HESI LVN 2020

A client is receiving antiinfective drug therapy for a postoperative infection. Which complaint should alert the practical nurse (PN) to the possibility that the client has contracted a superinfection?

"My mouth feels sore." Sore mouth is a sign of a thrush superinfection resulting from oral flora alteration, which allows candida overgrowth.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?

End-stage renal

A client who had a surgery for a ruptured appendix develops peritonitis. What clinical finding related to peritonitis should the nurse expect the client to exhibit?

Fever Abdominal muscle rigidity.

Example of Assault

Forcing a client to take a medication

An elderly client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube. What is the best position in which the practical nurse (PN) should place the client for administration of the bolus tube feedings?

Fowler

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions?

Frequent changes in position.

List four common causes of fluid volume deficit.

GI causes: vomiting, diarrhea, GI suctioning; decrease in fluid intake; increase in fluid output, such as sweating; massive edema, ascites.

Your client, an incest survivor, is speaking of her deceased father, the perpetrator. "He was a wonderful man, so good and kind. Everyone thought so." What would be the most useful intervention at this time?

Gently point out the positive and negative aspects of her relationship with her father. Try to minimize the idealation of the deceased.

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremeties, the nurse notes that the client has thin, shiny, skin, decreased hair growth and thickened toenails. The nurse understands that this may indicate:

Arterial Insufficiency.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which lab test to evaluate the client's hypoxia?

Arterial blood gas

During the intraoperative period, what activities should the operating room nurse do to ensure safety during surgery?

Ascertain correct sponge, needle, and instrument count -Position client to avoid injury -Apply ground during electrocautery use. -Strict use of surgical asepsis.

A client returns from the post-anesthesia care unit after a right rotator cuff repair. What should the nurse do when performing a neurovascular assessment?

Assess for capillary refill in the nail beds.

A client is admitted to the hospital and benazepril hydrochloride (Lotensin) is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication?

Assess for dizziness

Which nursing intervention is most appropriate for a client in a skeletal traction?

Assess the pin sites at least every shift if needed.

Operative phase

Assessment, management of the operative suite

A child with acute appendicitis who is scheduled for surgery in 3 hours is complaining of abdominal pain. Which intervention should the practical nurse implement?

Assist the child into a position of comfort.

Hypoventilation

Associate with the decrease in ph or an increase in Pco2 (Co2 is retained)

Hyperventilation

Associated with an increase in pH or a decrease in Pco2 *Co2 is lost

A nurse is caring for a client who sustained a transection of the spinal cord. The nurse continually monitors this client for what medical emergency?

Autonomic hyperreflexia.

Identify three nursing interventions to prevent postoperative urinary tract infections.

Avoid postoperative catheterization. Increase fluid intake. Empty bladder every 4-6 hours, early ambulation; teach client how to brace site with pillow when coughing. Note any stain on incision site, report any stain on the incision site to health care provider and the RN.

List four common causes of respiratory failure in children?

Congenital heart disease, infection or sepsis, respiratory distress syndrome, aspiration, fluid overload or dehydration

How would the nurse assess the adequacy of compressions during CPR? How would the nurse assess for adequacy of ventilations during CPR?

Check for a carotid or femoral pulse. Watch for chest excursion and auscultate bilaterally for breath sounds.

What is the priority nursing care in the immediate postoperative period for a toddler with a newly applied hip spica cast?

Checking the toddler for peripheral circulation

When changing the soiled linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear?

Clean gloves

A nurse is evaluating the effectiveness of treatment for a client with an excessive fluid volume. Which clinical finding indicates the treatment has been successful?

Clear breath sounds

What items should the nurse assist the client in removing before surgery?

Contact lenses, glasses, dentures, partial plates, wigs, jewelry, prostheses, makeup, and nail polish.

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client?

Contact precautions.

The practical nurse (PN) is interacting with a young adult female client admitted to the psychiatric unit for acute depression related to a recent divorce. Which assessment is most indicative of a client suffering from loss and depression?

Client verbalizes a negative self-image *Feelings of hopelessness and poor self esteem are characteristics of loss and depression

A 2-year-old child had tympanostomy ventilating tubes inserted into both tympanic membranes (TMs) 1 week earlier. During a postoperative clinic visit, the practical nurse (PN) notes that the child has a purulent discharge from the right ear, and the mother explains that the toddler has had a cold for 3 days. What action should the PN plan to implement?

Collect a specimen of the otorrhea for culture.

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming "I can't breathe!" the nursing priority action is

Elevate head of the bed and obtain vital signs.

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for nurse to include in a client's plan of care?

Encourage early mobility

A client has the following labarotory values: pH of 7.55 HCO3 of 22 PCO2 of 20mmHg. Which action should the nurse plan on taking?

Encourage the client to slow down breathing

What are the priorities when a client with sudden cardiac arrest is found?

Immediate activation of the emergency response system and the start of chest compressions.

A patient is admitted to the health care facility for treatment of COPD. Which nursing diagnosis is most important for this patient?

Impaired gas exchange related to airflow obstruction.

Why is a client with liver disease at risk for operative complications?

Impairs ability to detoxify medications used during surgery. Impairs ability to produce prothrombin to reduce hemorrhage.

Why is a client with liver disease at increased risk for operative complications?

Impairs ability to detoxify medications used during surgery. Impairs ability to produce prothrommbin to reduce hemmorhage.

The nurse is caring for a client who is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having a desired effect?

Improved hemoglobin and hematocrit levels.

Steroid therapy is prescribed for a client with an exacerbation of ulcerative colitis. The nurse evaluates that teaching is effective when the client says, "I should take this medicine:

In the early morning with food. Helps reduce gastric inflammation.

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained thick secretions. To decrease the amount of secretions retained, the nurse plans to:

Increase fluid intake to at least 2L a day.

The RN is conducting patient teaching about cholesterol in the body. When discussing the patient's elevated LDL and lowered HDL levels, the patient shows an understanding of the significance of these levels by stating that

Increased LDL and decreased HDL increase my risk of coronary artery disease.

4. Name two changes from the 2005 AHA BLS guidelines to the present 2015 guidelines.

Increased focus on high-quality, immediate chest compressions and a ratio of 30 compressions to 2 breaths for one and two rescuers.

During the neurological assessment of a client with a tentative diagnosis of Guillain-Barre syndrome, the nurse expects that the client will manifest

Increased muscular weakness.

Two days after delivery, a client has a temperature of 101*, general malaise, anorexia, and chills. What does the nurse expect to find on the client's lab report?

Increased white. blood cells

A client is scheduled for a lumbar puncture. What nursing care should be implemented after procedure?

Maintaining the client in the supine position for several hours.

What modalities are associated with the gate control pain theory?

Massage, heat and cold, acupuncture, TENS

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client?

Monitor for electrolyte imbalance.

X-ray films reveal that a client has sustained an intracapsular fracture of the left hip as a result of.a fall. The client is placed temporarily in buck's traction. When providing care, the nurse should"

Monitor for tenderness in the left calf area.

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the practical nurse (PN) that her feet have begun to swell. Which information should the PN provide that will aid in the prevention of pooling of blood in the lower extremities?

Move about every hour

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client:

Moves the walker no more than 12 inches from the client during use.

A nurse is caring for a client who is experiencing an underproduction of thyroxine (T4). Which client response is associated with an underproduction of thyroxine?

Myxedema

What mechanism is involved in the reduction of pain through the administration of nonsteroidal intiinflammatory medications?

NSAIDs act by the peripheral mechanism at the level of damaged tissue by the inhibiting prostaglandin synthesis and other chemical meditors involved in pain transmission.

Adalosterone

Na retaining (K exreting hormone)

Which sodium (Na+) Is within normal range?

Na+138 Normal sodium values 135-145

What is the antidote for narcotic induced respiratory distress

Nalaxone (Narcan)

List four side effects of narcotic medications

Nausea, vomiting, constipation, CNS depression and respiratory depression.

Define myocardial infarction.

Necrosis of the heart muscle because of poor perfusion of the heart.

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should assign this client which type of room?

Negative airflow room.

Cite the normal ABG levels for the following: A. pH. B. PCO2 . C. HCO3

Normal levels include: A. 7.35 to 7.45 pH. B. 35 to 45 mm Hg PCO2 . C. 21 to 28 mEq/L HCO3

What six factors should the nurse include when assessing the pain experience?

Location, Intensity, comfort measures, quality chronology, and subjective view of pain

A client reports vomiting and diarrhea for 3 days. What clinical finding most accurately will indicate that the client is in a fluid deficit?

Loss in body weight.

List three systems that maintain acid-base balance.

Lungs; kidneys; chemical buffers.

A primary health care provider prescribes a diagnostic workup for a client who may have had myasthenia gravis. The initial nursing goal for the client during the diagnostic phase is that the client will:

Maintain present muscle strength.

The practical nurse (PN) is assigned to care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours of hospital admission?

Maintain safety in the client's milieu.

Based on the nursing diagnosis of "Risk for infection," which intervention is best for the practical nurse (PN) to implement when providing care for an elderly incontinent client?

Maintain standard precautions

A client has seeds contaminating radium implanted in the pharyngeal area. What should the nurse include in the client's plan of care?

Maintain the client in a isolation room.

What is the priority intervention for a client during the immediate postoperative period?

Maintaining a patient airway.

A client with a diagnosis of uncontrolled diabetes began receiving Lasix (Furosemide) two days ago. The nurse reviews the morning lab result and discovers that the client's potassium level is 2.8mEq/L. What is the most appropriate action for the nurse to take?

Notify the primary healthcare provider of the result, which is critically low.

A client has been particularly restless, and the practical nurse (PN) finds the client trying to leave the psychiatric unit. The client tells the PN, "Please let me go! I must leave because the secret police are after me." What is the best approach for the PN to take?

Offer to sit with the client in a quiet room

After feeding a newborn, how should the practical nurse (PN) position the infant in the crib?

On the right side The right side-lying position facilitates gastric emptying. All other positions encourage aspiration or regurgitation. Never place an infant on his or her back after feeding.

A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation?

Only a small part of the body is irradiated.

A nurse instructs a client to breathe deeply to open collapsed alveoli. What should the nurse include in the explanation of the relationship between alveoli and improved oxygenation?

Oxygen is exchanged for carbon dioxide in the alveolar membrane.

Identify the waveforms found in a normal ECG.

P wave, QRS complex, T wave, ST segment, PR interval

What blood value indicates hypoventilation?

PCO2 is greater than 45mm Hg

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of pronged watery diarrhea. Which prescription should the nurse question and why?

Parenteral albumin (Albuminar) because it is hypertonic and will draw additional fluids from the tissues into the interstital space.

Levodopa crosses the blood brain barrier and converts to dopamine a substance depleted in

Parkinson's disease

A client being treated for Influenza A (H1N1) is scheduled for.a computated tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution?

Place a surgical mask on the client.

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. What is the PRIORITY nursing intervention?

Place client in a high fowler's position.

Two nurses are planning to help a client with one-sided weakness to move up in theb ed, What should the nurse to do conform to a basic principle of body mechanics?

Position thenurses on either side of the bed with their feet apart. gather the pull sheet close to the client, turn towards the head of the bed and then move the client.

A nurse is caring for a client with acute pancreatitis. Which elevated lab test result is most indicative of acute pancreatitis?

Serum lipase.

A nurse begins planning for the discharge of a client who had a brain attack (CVA) with residual hemiparesis and hemianopsia. What information should the nurse include in the discharge teaching plan for this client?

Significance of a safe enviornment.

A client is newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan to:

Space activities throughout the day.

List three nursing actions to prevent postoperative wound dehiscence/evisceration.

Splint incision when coughing, encourage coughing/deep breathing in early postoperative period when sutures are strong. Monitor for signs of infection, malnutrition, and dehydration. Encourage high-protein diet.

Name four nursing interventions to prevent injury in clients with DIC

Gently provide oral care with mouth swabs. Minimize needle sticks and use the smallest-gauge needle possible when injections are necessary. Eliminate pressure by turning the client frequently. Minimize the number of BPs taken by cuff. Use gentle suction to prevent trauma to mucosa. Apply pressure to any oozing site.

When reviewing the laboratory findings of a client at 16 weeks' gestation, the practical nurse (PN) determines that the alpha-fetoprotein (AFP) level is elevated. What information is most important for the PN to use when interpreting this finding?

Gestational age

In assessing a client for complications of total parenteral nutrition (TPN), it is most important for the practical nurse (PN) to monitor which laboratory value regularly?

Glucose TPN Solutions contain high concentrations of glucose

A patient has been hospitalized for treatment of acute bacterial lobar pneumonia. Which outcome indicates an improvement in the patient's condition?

The patient has a partial pressure of arterial oxygen (PaO2) value of 90mmHg or higher.

A graduate nurse is preparing to apply to the State board of nursing for licensure to practice. What group primarily is protected under the regulations of the practice of nursing?

The public

What criteria should alert a client with known angina who takes nitroglycerin tablets sublingually to call the EMS?

Unrelieved chest pain after rest, 5 minutes after taking nitroglycerin, or if accompanied by other symptoms such as nausea or sweating.

The practical nurse (PN) is providing morning care to a newly admitted child with bacterial meningitis. What is the most important intervention for the PN to implement?

Use designated isolation precautions.

A client with osteoarthritis who has a left total hip replacement returns to the unit after surgery. The nurse should place the client in which position?

Use pillows to keep the client's legs abducted.

How and why is the client positioned in the immediate postoperative period?

Usually on the side or with the head to the side so as to prevent aspiration of any emesis.

A 20-year old developmentally disabled woman is a resident in a group home. She has had four abortions in the past 2 years, and the agency supervisor recommends that she be sterilized. It is obvious that the client is unable to exercise informed consent for sterilization. The nurse understands that the procedure cannot be performed without legal consent from the

court appointed individual or group

Exposure of a Person

after death, the client has the right to be observed, excluded from unwanted operations and protected from unauthorized touching of the body.

Early signs of shock are

agitation and restless resulting from cerebral hypoxia

Laryngeal nerve injury can cause laryngeal spasms, resulting in

airway obstruction.

Atropine sulfate (atropine)

an anticholinergic agent, is given to decrease oral secretions during a surgical procedure

Abduction reduces stress on

anatomical structures and maintains the head of the femur in the acetabulum.

A patient admitted to an acute care facility with pnemonia is receiving supplemental oxygen, 2L/minute via nasal cannula. The patient history includes COPD and coronary artery disease. Because of these history findings, the nurse closely monitors the oxygen flow and the patient's respiratory status. Which complication may arise if the patient receives a high oxygen concentration?

apnea

The major concern when caring for a client with the diagnosis of hyperthyroidism is

arranging for rest periods.

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication?

aspiration pneumonia

A client with an infection should not be

assigned to share a room with a surgical or immunocompromised patient.

Narcotic analgesics block the

attachment of narcotics to the receptors such as narcan

Freedom from unlawful restraint is a

basic human right and is protected by law.

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. The assessment should be documented as

crackles

Do not take away the coping style of denial when it's being used in the

crisis stage. ; it can be very useful and a needed tool at the intial stage for some individuals.

Caregivers who are pregnant may choose not to provide care for a client with

cytomegalovirus (CMV)

A client who is HIV positive is admitted to the surgival unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissibile through:

blood and semen

A patient is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the patient's response and checking for side effects. Which sign is most likely to change after taking nitroglycerin?

blood pressure (hypotension)

Regional anesthesia lowers the

blood pressure, which puts the mother and fetus in jeporady

Dehydration is measured most readily and accurately by serial assessments of

body weight.

Body weight should be placed on the hands and not under the arms to prevent damage to the

brachial plexus nerves and prevent "Crutch paralysis"

Incomplete oxidation of fat results in fatty acids that further

break down ketones

Once Narcan has been given additional narcotics

cannot be given until nacan effects have passed.

Myelosuppression (bone marrow toxicity) is the highest priority complication that can potentially affect clients managed with

carbamazepine therapy.

Hyperkalemia causes

cardiac dysrhymthmias.

Irritability and restlessness are early signs of

cerebral hypoxia; the client is not getting enough oxygen to the brain.

Involuntary admission requires

certification by a healthcare provider or police officer that the person is danger to self and/or others.

Priority nursing care for any cast application includes

checking the color and temperature of the area surrounding the cast to ensure that the cast is not too tight.

Voluntary Admission

client admits himself/herself to an instution treatment and retains civil rights. They can withdrawl at any time

The practical nurse (PN) is assessing an 8-month-old who has a medical diagnosis of tetralogy of Fallot. The child demonstrates cyanosis with crying and exertion. Which other symptom is this infant most likely to exhibit?

clubbed fingers

Tetralogy of Fallot, a cyanotic heart defect cause

clubbing of fingers and toes resulting from tissue hypoxia

Example of false imprisonment

confinement or use of restraints and protective devices without the client's consent, referred to as confinement without authorization.

Sound waves are easily transmitted over

consolidation tissue.

After becoming incontinent of urine, an older client is admitted into a nursing home. The client's rheumatoid arthritis contributes to seveely painful joints. The primary consideration in the care of this client is the need for

control of pain.

A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is

coughing and deep breathing.

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing ascites?

decreased liver function.

Bronchial breath sounds are heard over areas of

density of consolidation.

False imprisonment

detaining a competent person against his/her will

Kussmaul respirations occur in

diabetic coma as the body attempts to correct a low pH caused by the accumulation of ketones ( Ketoacidosis)

Hypokalemia can lead to

digitalis toxicity

A client sustains a fracture of the femur after jumping from a second story building during a fire. THe client is placed in Buck's taction until an open reduction and internal fixation is performed. The client keeps slipping down in bed. To alleviate this problem the nurse should

elevate the foot of the bed.

Respiratory acidosis is caused by

excess carbon dioxide retained in the lungs from conditions such as hypoventilation or COPD.

Fever can cause dehydration from

exexcessive fluid loss in diaphoresis.

Restraints of any kind may constitute

false imprisonment

A client is admitted to the hospital with diabetic ketoacidosis. The nurse identifies that the elevate ketone level present with this disorder is caused by the incomplete oxidation of

fats

When assisting a client who had a total hip replacement onto the bedpan on the first postoperative day, the nurse should instruct the client to:

flex the unaffected knee and pull on the trapeze bar to raise the pelvis.

Infiltration is caused by catheter placement allowing

fluid to lake into the tissues.

Although this is the normal progression of grief stages it is not unusual for a client to

go back and forth between stages.

The nurse is teaching a patient how to take nitroglycerin to treat angina pectoris. The patient verbalizes an understanding of the need to take up to three sublingual nitroglycerin tablets at 5 minute intervals, if necessary, and to notify the doctor immediately if chest pain does not subside within 15 minutes. The nurse knows that nitroglycerin may cause

headache, hypotension, dizziness.and flushing

Protamine sulfate is the antidote specific to

heparin

A minor client 14 years of age and older must agree to treatment along with

his/her legally responsible parent or guardian.

Example of Battery

hitting or striking the client.

Dextrose 10% is a

hyperosmolar solution and should be administered IV.

Repeated tap water enemas deplete cells and extracellular fluid of potassium and sodium resulting in

hypokalemia, hyponatrema, and the potential for water intoxication.

What is the most common cause of shock?

hypovolemia

Fluid shift from the intravascular space to the abdomen as fluid is removed, leading to

hypovolemia and compensatory tachycardia

Thrombophlebitis is a common complication of

immobility in situations related to the application of traction.

Pyridostigmine (Mestinon) is prescribed for a client with myasthenia gravis. The primary reason that the nurse instructs the client to take pyridostigmine about one hour before meals to

increase chewing strength.

The enlarged cirrhotic liver impinges on the portal system, causing

increased hydrostatic pressure and resulting in ascites.

Increased temperature also

increases metabolism and the demand for oxygen.

In disaster/bioterrorism management, the nurse must consider both the

individual and the community

Meticulous care of the suture line is necessary because

inflammation and sloughing of tissue disrupt healing

A client manifests right-sided hemianopsia as a result of a brain attack (CVA). The nurse develops a plan of care and includes

instruct the client to scan surroundings.

A patient is recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths per minute, a heart rate of 110 beats/min, a blood pressure of 162/90mmHg, and a temperature of 98.6F. To help correct respiratory alkalosis, the nurse should;

instruct the patient to breathe into a paper bag.

Skin elasticity will decrease because of decrease in

interstitual fluid.

Invasion of privacy

intrusion into another's body or into confidential information.

Use only isotonic solutions in

irrigations, infusions and so on unless the specific aim is to shift fluid.

Normal saline is an

isotonic solution and used for irrigations such as bladder irrigations or IV flush lines with intermittent IV medication.

A client with untreated type 1 diabetes mellitus may lapse into a coma because of acidosis. An increase in which component in the blood is a direct cause of this type of acidosis?

ketones

The nurse is caring for a client with arthritis. The client asks, "Can I take a tylenol instead of Aspirin? Aspirin irritates my stomaches. The nurse explains that acetaminophen (tylenol)

lacks an inflammatory action

Potassium imbalances are potentially

life threatening and must be corrected immediately.

Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube; the imbalances that result can be

life threatening.

A patient hospitalized for treatment of pulmonary embolism develops respiratory alkalosis. Which clinical finding commonly accompany respiratory alkolosis?

lightheadedness, paresthesia

Parenterally administered diazepam is a benzodiazepine that is a muscle relaxant and anticonvulsant effects that help

limit massive muscular spasms.

A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to:

loosen up pulmonary secretions.

A low mangesium often accompanies a

low potassium especially with the use of diuretics.

In ARDS common lab finding is a

lowered PO2, clients are not very responsibe to high concentrations of oxygen.

Pediatric HIV is often evidenced by

lymphoid interstitial pneumonitis, pulmonary lymphoid hyperplasia, and opportunistic infections

Monitor all clients as well as the

machine

The nurse is caring for a client two days after the client had a brain attack (CVA). To prevent the development of plantar flexion, the nurse should

maintain the feet at right angles to the legs.

The good Samaritan act protects health care practitioners against

malpractice claims for emergency care provided in "good faith"

The concentration of potassium is greater risk inside the cell and is important in establishing

membrane potential, a critical factor in the cell's ability to function

Assault

mental or physical threat to touch without permission

Civil procedures

methods used to protect the rights of psychiatric clients.

+4 edema

more than 1cm accompanied severe leg swelling

High alpha fetaprotein levels after 15 weeks gestation can indicate

neural tube defect such a spina bifida or anencephaly

Tuberculosis is a serious risk to

nonpregnant caregivers that is not related to break in standard precautions (needles, sticks, etc)

Vesicular breaths sounds are

normal

Clients suffering from venous insuffiency often may have

normal colored extremities, normal temperature, marked edema, and brown pigmentation around the ankles.

Infection increases the body's metabolic rate, and insulin is

not available for increased demands.

Duty

obligation to maintain the nursing standard.

A nurse provides crutch-walking instructions to a client that has a left-leg ankle cast. The nurse should explain that weight must be placed

on the hands.

Hemiparesis means muscular weakness of

one half of the body

Hemoglobin carries

oxygen to all of the tissues in the body -If the hemoglobin level is low the amount of oxygen carrying capacity is also low.

A patient with Guillain Barre syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas confirms respiratory acidosis?

pH 7.25 PaCo2 50mmHg

Postanesthesia phase

pain management, post anesthesia precaution (vital signs)

Clients suffering from arterial insufficiency present with

pale colored extremeties when elevated and dusty red color extremities when lowered. -Lower extremities might be cool to touch, pulse may be mild, and skin may be shiny or thin, with decreased hair growth and thickened nails.

The osmolarity of intracellular fluid (ICF) is related to many particles, with

potassium being the primary electrolyte

A nurse assesses a client's serum electrolyte levels in the lab report. What electrolyte in intracellular fluid should the nurse consider most important?

potassium.

Morphine is the

preferred narcotic (Remember it causes respiratory depression.

A nurse is caring for a postoperative client who has diabetes. Which is the MOST common cause of diabetic ketoacidosis that the nurse needs to consider when caring for this client?

presence of infection

A client with a history of alcoholism and cirrhosis is admitted with severe dyspnea as a result of ascites. The nurse concludes that the ascites is most likely to result of increased

pressure in the portal vein.

Postoperative phase

prevent and assess for complications, pain management, dietary restrictions, and activity.

Staying flat may help

prevent spinal fluid leakage and post procedure headache.

Which factor in a client's history increases the risk for osteoporosis?

prolonged immobility

A post operative patient is receiving heparan after developing thrombophlebitis. The nurse monitors the patient carefully for adverse effects of heparin, especially bleeding. If the patient starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. WHich agent fits this description?

protamine sulfate

Describe universal precautions

protection from blood and body fluids is the goal of universal precautions

The goal for hospice is to

provide the highest quality of end-of-life care for dying individuals.

When delegating, the nurse delegating must understand the

qualifications of the person receiving the task or assignment

Vitamin b12 is essential for the appropriate maturation of

red blood cells.

Acetylsalicylic acid (Aspirin) is precribed for a client with rheumatoid arthritis. The nurse understands that the major rationale for this treatment is

reduction of joint inflammation.

Preparation phase for operation

reinforce education about postoperative care, nothing by mouth (NPO) . -Assist with meeting family needs.

A client with a fractured tibia and fibula is to be discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, the nurse should teach the patient to

remove loose rugs from the enviornment.

The nurse is caring for a client who is hyperventilating. The nurse recalls that the client is at risk for

respiratory alkaloisis

Hyperventilation causes excess amounts of carbon dioxide to be eliminated, causing

respiratory alkalosis

Intercostal retractions result during the

respiratory effort to draw air into restricted airways.

HIV clients with tuberculosis require

respiratory isolation.

Frequent changes of position minimize pooling of

respiratory secretions and minimize chest expansion, which aids in the removal of secretion.

The T wave represents repolarization of the ventricle, this is a critical time in the heart beat because this action represents the

resting and regrouping stage so that the next heart beat can occur.

A subject assessment of pain can be collected by asking the client to rate his or her pain on a

scale from 0 to 10, where 0=no pain and 10=the worst pain possible.

Suction only when

secretions are present.

Pulmonary edema is associated with

severe preeclampsia.

Myxedema is the

severest form of hypothyroidism.

Changes in osmolarity cause

shifts in fluid

A nurse is monitoring a client who is receiving an IV infusion of normal saline. What is a serious complication of IV therapy?

shortness of breath with crackles.

A patient reports recent onset of chest pain that occurs sporadically with exertion. The patient also has fatigue and mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. When exploring the chief complaint, the nurse should find out if the patient has any other common cardiovascular symptoms, such as

shortness of breath.

A nurse identifies that a client exhibits the characteristic gait associated with Parkinsons disease. When recording on the clien's record, the nurse documents the gait as

shuffling

The osmolarity of the extracellular fluid (ECF) is almost entirely caused by

sodium

Crackles are abnormal breath sounds described as

soft crackling, bubbling sounds produced by air moving across fluids in the alveoli.

A client has a thyroidectomy for cancer of the thyroid. To evaluate for nerve injury that may be the result of a surgery related trauma, the nurse assesses the client's ability to

speak.

Capillary refill is the quality of the pulse in the affected arm reflect the

status of circulation distal to the operative site.

What is the nursing priority that the practical nurse (PN) should identify for a client who is admitted for a possible kidney stone?

straining all urine

If the nurse informs the health care provider of his/her lack of preparation in carrying out a prescription and carries out the prescription anyway,

the nurse and the health care provider are liable for any damages.

For a client with dysrhythmias the most important information is observing

the client for tolerance of the current rhythym.

A primary nurse receives prescriptions for a newly amdmitted client and has difficulty reading the doctor's handwriting. Who should the nurse ask for clarification of this prescription?

the doctor who wrote the presciption

Health care providers may refer clients to hospice during

the dying process.

Site marking should be done with

the involvement of the client.

What does the CD4 T-cell count describe?

the number of infection-fighting lymphocytes the patient has

If the nurse carries out a health care provider's prescription for which he/she is not prepared and does not inform the health care provider of his/her lack of preparation,

the nurse is solely liable for any damages

Nursing assignments should be based on

the nurse's abilities, the individual client's needs and the need for the entire group of assigned client.

Lipase concentration is increased in the pancreas and is elevated in the serum when

the pancreas becomes acutely inflamed.

Competent emancipated minors can con consent to treatment without

the parent or gaurdian

An air embolism can be fatal if

the pulmonary capillaries are blocked. *Watch for empty IV containers, Ensure all central lines are capped and locked if not in use.

The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it on

the right sided.

Maintaining the feet at right angles to the legs produces dorsiflexion of the feet and prevents

the tendons for shortening, preventing footdrop.

a cane should be used on

the unaffected strong side of the body

Narcotic analgesics are preferred for pain relief because

they bind to the various opiate receptor sites in the CNS.

If cardiogenic shock exists with the presence of pulmonary edema, position the client

to REDUCE venous return (High fowlers position) with legs down to decrease venous return further to the left ventricle.

Slandar

to defame; to speak maliciously of someone

If the ECG monitor shows a severe dysrhythmia, but the client is sitting up quietly watching tv without any sign of distress assess

to determine whether the leads are attached properly.

Battery

touching without permission, with or without the intent to do harm

ARDS is an

unexpected, catastrophic pulmonary complication occuring in a person with no previous pulmonary problems. Clients are critically ill and are managed in the ICU setting. Mortality rate is high.

Use of suction upon withdrawl of a suction catheter reduces

unnecessary removal of oxygen.

antidiuretic hormone (ADH)

water retaining hormone where Na goes, water flows.

What is the difference between supervision and delegation?

Transferring the responsibility of a task or assignment only occurs during delegation

Identify the way HIV is transmitted

Transmitted through blood or bodily fluids

A client is admitted to the hospital with a tentative diagnosis of Guillain-Barre syndrome. Which question by the nurse will elicit information that supports this diagnosis?

"Have you experienced an infection recently"

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions?

"I should carry objects close to my body"

A male client with dementia due to Parkinson's disease has been placed in a nursing home. His wife appears to be tired and angry on her first visit with her husband. As she is leaving she says to the unit nurse in a sarcastic tone. "Let's see what you can do with him" What is the most therapeutic response by the nurse?

"It sounds like it's been difficult for you.

An 80 year old female is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated because she is alert and able to care for herself. The nurse's best response is.

"The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

The RN is teaching a patient who will be discharged soon with a prescription for warfarin (coumadin). Which statement do you anticipate being included in the discharge teaching?

"avoid aspirin while taking warfarin.

One primary action for the practical nurse is to record the activities

(CPR, drug administration, intubation, IV insertion, etc.) that occur during the resuscitation.

The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis?

-Excessive thirst -Fruity-scented breath -Confusion

What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)?

-Pain relief, Antipyresis, Reduced inflammation

What are some clinical indicators that a nurse expects when intravenous (IV) line has infiltrated?

-Pallor -Edema -Decreased flow rate

List four nursing interventions to prevent postoperative thrombophlebitis.

-Perform in bed exercises. -Early ambulation -Apply antiembolus stockings -Avoid positions/pressure that obstruct venous flow.

Use of complimentary or noninvasive methods for pain management when possible

-Relaxation exercises -Distraction -Imagery -Biofeedback -Interpersonal skill -Physical care: Altering position, touch hot and cold application (as ordered by healthcare provider)

A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis. Which clinical findings related to this event should the nurse document in the client's clinical record?

-acetone breath -decreased arterial carbon dioxide level.

For narcotic-induced respiratory depression, naloxone (Narcane)

0.1 to 0.4mg IV can be given every 2 to 3 minutes as needed until 1mg is achieved.

5 rights of delegation

1. Right task 2. Right circumstance 3. Right person 4. Right direction/communication 5. Right supervision/evaluation

What percentage of O2 should a child in respiratory distress receive?

100%

A child in severe distress should be on

100% oxygen.

Which is most indicative of a systemic infection.

101.3* oral temperature.

The correct procedure regarding using a walker is to move the walker no more than

12 inches in the front to maintain balance and to be effective in forward movement.

2. Negligence is measured by how "reasonable" an action is. How does a PN decide whether an action is "reasonable"?

2. Is the action something that a rational, responsible, and prudent nurse would do in a similar situation?

1L of fluid weighs

2.2lb

During one-rescuer CPR, what is the ratio of compressions to ventilations for an adult who has no pulse?

30 Compressions and 3 breaths

What is the established minimum renal output per hour?

30mL/hr

Choose the best answer for a normal calcium range?

9-10.5

A nurse is assigned to take care a group of clients. Which client should the nurse see first?

A 2 year old male with diarrhea; will be at higher risk fro fluid and electrolyte imbalance which put the client at a life threatening situation.

Define DIC

A coagulation disorder in which there is paradoxical thrombosis and hemorrhage.

Injury/Damage

A failure to meet the standard of practice caused mental or physical injury or damage to the plantiff.

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin the blood has what effect on oxygenation status?

A low hemaglobin level causes reduced oxygen carrying capacities.

A client has undergone a subtotal thyroidectomy, The client is being transferred from a post anesthesia care unit/ recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client?

A tracheostomy tray

The practical nurse (PN) is taking the temperature of a 5-year-old child with otitis media. During the previous 24 hours, the child's temperature readings have ranged from 101.2° F oral to 102° F tympanic. Which statement accurately evaluates these findings and should be considered when planning care for the remainder of the shift?

A tympanic temperature and an oral temperature are equally accurate techniques in evaluating the child's fever.

What is the most important assessment data for the nurse to obtain on a client with dysrhythmia?

Ability of the client to tolerate the dysrhytmia.

A nurse is taking the health history of a client who is to have surgery in one week. The nurse identifies that the client is taking ibuprofen (Advil) for discomfort associated with osteoarthritis and notifies health care provider. Which drug does the nurse expect will most likely be prescribed instead of Advil?

Acetaminophen (Tylenol)

A mother is being discharged following the birth of her second child. The mother tells the practical nurse (PN) that her first child died at 6 weeks of age because of sudden infant death syndrome (SIDS), and she fears that this infant will also develop SIDS. What information is best for the PN to provide to this mother?

Acknowledge the fear of losing another child and allow couple to discover their own solutions.

What modalities are thought to increase the production of endogenous opiates?

Acupuncture, administration of placebos, TENS

An obese client discusses with the practical nurse (PN) that the client plans to begin a long-term weight loss regimen. In addition to dietary changes, the plans include an intensive aerobic exercise program 3 to 4 times a week and stress management classes. After praising the client for these decisions, which information is most important for the PN to provide?

Advise the client to have a complete physical examination before beginning any exercise program

The nurse is caring for a client for hours after the client's hip replacement surgery. When assisting the client out of bed, the nurse should:

Advise the clients that the legs must continually be kept wide apart.

A nurse is caring for a client whom segmental postural drainage treatments are prescribed. The nurse should avoid scheduling the treatment at what time?

After a meal; because productive coughing induced by postural drainage can cause nausea and vomiting.

List five variables that increase surgical risk

Age: very young and very old, obesity and malnutrition, preoperative dehydration/hypovolemia, preoperative infection, use of anticoagulants (aspirin) preoperatively

List five variables that increase surgical risk.

Age: very young and very old, obesity and malnutrition, preoperative dehydration/hypovolemia, preoperative infection, use of anticoagulants (aspirin) preoperatively

When caring for a client with varicella and dissemination herpes zoster, the nurse should implement which type of precautions?

Airborne Contact Standard

The practical nurse (PN) in the clinic receives a phone call from the mother of a 6-year-old child with a newly applied cast for a fracture of the femur. The mother reports that the child is in pain and is crying and that the child's foot appears swollen and blue. Which nursing diagnosis supports the PN's initial intervention?

Altered peripheral tissue perfusion

What are the possible lethal dysrhytmias?

Any atrial or ventricle dysrhythmia that becomes unstable that is, atrial fib, atrial flutter, ventricle fib, ventricle flutter. Third degree AV block.

Which statement by a client should indicate to the practical nurse (PN) that the client understands how HIV is transmitted?

Anyone can contract HIV if high-risk behaviors are practiced. COMPLETE ABSTINENCE

A 5-year-old tells the practical nurse (PN) that she "needs a Band-Aid" when she has an injection. Which action is best for the PN to take?

Apply a band aid over the injection site.

A client's chest tube is accidentalyl dislodged. What is the nursing action of highest priority?

Apply a petroleum gauze dressing over the site.

When suctioning a client with a tracheostomy, an important safety measure for the nurse is to:

Apply suction only as the catheter is being withdrawn.

List four measurable criteria that are the major expected outcomes of a shock crisis.

BP mean of 80 to 90 mm Hg; PO2 more than 50 mm Hg; CVP greater than 6 cm of H2O; urine output at least 30 mL/hr.

A 65-year-old patient with pneumonia is receiving amikacin (Amikan). It would be most important for a nurse to monitor which of the following laboratory values in this patient?

BUN and creatinine

A patient with chronic congestive heart failure is examined in the outpatient department to investigate recent onset and peripheral edema. and increased shortness of breath. Physical findings include bilateral crackles, and third heart sounds (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?

Barely detectible depression when thumb is released from swollen area; Normal foot and leg contours.

One should never make blind sweeps into the mouth of a choking child or infant. Why?

Because the object might be pushed farther down the throat.

Why does the CD4 T-cell count drop in those with HIV infections?

Because the virus destroys CD4 T-cells as it invades them and replicates.

What PO2 value indicates hypoxemia?

Below 60 mm Hg

The health care provider prescribes carbamazepine for a child whose tonic-clonic seizures have been poorly controlled. The nurse informs the mother that the child must have blood tests every week. The mother asks why so many blood tests are necessary. What complication is assessed through frequent laboratory testing that the nurse should explain to this mother?

Bone marrow suppression

A nurse is planning to teach facts about hyperglycemia to a client with the diagnosis of diabetes. What information should the nurse include in the discussion about what causes diabetic acidosis?

Break down of fat stores for energy.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration?

Elevate HOB 30-40 degrees.

A pregnant client with severe preeclampsia is receiving IV mangesium sulfate. What should the nurse keep at the bedside table to prepare for the possibility of magnesium sulfate toxicity?

Calcium gluconate

A short arm cast is applied to a child with a fractured right ulna. The practical nurse (PN) is preparing the parents with home instructions and should reinforce that the parents follow which discharge instruction?

Call the health care provider immediately if the nail beds appear "blue" or "empty."

A nurse applies a cold back to treat an acute muscoloskeletal injury. Cold therapy decreases the pain by

Causing local vasoconstriction, preventing edema and muscle spasm.

A female whose mother died of pancreatic cancer asks the practical nurse (PN) how she can avoid this disease. Which lifestyle change is most important for the PN to suggest to avoid developing pancreatic cancer?

Cease cigarette smoking. (Twice as high)

Describe the calculation of the heart rate using an ECG rhythm strip.

Count the number of RR intervals in the 30 large squares and multiply by 10 to determine the heart rate for 1 minutes.

A client with abdominal wound infection with methicillin-resistant. Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution?

Cover the infected site with a dressing.

A client who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor which initial sign of fluid overload?

Crackles in the lungs.

Which intervention should the practical nurse implement when a child cannot swallow prescribed tablets?

Crush tablet and mix with a small amount of crushed food.

Ankle pumping is the most effective exercises to prevent

DVT

The nurse is preparing a child for transport to the operating room for an emergency appendectomy. The anesthesiologist prescribes atropine sulfate IM STAT. What is the primary purpose for administering this drug to the child at this time?

Decrease Oral Secretions

A client is schedule for a surgical resection of the colon and creation of a colostomy for bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to

Decrease bacteria in the intestine.

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?

Decreased blood pressure.

What is the first sign of tolerance to pain analgesics?

Decreased duration of drug effectivenes

A nurse is assessing a client and suspects diabetic ketoacidosis. What clinical findings support this conclusion?

Deep respirations and fruity odor to the breath.

A client in cardiac arrest is noted on the bedside monitor to be in pulseless ventricular tachycardia. What is the first action that should be taken?

Defibrilation

A client has been told of a positive breast biopsy report. She asks no questions and leaves the health care provider's office. She is overheard telling her husband. "The doctor didn't find a thing." What coping style is operating at this stage of grief?

Denial

Identify the five stages of death and denying

Denial, anger, bargaining, depression, acceptance

Which clinical findings should the nurse expect when assessing a client with hyperthyroidism?

Diarrhea Weight Loss

A client has a tonic-clonic seizure that involves all extremeties. The nurse anticipates that the health care provider will prescribe the intravenous adminisitration of:

Diazepam (Valium)

A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify?

Difficulty swallowing saliva.

A client reports nausea, vomiting and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings?

Digoxin (Lanoxin)

Which clinical finding does the nurse anticipate when admitting a client with an extracellular fluid volume excess?

Distended jugular veins

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take?

Don a N95 respirator mask before entering the room.

List three symptoms of respiratory failure in the adult?

Dyspnea/tachypnea, intercostal retractions, cyanosis

Identify nursing/medical intervention to prevent postoperative paralytic ileus.

Early ambulation. Limit use of narcotic analgesics. NG tube decompression.

Breach of duty.

Failure to maintain nursing standard.

A clients IV infusion infiltrates. The nurse concludes that what is most likely the cause of infiltration?

Failure to secure the catheter adequately.

True or false: When feeling for the presence of a carotid pulse, no more than 5 seconds should be used.

False: palpate for at least but no more than 10 seconds, recognizing that dysrhythmias or bradycardia could be occurring.

The practical nurse (PN) is assisting the health care provider with an amniotomy of a laboring client. Immediately after the procedure is completed, what is the most important information for the PN to obtain?

Fetal heart rate

How does a PN decide whether he/she can perform a procedure?

Has the PN received sufficient education, training, and experience? Refer to the job description, policies and procedures of the healthcare facility; be consistent with the state's Nurse Practice Act.

A child is brought to the emergency room with burns over 50% of the body. Using a modified "Rule of Nines" to estimate the percentage of the body surface area burned, the practical nurse (PN) considers that which part of the child's body is proportionally larger than an adult's?

Head and neck

2. List four common causes of fluid volume overload.

Heart failure (HF); renal failure; cirrhosis; excess ingestion of table salt or overhydration with sodium-containing fluids.

List the six modalities that are considered noninvasive, nonpharmalogic pain relief measures

Heat and cold applications TENS massage Distraction techniques biofeedback techniques.

What drug is used is used in the treatment of DIC?

Heparin

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort?

High fowler's position using the bedside table as an arm rest.

Is it important to differentiate between hypovolemic shock and cardiogenic shock? Hiow might the nurse determine the existence of cardiogenic shock?

History of MI with left ventricular failure or possible cardiac myopathy, with symptoms of pulmonary edema.

A client has been admitted to the hospital with the diagnosis of cancer of the thyroid and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period?

Hoarseness and airway obstruction may result from laryngeal nerve damage.

A client appears anxious, exhibiting 40 shallow respirations per minute. The client complains for feeling dizzy and lightheaded and of having tingling sensations of the fingertips and around the lips. The nurse concludes that the client's complaints probably are related to:

Hyperventilation

If the U wave is most prominent, what condition might the nurse suspect?

Hypokalemia

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurence of:

Hypokalemia

The doctor prescribes digoxin (Lanoxin) for a patient with congestive heart failure. During digoxin therapy, which electrolyte imbalance may predispose the patient to digitalis toxicity?

Hypokalemia

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6mEq/L. Based on the lab result and symptoms, what is the client experiencing?

Hyponatremia.

The nurse is caring for a client who has just received epidural anesthesia. Which finding would be of most concern?

Hypotension.

Identify the condition that exist when the PO2 is less than 60mm Hg and the Fi02 is greater than 60%.?

Hypoxemia

Client is on warfarin (Coumadine) for which atrial fibrilation with daily PT/INR labs drawn. Which is the desired therapeutic range of INR when on warfarin?

INR 2-3

In completing a client's preoperative routine, the practical nurse (PN) finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. What action should the PN take next?

Inform the charge nurse that the operative permit is not signed and that the client has questions about the surgery.

Prednisone (Meticorten)

Inhibits phagocytosis and supresses other clinical phenomena of INFLAMMATION

If narcotic agonist/antagonist drugs are administered to a client already taking narcotic drugs, what may be the result?

Initiation of withdrawal symptoms

The practical nurse (PN) is assessing a child with asthma for retractions during respirations. When should the PN recognize the absence or presence of intercostal retractions?

Inspiration

As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is MOST appropriate when targeting older adults' most frequent cause of falls?

Instructing the client to call the nurse before going to the bathroom.

After a deep vein thrombosis developed in a postpartum client, an IV infusion of heprarin therapy was instituted two days ago. The client's aPTT is not 98 seconds. What should the nurse do?

Interrupt the infusion and notify the practitioner of the aPTT result. 98 seconds is three times the normal limit (25 to 36 seconds)

A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis. What is the initial intervention that the nurse should expect the health care provider to prescribe for this client?

Intravenous IV fluids

Which route of administration for pain medication has the quickest onset and shortest duration?

Intravenous push or bolus

Predisone (Meticorten), an adrenal steroid is prescribed for a client with exacerbation of colitis. When administering the first does of medication, the nurse should inform the client that the medication :

Is not curative but it does cause the supression of the inflammatory process.

The practical nurse (PN) is examining a child with an exacerbation of juvenile rheumatoid arthritis (JRA) and notes that the child's mobility is greatly reduced. What factor should the PN observe that affects the child's mobility?

Joint inflammation

Client is on furosemide without a supplemental potassium (K+) replacement. Which lab result is most likely?

K+2.8 -Normal potassium levels are 3.5-5

A nurse is assessing a client experiencing a diabetic coma. What unique response associated with diabetic coma that is not exhibited with hyperglycemic hyperosmolar nonketonic syndrome should the nurse identify when assessing this client?

Kussmaul Respirations

The nurse observes a client with diabetic ketocacidosis who is experiencing abnormally deep regular, rapid respirations. How should the nurse correctly document this observation in the medical record?

Kussmaul's respirations

Proximate Cause

Legal cause; exists when the connection between an act and an injury is strong enough to justify imposing liability.

A client is admitted to the hospital with the diagnosis of Parkinson disease. What medication should the nurse expect the health care provider to prescribe to relieve the client's physiological response to the disease.

Levodopa (I-Dopa)

A primipara presents to the perinatal unit describing spontaneous rupture of the membranes (SROM) that occurred 12 hours before she came to the hospital. Eight hours after admission, the client's contractions are irregular and mild. What vital sign should the practical nurse (PN) monitor with greater frequency than the typical protocol?

Maternal temperature

The practical nurse (PN) should implement droplet precautions for a client admitted with which diagnosis?

Meningococcal pneumonia

The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid base disorder?

Metabolic acidosis.

The nurse is caring for a client with a nasogastric tube that is attached to a low suction. The nurse monitors the client closely for which acid-base balance that is most likely to occur in this situation?

Metabolic acidosis. -The loss of gastric fluid via NG tube suction or vomiting causes a metabolic condition.

A client has an open reduction and internal fixation for a fractured hip. Postoperatively the nurse should place the client's affected extremity in what position?

Moderate abduction

A practical nurse (PN) is working on a mental health unit and receives a community call from a person who is tearful and who states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The PN should refer the call to the registered nurse (RN) based on which assessment?

Moderate levels of anxiety

What is the effect of DIC on the following laboratory tests: PT, PTT, platelets?

Prothrombin time—prolonged; partial thromboplastin time—prolonged; platelets—decreased.

A female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. What intervention should the practical nurse (PN) include in this client's care?

Provide a structured environment with little stimuli.

While auscultating the lungs of a client admitted with severe preeclampsia, the nurse identifies crackles, What interference does the nurse make when considering the presence of crackles in the lungs?

Pulmonary edema has developed.

If a client is in cardiogenic shock, what might result from administration of volume-expanding fluids? What intervention can the nurse expect to perform in the event of such an occurrence?

Pulmonary edema; administer cardiotonic drugs such as digitalis preparations.

The practical nurse (PN) is caring for a child with Wilms' tumor. Which preoperative intervention should the PN implement?

Put a sign above the bed reading "Do not palpate abdomen" You don't want to rupture!

When turning an immobile bedridden client without assistance, which action by the practical nurse (PN) best ensures client safety?

Put the bed rails up on the opposite side

In an ECG reading, what complex represents depolarization of the ventricle?

QRS complex

What is the goal of treatment for hypovolemic shock?

Quick restoration of cardiogenic output and tissue perfusion

The nurse should place the client in which position to obtain the most accurate reading of jugular vein distension.

Raised 45 degrees

What intervention is used to restore cardiac output when hypovolemic shock exists?

Rapid infusion of volume expanding fluids.

A client is diagnosed with diabetic ketoacidosis. Which insulin should the nurse expect the healthcare provider to prescribe?

Regular insulin (Novolin R)

What causes septic shock?

Release of endotoxins from bacteria that act on nerves in vascular space in periphery, causing vascular pooling, reduced venous return and decreased cardiac output, resulting in poor systemic perfusion

The practical nurse (PN) is reinforcing the information about a Milwaukee brace with an adolescent girl with scoliosis. Which information should the PN reinforce?

Remove the brace 1 hour each day for bathing only

Minocycline 50 mg PO every 8 hours is prescribed for a 18-year-old adolescent girl diagnosed with acne. The nurse discusses self-care with the client while she is taking the medication. Which teaching points should be included in the discussion? (

Report vaginal itching or discharge. Protect skin from natural and artificial ultraviolet light. Avoid driving until response to medication is known. ETake with an antacid tablet to prevent nausea.

In an ECG reading, which wave represents depolarization of the atrium?

Represented by the T wave

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease COPD. The nurse should monitor the client for which acid base imbalance?

Respiratory Acidosis

A client with chronic obstructive pulmonary disease ( COPD) has a blood ph of 7.25 and Pco2 of 60. These blood gases require nursing attention because they indicate

Respiratory acidosis

Preoperative teaching should include demonstration and explanation of expected postoperative client activities. What activities should be included?

Respiratory activities; coughing and breathing, use of spirometer. Exercises range of motion exercises, leg exercises, turning, pain management.

The nurse is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and PCO2 of 32mmHg. The nurse determines that these results are indicative of which acid-base disturbance?

Respiratory alkalosis

The nurse is assigned to a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. In planning care for this client, which of the following nursing action would be unsafe?

Restricting the client's potassium intake. -Restricting potassium makes the client more prone to digitalis toxicity.

Defamation

Revealing privleged information.

Identify two examples of isotonic IV fluids.

Ringer's lactate; normal saline.

A nurse is feeding an infant who recently underwent surgical repair of a cleft lip. What does the nurse plan to do for the infant just after each feeding?

Rinse the suture line

The practical nurse (PN) reinforces instructions in the use of a gait belt to a caregiver whose spouse has right-sided weakness and needs assistance with ambulation. The caregiver-spouse performs a return demonstration of the skill. Which observation by the PN indicates that the caregiver-spouse has learned to perform this procedure correctly?

Standing on his spouse's weak side, the caregiver provides security by holding the gait belt from the back.

The practical nurse (PN) is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the PN to implement?

Stay with the client when standing

During a well-child clinic visit, the practical nurse (PN) is teaching the parents of a toddler about prevention of accidental poisonings. What information should the PN reinforce?

Store all toxic agents and medicines in locked cabinets

A client has a paracentesis, and the health care provider removes 1500 mL of fluid. To monitor for a serious postprocedure complication, the nurse should assess for:

Tachycardia

A 26-year-old gravida 2, para 1 client is admitted to the hospital at 28 weeks' gestation in preterm labor. She is given three doses of terbutaline sulfate 0.25 mg subcutaneously to stop labor contractions. The practical nurse (PN) should monitor for which primary side effects of terbutaline sulfate?

Tachycardia and a feeling of nervousness

8. List five assessment findings found in most shock victims.

Tachycardia; tachypnea; hypotension; cool, clammy skin; decrease in urinary output.

A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first?

Take vital signs and notify the charge nurse or healthcare provider.

The practical nurse (PN) finds a client crying behind a locked bathroom door. The client will not open the door. What action should the PN implement first?

Talk to the client and attempt to find out why the client is crying.

A client had a hemiarthroplasty of the left hip yesterday because of a fracture resulting from a fall. Which instruction should the practical nurse (PN) reinforce while reviewing hip precautions with the client?

Tell client to place a pillow between knees while lying in bed.

A client has a history of progressive carotid and cerebral aterosclerosis and experiences transient ischemic attacks (TIAs). The nurse explains to the client that TIAs are

Temporary episodes of neurological dysfunction.

A nurse applies a heating pad to a client's buttox. Upon removal of the heating pad, the nurse discovered that the client received burns due to incorrect settings when use of the heating pad was initiated. Which principle would legally apply?

The nurse could be held liable for the injury that occured.

The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it on:

The right side. (Stronger side)

What does the PR interval represent?

The time required for the impulse to travel from the atria through the AV node.

Mrs. Green lost her husband 3 years ago. She has not disturbed any of his belongings and continues to set a place at the table for him nightly. Is this response indicative of a normal or a complicated grief reaction?

This is a dysfunctional grief reaction. Mrs. Green has never moved out of the denial stage of her grief work.

Your client feels responsible for his sister's death because he took her to the hospital where she died. "If I hadn't taken her there, they couldn't have killed her." It has been 1 month since her death. Is this response indicative of a normal or a complicated grief reaction?

This is a normal expression of anger and guilt that occurs. Try to minimize the rumination of these thoughts.

The practical nurse (PN) is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding?

Three vessels: two arteries and one vein

Describe the ways a pediatric client might acquire HIV infection

Through infected blood products, sexual abuse or breast mark.

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator?

Tissue turgor

Vertical transmission occurs how often (From mother to fetus) if the mother is not treated during pregnancy?

Vertical transmission occurs 30-50%

A client has a fractured mandible that is immobilized with wires. For which life-threatening postoperative problem should the nurse monitor this client?

Vomiting

Client has a baterial infection. Which lab is most likely?

WBC 18000. White blood cells fight off infection.

9. If a person is choking, when should the rescuer intervene?

When the person points to his or her throat and can no longer cough, talk, or make sounds.

Define shock

Widespread, serious reduction of tissue perfusion, which leads to generalized impairement of cellular function

Libel

Written defamation

3+ edema

a deeper depression (5-10mm) accompanied foot and leg swelling

2+ edema

a detectable depression of less than 5mm accompanied by normal leg and foot contours

Malpractice

a negligent act performed by an individual in a professional role that results in INJURY.

A pH of 7.25 is

acidic