Contact the regional organ procurement team. 4. Ask the family to select a funeral home.

3. Contact the regional organ procurement team.

The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial assessment the client reports experiencing "numb feet." What nursing action takes priority? 1. Check blood glucose level. 2. Assess for proper shoe size. 3. Examine the client's feet for signs of injury. 4. Test sensory perception in the client's feet.

3. Examine the client's feet for signs of injury.

During evening rounds, the nurse discovers that a violent client with a history of threats against a former girlfriend cannot be located. The client's window is open and personal belongings missing. Based on recent threats of violence against the girlfriend, what is the nurse's initial action? 1. Look for the client quietly to maintain confidentiality. 2. Notify the local police to organize a search party. 3. Initiate the missing client protocol. 4. Complete an "Against Medical Advice" (AMA) form on the client's elopeme

3. Initiate the missing client protocol.

A client is returned to the surgical unit following gastric/esophageal repair of a hiatal hernia. They have an IV, NG tube connected to suction, and an abdominal incision. To prevent disruption of the esophageal suture line, what is most important for the nurse to do? 1. Assess the wounds for drainage. 2. Give ice chips sparingly. 3. Maintain the patency of the NG tube. 4. Monitor for the return of peristalsis.

3. Maintain the patency of the NG tube.

Donepezil has been prescribed to a client with cognitive impairment. Which statement by the family member indicates understanding of the nurse's instructions on this medication? 1. This medicine will control agitation and aggression. 2. This medication should be given at bedtime since it is for insomnia. 3. Notify the primary healthcare provider if the client is vomiting coffee ground material. 4. This drug is given as needed for confusion.

3. Notify the primary healthcare provider if the client is vomiting coffee ground material.

A client arrives in the emergency department with fever, nuchal rigidity, and seizures. What action should the nurse take first? 1. Administer Penicillin IVPB. 2. Obtain blood cultures from two sites. 3. Place on droplet precautions. 4. Set up for lumbar puncture.

3. Place on droplet precautions.

The nurse is caring for a client admitted to the skilled nursing unit approximately 3 months ago. Since admission, the client has lost 8 pounds. There have been no documented changes in the client's physical health. Which strategy may help to improve caloric intake for this client? 1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for all meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the unlicensed assistive personnel to feed the client at each meal.

3. Provide a high protein supplement 30 minutes before meals.

The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client? 1. Watching TV with two other clients in the day room. 2. Watching TV alone in a conference room. 3. Spending time in brief one on one interactions with the nurse. 4. Sitting in the day-room away from other clients.

3. Spending time in brief one on one interactions with the nurse.

The licensed practical nurse (LPN) is assisting with care for a client who has an absolute neutrophil count of 500. Which action by the LPN would warrant intervention by the RN? 1. Using an alcohol-based hand rub for hygiene before and after glove removal. 2. Advising visitor with known respiratory infection to not enter the client's room. 3. Taking fresh flowers into the client's room that were delivered by the local florist. 4. Leaving the thermometer and sphygmomanometer in the client's room.

3. Taking fresh flowers into the client's room that were delivered by the local florist.

A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B12 intramuscularly. What should the nurse include in discharge instructions? 1. B12 can be stored in a lighted area. 2. The B12 injections will be stopped when symptoms disappear. 3. The B12 injections will be continued for the client's life. 4. Vitamin B12 will be taken by mouth once the maintenance dose is determined.

3. The B12 injections will be continued for the client's life.

Blood and urine samples are sent to the laboratory for a client who has had a spinal cord injury. After reviewing these results, the nurse would expect which finding? 1. Gross hematuria 2. Septicemia 3. Urinary tract infection 4. Anemia

3. Urinary tract infection

The nurse is caring for a client receiving an intravenous infusion of normal saline that is prescribed at 150 milliliters per hour. Using a tubing that has a drop factor of 15, how many drops per minute should the nurse deliver? Round answer to the nearest whole number.

38

While a nurse was in shift report, four clients called the nurses' station. Which client should the nurse see first? 1. Child whose colostomy bag is leaking. 2. Three day post op client requesting pain medication. 3. Child admitted with failure to thrive, whose mother requested formula. 4. Client who needs a peak blood level drawn because the antibiotic just finished infusing.

4. Client who needs a peak blood level drawn because the antibiotic just finished infusing.

The nurse receives the morning lab results of four clients during the change of shift report. Which client should the nurse assess first? 1. Vomiting and diarrhea with a potassium 3.3 mEq/L (3.3 mmol/L). 2. One day post-operative hip replacement with a Hct 30% (0.30) / Hgb 10 g/dL (100 g/L). 3. Pneumonia with a White Blood Cell (WBC) count of 12,000/mm3 (12 x 10^9/L). 4. Diabetes with a Fasting Blood Sugar (FBS) of 40 mg/dL (2.2 mmol/L).

4. Diabetes with a Fasting Blood Sugar (FBS) of 40 mg/dL (2.2 mmol/L).

The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client? 1. Increase carbohydrate intake. 2. Decrease fluid intake. 3. Avoid shellfish. 4. Increase fiber.

4. Increase fiber.

What is most important for the nurse to monitor when administering intravenous erythromycin to a client? 1. Nausea and vomiting. 2. Clotting studies. 3. Premature atrial contractions. 4. Prolonged QT interval.

4. Prolonged QT interval.

The nurse is completing a focused assessment on a client post coronary artery bypass surgery (CABG). What finding warrants immediate attention by the nurse? 1. Central venous pressure (CVP) 6 mmHg 2. Mediastinal chest tube drainage of 70 mL in 1 hour 3. Incisional pain rated 9/10 4. Pulsus paradoxus

4. Pulsus paradoxus

What should the chemotherapy infusion nurse recognize as the major barrier of chemotherapy success in treating cancer clients? 1. Inadequate knowledge of the side effects of chemotherapy 2. Difficulty obtaining an IV access 3. The development of alopecia 4. Toxicity to normal tissues

4. Toxicity to normal tissues

A charge nurse receives a report of back discomfort after work every day from a surgical nurse. Which action by the surgical nurse should be addressed by the charge nurse? 1. Frequently shifting weight from one foot to the other. 2. Standing straight with knees slightly bent. 3. Raising work station to waist level. 4. Twisting at the waist to reach for an object during cleanup.

4. Twisting at the waist to reach for an object during cleanup.

What is most important for the nurse to do prior to initiating peritoneal dialysis? 1. Aspirate for placement. 2. Have the client void. 3. Irrigate the catheter for patency. 4. Warm the dialysate fluid.

4. Warm the dialysate fluid.

A client weighing 140 pounds (63.64 kg) has been admitted to the telemetry unit with a diagnosis of Class III pulmonary hypertension. The primary healthcare provider prescribes digoxin. How many micrograms should the nurse administer now? Round to the whole number.

477

A postoperative surgical client has a prescription for monitoring of intake and output (I&O). The I&O sheet has been picked up by the unlicensed assistive personnel (UAP) for the 7AM-3PM shift. IV fluid-1025 mL Urine - 1350 mL PRBC-250 mL NG tube - 75 mL Jackson Pratt - 22 mL

612

Case Study 1/6: The telemetry nurse is reviewing the transfer report prior to the arrival of the client. Highlight the findings that are of immediate concern to the nurse.

85-year-old female presented to the ED from a long-term care facility with profuse, watery diarrhea x 3 days. She is lethargic and febrile. T-102.6 Poor Skin Turgor over Scapula Sinus Tachy rate 122

Case Study 4/6: The nurse is speaking with the primary healthcare provider regarding the treatment plan for the client who was just diagnosed with Clostridioides difficile (C. diff) colitis. For each potential prescription, click to specify whether the potential prescription is indicated, nonessential, or contraindicated for the client.

Administer Anti-Diarrhea Meds - Contraindicated D/C precaution 24 hours after treatment has started - Contraindicated Vancomycin 125 mg orally 4 times per day x 10 days - Indicated Provide food high in protein - Non-essential Use Disposable Equip - Indicated Clean Surfaces in room w bleach - Indicated Use gown and gloves for all client care - Indicated

Read the following case study, then refer to the case study to answer the questions. The nurse is assessing a 54-year-old male client who has been admitted to the mental health unit with a diagnosis of depression.

Administer daily medications at 0900 - Contraindicated Cluster activities to promote rest - Contraindicated Provide extra blankets on bed - Indicated Monitor for tachycardia, restlessness, nervousness, insomnia - Indicated Incentive spirometry every 2 hours while awake - Indicated Provide foods high in fiber - Indicated

Read the following case study, then refer to the case study to answer the question. A 60-year-old male is admitted to the surgical unit for a scheduled BKA of the right lower extremity in the morning. Based on the nurse's documentation, what actions should the nurse initiate?

Administer furosemide 20 mg IV now. Assess vital signs every hour. Begin oxygen saturation monitoring. Decrease IV infusion rate to keep vein open. Elevate head of bed to semi-Fowler's position. Place anti-embolic stocking to left leg.

Case Study Question (4/6): The primary healthcare provider diagnoses the client with meningitis, likely bacterial. Drag the potential interventions the nurse should take to care for this client to the box on the right. Choose only the options that are appropriate.

Appropriate Interventions: Assess neuro status every 15 minutes. Darken the room. Initiate droplet precautions. Pad side rails. Set up for a lumbar puncture.

Case Study Question (3/6): Complete the following sentence(s) by choosing from the list of options:

Based on the nurse's assessment of the client, the nurse determines that the client has likely developed MENINGITIS as evidenced by the classic triad of FEVER, NUCHAL RIGIDITY and IRRITABILITY.

Case Study 3/6: Complete the following sentence(s) by choosing from the list of options:

Based on the results of this recent lab test, the nurse will initiate evidence-based interventions to prevent the spread of this infection. These interventions will include CONTACT precautions, a PRIVATE ROOM , and USE OF SOAP AND WATER BEFORE AND AFTER CLIENT CONTACT.

Read the following case study, then refer to the case study to answer the questions. The nurse is assessing a 54-year-old male client who has been admitted to the mental health unit with a diagnosis of depression.

Current: 142/92 56 bpm 97.2F 185 lbs 7.5 mU/L 3.9 mcg 244 mg/dL

The client was sent for percutaneous intervention. Six hours following percutaneous intervention, the nurse continued to care for and assess the 54-year-old male client post MI who had an admitted diagnosis of hypothyroidism. Drag the assessment finding to the box on the right that would indicate to the nurse that the client's condition has improved. Choose only the steps that are appropriate:

Findings Indicating Client Improvement -BP 106/62, Pulse 72, RR 18, T 98°F (36.6°C) -T4 of 4.5 mcg/dL -ECG rhythm

Case Study Question (1/6) Drag the 5 priority findings that would require immediate follow-up by the nurse to the box on the right.

Findings Requiring Immediate Follow Up: Positive brudzinski sign Headache 9 on 1-10 scale Positive kernig sign Nuchal Rigidity T: 103 F

Case Study 2/6: The nurse is reviewing the client's medical record. Drag each potential issue that the client is at risk for to the box on the right.

Hypokalemia C Diff Metabolic Acidosis

Case Study Question (2/6): For each client finding below, click to specify if the finding is consistent with increased intracranial pressure, meningitis, or migraine. Each finding may support more than 1 disease process. Note: Each column must have at least 1 response option selected.

Increased ICP: Generalized Headache, Irritable, Drowsy, but oriented Meningitis: Generalized Headache, N/V, Irritable, Photophobia, Drowsy but Oriented, T: 103 F, +Brudzinski Sign, +Kernig Sign and Nuchal Rigidity Migraine: N/V, Irritable, Photophobia, Drowsy but Oriented

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Nursing Actions - Initiate IV access Place on 2 Liters humidified Oxygen Potential Condition - Asthma Parameters to Monitor O2 saturation Peaked expiratory flow rate.

Case Study Question (6/6): Nurses have performed the interventions as prescribed by the primary healthcare provider for the client over the past 24 hours. Below are the current assessment findings for the client. For each assessment finding, click to specify if the finding indicates that the client's condition has improved, has not changed, or has declined.

Photophobia - No change BP 92/54 - Declines + Kernig's - No change Urinary Output 490 mL over 1 hour - Declined T 101 - Improved Sodium 147 - Declined

Read the following case study, then refer to the case study to answer the question. The home health nurse is caring for a client with end-stage chronic renal failure. Complete the diagram by dragging from the choices below to specify 1 potential problem the client is at greatest risk for, 2 assessment findings that support the risk for this problem, and 2 nursing actions the nurse should take to prevent the problem.

Potential Problem - Impaired Skin integrity Greatest Risk of Development - Severe Itching and Small White Crystals noted on forearms Assessment Finding that Supports the Risk for ISI - Apply Emollients to the Skin and Place cotton gloves on hands during sleep.

Read the following case study, then refer to the case study to answer the questions. The nurse is assessing a 54-year-old male client who has been admitted to the mental health unit with a diagnosis of depression.

Responds to Question slowly: Extreme Fatigue: Depression, Hypothyroidism and CAD Weight gain of 5 pounds: Depression, Hypothyroidism Lack of Awareness: Depression BP 142/92 - Hypothyroidism, CAD Pulse 56/ Regular - Hypothyroidism Temp 97.2 - Hypothyroidism I'm Always Cold - Hypothyroidism Feet Cold to the touch - Hypothyroidism, CAD Cap Refill of toes is 3 seconds - CAD TSH 5.2 - Hypothyroidism T4 - Hypothyroidism Cholesterol - CAD

Case Study 5/6: The nurse is continuing to monitor the client. Based on the data obtained, what actions should the nurse take?

SATA: Auscultate lung sounds hourly Increase IV rate to 150 mL/hour Initiate oxygen at 2 L/nasal cannula Measure urine output hourly Monitor vital signs every 15 minutes

The obstetrical nurse is caring for a client at 24 weeks of gestation in the clinic. Based on the data obtained, what actions should the nurse initiate?

Schedule client for non-stress test. Teach the client how and when to monitor her glucose.

Read the following case study, then refer to the case study to answer the questions. The nurse is assessing a 54-year-old male client who has been admitted to the mental health unit with a diagnosis of depression.

The nurse identifies the client's primary problem as hypothyroidism, as evidenced by weight gain, cold intolerance, and T4 of 3.9 mcg/dL.

Read the following case study, then refer to the case study to answer the questions. The nurse is assessing a 54-year-old male client who has been admitted to the mental health unit with a diagnosis of depression.

The nurse is called to the client's room at 0910. Based on the nurse's findings, what actions should the nurse take? SATA Administer nitroglycerin 0.4 mg SL Initiate oxygen at 2 L/NC Notify rapid response team Obtain an electrocardiogram Request a stat troponin level