MED SURG HESI BSN 266

A client is being treated for minor injuries following an automobile accident in which the only other passenger was killed. The client asks the nurse, "Is my friend who was in the car with me ok?" What response is best?

"I am sorry, but your friend was killed in the accident"

Nurse knows the pt with a mechanical valve replacement understands the DC teaching. When states?

"I will need to take antibiotics before any type of invasive dental work"

When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective?

"I will use my crutches to keep my weight off my knee"

In performing the admission assessment for pt experiencing complications of long-term PD, which Q provides best info about progression?

"Have you ever been frozen to a spot and unable to move?"

A client is receiving an IV infusion of regular insulin, 75 units in 100 ml of normal saline at 9 units per hr. The nurse should program the pump to deliver how many ml/hr?

12

Pt receiving intermittent infusion of erythromycin lactobionate inj, USP 1 gram in 250ml of NS over 2 hrs. Nurse programs infusion pump ml/hr?

125

A client receives a prescription for acetylcysteine (Mucomyst) 1.4 grams per nasogastric tube q4 hours. Acetylcysteine is available in a 10% solution (10 grams/100ml). How many ml of the 10% solution should the nurse administer per dose?

14

The healthcare provider prescribes 250mg/hr of magnesium sulfate. The pharmacy delivers 500 ml IV that contains 4 grams of the drug. The nurse should set the IV infusion pump to deliver how many ml per hour. Round to the nearest whole number if needed.

16 ml/hr

The nurse plans to administer an IV heparin bolus of 80 units/kg to a client who weighs 210 pounds. How many units should the nurse administer?

7636

A newly graduated and licensed registered nurse (RN) is in the second day of orientation to the hospital unit. The education director tells the charge nurse that the new graduate should be assigned to care for one client. Which client is best for the nurse to assign to this new graduate?

A client who is 4-days post myocardial infarction

Nurse assessing Pt 8 hrs postparathyroidectomy. Assessment findings include a negative trousseaus sign. Action?

Document the finding

To assess with meningitis for meningeal irritation, how to position head?

Head and neck are flexed toward the chest

A male client with Addison's disease tells the nurse that he is taking hydrocortisone in a divided daily dose. He reports increasing fatigue and weakness. What action should the nurse take?

Interview the client about any sources of increased stress in his life

Identify location of tragus on the outer auricle.

Little bump inside

In assessing client diagnosed with left- sided HF, nurse observes new findings of Jugular venousdistension (JVD) and pedal edema. What action?

Notify HCP of the onset of R-sided failure

To assess for the presence of diaphragmatic breathing, what action should the nurse take

Observe the movement of the abdomen

To administer saline enema, nurse inserts the enema tubing 3 inches into rectum, elevates saline container 6 inches above body. After nurse opens clamp, saline does not infuse. What action?

Raise the saline container 6 more inches above the body

After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first?

Re-connect the tube to the suction.

The nurse is preparing discharge instructions for a client recovering from a mastectomy. What will the nurse include to ensure maximum functioning of the client's upper extremities after the surgery?

Review post-mastectomy arm exercises as prescribed

A female client who had a total thyroidectomy several weeks ago is admitted with myxedema coma. Which finding indicates that the client has been noncompliant with her postoperative treatment plan?

Serum T3 and T4 levels are below normal

In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-type Naturetic peptide (BNP) is elevated. Action?

Administer the dose of furosemide as scheduled

Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)

An elderly female client with cancer and her children who are trying to decide whether to change to palliative care measures or continue disease control

The nurse who is performing blood sugar and cholesterol screenings at a community health fair determines that a female client's blood sugar is 59 mg/dl at 10:00 a.m. Which nursing intervention is most important for the nurse to implement?

Ask the client how she is feeling

A relative comes into the Emergency Department asking for information about a female adult client who was admitted in stable condition following a motor vehicle collision. What action should the triage nurse take?

Ask the client if she would like to talk with the relative, and then bring the relative to the bedside

A male translator is working with the nurse who is giving discharge instructions to a non-English speaking client. When the translator restates what he nurse is saying, it appears that he is saying much more than what the nurse said. What action should the nurse take?

Ask the translator if there is a reason for the lengthiness of the translation.

A client who is scheduled to have surgery in two hours tells the nurse, "My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper." Action?

Call the surgeon back to clarify the information with the client

While flushing the proximal port of a triple lumen central venous catheter with heparin solution, the nurse meets resistance. Action?

Cover the cap with tape and label the port as being obstructed

Which approach is best for the nurse to use when communicate with a client with ALS?

Demonstrate a positive, caring demeanor

A male client with chronic asthma tells the nurse that he is having more episodes of bronchoconstiction and increased mucous production. Which action should the nurse implement?

Determine if rescue inhaler is being used first during an acute episode

What instruction is most important for the nurse to provide a client with neutropenia?

avoid sources of potential infection

The nurse is caring for a client with jaundice. Which serum laboratory value is likely to be elevated for this client?

bilirubin

In monitoring a client receiving propylthiouracil (PTU) for hyperthyroidism, an increase in which finding indicates that the medication is producing the desired effect

body weight

A client taking tamoxifen citrate following a lumpectomy reports several problems to the nurse. It is most important for the nurse to follow-up on which reported problem

calf tenderness

A 25-year-old female client reports to the nurse that she has a throbbing headache over her left eye that began early yesterday right after experiencing dark spots in her vision. Movement makes her nauseous, but lying still in a dark room does provide some relief. Over-the-counter pain medications have not helped. This client is describing which type of headache?

classic migraine

The healthcare provider prescribes isosorbibide (Isordil) 40 mg every 8 hours for a male client with acute angina pectoris. Which finding should the nurse report to the healthcare provider prior to administering Isordil?

currently, takes sildenafil

When obtaining a throat culture from a 6 year old with possible strepococcal infection, which action is most important for the nurse to implement?

Swab the child's erythematous oropharyngeal surfaces or tonsilar pustules.

A client who sustained a pellet gun injury with a resulting comminuted skull fracture is admitted overnight for observation. Which assessment finding obtained two hours after admission necessitates intervention?

The client repeatedly falls asleep while talking with the nurse

A client has produced the first of a series of sputum samples for cytology. Action?

Transport the sputum container to the laboratory in a biohazard bag

A client with endometrial carcinoma is receiving bradytherapy and has radioactive Cesium loaded in a vaginal applicator. Action?

Wear a dosimeter film badge when in the client's room

A client with chronic kidney disease (CKD) is scheduled for hemodialysis Monday and Wednesday mornings. Based on findings reported in the client's medical record, which action should the nurse implement on Wednesday morning?

Withhold the morning dose of lisinopril (Zestril).

The nurse is preparing to administer an IM dose of Vitamin B1 (thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, "what do you think you're doing?" Response?

"This shot will help relieve the pain in your feet

Female client instructed to do kegel exercises. What statement indicates the client understands how to perform?

"When I urinate I should tighten those muscles and stop the flow of urine for 10 sec and repeat this 5-10 times"

A client recovering from surgery to remove a pituitary tumor has an 8- hour urine output of 1500 mL and a specific gravity of 1.001. This finding is consistent with which complication from the surgery?

diabetes insipidus

The nurse is caring for a 42-year-old male client who is excreting less sodium than he is consuming. If this condition continues, what complication can the nurse expect this client to exhibit?

edema

A client is diagnosed with secondary polycythemia. Which health condition contributed to the development of this secondary problem?

hypovolemia

Accutane (acne medication)

instruct the client to stop taking vitamins(vitamin A)

Lumber Puncture

lie flat and monitor for headaches

Pheochromocytoma

monitor blood pressure

The nurse is triaging clients from a train wreck. A client has multiple open wounds, a BP of 90/50, and Pulse of 112. Which triage tag color should the nurse place on this client?

red

The nurse is conducting a physical examination of a client with acute laryngitis. Which finding indicates the client's health status is deteriorating?

respiratory rate 26 per min

An elderly client is experiencing disturbed sleep patterns. Which intervention should the nurse implement to help the client attain maximal sleep function Assess daytime somnolence?

review medication side effect profiles

When administering an intramuscular injection containing 3 ml of a painful medication, Intervention?

select a large, deep muscle mass

The nurse is planning care for a 48-year-old client, diagnosed with schizophrenia at age 25, who has been taking antipsychotic drugs since diagnosis. Long-term use of these drugs is associated with which side effect?

tardive dyskinesia

Locate the optic disk

the really light area on the right

A man calls the hospital and asks to talk with the nurse about his girlfriend who was extremely intoxicated on admission and is receiving services for detoxification. He knows that she is in the facility and asks the nurse about her condition. Response?

" I cannot acknowledge if a client is here or not"

Nurse evaluating teaching about short-acting insulin coverage to newly diagnosed with type 1. Which statement indicates understanding?

"After taking my regular insulin, I need to eat a meal soon to prevent hypoglycemia episode."

The nurse is reviewing content created for an educational session on cultural diversity when providing client care. Which statement would the nurse question as not being culturally sensitive?

"All hispanic clients do not provide personal information to strangers."

A male client diagnosed with gastroesophageal reflux (GERD) often wakes up at night experiencing heartburn. He tells the nurse that he sleeps with the head of the bed on blocks, and always drinks a glass of milk at bedtime to help him fall asleep. How should the nurse respond?

"Drinking milk before bedtime can increase your symptoms at night."

A client diagnosed with a deep vein thrombus (DVT), followed by a diagnosis of pulmonary embolism (PE), is receiving heparin via an infusion pump at a rate of 1400 U/hr. The client tells the nurse, "I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home." What response is best for the nurse to provide?

"Heparin prevents future blood clot formation, but your risk of bleeding needs to be monitored closely."

Client diagnosed with schizophrenia looks frightened and tells nurse "keeps hearing voices telling me to hurt somebody" Don't you hear them?" Nurse response?

"I don't hear the voices, but you seem very frightened"

Newly diagnosed type 1 D receives 28 units of Humulin N at 0700. Nurse is making rounds at 1330. Which client statement requires immediate follow-up intervention?

"I let my wife eat my lunch since I wasn't hungry"

Teaching using a Holter monitor, which statement indicates understanding the procedure?

"I must record any symptoms occurring with my activity"

Nurse preparing a native-American for surgery In 1 hr. client says "I want to have my med man called before surgery." Response?

"I will be happy to assist you in contacting your medicine man right away."

The nurse knows the client with a mechanical valve replacement understands the discharge teaching when the client makes which statement?

"I will need to take antibiotics before any type of invasive dental work"

Nurse agrees to work double because of shortage, but requests another nurse be assigned to care for demanding client. Response?

"I'll assign the client to another nurse, but your help may be needed"

Question about nasal decongestants medication

Alternate the nostrils when giving the medication

A male client develops oral candidiasis. He has MRSA-positive sputum, is dyspneic, and is receiving oxygen per facemask and linezolid (Zyvox) 600 mg BID IV. In planning care for this client, the nurse identifies which factor as the probable cause of the stomatitis?

Antibiotic therapy.

A mist tent and intravenous fluids are prescribed to a 6 month old with respiratory syncytial virus (RSV) is a virus that causes respiratory tract infections. It is a major cause of lower respiratory tract infections and hospital visits during infancy and childhood. When the parent inquire why there child is not receiving antibiotics.

Antibiotics are not effective treatments for viral illnesses such as RSV infection

An elderly male client is experiencing urinary incontinence. What is the best initial nursing action?

Apply an external condom catheter.

Assessing both lower extremities with chronic venous insufficiency; identifies bilateral stasis dermatitis and an ulcer n the medial surface of left ankle. To promote effective self-care what teaching?

Apply compression stockings before ambulation

A client with pneumonia is demonstrating progressive drowsiness and difficulty arousing. Which diagnostic test would be the priority when planning care for this client?

Arterial blood gases.

Assessment intervention should the psych nurse implement when performing mental status exam?

Ask pt to interpret the proverb, "A stitch in time saves nine"

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Ask the client about gastrointestinal pain

An elderly male client tells the nurse that he often wakes up during the night. What action should the nurse implement first

Ask the client to describe what happens when he awakens

A male admitted to the mental health unit for somatoform disorder, become angry because he cannot have his pain medication. He demands that the nurse call the HCP and threatens to leave the hospital. Action?

Ask what other methods he uses to deal with pain

At community health fair, 50 yr old tells nurse she has an annual physical exam that includes a clinical breast exam and annual mammogram. How to respond?

Ask woman if she also performs monthly breast self-exams

The nurse plans to administer 5,000 units of heparin, an anticoagulant. Which procedure should the nurse implement when administering this drug?

Assess all needle insertion sites daily for hematoma and signs of inflammation

A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first?

Assess the client for pallor

The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement?

Assess the need for continued restraint

"Oxygen at 5 liters/min per nasal cannula PRN difficult breathing" is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?

Avoiding the administration of oxygen at high levels for extended periods

The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway?

Bilateral breath sounds can be auscultated

Diagnosed with severe acute diverticulitis and being admitted to med unit. Priority Q?

Bisacodyl (Dulcolax) rectally PRN for constipation

Which assessment is most important for the nurse to perform before ambulating a client with a history of syncope?

Blood pressure

A 78-year-old client in a wheelchair wants to return to bed after eating breakfast. What assessment is most important for the nurse to consider before assisting this client?

Blood pressure of 86/54.

A grant is awarded to provide primary preventative health care to a community-based healthcare system. When designing the program to meet the grant objective, which services should the nurse consider for inclusion?

Breast screening for older women Blood pressure assessments

A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?

Breath sounds

Following a thyroidectomy, a client experiences tetany. The nurse should expect to administer what intravenous medication?

Calcium gluconate

The home health nurse visits a client with heart failure (HF). Assessment findings include: temperature 97.6oF, pulse 116 beats/minute, respiratory rate 36 breaths/minute, blood pressure 140/70, pulse oximeter 86% on 2 L/min of oxygen, and crackles are heard throughout the lung fields. Which intervention has the highest priority

Call 911 and prepare the client for transport

18 yr old female with primary dysmenorrheal does not want to take meds for symptoms, asks nurse which herbals likely to help alleviate the pain. What supplement?

Chamomile

During morning rounds, the nurse finds a client who has no spontaneous respirations and does not respond to shaking. The nurse activates the "Code-Blue" system. While waiting for the code team to arrive, what action should the nurse implement

Check the pulse for 10 seconds and begin chest compressions

The nurse plans to obtain a urine specimen for culture from a client's indwelling catheter. The nurse enters the room with the syringe and notes there is 100ml of urine in the drainage bag, but no urine is in the tubing. What action should the nurse take?

Clamp the tubing until urine is observed in the tubing

At 1000 the healthcare provider prescribes an increased in the dosage of a client's loop diuretic from 40 mg to 80 mg a day. The nurse has already administered today's 40 mg dose of the loop diuretic at 0600. Which action should the nurse implement ?

Clarify the start date of the new dose with the healthcare provider

Which nursing entry to the client record best reflects significant data on a male client who admitted with complaints of chest pain?

Client states he will notify the nurse if chest pain returns

After change of shift report on psych unit of general hosp, which client see first?

Client with depression who states she is leaving because she feels better

Before administering a parenteral nutrition solution through a central vein, the nurse should confirm information from which sources

Client's identification band Healthcare provider's prescription Solution label Medication administration record

After implementing a new fall prevention protocol on the nursing unit, which action by the nurse-manager best evaluates the protocol's effectiveness?

Compare the number of falls that occurred before and after protocol implementation

Which action should the nurse implement when assessing a client's blood pressure and determining that there is an auscultatory gap?

Compare the palpated systolic blood pressure with the auscultated pressure

Nurse is preparing to transfer a client who I receiving a primary infusion of normal saline and a secondary infusion of an antibiotic??? Peak and trough levels need to be obtained after transfer. What information is most important for receiving when the client arrives?

Completion time of the secondary infusion

At bedtime, an unlicensed assistive personnel (UAP) is positioning a client with obstructive sleep apnea syndrome (OSAS). The UAP elevates the head of the bed and encourages the client to turn on side. In supervising the UAP, what action should the nurse take

Confirm that the UAP has placed the call bell within reach of the client

A nurse is named as a defendant in a malpractice case. What action should the nurse take?

Contact the nurse's professional liability insurance company.

When instructing an elderly client on insulin self-administration the client says "my daughter is going to give me the shots every day." Which action would the nurse take at this time?

Continue teaching the client.

An adult male who admits to abusing IV drugs obtains the results of HIV testing. When informed that the results are positive, he states that he does not want his wife to know. Action?

Counsel the client about the importance of notifying his sexual partner(s)

A client with an electrical burn is admitted to the Emergency Department on a backboard with a cervical collar. Which intervention should the nurse implement?

Place the client on cardiac telemetry

Client who has L AKA 2 days ago has a soft stump dressing. To prevent the development of contracture on the left leg, which intervention?

Position client prone 3-4 times a day

With the client's eyes closed, the nurse places a common object in the client's hand and asks the client to describe the object. The client accurately names the object. How should the nurse document the assessment finding ?

Positive for stereognosis

When the nurse is designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic?

Preoperative and postoperative teaching for adrenalectomy

Which intervention would nurse expect to decrease discomfort and muscle spasms in elderly pt with fractured left hip?

Prepare the client for application of Buck's traction

Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Action?

Prepare the medication using a new syringe

The nurse is caring for a client recovering from a submucosal resection for a deviated nasal septum. What will the nurse explain to the client as the reason for nasal packing?

Prevent postoperative bleeding.

The nurse should explain to a client with lung CA that pleurodesis is performed to achieve which expected outcome?

Prevent the formation of effusion fluid

A man who has a known problem with alcohol is accused of stealing from his employer. When he returns home that evening, he accuses his son of stealing from school, and physically abuses the child for what the father describes as the child's dishonest behavior. Which two defense mechanisms are being used by the father?

Projection and displacement

Female diagnosed with major depression admitted to psych unit. Refuses to take a bath, dress, eat, and wants to sleep during day. Which intervention?

Provide and maintain a safe, structured daily routine

The nurse provided discharge teaching to a male client who was recently diagnosed with diabetes mellitus (DM). After receiving the instructions, the client states he understands when, how, and why to take his prescribed medications at home. Which intervention is most important or the nurse to implement?

Provide the client with a printed list of medicines and a schedule for administration.

A client who is an Orthodox Christian asks that the morning insulin dose and breakfast be delayed until after the parish priest comes to provide communion. What action will the nurse take?

Provide the insulin and breakfast after the parish priest provides communion.

Pt with AV graft for hemodialysis in left forearm and an infiltrated IV in right arm. After disconnecting the IV, where to start the next IV?

R arm proximal to the former IV

The nurse observes and unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. What action should the nurse take?

Remind the UAP to continue rubbing the hands together until they dry

A client with acute renal failure has a daily urine output of 1000 mL per day and is experiencing nausea, vomiting, diarrhea, and weakness. Which action would help the client at this time?

Remove potassium from intravenous fluids.

A client is leaving the hospital against medical advice (AMA) and voluntarily signs the AMA forms. Which nursing action is essential prior to the client leaving?

Remove the client's peripheral IV access

What diet modification is most important for the nurse to recommend to a client with high cholesterol?

Replace beef with fish or poultry

Nurse is preparing a male client for a bilateral adrenalectomy. Which info in preop teaching?

Replacement therapy with corticosteroids will be needed for the rest of his life

Pt admitted to inpatient psych unit and antipsychotic drug clozapine is Rx. Which intervention?

Report findings from the client's weekly WBC counts to the HCP

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. What action should the nurse take

Report the complaint of eye pain to the surgeon

A male Muslin client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. Which action should the nurse implement?

Reschedule administration of the antibiotic until after he completes his prayers.

The nurse administers the opioid antagonist naloxone HCI (Narcan) to a young adult client who overdosed on hydromorphone (Dilaudid). Which assessment data indicates that the naloxone is effective?

Respirations increase from 8/minute to 12/minute

Adult woman and live-in boyfriend are seen in the ED following MVA. Based on which finding should further assess for domestic violence?

Several old bruises appear in the woman's chest and neck

A client is admitted with a medical diagnosis of acute pancreatitis. When taking the health history, which client complaint should be expected?

Severe mid-epigastric pain after ingesting a heavy meal

The DASH (Dietary Approaches to Stop Hypertension) diet is prescribed for a client with uncontrolled hypertension. Which dietary choices should the nurse instruct the client to eat?

Shredded wheat

A client who is diagnosed with amyotrophic lateral sclerosis (ALS) is having difficulty swallowing and articulating words. Intervention?

Sit upright and flex chin forward while swallowing

Client receiving chemo for lung CA with brain Metastasis scheduled for cranial radiation therapy today. Provide what info?

Skin markings and head positioning devices are used to ensure that only the tumor site is radiated

To differentiate adventitious lung sounds associated with heart failure from those associated with bacterial pneumonia, what information should the nurse review?

Sputum culture findings

The medical record of a child with Duchenne muscular dystrophy (MD) states that a Gower sign is present. Based on this documentation, the nurse should expect the child to exhibit which behavior?

Stands from sitting on the floor by using hands to walk up legs

Male pt with history of generalized tonic-clonic seizures tells nurse he feels like about to have seizure. What do?

Stay with the client and call for assistance

The nurse is preparing a teaching plan for a 23-year-old female client who has had a kidney transplant. What should be the nurse's focus in conducting this teaching?

Stressing the importance of life-long medical follow-up care after the kidney transplant.

A young woman is preparing to leave for a 7-day boat trip. She requests a prescription for motion sickness so the healthcare provider prescribes meclizine (Antivert). Which instruction should the nurse include in this client's teaching?

Suck on hard candy for a dry mouth while taking this drug

During breath sound auscultation of Pt being mechanically ventilated, nurse hears coarse, snoring sounds over the upper anterior chest with clear sounds over the other lung fields. What implement?

Suction the client's ET tube

Three days after surgery, a male client who had a laryngectomy has an elevated pulse and respiratory rates. His skin is dry to touch and he is beginning to thrash about in the bed. What intervention should the nurse implement first?

Suction the client's tracheostomy.

A client with Type I diabetes mellitus (DM) is admitted for an emergency cholecystectomy. To prevent diabetic ketoacidosis (DKA), which intervention is most important for the nurse to implement?

Supplement insulin needs using a sliding scale

The nurse preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?

Tachycardia, mental status change, and low urine output

A 20 year old male client is diagnosed with Ewing's sarcoma following examination for a knee injury. Which instruction is most important for the nurse to provide the client?

Take analgesics regularly to reduce the pain

A client with active tuberculosis (TB) is receiving isoniazid (INH) and rifampin (RMP) daily, so direct observation therapy (DOT) is initiated while the client is hospitalized. Instructions?

Take medication in the presence of the nurse

An unlicensed assistive personnel (UAP) is teamed with a nurse who is caring for four clients. Client A is admitted to the medical unit for heart failure (HF). Client B has just returned from surgery. Client C, with chronic obstructive pulmonary disease (COPD), needs new oxygen tubing. Client D is waiting to be discharged. Which activity should the nurse delegate to the UAP as having the highest priority

Take vital signs of the client who has just returned from surgery

The nurse observes that a client with COPD is exhibiting fingernail clubbing. What action should the nurse take?

Document the assessment finding in the nurses' notes

Obtaining a health history, male client tells nurse become impotent. What part of info is likely to be significant to the dysfunction?

Dx with DM 10 years ago

The nurse observes that a client who is to avoid any weight-bearing on the left leg is using a 3-point crutch gait for ambulation. What is the best action?

Encourage use of the 3-point gait by the client

When lactulose (Cephulac) 30ml QID is prescribed for a male client with advanced cirrhosis, he complains that it is causes diarrhea. What action should the nurse take in response to the client's statement?

Explain that diarrhea is expected, but the drug reduces ammonia levels

Nurse caring for dyspneic pt whose O2 sat of 90%. What position?

Fowler's with both legs supported

Female pt just completed full chemo cycle for CA, lost 15 lbs from anorexia, N/V. BMI is 19. Nurse reinforces nutrition during DC. What dinner selection?

Fried chicken breast, sweet potato, spinach, roll and butter, protein milk

The community health nurse is planning a nutritional program that targets older adults who live alone and who may be in need of additional community services. Which intervention should the nurse implement first?

Gather information about the makeup of the population using a windshield survey.

A male client with chronic alcohol use is admitted with signs of early cirrhosis. Which nursing action should the nurse delegate to the unlicensed assistive personnel (UAP)?

Gather oral hygiene products for client's use

An elderly client at an adult daycare center with type 2 DM becomes unresponsive verbally with the other daycare participants and tells the nurse, "I just don't feel right." Action?

Give 4 ounces of apple juice

Nurse caring for Pt being treated for fever. Intervention to prevent chills?

Give Rx antipyretics around the clock

Which menu selection by a male client indicates to the nurse that he understands the dietary management of Crohn's disease?

Grilled chicken sandwich and pasta

A male client who has a serum potassium level of 5.9 mEq tells the nurse that he has decided to leave the hospital, even though his healthcare provider has not discharged him. He also states that he does not care if he is discharged, he is refusing all treatments. It is most important for the nurse to ensure that the client understands which fact prior to leaving the facility?

He must understand that his condition is extremely serious and that he could die as a result of his decision.

The nurse and a social worker are talking when a male client with psychosis angrily shouts at the nurse, "Stop talking about me." The nurse should document the client is exhibiting which symptom

Ideas of reference

A female client with Type 1 diabetes mellitus is trying to lose weight, and recently started an exercise program. Which information is most important for the nurse to provide this client?

Increase carbohydrate intake before exercising.

A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are: BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are: PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority?

Increase the client's IV fluid rate to 200 ml/hr.

The nurse is administering a continuous IV infusion of dopamine (Intropin) to a client. Which assessment finding indicates that the therapeutic effect has been achieved?

Increased blood pressure.

A client who is experiencing panic attacks receives a prescription for the benzodiazepine alprazolam (Xanax). Which instruction should the nurse provide this client?

Instruct the client of safety issues since this medication causes drowsiness

An adult make who returned from a vacation in Mexico three weeks ago calls the clinic complaining of abdominal pain, weight loss, and diarrhea. What action should the nurse take?

Instruct the client to bring in a stool sample

A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which instruction should the nurse provide to the client's family?

Involve the client in usual at-home activities.

ACE inhibitor is prescribed for male with diabetes whose BP is 120/60. He asks the nurse why he is getting the med when his BP is normal. Response?

It slows the progression of kidney damage often associated with diabetes

Which instruction regarding immediate postoperative care should the nurse plan to include in the preoperative teaching for a client scheduled for an incisional rotator cuff repair?

It will be necessary to wear a sling to keep the joint still

The nurse working in an emergency center collects physical evidence 6 hours following a reported sexual assault. After placing the samples in sealed containers, which action is most important for the nurse to implement?

Maintain possession of the evidence collection kit at all times until submitted to law enforcement

What intervention should the nurse implement to prevent edema and promote healing of a client's incision resulting from an above-the-knee amputation?

Maintain the residual limb in a compression dressing

A female client admitted to a long-term care facility appears to be confused and frightened. She offers her belongings, including valuable jewelry, to members of the nursing staff if they promise to stay with her and not leave her alone. What action should the nurse implement?

Make and inventory of the belongings and send the valuables home with a family member.

Which activity is best for the nurse to initiate with a depressed client?

Make cut-out cookies

When irrigating an occluded NG tube, what action should the nurse include?

Measure the amount of fluid instilled and returned

The nurse notices that a client with DM type 1 has a fruity breath odor. Priority action?

Measure the client's capillary blood glucose

While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. Action?

Measure the length of the apneic periods

A client with a BMI of 60.2 kg/m2 is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first?

Mechanical ventilation

A male client with hepatitis A is admitted with elevated hepatic enzymes and jaundice. Which intervention should the nurse implement

Meticulous hand washing after each client contact

A client is being evaluated for sciatica. What will the nurse most likely assess in this client?

Pain in the buttock that radiates down the leg.

What is the rationale for the nurse to teach a client to compress the lacrimal duct after eye drop instillation?

To prevent systemic absorption of the medication.

A client slips and falls while getting out of bed and the charge nurse instructs the nurse who is caring for the client to complete an incident report. What is the main purpose in having the nurse complete the incident report?

To provide computer documentation of the incident as a basis for further investigation

In reviewing the goals of "Healthy People", the nurse determines that the community has a significant problem in preventing dental caries among children. To bring about change that addresses this identified community health problem, where is the best place to initiate a prevention program?

WIC program intake offices.

The nurse is investigating a client injury that occurred when a mechanical lift malfunctioned while moving a client from the bed to an orthopedic-chair. Which question should the nurse ask first?

Was the equipment used according to policy

After a 92-year-old client fractured a hip trying to get out of bed, a nurse is accused of failing to notify the healthcare provider that the client was disoriented. In determining whether the nurse is guilty, a jury would consider which standard?

What a reasonable and prudent nurse would have done in the same situation

Angina experiences chest pain after morning care. First?

administer a nitro tab

Nursing diagnosis, "high risk for infection" is most relevant for client with which hematologic problem?

agranulocytosis

The nurse begins an oral medication prescription to be given daily to a male client who tells the nurse that he will take his medication later. What action should the nurse implement?

agree upon the time to return to the client's room with the medication

A 6-month-old client is diagnosed with intussusception. For which medical intervention will the nurse prepare this client?

an enema

The nurse is planning care for an assigned group of clients in a small nurse care facility, which client should the nurse see first?

an older client with addison's disease and 20 mmHg decline in systolic pressure

40 yr old with type 1 developed CKD 6 mos ago from secondary complications associated with this illness. Nurse carefully assesses for?

anemia

The nurse is reviewing the medication history of a client who is demonstrating tardive dyskinesia. Which medication classification will the nurse focus on during this review?

antipsycotics

A client with acute laryngitis reports feeling "short of breath". The nurse assesses that the client's respiratory rate has increased from 16/minute to 28/minute. What intervention should the nurse implement?

assess the client for stridor and increased respiratory effort

About 85 victims of a train derailment are brought to the Emergency Department of a small rural hospital. An older male with extensive crush injuries to his lower extremities and pelvis has a blood pressure of 42/28, a thread pulse of 120 beats/minute, and a respiratory rate of 10 breaths/minute with periods of apnea. Using the disaster triage system, which action should the nurse take?

assign a black triage color

An adult Muslim client with ulcerative colitis was admitted to the post-surgical unit earlier today following a bowel resection with temporary colostomy. Which intervention is most important for the nurse to implement?

assign a care provider of the same gender

A male client with multiple myeloma is admitted with pneumonia and pancytopenia. The nurse reviews the complete blood cell count findings and identifies a platelet count of 20,000 cells/mm3. Which intervention should the nurse include in the client's plan of care?

avoid intramuscular injections

The nurse is assessing a client on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor?

calcium

An adult female client is admitted to the psychiatric unit because of a complex hand washing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's hand washing is an example of which clinical behavior?

compulsion

Which assessment finding has the highest priority when planning nursing care for a client with peptic ulcer disease (PUD)?

dark tarry liquid stools

A client with type 1 diabetes mellitus is prescribed 10 units of intermediate acting insulin to be administered at bedtime. For which health problem is the insulin being administered at this time of day?

dawn phenomenon

A client with pneumonia is admitted with severe shortness of breath and arterial blood gases of pH 7.30, PaO2 60 mm Hg, PaCO2 62 mm Hg, HCO2 35 mEq/liter. Which information should the nurse communicate immediately to the healthcare provider?

drowsiness and difficulty in arousing

A 2 year old boy who has short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temp is 102.2 and he has vomited twice in the past 4 hrs. Which assessment finding indicates that the child is dehydrated?

elevated urine specific gravity

20 year old female client tells nurse her menstrual periods occur about every 28 days, and her breasts are quite tender when her flow is heavy. She also states that she performs her breast self-exam on the first day of every month. Action?

encourage the client to perform BSE 2-3 days after menstrual period ends

The parents of a 6-year-old recently diagnosed with Duchene muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

encourage the parents to allow the child to continue attending swimming lessons with supervision

The nurse initiates a one-to-one relationship with a 35-year-old depressed female client who was recently admitted to the psychiatric facility. Which nursing action is most effective in promoting the development of a therapeutic relationship?

ensure that scheduled appointments begin according to the schedule

A female client chooses to have a prophylactic mastectomy because she has a positive BRCA1 mutation, her mother died of breast cancer at age 30, and her cousin was diagnosed with breast cancer at age 28. Which intervention is most critical for the nurse to include in this client's immediate postoperative plan of care?

esure adequate pain control using postoperative analgesics

The nurse is preparing an education program for community members on breast cancer. Which information would the nurse include as risk factors for the development of this disease?

family history

Nurse overhears 2 employees discussing confidential pt info in cafeteria. Breach of which ethical principle?

fidelity

When completing a mental health assessment, the nurse wishes to obtain information about a client's insight and judgment. Which interview technique is most useful in assessing these mental abilities

have the client describe what should be done if a child was observed alone in a locked car on a hot day

Paracentesis

have the client void before the procedure

As a means of relieving a client's pain associated with osteoarthritis, the nurse plans to provide local rest. To implement this intervention, which action should the nurse take?

immobilize the affected joint with a splint

Bell's Palsy

inability to raise the eyebrows, frown, smile, close the eyes (question was something about how to tell if the client is having a stroke or if its something else)

A client is admitted with syncopal episodes related to a third degree heart block. After the placement of a transcutaneous pacemaker, the nurse observes several episodes of the pacemaker's failure to sense. What action should the nurse take?

increase the sensitivity

Which self-care measure is most important for the clinic nurse to emphasize when teaching a client who was recently diagnosed with osteoporosis?

inspect your home for safety hazards

What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

inspection of the mouth

A male client with chronic kidney disease is involved in a motor vehicle collision and is brought to the emergency department with a rapidly hemorrhaging leg fracture. The healthcare provider inserts a central venous catheter (CVC). To promote rapid volume expansion, which equipment should the nurse obtain?

lactated ringers

A client in the oliguric phase of acute renal failure (ARF) has a 24 hour urine output of 400ml. nurse should allow this client to have how much oral intake during the next 24 hours?

limit oral intake to 900. to 1000ml

A client receiving chemotherapy as part of cancer treatment has developed an upper respiratory infection. The nurse realizes the cause of this infection may be due to:

low wbc count

What nursing action has the highest priority in preventing postoperative bleeding following a submucosal resection for a deviated septum?

maintain intact nasal packing

While assessing the nasogastric tube drainage, the nurse discovers rust colored flecks, which action should the nurse take?

manually aspirate the gastric secretions

A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the UAP who is completing morning care for this client?

measures all emesis accurately

A male client awaiting surgery tells the nurse that he has some concerns about the surgical procedure that were never addressed. Which nursing intervention reflects the nurse's role as a client advocate?

notify the surgeon of the clients concerns

In caring for a 9 month old child following surgical correction of a clubfoot. Which intervention should the nurse implement to determine the child's need for analgesic administration???

observe feeding and sleeping pattern

A client with metastatic cancer who was taking hydromorphone (Dilaudid) PO at home is not receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the Dilaudid, what assessment should the nurse complete?

pain scale

When assessing a client several hours after surgery, the nurse observes that the client grimaces and guards the incision while moving in the bed. The client is diaphoretic, has a radial pulse of 110 and a respiratory rate of 35. What assessment should the nurse perform first?

pain scale

The nurse has explained safety precautions and infant care to a primigravida mother and observes the mother as she gives care to her newborn during the first two days of rooming-in. which action indicates the mother understands instructions?

positions the infant supine in the crib to sleep

The industrial health nurse who works in a mobile clinic is developing an exposure control plan for blood-borne pathogens. Which topics should be included in this plan? (Select all that apply.)

puncture-resistant containers for needle disposal Hepatitis B vaccination series. Self-sheathing or needleless medication systems.

The nurse is working with an interdisciplinary group to write procedures for assessment of clients from a multiracial inner city population. The guidelines include a statement that reads, "Remember that all Hispanic clients may not wish to give personal medical information to a stranger." Which action should the nurse take?

recommend changing the language that stereotypes one ethnic group

A child is brought to the clinic complaining of fever and joint pain and is diagnosed with rheumatic fever. When planning care for this child what is the primary goal of nursing care?

reduce fever

An 18-year-old female client is admitted to the unit after ingesting an overdose of Phenobarbital (Luminal). She is unresponsive and ABG results are: pH 7.18, PaCO2 60 mmHg, and HCO3 26 mEq/L. Which interpretation of the client's ABG results by the nurse is accurate?

respiratory acidosis, uncompensated

The scrub nurse places the fenestrated drapes to expose the operative area for a client who is having a hepatic tumor removed. The scrub nurse should assist with applying the sterile impermeable adhesive drape or surgical skin barrier to which area?

right subcostal

An infant is treated for intussusception with hydrostatic reduction. What instruction should the nurse include in the parents' teaching plan?

s/s of reocurrence

The unit manager of an acute care unit evaluates the time management skills of the nursing staff and determines that one staff nurse is consistently behind in meeting the needs of assigned clients. What action should the unit manager take?

schedule a private meeting with the staff nurse as soon as possible

In evaluating the effectiveness of a client's nocturnal sleep patterns, what information is best for the nurse to obtain?

self-evaluation of feeling well rested upon awakening

A middle-aged male client is being evaluated for lower extremity edema. Which laboratory value will be used to aid in determining the cause of this client's manifestation?

serum sodium

Following rectal surgery, a female client seems very anxious about the pain that she may experience during defecation. The nurse should collaborate with HCP to administer which type of medication?

stool softener

The nurse is obtaining a throat culture of a client's posterior oropharyngeal region. For which health problem will this specimen be used to diagnose?

strep throat

A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks her what happened. She doesn't respond. Next?

take the client to a room for supervision by staff

A mother brings her 4 month old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

the hernia is normal variation that resolves without treatment

An emergency department nurse is giving discharge instructions to the wife of a young adult male client who sustained a concussion after a fall. The nurse should provide the wife with what instruction as part of the discharge teaching plan Tell the wife to bring her husband back to the emergency department if he has projectile vomiting or an

unsteady gait

When caring for a client who had a craniotomy yesterday for removal of a pituitary tumor, which finding indicates to the nurse that further information is needed?

urine output for 8 hours is 2000 ml with a specific gravity of 1.001

The nurse is teaching a class on child care to new parents. Which instruction should be included about the prevention of rotavirus in infants who are starting to eat foods?

wash hands before any food prep

When the charge nurse presents a change in unit procedure to the nursing staff. One of the nurses states "it's never going to work" Which response by the charge nurse is likely to be most effective.

why don't we try the solution and see if it works

An older female is admitted for a 24 hour observation after suffering several broken ribs as a result of a fall in her home. Which finding should the nurse report to the healthcare provider immediately?

widening pulse pressure with an increase in pulse rate

After receiving report on an inpatient acute care unit, which client should the nurse asses first?

with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity.

Which laboratory finding should the nurse expect to see in a child with acute rheumatic fever?

Positive ASO titer

When the nurse enters the room to change the dressing of a male client with cancer, he asks, "have you ever been with someone when they died?" Best response?

"Yes I have. Do you have questions about dying?"

A 60-year-old male client with cancer of the liver has been in a hepatic coma for the past 24 hours. On admission, the client signed a release of information to his family. His oldest son arrives from out of town and asks the nurse how his father is doing. Which response is best for the nurse to provide?

"Your father has given no response for 24 hours. His condition is extreemely critical at this time."

A 58-year-old male client with chronic kidney disease (CKD) is receiving aluminum hydroxide (Amphojel). He tells the nurse that since he does not have indigestion there is no need for him to take the antacid with his meals. Which response is best for the nurse to provide?

"Your serum phosphate levels are up, and aluminum antacids prevent absorption of phosphates in foods"

A female client presents to the ED in the early evening complaining of abdominal cramping, watery diarrhea, and vomiting. She tells the nurse that she was at a picnic and ate BBQ that afternoon. What question is important to ask?

"is anyone else sick who was also at the picnic?"

A client receives a prescription for bacitracin 20,000 units every 12 hours IM. The medication is available in a vial that contains 50,000 units and includes reconstitution instructions: "Use 4.8 ml diluent to yield a total volume of 5 ml." how many ml should the nurse administer?

2

HCP prescribes amoxicillin (Amoxil) 1.5 grams PO daily, in equally divided doses to be administered every 8 hours. The medication is available in a bottle labeled, "Amoxicillin (Amoxil) suspension 200mg/5ml." How many ml should nurse administer every 8 hours?

12.5

Following a left above the knee amputation, the client voiced several complaints. What statement should serve as a warning to the nurse that the client may be experiencing complications?

I've been feeling light headed

HCP prescribes etanercept (enbrel) 50mg Sub-Q weekly for rheumatoid arthritis. Nurse should evaluate effectiveness of med within what time frame?

2-4 weeks

A male client with bipolar disorder has difficulty concentrating and plans to attend group for the first time. He tells the nurse that he will try to stay for the music relaxation group. After 20 minutes in the group, he becomes restless and begins to leave. What should the nurse do

Allow the client to leave the group

Nurse gives pt daily dose of Rx for captopril 12.5mg PO Q AM. Shortly after, med the HCP instructs nurse to give another dose to reach the newly Rx dose of 50mg PO daily. Med is avail in 12.5 mg tabs. How many additional tabs should nurse give?

3

In shift report the charge nurse is told of several problems. Which problem should the nurse address first?

A bucket of water was spilled in the hallway.

A client with a permanent pacemaker develops loss of capture resulting in symptomatic sinus bradycardia at a rate of 38/minute. Which intravenous medication should the nurse prepare to administer immediately?

Atropine sulfate (Atropine).

School-aged child with OM receives Rx for Azithromycin 300mg once, then 150 mg daily for 4 days. Med is avail in solution containing 200mg/5ml. How many mls should nurse administer on the 1st day of Tx?

7.5ml

Which of these women, all of whom have recently discovered a new breast lump, is at greatest risk for a diagnosis of breast cancer?

A 51-year-old whose mother had breast cancer and describes the lump as non-tender.

The nurse is obtaining the medical histories of new clients at a community-based primary care clinic. Which individual has the highest risk for experiencing elder abuse?

A 78 year old female on a fixed income who lives with her relatives

Which client situation requires the most immediate intervention by the nurse ?

A bedfast client experiences an episode of urinary incontinence

Preparing to administer liter of IV solution to toddler with gastroenteritis who is dehydrated. Which action to prevent overload?

Attached a volume-control device below the primary infusion

The triage nurse in an emergency center must prioritize the admission of four clients from the waiting area to a treatment room. Which client should the nurse identify as the first to receive care?

A female teenager who states she took 9 of her mother's amitrptyline hydrochloride (Elavil) pills an hour ago

Which client situation requires the most immediate intervention by the nurse?

A four-centimeter area of dehiscence is observed on a client's abdominal incision one day after surgery.

Which client requires careful nursing assessment for signs and symptoms of hypermagnesemia?

A middle-aged male client in renal failure following an unsuccessful kidney transplant

Which situation is a violation of the client confidentiality, as described in the Health Insurance Portability Accountability Act (HIPPA)?

A nurse's handwritten notes from a telephone report discarded in the office wastebasket

The charge nurse is making assignment for clients on an endocrine unit. Which client is best to assign to a new graduate nurse?

A perimenopausal woman with Grave's disease who is nervous and has exophthalmos

The nurse on a busy surgical unit is assigning client care to a registered nurse (RN) and a practical nurse (PN). Which client is best to assign to the PN?

A preoperative client who has developed urinary retention and needs a urinary catheter inserted

The nurse is providing preoperative teaching to a female client scheduled for surgery tomorrow at an ambulatory surgery center. Which instruction is most important for the nurse to include?

Advise the client to make arrangements for someone to drive her home.

A client is admitted to the emergency room because of an overdose of acetaminophen (Tylenol). Following gastric lavage, the nurse should expect to administer which medication?

Acetylcysteine (Mucomyst).

The nurse is attempting to teach a male client newly diagnosed with diabetes how to administer insulin. When the nurse attempts to answer the client's questions he becomes angry and tells the nurse that the entire process is just too much to learn. What action is best for the nurse to take?

Acknowledge the client's feelings, and tell him that he will eventually be able to do self-administration.

A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for a 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior anymore since all she does is care for their son. What intervention should the nurse implement?

Acknowledge the client's stress and suggest that she consider respite care.

The nurse believes that a client who frequently requests pain medication may have a substance abuse problem. Which intervention reflects the nurse's value of client autonomy over veracity?

Administer the prescribed analgesic when requested

While reporting BG results to nurse, LPN states the glucometer was not calibrated prior to use because the report given by the night shift staff ran late. What action?

Advise the LPN of the implications involved by not calibrating the glucometer

A client with gestational diabetes, at 39-weeks gestation, is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?

Assist the client to sharply flex her thighs up against the abdomen.

When preparing the client for a thoracentesis, it is An older male client diagnosed with end-stage chronic obstructive pulmonary disease (COPD) is on strict bed rest, and asks the nurse, "Why can't I get out of bed?" what response for the nurse to provide?

Bed rest decreases your body's need for oxygen

Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective?

Decreased abdominal girth.

To identify a client's learning needs prior to surgery, what action should the nurse implement?

Demonstrate cough and deep breathing techniques

A terminally ill client on a palliative care unit has an advanced directive stipulating comfort measures only. The client has not taken oral fluids in the last 36 hours and is not receiving intravenous fluids. The client's blood pressure is 64/38 and urinary output is 50 ml for the last 12 hours. What is the priority nursing intervention?

Determine the client's level of discomfort

A client whose finger stick glucose is 210mg/dl is receiving a sliding scale dose of short-acting insulin before breakfast. In what sequence should the nurse prepare the dose of insulin?

Determine the number of units to be administered Cleanse the top of the vial with an alcohol swab Use an insulin syringe to withdraw the amount of units to be given Verify the units of insulin in the syringe with another nurse

The nurse is preparing to administer medication to a client through a nasogastric tube connected to suction. What would the nurse do first when administering this medication?

Disconnect the suction from the nasogastric tube.

A client who had an intraosseous (IO) cannula placed by the HCP for an emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. ACTION?

Discontinue the IO infusion

Which technique(s) should the nurse use to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)?

Ensure that the needle is inserted into the skin with the bevel up Use a 25 gauge ½ inch needle on a 1 ml calibrated syringe Assess skin for a bleb when injecting the tuberculin antigen (ID)

The nurse is giving medications to an older client who has a percutaneous esophageal gastrostomy (PEG) tube in place. Which medication drug form should the nurse question?

Enteric-coated aspirin (Ecotrin)

Nurse with a history of drug impairment returns from rehab, best initial action by charge nurse?

Establish a contract with the nurse about role limitations

The nurse is conducting discharge teaching about the antianxiety drug diazepam (Valium). Which instruction has the highest priority for inclusion in the teaching plan?

Evaluate the ingredients of all over-the-counter drugs for alcohol content.

A 60 yr old male with type 2 DM tells the nurse that he is going to join a gym and start working out. Which information is most important for the nurse to obtain?

Exercise tolerance test with EKG results

Client with depression remains in bed most of day, declines activities, refuses meals. Dx?

Feeding Self-care deficit

Nurse working in health clinic assessing need for Hep A vaccine. Which client has greatest risk of contracting?

Female who regularly consumes raw oysters

Which condition would likely cause secondary polycythemia?

High altitude exposure.

A 37 year old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client's plan of care?

High risk for injury related to ambulation

The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that the client's telemetry pattern shows a second-degree heart block with a ventricular rate of 50. What action should the nurse take?

Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern.

Charge nurse should intervene when what behavior is observed?

Hospital transporter is reading a Pts H&P while waiting for an elevator

A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?

Ineffective airway clearance

A male client sustained a burn injury to more than 25% of this total body area in an industrial fire. Which nursing intervention is most essential to be implemented during the emergency phase?

Infuse intravenous fluids as prescribed

The HCP prescribes lidocaine (Lidoject-1) 100mg IV push for ventricular tachycardia (VT) for an unconscious client. Intervention?

Infuse lidocaine (Lidoject-1) at 20-50 mg/minute

Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?

Learning to self-administer insulin injections after being diagnosed with diabetes mellitus

Inserting an indwelling catheter for female and notes catheter in vagina. Steps?

Leave in vagina Obtain new catheter kit Use forceps and cotton ball to cleanse Insert the catheter and observe for flow Inflate the indwelling balloon Remove the wrongly placed one

A male client with moderate Alzheimer's disease had abdominal surgery yesterday. Today, when the nurse begins to perform a dressing change, the client states, "I don't want you to change my dressing." What is the best initial action for the nurse to take?

Leave the room and re-approach the client in about 30 minutes.

A female who was admitted for alcohol detoxification is nauseated and describes feeling like roaches are crawling all over her. She is tremulous, and her blood pressure is 146/92; her pulse rate is 94 beats/minute; and her temperature is 100.8oF. Which PRN medication should the nurse administer first?

Lorazepam (Ativan)

Abdominal aneurysm

Lower back pain is a sign of an emergency

A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating?

Maintain a protective isolation environment.

Pt with chronic controlled A-fib develops symptoms of PE. What intervention?

Monitor O2 saturation via pulse Ox

A female client who has been taking diclofenac (Zipsor) for the past month is admitted with right upper quadrant tenderness, jaundice, and flu-like symptoms. She is also complaining of fatigue, diarrhea, and pruritis. Which intervention is most important to include in this client's plan of care?

Monitor serum bilirubin levels

Which action should the nurse include in the plan of care for a client who is receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)?

Monitor serum creatinine levels

A male client with Type 1 diabetes mellitus takes a combination of short acting and intermediate acting insulin. The client complains of headaches when awakening and his blood glucose average for the past week has been 210. The nurse recognizes the client is experiencing a daily Somogyi, or rebound effect. Which dosing method is likely to relieve these symptoms?

Move the PM intermediate- acting dose to bedtime.

The nurse learns that a client in a semi-private room has a postoperative wound that is colonized with a multi-drug resistant organism. What action should the nurse implement

Move the client to a private room and implement contact precautions for the client

The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic?

Narrow therapeutic index.

What nursing intervention is most important to implement after a client has completed a myelogram?

Neurovascular assessment of lower extremities

60 yr old male admitted complaining of R knee pain for past week; knee and calf are warm and edematous, history of diabetes and arthritis. What info obtain?

Neurovascular status of lower extremities

A client complains of feeling tired and not sleeping well during the night. What will the nurse include when assessing the effectiveness of this client's sleep pattern?

Number of hours of sleep each night.

While caring for a client with a new onset of diabetes mellitus, which intervention is most important for the nurse to include in the client's plan of care?

Observe client's glucose self-monitoring technique

1 day old neonate awaiting surgical correction of myelomeningocele. During pre-op what is priority?

Observe for CNS infection R/T sac trauma

During the second treatment with IV antibiotic, the client develops a rash on the upper torso. What intervention should the nurse implement first?

Observe the client's breathing pattern.

A client who has suffered 3rd degree burns over 60% of the body is admitted to the emergency department. The healthcare provider writes a prescription for "IV Lactated Ringer's 350 ml/hr". Which intervention should the nurse implement?

Obtain an intravenous infusion pump prior to administering the IV.

A family member contacts the nurse at the community mental health center and wishes to share concerns and ask questions about a client's medications. What action is best for the nurse to take?

Obtain written consent from the client to talk to the family member about treatment.

The nurse observes that a client receiving an aminoglycoside for an infection appears dizzy when ambulating. The nurse should consult with the healthcare provider regarding the need for which test?

Peak and trough.

The nurse is evaluating an asthmatic client's response to an inhaled corticosteroid medication. What assessment finding indicates that the medication has been effective in controlling the asthma symptoms? The client has increased

Peak flow meter rates.

A client just returned to the nursing unit after surgery, and initial assessment findings include a pulse rate of 120 beats/minute, restlessness, cyanosis, and gurgling sounds on inspiration and expiration. What action should the nurse take first?

Perform oropharyngeal suctioning.

A client is diagnosed with a frontal lobe glioma, which is a benign brain tumor. When teaching the client about the tumor, which information should the nurse consider?

Personality changes or expressive aphasia are likely.

Following a devastating hurricane, a client is admitted for dehydration as the result of vomiting and diarrhea that occurred after ingesting contaminated water. The client expresses feelings of fear and anger about the destruction of homes, the loss of property due to the storm, and the looting that occurred following the storm. According to Maslow's hierarchy of needs, what priority need should be addressed first

Physiological needs

A male client with schizophrenia is jerking his neck and smacking his lips. Which finding indicates to the nurse that he is experiencing an irreversible side effect of antipsychotic agents?

Worming movements of tongue

What assessment data should lead the nurse to suspect that a client has progressed from HIV infection to AIDS?

Recent history of recurrent pneumonia

A client who has been taking diazepam (Valium) for anxiety at home is demonstrating reduced respirations and unresponsiveness. On what will the nurse focus when assessing for the possible cause of the client's manifestations?

Recent intake of alcohol.

The nurse is caring for six clients on a medical-surgical unit. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)

Record vital signs every four hours Assist with ambulation as prescribed Provide oral care after meals

Nurse observes client standing with use of crutches and notes that arms are fully extended and tops of crutches are securely pressed into axillae. What intervention?

Reduce the length of the crutches

The nurse is managing four clients who are mechanically ventilated. The client with which assessment finding requires the most immediate intervention by the nurse?

Restrained and restless with a low volume alarm

A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. Intervention?

Restrict oral fluid intake

Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg

Right calf is 3 cm larger in circumference than the left

Nurse developing plan of care for Pt returning from surgery after total cholectomy and ileostomy. Which diagnosis has the highest priority for the client in immediate post-op period?

Risk for electrolyte imbalance R/T ileostomy

A client with chronic kidney disease is being discharged with continuous ambulatory peritoneal dialysis (CAPD). What is the priority nursing diagnosis the nurse should use when developing a discharge teaching plan for this client?

Risk for sepsis

Administering IV med through central venous catheter with hep lock. Which sequence?

Saline, med, saline, hep

A client with a history of recurrent atrial fibrillation is taking amiodarone (cordarone) and warfarin (Coumadin). Which meal should the nurse provide for the client?

Seared tuna steak and stewed squash

Two weeks following a Biliroth II (gatrojejunostomy), a client develops nausea, diarrhea and diaphoresis after every meal. When the nurse develops a teaching plan, which expected outcome statement is the most relevant?

Selects a pattern of small meals alternating with fluid intake

What instruction should the nurse include in the discharge-teaching plan of a client with ulcerative colitis who has had a traditional ileostomy?

Tell the client to notify the healthcare provider if the stoma becomes purple.

The nurse is preparing a client for a scheduled cesarean section. In what order should the nurse perform these actions (place the first action on top and the last action on the bottom)?

Verifying the consent form is signed Inserting an indwelling catheter Prepping the site with iodophor (Betadine) Performing a time-out procedure

A client with type 2 DM is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketonic syndrome (HHNS), should the nurse report to the HCP?

Visual disturbances Increased heart rate Decreased mentation

A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?

The full thickness burn has destroyed the nerves

A male adult client is transferred to a psychiatric facility following release from the hospital for treatment of a self-inflicted gunshot wound. In attempting to develop a therapeutic relationship with the client, which information is most important?

The nurses' feelings about this client

The nurse observes a newly-employed unlicensed assistive personnel (UAP) taking an elderly client's blood pressure. The nurse says, "You need to start over. The blood pressure reading you obtained was falsely high for that client." What is the most likely explanation for the erroneous reading?

The size of the cuff used was too small for this adult client's arm

The nurse is responding to telephone messages at a psychiatric day clinic. Which client situation requires immediate intervention by the nurse?

The wife of a client with post-traumatic stress syndrome reports that her husband is threatening to kill her

The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours

A frail, elderly female with rheumatoid arthritis (RA) complains to the nurse that the weight of the sheets on her legs hurts all the time. Which action should the nurse implement ?

Use a bed cradle to keep linens off her legs

A client who is being prepared for discharge following a transurethral resection of the prostate (TURP) tells the nurse that he is concerned about becoming constipated. Which instruction should the nurse provide to this client?

Use oral stool softeners daily.

A client has a history of vasovagal attacks resulting in brady-dysrhythmias. Which instruction is most important to include in the teaching plan?

Use stool softeners regularly

A 70-year old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain?

Usual and current weight

On admission, the healthcare provider prescribes a broad-spectrum antibiotic, ticarcillin (Ticar), for a client with a gram-negative infection. Before administering the first dose, it is important for the nurse to implement which prescription?

Wound and blood specimens for culture and sensitivity.