H2***
The nurse instructs a UAP to turn an immobilized client with a urine Cather every 2 hrs, what action should the nurse ask the UAP to do in addition to turning q2hrs?
Offer water oral fluids
What conditions are most likely to respond to antihistamines? Select all that apply
*Allergic rhinitis *Contact dermatitis
A male client with mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute ineffective endocarditis. During admission assessment the nurse observes multiple area of petechiae on the clients skin. Which interventions should the nurse include in the plan of care? (Select all that apply)
*Monitor cardiac rhythm *Initiate contact transmission precautions *Report conditions in pre-existing Murmur
The nurse is assigning care of a client with prostatitis the pn. What instruction should the nurse provide to the pn regarding care for the pt?
AVOID URINARY CATHERIZATION
A clients moring assesment includes bounding peripheal pulses, weight gain of 2lbs, pitting ankle edema, and moist crackles bilaterally. Which intervention= is most important for the nurse to include in the plan of care?
Administer Diuretic
The client is admitted with a severe asthma attack, for the last 3 hours the client has experienced increase. Arterial blood gas ph 7.22, PAO 55, HC03 25. Which intervention should the nurse implement?
Administer the PRN dose of albuterol
which class of drugs is the only source of a cure for septic shock?
Antiinfective ABT's Septic shock is an infection in the body that has lead to the blood stream
after years of struggling with losing weight, a man is evaluated for gastroplasty. He has experienced difficulty with managing his DM and HTN but he is approved for surgery. Which intervention is most important for the nurse to include in the clients plan of care?
Apply sequential compression stockeing
The mother of a 12yr old with cystic f reports that her child is experiencin g increasing congestion despite the use of chest physcial therapy bid and has expereienced a loss of appettie. What instructions should the nurse provide
CPT should be performed more frequently but at least an hour before meals
A mother runs into the er with her baby stating that they got a hold to some cleaning products. The child smells of chemicals on the hands face and the front of the clothes. After insuring that the airway is patent what action should the nurse implement first?
Determine the type of chemical
A nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurs include as a indictaiton to begin implementing the detox medication protocol?
Dilated pupils, tachycardia, elevated bp, elation
the husband of an older woman dx with pernicious anemia calls the clinic and reports that his wife still has memory loss and some confusion since she received the first does of nasal cyanocobalamin 2 days ago. he tells the nurse that he is worried that she may be getting Alzhemiers dx. What action should the nurse take?
Explain that memory loss and confusion are common with Vitamin B-12 deficiency
After placement of the CVC the nurse receives report of the X-ray that the CVC is in the clients superior vena cava. What should the nurse implement?
Initiate IV as prescribed, that exactly where it should be!
when the nurse attempts to teach self-administration of insulin injections to a client who is newly dx with dm1 the client tells the nurse in a loud ass voice to leave the room What should the nurse do?
LEAVE the damn room, Give him some space and try again later.
The nurse is planning a event on how to prevent SID. Which information is most important to provide parents of newborns and infants?
Position the baby in a supine position when sleeping. (Back to sleep)
The nurse is planning a preoperative teaching for a 12year old girl that is scheduled for surgery, to help reduce anxiety which action is best for the nurse to implement?
Provide dolls to reinact feelings associated with painful procedures
A client with ESRD is refusing all treatments and requests that no life saving measures be implement. The health care provider refuses to write do not resuscatie instructions. Which action should the nurse take?
Provide the DR with a copy of the Pt's bill of rights!
A client develops uticaria on the trunk and neck shortly after a 2ndary infusion of pipercillin abt. In which order should the nurse implement these interventions? Arrange in priority
Stop the infusion Check VS Contact PCP Document the reaction to the drug initate report
Then nurse is caring for a client who reports pain. 2-10 on a safe, which RX should the nurse administer?
Tylenol
which client is BEST to assign to the PN who is assisting the RN with the care of a group of clients?
and adult who is one day postoperative for a laparoscopic cholecystectomy
At the end of a preoperative teaching on pain management techniques, a client starts crying and states " I just know that i cant handle all of the pain" what is the priority nursing problem for this patient?
anxiety
A older man is dx with a possibleCVA. He has Facial paralysis and cannot move his left side. When entering the room, the nurse finds the clients wife crying and trying to unsuccessfully give him a drink of H2o. What action should the nurse take?
ask the wife to stop and assess the clients swallowing reflex
A client with CAD has a AV fistula in the left arm. which observation by the nurse indicates that the fistula is patent?
assessment of the bruit in the left arm
during the discharge teaching an overweight client with hf is asked to make a grocery list for the nurse to review. Which food choices included on the clients list should the nurse encourage
natural whole almonds plain air popped popcorn
Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client?
orthopnea (Discomfort when breathing while lying down flat) common in ppl with some type of lung disease
A client is recovering in the outpatient surgical unit after and endoscopy carpel tunnel release. The nurse assesses the clients vital signs, pain level and dressing. Before discharging the client which intervention should the nurse implement.
check neurovascular status of the distal digits
The nurse requests a meal tray for a client who follw mormon beliefs and who is on a clear liquid diet following abdomenal surgery. Which menu items should the nurse request for this client ( select all)
chichen broth apple juice
during discharge teaching, a male client recently diagnosised with malignant htn tells the nurse that he really enjoys downhill skiing and asks if he can continue with this sport. Whic is the best response by the nurse?
cold weather may constrict your blood vessels and increase your BP
When caring for a client with full thickness burns over both lower extremities, which assessment findings warrants immediate intervention by the nurse (select all that apply)
complain of increase pain and pressure change in the quality of peripheral pulse Loss of sensation to the left lower extremity
The nurse is caring for a client who is receiving peritoneal dialysis and notes that the output flow is 100ml less than the input flow. Which action s should the nurse implement?
continue to monitor the intake and output with next exchange
After an unsuccessful resuscitation attempt, the nurse calls the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enter the room.
place pillow under the head remove resustation equipment gently close the eyes
The UAP reports that the clients bp cannot be measured because the client has casts on both arms, and is unable to be turned to the prone position to gain a bp on the leg. What should the nurse implement?
deminstrate how to palpate the popliteal pulse with the client supine and the knee flexed
The nurse expects the dude with Chrons dx to show what signs?
diarrhea, stomach pain, and weight loss
THe nurse is preparing to administer 1.6ml of medication IM to a 4month old baby, which action should the nurse include.
divide the medication to 2 doses only 1ml per dose for a baby so young
a newly hired UAP is assisigned to a home health care team along with two experienced UAP's. Which interventions should the home health nurse implement to ensure adaquate care for all clients?
evaluate the new UAP compentency by observing them deliever care
IV abt is prescribed for a client with a postoperative infection. The medication is to be divided in 4 doses. What schedule is best for administering all of the doses?
every 6 hours 1000 ,1600, 2200, 0400
a client with artho has been recievieng treatment with naproxen and now reports ongoing stomach pain, increasing weakness and fatigue. Which laboratory test should the nurse monitor?
hemogolobin
a client with menopause reports being lactose intolerant. She excersises 3 times a week, drinks wine 1-3 times a month an drinks coffee a cup a day. Which instructions should the nurse provide to the client to reduce her risk of developing osteoporosis
increase calcium intake
A client is experiencing withdrawal from the benzo alzapram is demonstration severe agitation and tremors. What is the best initial nursing action?
initiate seizure precautions
a male with a fx of the left femur has skeletal traction in place while waiting on surgery. The dude is restless and tells the nurse that he needs to pee urgency. what intervention should the nurse take.
insert an indwelling Cather
The nurse is preparing a client with acoustic neuroma for a MRI. Which client complaint is life threating and should be reported to the health care provider immediately?
intensifying headache
A female who is under chemotherapy tells the nurse she plans to volunteer at the elementary school this winter. Which question is best for the nurse to ask this client?
is it possible that you will be in direct contact with the kids at the school?
And older client arrives to the ED with reports of sever n/v large amounts of liquid brown emesis at home. The clients VS are 95.4 heart 112, r 14, bp 74/37. Which intervention is most important for the nurse to implement
keep hob raised to 45 degrees
A client with Siad has been admitted with hyponatremia. Which intervention is is MOST important for the nurse to include in the plan of care to protect the client for injury
limit h2o intake
A older client returns to the clinic and revives refills on several medications. The client shares concerns with the nurse about having to take so many medication s and asks if one pill would be substituted for many of the others. Which instructor should the nurse implement to address the clients concerns?
use a med reminder system to prevent forgetting to take the right mediations at the right time
A nurse is preparing a client who had a BKA and is ready for discharge, which recommendation's should the nurse provide to the client.
wash stump with soap and water use residual limb shrinker inspect the skin for redness
A nurse is teaching a woman about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?
weight bearing exersise
A client with COPD is experiencing worsening dyspnea and low oxygen levels. VS are 99.6, 98,r28,140/82,88%. What action should the nurse implement?
Prepare the client for endotracheal intubation
A client is admitted witt an exacerbation of heart failure secondary to COPD. Which observation by the nurse require immediate intervention to reduce the likely hood of harm to this client?. Select all
A fell pitcher of water is on the bedside table the client is lying in a supine position in bed
A client is admitted with an exacerbation of hf secondary to COPD. Which observation by the nurse require immediate intervention to reduce the likelihood of harm to this client> (Select all)
A full pitcher of h20 Ole boy is lying in a supine position
A older child calls the home health and reports that her mother has become forget at night. The daughter states that her mothers behavior changed a few days ago and is getting worse. What actions should the nurse take. (Select all)
Ask if mom has fell recently Ask to check moms temp Ask if mom is experiencing any pain with urination
The nurse is preparing to give fentalyn 0.075mg IM to a client who is scheduled for a colonoscopy. the medication is labeled 50mcg/ml. How many ml should the nurse administer? (Enter numerical value only) if rounding round to the nearest 10
1.5
a man that smokes 2 packs of cigarettes per day(damn) is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at hime when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler correct
After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away
The nurse enters the room to administer oral med and finds the CNA providing personal care to the client, his condition has deteriorated. The client is lying supine and is hella weak, pale and diaphoretic. What is the priority nursing action?
Assist the CNA so this boy can receive his oral meds
a 15yr old client has recently been diagnosed with DM 1, he states that it is difficult to stick to his meal plan when out with his friends, what action should the nurse implement?
Assist the client in finding fast food restaurants that are with in his meal plan for diabetes
When the parents of a 6-year old boy with a brain tumor are told that his condition is terminal, the mother shouts at dad, and states " this is your fault it would have never happened if we would have sought treatment sooner. Which intervention is BEST for the nurse to implement?
Assure the parents that the terminal dx was inevitable
A child is diagnosed with aplastic anemia. The nurse knows that this child has the best prognosis with which treatment?
BLOOD TRANSFUSIONS
The nurse is caring for someone who has been diagnosed with malnutrition, which findings support this diagnosis?
BMI 17
The mother of a child with Cerebra Palsey asks if the childs impairment would get worse as he gets older? Which response is the best explanation
Brain damage with CP does not have a variable course
A client with A-Fib receives a RX for dabigatran etexilate. Which instructions is important for the nurse to emphasize when teaching the client about this medication?
Bruising and bleeding is all bad!
The nurse is providing teaching to a pt that has recently been diagnosed with gestational dm. which complication poses the greatest risk to the fetus if normal (euglycemic ) is not maintained?
Pretermed birth
A nurse who is working the triage in the ED is presented with four clients at the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse?
Chest discomfort 1hr after eating something spicy
After inflating a blood pressure cuff and releasing the valve, the nurse hears a silence followed by a korotkoff sound, what action should the nurse take next?
Continue with the bp assessment this is the sounds heard of the blood flowing thru the arteries, its normal
A nurse is caring for a client whos entering the 2nd stage of labor, which action should the nurse implement first?
Convey to the client that the birth is imminent The baby is coming!!
A client exposed to TB is schedule to start receiving their isonized therapy, which information is the most important to know before administering 1st dose?
Current diagnosis of hep B
What will the nurse suggest to a client with fibrocystic breasts in an attempt to help relieve her symptoms?
Eliminate CAFFEINE
The home care nurse visits a client that has cancer, the client reports having a good appetite, but experiencing n/v when csmelling the food cooking. what action should the nurse implement?
Encourage the fam to cook the food outside and bring the cooked food inside
The nurse asks the parents to stay during the examination of the males genitals. What intervention should the nurse implement?
Examine private parts last
and adult and reports recently experiencing a episode of chest pressure and breathlessness when he was running. The client expresses concern because his parents are dead and they had heart dx and his dad had dm. he lives with his male partner, is a vegetarian, takes atenolol which maintains his bp at 130/74. What risk factors should d the nurse explore further ?
Family history history of HTN
A older client admitted into respiratory distress secondary to HF, CAD, HTN, and Afib. When nursing problems should the nurse include in the clients plan of care?
Fluid volume n excess Decreased cardiac output Altered peripheal tissue perfusion Fatigue
A mother brings her kid who has asthma to the ER. The kid is wheezing and speaking one word thru each breath. The kid is anxious, has tachycardia and has labored respirations. Which assessment is most important for the nurse to obtain?
Frequency that the child uses a rescue inhaler
A CLIENT HAS BEEN admitted with possible urosepsis. What intervention should the nurse perform as soon as possible?
Get specimen for culture and sensitivity! DUH
The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to promote burn healing. What information should the nurse provide to the client
The xenograft is taken from a nonhuman source
The health care provider prescribes methylergonovine for a post partum client with uterine atony. which finding should indicate to the nurse to with hold the next dose of the medication?
High BP
The nurse is assessing a male client with a history of Addison. The client has flu-like symptoms and n/v for the past week. The clients spouse reports that he acted confused and was extremely weak when awaken this morning. The client is febrile and has tachycardia. The health care provider diagnosis adrenal insuffiency. Which medication would most likely be prescribed?
Hydrocortisone 100ml IV q6hrs until the bp is decreased
A female client who has borderline personality disorder is being discharged today, when the nurse makes morning rounds the client begins the interaction by complaining about the night shift, and expresses joy by stating "my fav nurse is on duty now" which response is best for the nurse to respond to the patients dischotomus tendency?
I am happy that you are getting better and will be able to get home soon.
A lay who was recently dx with DM2 is seen in the clinic for labs. she is 5'2 165lbs. Her recent lab finding are described above. In planning nutrition teaching for this lady, what diet modifications should the nurse recommend? Select all
Increase fiber such as whole grains Decrease Carbs Stop drinking alchol only on special ocassions
A client with acute renal failure is admitted for uncontrolled type 1 diabetes M and hyperkalemia. The nurse administers an IV does of regular insulin per sliding scale. Which intervention is most important for the nurse to include in the clients plan of care?
Monitor the cardiac via telemetry
The nurse is preparing a teaching plan for an older female client dx with osteoporosis. Which expected outcome has the highest priority for this client?
Names 3 home safety hazards to be resolved immediately
A older male is admitted to the ER because of COPD exacerbation. The client is struggling to breath and the health care team is preparing for endotracheal intubation. The spouse's wife who is 30yrs younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the clients living will. Which action should the nurse take?
Notify the doc of the patients wishes
The client with dementia has become increasingly confused at night an is picking at an abdominal dressing surgical site dressing and the tape securing the IV line. The abdominal dressing in no longer occlusive and the IV dressing site is pink. Which interventions should the nurse implement?
Redress the abdomen dressing
A client with cirrosis of the liver is admitted with complications related to end stage liver disease. Which interventiron would the nurse implement? (Select all)
Report serum albumin and globulin levels Monitor abdominal girth Note sigs of swelling
The nurse noted the older client has a moist cough that increases in severity before and after meals. Based on this finding which action should the nurse take?
Request a consult to confirm dysphagia
A client has episodes of clear water diarrhea that started on yesterday, which action should the client implement?
Review the current med list
A multipara client who delivered her infant a 3 hours ago asks the nurse can she take a sitz bath because it helped reduce perineal pain during another pregnancy. which action should the nurse implement?
Review the sitz bath equipment with the patient
The dr prescribes a diet for a client with ulcerative colitis. What food selection to the nurse indicates that the boy understands the prescribed diet?
Roasted turkey, canned veggies
What is the primary goal when planning nursing care for a client with DJD?
Satisfactory PAIN control baby!!
A client with MS is experiencing scotomas (blind spots) which are limiting peripheral vision. What intervention should the nurse include in the dudes plan of care?
Scan the environment Peripheral vision is vision loss when you can't see shit unless its directly in your face
A client who has recurrent episodes of depression tells the nurse that he would like to discontinue taking the medication that he has been taking for a couple of weeks because he feels. better and he does not like the way the side effects make him feel. How should the nurse respond?
Tell him to discuss those side effects with his doctor.
The nurse working in the psych unit has phone messages from several clients which one should she call first?
The dementia client that has been gone for more than 5hrs
The wife of a newly dx Parkinson's disease asks the nurse if alternative or complimentary medical therapies may cure the disease. Which response should the nurse provide?
The neurologist would know more information regarding Parkinson's and a cure.
a school nurse is preparing a presentation for elementary school teacher to inform them about when a child should be referred to the school clinic for further f-u. The teacher should be instructed to report which situation to the school nurse? Select all
Thirst and frequent bathroom breaks shaking that changes in the child handwriting legibility Sunburn with blisters on the face arms and hands
A clients telemetry monitor indicates V-Fib. What action should the nurse implement immediately
V-Fib= Defibrillate with the shocker!!
the public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurses proposal?
Vitamin supplements for high risk pregnant women
The nurse is caring for a client with neuropathy who reports increase numbness and tinglingness in the lower extremeties. Which problem should the nurse determine is the priority for promoting foot care at this time?
risk for infection
A client with cirrihois of the liver is having several loose liquid stools and continues to be confused, in reviewing the pt's labs the nurse observed a elevated serum albumin level based on this result which medication would you expect the client to receive?
lactulose
Following moring care, a client with a c-5 pinal cord injury who is sitting in a wheel chare becomes flushed and complains of a headache. Which intervention should the nurse implement first?
relieve any kinks in his foley tubing
Which lab values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis
renal and liver function tests
a male client that was in a MVA yesterday is receiving a unit of packed red blood cells. When 1/2 of the units are infused the client reports lower back pain, the nurse observes a fine rash over the chest and pack. Which intervention should the nurse implement?
replace the transfusion with NS.
