Nclex & nurse exit exams

Which of the following interventions should be the first priority when treating a client experiencing chest pain while walking? 1. Sit the client down 2. Get the client back to bed 3. Obtain an ECG 4. Administer sublingual nitroglycerin

1. Sit the client down ( 1. Sit the client down = when we sit the client down we are decreasing their oxygen demand. Remember if a client is having chest pain/ MI we want to do two things. One is Increase oxygen and Two decrease their demand for oxygen. Once you tell the patient to sit down and rest that decreases their demand for oxygenation. 2. Get the client back to bed = do later 3. Obtain an ECG = do later 4. Administer sublingual nitroglycerin = do after you after you sit patient down. )

What is the first intervention for a client experiencing MI? 1. Administer morphine 2. Administer oxygen 3. Administer sublingual nitroglycerin 4. Obtain an ECG

2. Administer oxygen ( 1. Administer morphine = wonderful, after we give them oxygen. 2. Administer oxygen = the first thing we are going to do is administer oxygen! Increase their oxygenation because the heart need oxygen! So you're are going to Increase the oxygen in the patient and decrease the demand for it in the patient. 3. Administer sublingual nitroglycerin = wonderful, after we give them oxygen. 4. Obtain an ECG = diagnostic test to look and see what's going on with heart. But first thing to do is increase their oxygen )

Which of the following clients is most at risk for losing his or her balance? 1. A woman who is 9 months pregnant walking down a flight of stairs 2. A 16-year-old skate boarding down a 15-degree slope 3. A 45-year-old taking hypertensive medication 4. A 4-year-old riding a tricycle

1. A woman who is 9 months pregnant walking down a flight of stairs ( 1. A woman who is 9 months pregnant walking down a flight of stairs = because of the increase of the pregnant women's abdomen her center of gravity has shifted. So she's a fall risk walking on flat surfaces and stairs! Because of the pregnancy her center of gravity has shifted that's places her at risk. 2. A 16-year-old skate boarding down a 15-degree slope = not a big angle down 3. A 45-year-old taking hypertensive medication = yes it brings down blood pressure but it's not enough information to place this patient at more risk than the 9 month pregnant women. 4. A 4-year-old riding a tricycle )

Which comment by the client diagnosed with rule-out Guillain-Barre (GB) syndrome is most significant when completing the admission interview 1. "1 had a bad case of gastroenteritis a few weeks ago." 2. "I never use sunblock and I use a tanning bed often." 3. "1 started smoking cigarettes about 20 years ago." 4. "I was out of the United States for the last 2 months."

1. " I had a bad case of gastroenteritis a few weeks ago." ( 1. " I had a bad case of gastroenteritis a few weeks ago." = Guillain-Barre (GB) syndrome is when the patient own immune system is attacking their nerves. There is a correlation that Guillain-Barre (GB) syndrome is triggered by either bacterial or viral infection. For instance " have you had an upper respiratory infection lately? Or have you been sick lately? Because it's thought the = Guillain-Barre (GB) syndrome is triggered by either bacterial or viral infection 2. "I never use sunblock and I use a tanning bed often." 3. "1 started smoking cigarettes about 20 years ago." 4. "I was out of the United States for the last 2 months." )

The nurse cares for a client diagnosed with hepatitis A. the client complains of fatigue, anorexia, and intolerance to odors. It is MOST important for the nurse to recommend which of the following? 1. "Eat small, frequent feedings." 2. "Restrict the amount of protein that you eat." 3. "Decrease your caloric intake to 1,400 calories per day." 4. "Limit your alcohol intake to 3 oz of wine per day."

1. "Eat small, frequent feedings." ( 1. "Eat small, frequent feedings." =the act of eating is tiresome. The act of eating takes oxygen away from the patient they'r tired. We want them to eat small frequents meals while they get the nutrition food the food. 2. "Restrict the amount of protein that you eat." = patient needs protein!! Protein, vitamin c, 3. "Decrease your caloric intake to 1,400 calories per day." = they need to increase call to get energy 4. "Limit your alcohol intake to 3 oz of wine per day." = stop don't drink alcohol because they liver is already infected )

A mother of a 7-year-old girl and 2 1/2-year-old boy tells the clinic nurse that she works full-time, loves to garden in her spare time, and has lots of houseplants. She relates to the nurse that her 2 1/2-year-old is "into everything all the time and drives me to distraction!" Which of the following responses by the nurse is BEST? 1. "What kind of plants do you have?" 2. "Who is available to care for your son when you need a break?" 3. "Was your daughter like this when she was his age?" 4. "It must be hard balancing work and children."

1. "What kind of plants do you have?" ( 1. "What kind of plants do you have?" = what stage is the 2/12 child in? In the toddler stage where they are running around, exploring, and learning about their environment. We need to know what kind of plants mom has because what if she a plant that's poisonous? Because toddlers like to look, grab, and put things into their mouths. Remember with toddlers poisonous is a great concern!! 2. "Who is available to care for your son when you need a break?" = we do not care. We only care about patient safety. We want to make sure that child does not get poisoned or harmed therefore we need to know what kind of plants the mother has. 3. "Was your daughter like this when she was his age?" = we do not care. We only care about patient safety. We want to make sure that child does not get poisoned or harmed therefore we need to know what kind of plants the mother has. 4. "It must be hard balancing work and children." = we do not care. We only care about patient safety. We want to make sure that child does not get poisoned or harmed therefore we need to know what kind of plants the mother has. )

A client received 20 units of NPH insulin subcutaneously at 8:00 am. The nurse should check the client for a potential hypoglycemic reaction at which time? 1. 5:00 pm 2. 10:00 am 3. 11:00 am 4. 11:00 pm

1. 5:00 pm ( this is a famous question that they like to use on NCLEX. You're being asked about the peak in this question. However, other Nclex insulin questions like to ask about onset and Duration as well. If you're being asked about the onset " when are you going to make sure that patient eats?" onset is when that insulin starts working and that onset is going to make the patients blood suger go down. Duration for NPH is 24 hours that's how long it's lasting in the patient. 1. 5:00 pm = 5pm is the PEAK time of the NPH insulin. That's when we expect that NPH to peak. This intermediate acting insulin! Onset is 1-2/12 hours. The peak for NPH is 4- 12 hours. When you expect to see the peak of insulin is when the patients blood glucose is going to be the lowest. That is the time that the patient is most likely to pass out. Hypoglycemia is worse the hyperglycemia. The correct answer is 5p because it ask about peak ( 4-12 hours) . 2. 10:00 am 3. 11:00 am 4. 11:00 pm )

On data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe? 1. A fear of leaving the house 2. A fear of riding in elevators 3. A fear of speaking in public 4. A fear of uncleanliness and the need to bathe every hour

1. A fear of leaving the house ( 1. A fear of leaving the house = this person feels safe and secure only within the confines of their home. 2. A fear of riding in elevators = claustrophobia they have a fear of closed spaces. 3. A fear of speaking in public = that's social phobia. They have an intense fear of saying the wrong thing and looking like an idiot. 4. A fear of uncleanliness and the need to bathe every hour = obsessive compulsive disorder ( ocd). )

Which of the following statements by the nurse best describes magnesium sulfate's course of action on a client with pregnancy induced hypertension (PIH)? Magnesium sulfate: 1. Acts as a central nervous system depressant that results in overall systemic vasodilation. 2. Stimulates increased production of renin and angiotensin, which decreases blood pressure. 3. Acts as a tranquilizer, which decreases the risk of seizure. 4. Enhances renal function by affecting tubular secretion and reabsorption.

1. Acts as a central nervous system depressant that results in overall systemic vasodilation. ( 1. Acts as a central nervous system depressant that results in overall systemic vasodilation. = magnesium sulfate causes vasodilation it dilates all of the vessels which makes the blood pressure go down. 2. Stimulates increased production of renin and angiotensin, which decreases blood pressure. 3. Acts as a tranquilizer, which decreases the risk of seizure. 4. Enhances renal function by affecting tubular secretion and reabsorption. * magnesium sulfate cause vasodilation and brings down the blood pressure. Another thing magnesium sulfate does is relax the smooth muscles. So if a patient has an irritated uterus or is having contractions too soon the magnesium sulfate will relax/ reduce those muscles that are causing the contractions )

The nurse is assessing the client with psoriasis. Which data support this diagnosis 1. Appearance of red, elevated plaques with silvery white scales. 2. A burning, prickling row of vesicles located along the torso. 3. Raised, flesh-colored papules with a rough surface area. 4. An overgrowth of tissue with an excessive amount of collagen.

1. Appearance of red, elevated plaques with silvery white scales. ( 1. Appearance of red, elevated plaques with silvery white scales. = when you see silvery scales or silvery plaques. The first thing that needs to go into your mind is psoriasis. 2. A burning, prickling row of vesicles located along the torso. 3. Raised, flesh-colored papules with a rough surface area. 4. An overgrowth of tissue with an excessive amount of collagen. )

The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply. 1. Apply suction for up to 10 to 15 seconds. 2. Hyperoxygenate the client before suctioning. 3. Set the wall suction unit pressure at 160 mm Hg. 4. Apply suction while gently inserting the catheter. 5. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm.

1. Apply suction for up to 10 to 15 seconds. 2. Hyperoxygenate the client before suctioning. 5. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm. ( 1. Apply suction for up to 10 to 15 seconds. = textbooks say 10 seconds but Nclex is up to 15 seconds. 2. Hyperoxygenate the client before suctioning. = You are suctioning them to get rid of mucous plugs, they will still loose oxygen during the process. 3. Set the wall suction unit pressure at 160 mm Hg. = false. The normal range is 80-120 4. Apply suction while gently inserting the catheter. = false. Only suction when coming out. 5. Apply intermittent suction while rotating and withdrawing the catheter. = suction as you're pulling out in a circular motion. 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm. = insert until you fell resistance and then pull back 1cm, then suction)

The nurse is initiating a blood transfusion. Which interventions should the nurse implement Select all that apply. 1. Assess the client's lung fields. 2. Have the client sign a consent form. 3. Start an IV with a 22-gauge IV catheter. 4. Hang 250 mL of D5W at a keep-open rate. 5. Check the chart for the CP's order

1. Assess the client's lung fields. 2. Have the client sign a consent form. 5. Check the chart for the CP's order ( 1. Assess the client's lung fields. 2. Have the client sign a consent form. 3. Start an IV with a 22-gauge IV catheter. = false. The gauge we give for blood is 18 - 20 not anything higher than that. Why? The higher the needle gauge the smaller the hole is at the tip of the bevel. Remember blood are huge cells they cannot fit through a tiny bevel (22 gauge needle.) 4. Hang 250 mL of D5W at a keep-open rate. = false. Dextrose (D5W) is not compatible with blood. 5. Check the chart for the CP's order )

While admitting an 11-year-old child for elective surgery, the parent asks the nurse, "Is it true there is an IV medication kids can give themselves if they have pain after surgery?" In responding, the nurse is guided by which of the following principles regarding the use of patient-controlled analgesia (PCA) in children and adolescents? 1. Children who have reached Piaget's stage of concrete operations can be taught to use PCA. 2. Adolescents on PCA have a tendency to overmedicate themselves in order to feel "high." 3. It may be necessary for the parent to assist the child by pushing the release button when needed. 4. The use of IV narcotics should be avoided in children because of the increased risk of overdose.

1. Children who have reached Piaget's stage of concrete operations can be taught to use PCA. ( 1. Children who have reached Piaget's stage of concrete operations can be taught to use PCA. = usually around 9 to 11 years old. They can be taught to use PCA. Child has to be cognitively developed 2. Adolescents on PCA have a tendency to overmedicate themselves in order to feel "high." 3. It may be necessary for the parent to assist the child by pushing the release button when needed. 4. The use of IV narcotics should be avoided in children because of the increased risk of overdose. = with a PCA machines patient cannot overdose because there's a prescribed medication that will be given for example if the drug order 50 mcg to be given every 4 hours as needed the most that patient can get when they press the bottom for that 4 hours is 50 mcg ) * LPN cannot have a PCA patient only an RN

The nurse prepares to administer a prescribed dose of scopolamine (Transderm-Scop). The nurse should monitor for which side effect of this medication? 1. Dry mouth 2. Diaphoresis 3. Excessive urination 4. Pupillary constriction

1. Dry mouth ( scopolamine (Transderm-Scop) is an anticholinergic. What do we know about side effects of anticholinergics? Anticholinergics dry everything up they dry up all the secretions. Remember this loan - Can't see, can't spit, can't spit , can't shit. Blurred vision, water retention, and constipation. 1. Dry mouth = Can't see, can't spit, can't spit , can't shit. These are big side effects of anticholinergics. 2. Diaphoresis 3. Excessive urination 4. Pupillary constriction )

A six-year-old client has been receiving chemotherapy for two weeks. The laboratory results show a platelet count of 20,000. A priority nursing implementation is to: 1. Encourage quiet play. 2. Avoid persons with infections. 3. Administer p.r.n. oxygen. 4. Provide foods high in iron.

1. Encourage quiet play. ( 1. Encourage quiet play. = The normal range of platelet count is 150,000 to 450,000. Timber platelets is what keeps the patient from bleeding out. So if this child only has 20,000 platelets they're high risk for bleeding/hemorrhage. So we want this child to play quietly because we don't want them to hurt themselves because one bump against the wall or floor could make the child have internal bleeding. Clue the child is 6 ( play) ) 2. Avoid persons with infections. = for patients who WBC is very low. WBC level is suppose to be 5,000 to 10,000. 3. Administer p.r.n. oxygen. = for patients who O2 stats are low. 4. Provide foods high in iron. = platelets have nothing to do with iron. You would provide foods high in iron if the patients iron level was low. )

A client with schizophrenic disorder begins to talk about fantasy material. It would be most appropriate for the nurse to: 1. Encourage the client to focus on reality-based issues. 2. Allow the client to continue talking so as not to interrupt the delusion. 3. Ask the client to explain the meaning behind what he is saying. 4. Persuade the client that his thoughts are not true.

1. Encourage the client to focus on reality-based issues. ( 1. Encourage the client to focus on reality-based issues. = when dealing with psych patients YOU ALWAYS WANT TO REORIENT THE PATIENT BACK TO REALITY. Bring back patient to reality! 2. Allow the client to continue talking so as not to interrupt the delusion. 3. Ask the client to explain the meaning behind what he is saying. 4. Persuade the client that his thoughts are not true. )

Which information should the nurse discuss with the client to prevent an acute exacerbation of diverticulosis 1. Increase the fiber in the diet. 2. Drink at least 1,000 mL of water a day. 3. Encourage sedentary activities. 4. Take cathartic laxatives daily.

1. Increase the fiber in the diet. ( 1. Increase the fiber in the diet. = fiber pulls all of that crap that been sitting in the GI tract so the patient can have a formed bowel movement. 2. Drink at least 1,000 mL of water a day. 3. Encourage sedentary activities. 4. Take cathartic laxatives daily. )

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care? 1. Initiating seizure precautions 2. Using a wheelchair for out-of-bed activities 3. Assisting the child with ambulation at all times 4. Avoiding contact with other children on the nursing unit

1. Initiating seizure precautions ( 1. Initiating seizure precautions = this is going to take priority over the other choices! Seizures are abnormal firing of neurons in the brain. So you're going to put this child on seizure precautions. Seizure precaution means you will have the bed placed in the lowest position, side rails are up, side rails are padded, have a mat on the floor, make sure lights in the room are dim to decrease stimulation, make sure patient is not near the nurses stations where it's load at; they need to be at the end of the hall where it quite and less traffic. 2. Using a wheelchair for out-of-bed activities = seizure precaution comes first. 3. Assisting the child with ambulation at all times = seizure precaution comes first. 4. Avoiding contact with other children on the nursing unit = seizure precaution comes first. )

The client has had a pituitary tumor removed. Since the pituitary cannot secrete ADH at this time, how will this affect her fluid and electrolyte status? 1. Large volumes of water will be excreted. 2. Large amounts of sodium will be conserved by the body. 3. Large amounts of potassium will be retained. 4. Large amounts of magnesium will be retained.

1. Large volumes of water will be excreted. ( 1. Large volumes of water will be excreted. = the pituitary gland is responsible for anti diuretic hormone (ADH) . anti diuretic hormone makes the body reabsorb the fluids the fluids that the body needs. So if you remove your pituitary gland aka anti diuretic hormone you're going to be urinating all over the place, to the point of dehydration. 2. Large amounts of sodium will be conserved by the body. 3. Large amounts of potassium will be retained. 4. Large amounts of magnesium will be retained. )

The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to: 1. Measure the calf and thigh circumferences 2. Attempt to elicit Homans' sign 3. Palpate the temperature of the feet 4. Observe for a loss of hair and skin turgor in the lower legs

1. Measure the calf and thigh circumferences = ( 1. Measure the calf and thigh circumferences = you also have to measure the unaffected thigh and calf because you need a baseline for reference. You have to be able to compare! When a patient has thrombosis you are expected to see swelling, and pain in the affected leg. 2. Attempt to elicit Homans' sign = not reliable we don't do this anymore. 3. Palpate the temperature of the feet = this will tell you nothing. 4. Observe for a loss of hair and skin turgor in the lower legs = this less you know that their circulation is decreased. Skin turgor tells us how hydrated a patient is. )

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? Select all that apply. 1. Monitor the vital signs. 2. Monitor intake and output. 3. Increase water intake orally. 4. Monitor the electrolyte levels. 5. Provide a sodium-reduced diet. 6. Administer sodium replacements.

1. Monitor the vital signs. 2. Monitor intake and output. 3. Increase water intake orally. 4. Monitor the electrolyte levels. 5. Provide a sodium-reduced diet. ( 1. Monitor the vital signs. = because of the temperature 2. Monitor intake and output. = because of the skin turgor, flushed skin, and dry mucous membranes. 3. Increase water intake orally. = to help flush out hypernatriema ( high sodium levels) 4. Monitor the electrolyte levels. = 5. Provide a sodium-reduced diet. = because of the excess sodium this patient is having seizures. So we need to reduce sodium levels. 6. Administer sodium replacements. = absolutely not because the patient is hypernatramia ( already have high sodium ) )

The nurse is aware that an aggressive hospitalized client is one who: 1. Stomps away from the nurse's station, grabs a pool cue, and steps toward a client standing nearby. 2. Bursts into tears, leaves the community meeting, and sits on his bed pounding his pillow and sobbing. 3. Says to the primary nurse, "When you told me that I couldn't have a pass, I wished that you would fall down the stairs and crack your head open." 4. Tells the nurse, "I'm not going to take that, or any other medication, and you can't make me."

1. Stomps away from the nurse's station, grabs a pool cue, and steps toward a client standing nearby. ( 1. Stomps away from the nurse's station, grabs a pool cue, and steps toward a client standing nearby. = this is a behavior that can harm another client. 2. Bursts into tears, leaves the community meeting, and sits on his bed pounding his pillow and sobbing. 3. Says to the primary nurse, "When you told me that I couldn't have a pass, I wished that you would fall down the stairs and crack your head open." = this is not a behavior that could harm someone else or another client. They verbally stated but didn't actively act on it. 4. Tells the nurse, "I'm not going to take that, or any other medication, and you can't make me." )

The client reports a twisting motion of the knee during a basketball game. The client is scheduled for arthroscopic surgery to repair the injury. Which information should the nurse teach the client about postoperative care 1. The client should begin strengthening the surgical leg. 2. The client should take pain medication routinely. 3. The client should remain on bedrest for two (2) weeks. 4. The client should return to the doctor in six (6) months.

1. The client should begin strengthening the surgical leg. ( 1. The client should begin strengthening the surgical leg. = the client should begin moving asap. four things to be worried about after surgery is hemorrhage, DVT, pulmonary embolism ( when clots travel to lung), and infection. 2. The client should take pain medication routinely. = you never give pain medication routinely. You give it as needed. 3. The client should remain on bedrest for two (2) weeks. = absolutely not we don't want them to develop pneumonia, dvt, or a pulmonary embolism. 4. The client should return to the doctor in six (6) months. = no they going to come back that following week or asap )

The physician prescribes ampicillin 125 mg IM q6h for a 76-year-old woman. The injection site selected by the nurse should depend on which of the following? 1. The size of the muscle mass. 2. The total number of injections ordered. 3. The position of the patient in bed. 4. The gauge of the needle.

1. The size of the muscle mass. ( 1. The size of the muscle mass. = this is a 76 year old woman. Usually patients in the geriatric population are very often very thin and frail. As a nurse we need to make sure we don't hit any vessels, nerves because we don't want to give them neurovascular damage so we need to make sure that the patient has a lot of muscle at the injection site. 2. The total number of injections ordered. 3. The position of the patient in bed. 4. The gauge of the needle.

A nursing assistant on the pediatric unit may be pregnant. The charge nurse is unsure of the nursing assistant's immune status. Which of the following hospitalized children could the charge nurse safely assign the nursing assistant to care for? 1. Two-year-old with impetigo. 2. Four-year-old with varicella. 3. Six-year-old with Rubella. 4. Nine-year-old with Fifth disease.

1. Two-year-old with impetigo. ( 1. Two-year-old with impetigo. = impetigo is a bacterial infection. not contagious. 2. Four-year-old with varicella. = viral and contagious 3. Six-year-old with Rubella. = viral and contagious 4. Nine-year-old with Fifth disease. = viral and contagious )

Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L? 1. U waves 2. Flat P waves 3. Elevated T waves 4. Prolonged PR interval

1. U waves ( 1. U waves = potassium has a very narrow therapeutic range, 3.5-5. Anything out of this range that patient is at risk for dysthymias. However with a low potassium level ( less than 3.5 ) we may see the presence of U waves. 2. Flat P waves = actually we would expect to see peaked P waves when a patient has with hypokalemia. 3. Elevated T waves = in hypokalemia they would be flat T waves. 4. Prolonged PR interval = you would see a depressed PR interval with hypokalemia )

The client has gastroesophageal reflux disease. Which HCP order should the nurse question 1. Elevate the head of the client's bed with blocks. 2. Administer pantoprazole (Protonix) four (4) times a day. 3. A regular diet with no citrus or spicy foods. 4. Activity as tolerated and sit up in a chair for all meals.

2. Administer pantoprazole (Protonix) four (4) times a day. ( 1. Elevate the head of the client's bed with blocks. 2. Administer pantoprazole (Protonix) four (4) times a day. = protonix should be given once a day! Sometimes twice a day. Never 4 times a day! 3. A regular diet with no citrus or spicy foods. 4. Activity as tolerated and sit up in a chair for all meals. )

A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the treatment of heart failure. The nurse would particularly assess the client for: 1. Thrombocytopenia and weight gain 2. Anorexia, nausea, and visual disturbances 3. Diarrhea and hypotension 4. Fatigue and muscle twitching

2. Anorexia, nausea, and visual disturbance ( 1. Thrombocytopenia and weight gain 2. Anorexia, nausea, and visual disturbances = digoxin increases the contractility of the heart but it decreases the heart rate. Remember you have to check the patients apical pulse for 1 full minute before giving digoxin. Digoxin has a narrow therapeutic range 0.8 - 2. Signs of toxicity are Anorexia, nausea, and visual disturbances, and abdominal pains. 3. Diarrhea and hypotension 4. Fatigue and muscle twitching )

Which of the following conditions is associated with a predictable level of pain that occurs as a result of physical or emotional stress? 1. Anxiety 2. Stable angina 3. Unstable angina 4. Variant angina

2. Stable angina ( 1. Anxiety = should not cause chest pain. 2. Stable angina = it's predictable we know when it's going to come on and it's not as severe as unstable angina. Stable angina is short lasting, when you stop doing what's causing the angina it goes away. So stable angina we know what's going to bring it on, it mild not severe angina, and it's short lasting. 3. Unstable angina = unstable angina is unpredictable! you have no idea what will trigger the angina. Unstable angina pain is severe and its lasts a long time. The more time that goes by the worst the pain is. 4. Variant angina = varies. The patients can get chest pain in the morning or at night; it varies. It's severe chest pain that they get routinely; it's predictable and varies when they get the pain. )

An adult client with hepatic encephalopathy has a serum ammonia level of 120 mcg/dL and receives treatment with lactulose (Chronulac) syrup. The nurse determines that the client has the best response if the level changes to which after medication administration? 1. 2 mcg/dL 2. 5 mcg/dL 3. 70 mcg/dL 4. 100 mcg/dL

3. 70 mcg/dL ( 1 . 2 mcg/dL 2. 5 mcg/dL 3. 70 mcg/dL = normal ammonia levels is 10 to 80. That's what you want the ammonia range to be in. When a patient receives treatment with lactulose (Chronulac) syrup it helps binds all of that ammonia and brings it down. They way we know it's working is when the level come down to normal 4. 100 mcg/dL)

The nurse in the outpatient clinic counsels a client diagnosed with genital herpes. The client states, "I don't know how I keep getting reinfected because I am really careful!" Which of the following responses by the nurse is BEST? 1. "What do you mean, ' I am really careful'?" 2. "The virus remains in your body in a dormant state." 3. "Are you sure that you protect yourself adequately?" 4. "Have you notified all of your sexual contacts?"

2. "The virus remains in your body in a dormant state." ( 1. "What do you mean, ' I am really careful'?" 2. "The virus remains in your body in a dormant state." = something can trigger herpes to come back, such as stress on the body. Example of stress on the body is getting sick, menstrual cycle, or poor diet etc. Herpes never goes away it just goes into a dormant state where it's just sleeping and than it can become active again. It's very important to teach patients that when herpes is active and lesions are present they need to abstain from sex and sexual activity! 3. "Are you sure that you protect yourself adequately?" 4. "Have you notified all of your sexual contacts?")

A client was admitted to the hospital two days ago with a diagnosis of a manic episode of bipolar disorder. On entering the day room, the nurse finds the client dancing to the radio. The nurse's most appropriate response would be: 1. "Please turn the radio off so we can hear each other talk." 2. "You and I had planned to talk this morning. Let's go to your room." 3. "How are you every going to get any rest if you keep that music on?" 4. "Do you think you could sit for a few minutes so we could talk?"

2. "You and I had planned to talk this morning. Let's go to your room." ( 1. "Please turn the radio off so we can hear each other talk." = not therapeutic 2. "You and I had planned to talk this morning. Let's go to your room." = best therapuetic response 3. "How are you ever going to get any rest if you keep that music on?" = closed ended questions and not therapeutic. 4. "Do you think you could sit for a few minutes so we could talk?" = closed ended questions and not therapeutic. )

Which of the following positions would best aid breathing for a client with acute pulmonary edema? 1. Lying flat in bed 2. Left side-lying 3. In high Fowler's position 4. In semi-Fowler's position

3. In high Fowler's position ( 1. Lying flat in bed 2. Left side-lying 3. In high Fowler's position 4. In semi-Fowler's position)

A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident (stroke). In planning care for this client, the nurse implements which one of the following as an appropriate intervention? 1. Encourage an even gait when walking in place. 2.. Assess the extremities for unilateral swelling and muscle atrophy. 3. Encourage holding the breath frequently to hyperinflate the client's lungs. Teach the use of a two-point crutch technique for ambulation.

2. Assess the extremities for unilateral swelling and muscle atrophy. ( 1. Encourage an even gait when walking in place. 2. Assess the extremities for unilateral swelling and muscle atrophy. = unilateral means one side. we expect to see unilateral where ever that immobility is wherever that paralysis is on that one side. We expect to see unilateral swelling and muscle atrophy. The patient had a stroke on their left side, that means they had paralysis on their lift side( immobile on left side; paralyzed ) atrophy happens when muscles aren't used. Muscles shrink when they are not used this is know as atrophy. When a patient is not moving fluid movement slows down so the patient experiences swelling on the paralysis side. 3. Encourage holding the breath frequently to hyperinflate the client's lungs. 4. Teach the use of a two-point crutch technique for ambulation. )

A five-year-old child has been admitted to the hospital with a diagnosis of dehydration. The physician orders an intravenous fluid containing potassium chloride (KCI). Which of the following actions does the nurse take first? 1. Obtain weight. 2. Assess urinary output. 3. Monitor skin turgor. 4. Take vital signs.

2. Assess urinary output. ( 1. Obtain weight. 2. Assess urinary output. = this patient is receiving potassium chloride. Remember the level of potassium is surplus to range between 3.5 to 5.0. Anything less than 3 and anything more than 5 can kill the patient. When a patient is receiving a medication that has a narrow therapeutic index you have to monitor the patient for toxicity. When a patient is receiving a medication with a narrow therapeutic range like potassium you better check their urine output. To insure their kidneys is properly and accurately getting rid of the potassium. Patient urine output must be 30 ml an hour as well! If not hold the medication. 3. Monitor skin turgor. 4. Take vital signs. )

Which of the following actions is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease? 1. Decrease anxiety 2. Enhance myocardial oxygenation 3. Administer sublingual nitroglycerin 4. Educate the client about his symptoms

2. Enhance myocardial oxygenation ( 1. Decrease anxiety 2. Enhance myocardial oxygenation = coronary arteries are responsible for bringing oxygen, blood, vitamins, and nutrients to the heart. So we know that there's veins and theirs arteries. Veins brings unoxygenated blood back to the heart and arteries bring oxygenated blood to the whole body. So the heart is responsible for supplying oxygenated blood to all of your organs, tissues, and cells. Remember that the heart itself is a muscle; it's tissue and the heart itself needs its own supply of blood, oxygen, vitamins, and nutrients. So the coronary arteries specifically bring the heart that blood, oxygen, vitamins, and nutrients. So if the coronary arteries are in trouble the heart is not recieving oxygen, vitamins, and nutrients. So the first thing to do is increase oxygen supply !!!! 3. Administer sublingual nitroglycerin = it causes vasodilation,but this is not the first thing to do. 4. Educate the client about his symptoms )

To promote respiratory function in the immobilized client, the nurse should: 1. Change the client's position every 4 to 8 hours 2. Encourage deep breathing and coughing every hour 3. Use oxygen and nebulizer treatments regularly 4. Suction the client's secretions every hour

2. Encourage deep breathing and coughing every hour ( 1. Change the client's position every 4 to 8 hours = change patients position every 2 hours! This will decrease the clients risk of getting blood clots. 2. Encourage deep breathing and coughing every hour = to promote respiratory function. The reason you want them coughing and deep breathing it promotes inflation and expansion of the lungs. This is lungs exercises to make the patients lungs stronger. Remember Turn, cough, deep breath! 3. Use oxygen and nebulizer treatments regularly = give oxygen as needed if their O2 stats are down. But this does not help the lungs get stronger. 4. Suction the client's secretions every hour = patients are suctioned as needed. Suctioning the patient does not help the lungs get stronger. )

A client with a diagnosis of borderline personality disorder has become attached to one of the nurses. One day the favored nurse phones in sick. When given this news, the client goes into the hospital room, breaks a bottle of cologne, and scratches his arm with a jagged piece of glass. After providing first aid, what is the next most therapeutic nursing action in relation to the client's behavior? 1. Institute suicide precautions. 2. Help the client connect thoughts and feelings to the acting-out behavior. 3. Telephone the client's favorite nurse to talk with the client. 4. Permit the client to remain alone to regain composure.

2. Help the client connect thoughts and feelings to the acting-out behavior. ( 1. Institute suicide precautions. = they did not try to cut their neck. They cut their arm to get attention. 2. Help the client connect thoughts and feelings to the acting-out behavior. = patients with personality disorder like to have the attention. Talk to them so that they can feel noticed and seen. As a nurse you want this client to express their feelings to you. 3. Telephone the client's favorite nurse to talk with the client. = 4. Permit the client to remain alone to regain composure. * patients who have borderline personality disorder die accidentally. Recognize they cut/ scratched their arm not their juggler vein. They just wanted attention patients with borderline personality disorder wants all the attention and wants everything to be about them. )

Which assessment data indicate the client has developed a deep vein thrombosis (DVT) in the left leg 1. A negative Homans' sign of the left leg. 2. Increased left-leg calf circumference. 3. Elephantiasis of the left lower leg. 4. Brownish pigmentation of the left lower leg. 60. The 85-year-old client diagnosed with severe end-stage chronic obstructive

2. Increased left-leg calf circumference. ( 1. A negative Homans' sign of the left leg. 2. Increased left-leg calf circumference. = measure both legs. An increased circumference in left leg illustrates a clot. 3. Elephantiasis of the left lower leg. 4. Brownish pigmentation of the left lower leg. )

A client has been admitted to the hospital with a diagnosis of possible preterm labor. Which of the following tests would the nurse anticipate the physician ordering? 1. Oxytocin challenge test (OCT). 2. Nonstress test (NST). 3. Nipple Stimulation Test. 4. Glucose Tolerance Test.

2. Nonstress test (NST). ( 1. Oxytocin challenge test (OCT). = what is oxytocin? Pitocin! Pitocin cause contractions. 2. Nonstress test (NST). = the diagnosis says the client has possible preterm labor. That means that the patient is possibly going into labor earl; which we don't want. This gives you information about how the fetus is doing in the womb and the likeness of the fetus to be able to survive without causing contractions or putting the fetus into distress. 3. Nipple Stimulation Test. = stimulated nipples increases uterine contractions. We do not want to increase the preterm client contractions. 4. Glucose Tolerance Test. = they just through this in here! This has nothing to do with contractions. )

A client is getting up for the first time after a period of bed rest. The nurse should first: 1. Assess respiratory function 2. Obtain a baseline blood pressure 3. Assist the client with sitting at the edge of the bed 4. Ask the client if he or she feels light-headed

2. Obtain a baseline blood pressure ( 1. Assess respiratory function = the first assessment you do will be to take their baseline blood pressure because we are more concerned about orthostatic hypotension because the patient has been on bed rest. 2. Obtain a baseline blood pressure = the first thing you're going to do is take the client blood pressure. For this reason the patient has been lying in that bed for a long time we are concerned about orthostatic hypotension!!!! We are worried about when the patient stands up their blood pressure can immediately drop. 3. Assist the client with sitting at the edge of the bed = you want them to sit at the edge of the bed and dangle their feet. But this isn't the first thing to do. 4. Ask the client if he or she feels light-headed = this is subjective not something you can measure. Not the first thing you should do. )

The nurse will be admitting a mechanically ventilated client to the step down unit. To meet the goal of maintaining the client's safety, which of the following measures does the nurse plan to do? 1. Set the ventilator alarm at the lowest volume. 2. Place a manual resuscitation bag at the head of bed. 3. Restrain the client's wrists bilaterally. 4. Suction the client's endotracheal tube hourly.

2. Place a manual resuscitation bag at the head of bed. ( 1. Set the ventilator alarm at the lowest volume. = the alarm needs to be on the highest setting so that others and you can hear it. 2. Place a manual resuscitation bag at the head of bed. = for safety you nested have a resuscitation bag right nexts to that bedside in case something happens to that ventilator. 3. Restrain the client's wrists bilaterally. 4. Suction the client's endotracheal tube hourly. = concept you need to understand in nursing. YOU DO NOT SUCTION ROUTINELY! Because every time you suction a patient you're are taking away oxygen from them. YOU ONLY SUCTION AS NEEDED. Not routinely )

A nurse is preparing to ambulate a client on the 3rd day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation? 1. Encourage the client to cough and deep breathe 2. Premedicate the client with an anal gesic 3. Provide the client with a walker 4. Remove telemetry equipment because it weighs down the hospital gown.

2. Premedicate the client with an analgesic ( 1. Encourage the client to cough and deep breathe 2. Premedicate the client with an analgesic = an analgesic decrease pain. When patient pain is decreased it decreases the patient anxiety and oxygen demand. When it comes angina we want to increase oxygen while we decrease the demand for oxygen. 3. Provide the client with a walker 4. Remove telemetry equipment because it weighs down the hospital gown. )

A postoperative client requests medication for flatulence (gas pains). Which medication from the following PRN list should the nurse administer to this client? 1. Ondansetron (Zofran) 2. Simethicone (Mylicon) 3. Acetaminophen (Tylenol) 4. Magnesium hydroxide (milk of magnesia, MOM)

2. Simethicone (Mylicon) ( 1. Ondansetron (Zofran) = given for nausea/ vomiting 2. Simethicone (Mylicon) = this is what you give for gas pains. You either know it or you don't. 3. Acetaminophen (Tylenol) = Tylenol is an analgesic and sometimes it's used as an antipyretic to bring down the temperature. 4. Magnesium hydroxide (milk of magnesia, MOM) = Used as a laxative and. Sometimes as an antacid. But not used for gas pain.

During a flood, two ambulances arrive at an emergency substation at the same time. One contains a 2-year-old near drowning victim on a ventilator. The other contains an 80-year-old client with a left-sided CVA who is conscious and has a blood pressure of 220/130. Which patient should the nurse see INITIALLY? 1. The 2-year-old because she is on a ventilator. 2. The 80-year-old because he is hypertensive. 3. The 2-year-old because she is a victim of the flooding. 4. The 80-year-old because he is older.

2. The 80-year-old because he is hypertensive. ( 1. The 2-year-old because she is on a ventilator. = yes we care about the 2 year on the vent. But guess what? they're on the vent!! They're getting oxygen in their body. There's nothing that tells us that right now we need to get to them before that hypertensive client. 2. The 80-year-old because he is hypertensive. = which patient is the most unstable? In this situation it is the 80 year old. The blood pressure is an hypertensive crises this patient might have another stroke on us. 3. The 2-year-old because she is a victim of the flooding. 4. The 80-year-old because he is older. )

Which action by the nurse is correct for droplet precautions? 1. Tests N95 respirator for fit prior to use in client room. 2. Wears a surgical mask when within 3 feet of client. 3. Wears eye protection upon entering the client's room. 4. Uses sterile gloves when bathing the client.

2. Wears a surgical mask when within 3 feet of client. (

The nurse is caring for a client with peptic ulcer disease (PUD) who vomited 150 mL of blood-tinged green liquid. Which of the client's laboratory test results would be a priority to check? 1. serum pH 2. hematocrit (HCT) (key) 3. serum sodium level 4. blood urea nitrogen (BUN) level

2. hematocrit (HCT) ( 1. serum pH 2. hematocrit (HCT) (key) = when it comes to bleeding and lab values you re going to be concerned about the hemoglobin and the hematocrit. * remember Ulcers are very easy to cause bleeding 3. serum sodium level 4. blood urea nitrogen (BUN) level )

A client is admitted to the hospital after a motor vehicle accident with a diagnosis of blunt chest trauma. Analyzing the client's arterial blood gases (ABG), the nurse recognizes which value as being consistent with acute respiratory failure? 1. pH7.36. 2. pCO2 72. 3. р02 78. 4. 02 saturation 90%.

2. pCO2 72. ( 1. pH7.36. 2. pCO2 72. = This patients co2 level is 72 that means they have a lot of acid. This is what lets us know the patient is in an acidic state. In an acidic state the ph is going to be down and the co2 is going to up. They're holding onto their co2 instead of breathing it out. Co2 is acid! Which places the client at an acid state. range is 7.35 to 7.45 anything higher than 7.45 is alkalinic. Anything lower than 7.35 is acid. This patients co2 level is 72 that means they have a lot of acid. This is what lets us know the patient is in an acid state. When a patient is in respiratory failure that means they're not breathing the way they are supposed to be breathing. You are supposed to breath in oxygen and breath out co2. But now the clients breathing is compromised so what's happening? 3. р02 78. 4. 02 saturation 90%. * Do not confuse partial pressure of oxygen with your o2 stats. Your partial pressure you want it to be 88 to 100z your o2 stats you want it to be 95 to 100. )

A client calls a hotline and threatens to commit suicide. Which would be the most important question for the nurse to ask? 1. "Have you attempted suicide before?" 2. "What happened to make you so desperate?" 3. "How will you carry out your plan?" 4. "what will you accomplish by taking your life?"

3. "How will you carry out your plan?" ( 1. "Have you attempted suicide before?" 2. "What happened to make you so desperate?" 3. "How will you carry out your plan?" 4. "what will you accomplish by taking your life?" )

Which of the following statements regarding physical activity and its effect on activity tolerance made by a client shows the most informed knowledge regarding the connection between the two? 1. "I know I need to walk more if I want to get stronger." 2. "I don't like walking, but I do it because I know it will make me stronger." 3. "I try to walk a little farther each afternoon so I can dance at my grandson's wedding." "I walk with my son three evenings a week because it's good for his weight and for my bones."

3. "I try to walk a little farther each afternoon so I can dance at my grandson's wedding." ( 1. "I know I need to walk more if I want to get stronger." 2. "I don't like walking, but I do it because I know it will make me stronger." 3. "I try to walk a little farther each afternoon so I can dance at my grandson's wedding." = activity tolerance is the key word! Activity tolerance means to do an activity more and more and more each day. 4. "I walk with my son three evenings a week because it's good for his weight and for my bones." )

A 16-year-old had a full leg cast for 4 months, and it is being removed today. Which of the following statements made by the client shows the most informed understanding of the effects of immobilization of a muscle on its strength and stamina? 1. "I'm hoping to be back at soccer practice in 3 weeks." 2. "Walking and riding my bike will help regain the muscle." 3. "T'll practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring." 4. "There was a good bit of muscle and strength loss, but I'll work at getting it back like it was before the break."

3. "I'll practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring." 1. "I'm hoping to be back at soccer practice in 3 weeks." 2. "Walking and riding my bike will help regain the muscle." 3. "I'll practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring." = when patients been immobilized what happens to that muscle? It starts to shrink and get weak. So you have to do strengthening exercises to get it back to where it was. 4. "There was a good bit of muscle and strength loss, but I'll work at getting it back like it was before the break." = answer 3 is the overall better answer )

Which of the following statements made by a nurse caring for a client who experienced a myocardial infarction 8 hours ago shows the greatest insight as to the purpose for keeping the client on bed rest? 1. This has been exhausting; she needs a period of uninterrupted rest." 2. "The pain she experienced is exhausting; it's imperative that she rest." 3. "Keeping her on bed rest decreases the need her body has for oxygen" 4. "She needs complete rest; she is really very ill, especially her heart."

3. "Keeping her on bed rest decreases the need her body has for oxygen" ( 1. This has been exhausting; she needs a period of uninterrupted rest." 2. "The pain she experienced is exhausting; it's imperative that she rest." 3. "Keeping her on bed rest decreases the need her body has for oxygen" = when a patient has an heart attack ( myocardial infarcation) the priority and care for that patient is to decrease their oxygen demand/ decrease the demand on their heart. Morphine decrease pain and oxygen demand, Oxygen so heart can rest, Nitroglycerin dilates the vessels, aspirin is an anti platelet that fights against clotting. * remember MONA when it comes to myocardial infarction! M=morphine, O= oxygen, N= nitroglycerin, A= aspirin this is all given to decrease oxygen demand on the heart. 4. "She needs complete rest; she is really very ill, especially her heart." )

To provide for the psychosocial needs of an immobilized client, an appropriate statement by the nurse is which of the following? 1. "The staff will limit your visitors so that you will not be bothered." 2. "A roommate can be a real bother. You'd probably rather have a private room." 3. "Let's discuss the routine to see if there are any changes we can make." 4. "I think you should have your hair done and put on some makeup."

3. "Let's discuss the routine to see if there are any changes we can make." ( 1. "The staff will limit your visitors so that you will not be bothered." 2. "A roommate can be a real bother. You'd probably rather have a private room." 3. "Let's discuss the routine to see if there are any changes we can make." = what's great about this answer is that it gets the client involved in their plan of care. This helps the patient psychosocial. 4. "I think you should have your hair done and put on some makeup." = as a nurse never give your opinion! )

The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching? 1. "We need to encourage adequate fluid intake." 2. "Coughing spells may be triggered by dust or smoke." 3. "We need to maintain respiratory precautions and a quiet environment for at least 2 weeks." 4. "Good hand-washing techniques need to be instituted to prevent spreading the disease to others."

3. "We need to maintain respiratory precautions and a quiet environment for at least 2 weeks." ( 1. "We need to encourage adequate fluid intake." 2. "Coughing spells may be triggered by dust or smoke." 3. "We need to maintain respiratory precautions and a quiet environment for at least 2 weeks." = The convalescent stage is the final stage of infection. During this stage, symptoms resolve, and a person can return to their normal functions. this demonstrates a need for further teaching. This answer requires further teacher because the child is in the convalescent stage; the child does not need to be on respiratory precaution anymore. The pertussis stage is no longer communicable so they don't have to be under respiratory precautions. 4. "Good hand-washing techniques need to be instituted to prevent spreading the disease to others.")

It has been determined that all of the following clients are at risk for falling. Which one requires the nurse's priority for ambulation? 1. A 16-year-old with a sprained ankle being discharged from the emergency department 2. A 54-year-old who has taken the initial dose of an antihypertensive medication 3. A 45-year-old postoperative client up for the first time since knee surgery 4. An 81-year-old who is asthmatic and had a hip replaced 18 months ago

3. A 45-year-old postoperative client up for the first time since knee surgery ( 1. A 16-year-old with a sprained ankle being discharged from the emergency department 2. A 54-year-old who has taken the initial dose of an antihypertensive medication 3. A 45-year-old postoperative client up for the first time since knee surgery = postoperative meant patient just came from surgery. Anesthesia places client as fall risk and knee surgery places client as fall risk. The client has two risk factors that places them as severe fall risk. This is the greatest fall risk, this is our priority patient because they are postop. When a patient not moving blood slows down and clot so we need to prioritize this patient. 4. An 81-year-old who is asthmatic and had a hip replaced 18 months ago )

A child with a radial fracture complains of itching to the casted area. The appropriate nursing action to relieve itching is: 1. Allow the child to use a Q-tip to scratch the area. 2. Visualize the toes and area above the cast to identify areas of irritation. 3. Apply an ice pack for 10-15 minutes. 4. Explain to the child that itching is an indication the fracture is healing.

3. Apply an ice pack for 10-15 minutes. ( 1. Allow the child to use a Q-tip to scratch the area. = under no circumstances should a patient ever stick anything into the cast. For this reason, the patient can accidentally scratch that skin and it would become a risk for infection. 2. Visualize the toes and area above the cast to identify areas of irritation. 3. Apply an ice pack for 10-15 minutes. = if a patient has a cast and complains of itching apply an ice pack for 10 -15 minutes. Another option is to use a blow drying; place the blow drying on cool setting and blow it into the cast. 4. Explain to the child that itching is an indication the fracture is healing. )

Antiembolic stockings (thromboembolic device [TED] hose) are ordered for the client on bed rest following surgery. The nurse explains to the client that the primary purpose for the TEDs is to: 1. Keep the skin warm and dry 2. Prevent abnormal joint flexion 3. Apply external pressure 4. Prevent bleeding

3. Apply external pressure ( 1. Keep the skin warm and dry 2. Prevent abnormal joint flexion 3. Apply external pressure = Ted Hose are really tight. what happens is ted hose apply pressure and the pressure pushes the blood to go back up to the heart. Because when the patient is immobile on bed rest blood slows down and can clot!. * Ted Hose has to be placed on the client in the morning before they get out of bed!!!! Take off in the evening before they go to sleep. 4. Prevent bleeding )

The public health nurse assesses a patient who is complaining of a persistent cough with blood-tinged sputum and of night sweats. Which of the following actions should the nurse take FIRST? 1. Assess the patient's vital signs, including oxygen saturation. 2. Place the patient on 2 L oxygen per nasal cannula. 3. Assist the patient in putting on a mask. 4. Assess the patient's lung sounds.

3. Assist the patient in putting on a mask. ( 1. Assess the patient's vital signs, including oxygen saturation. 2. Place the patient on 2 L oxygen per nasal cannula. 3. Assist the patient in putting on a mask. = anytime you see PERSISTENT COUGH, blood- tinged sputum, and night sweats your mind should immediately go to Tuberculosis. So the first thing you're going to do is put a mask on the patient to Prevent that infection to spreading to others . Tuberculosis is a public health crises because it spreads so easily. When someone cough with tuberculosis their droplets stay in the air for hours and anybody that walks into in they can get infected when they breathe it in. 4. Assess the patient's lung sounds.)

A 4-year-old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse understands that which diagnostic study should confirm this diagnosis? 1. A platelet count 2. A lumbar puncture 3. Bone marrow biopsy 4. White blood cell (WBC) count

3. Bone marrow biopsy ( 1. A platelet count 2. A lumbar puncture 3. Bone marrow biopsy = there confirmatory test for all which is your acute lymphocytic leukemia is the bone biopsy. This is procedures in extremely painful. They take a needle and insert it all the way into the bone marrow and they test it. This is how they confirm if a patient has acute lymphocytic leukemia (ALL). 4. White blood cell (WBC) count )

The nurse checks the food on a tray delivered for an Orthodox Jewish client and notes that the client has received a cheeseburger and potato fries with whole milk as a beverage. Which action should the nurse take? 1. Deliver the food tray to the client. 2. Replace the whole milk with lactose-free milk. 3. Call the dietary department and ask for a different meal. 4. Ask the dietary department to replace the beef with pork.

3. Call the dietary department and ask for a different meal. ( 1. Deliver the food tray to the client. 2. Replace the whole milk with lactose-free milk. = cannot have mild with meat 3. Call the dietary department and ask for a different meal. = orthodox Jewish people do not eat meat and milk together. They also do not eat pork, and shellfish. 4. Ask the dietary department to replace the beef with pork. )

The nurse assists in developing a plan of care for a client with hyperparathyroidism receiving calcitonin- human (Cibacalcin). Which outcome has the highest priority regarding this medication? 1. Relief of pain 2. Absence of side effects 3. Reaching normal serum calcium levels 4. Verbalization of appropriate medication knowledge

3. Reaching normal serum calcium levels ( 1. Relief of pain 2. Absence of side effects 3. Reaching normal serum calcium levels = the priority of the medication is to reach normal calcium levels. Normal calcium levels are 8.5- 10.2 4. Verbalization of appropriate medication knowledge )

The client diagnosed with cancer of the larynx has had a partial laryngectomy. Which client problem has the highest priority 1. Impaired communication. 2. Ineffective coping. 3. Risk for aspiration. 4. Social isolation

3. Risk for aspiration. ( 1. Impaired communication. 2. Ineffective coping. 3. Risk for aspiration. = this will kill the patient. So this will have the highest priority. 4. Social isolation )

An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as: 1. Harsh crackles 2. Wheezing on inspiration 3. Diminished breath sounds 4. Bronchovesicular whooshing

3. Diminished breath sounds ( 1. Harsh crackles = when you hear crackles that means it's fluid in the lungs. So if a patient has pneumonia you would hear crackles. 2. Wheezing on inspiration = when you hear wheezing that means the patient has limited airway. For example if a patient has asthma. 3. Diminished breath sounds = a person that has atelectasis means that have a collapsed lung. Yourre goin to hear diminished breath sounds because the patient is not breathing the way they are supposed to. 4. Bronchovesicular whooshing = don't know made up . )

During conversation with the nurse, a schizophrenic client uses the word "evorriation." How will the nurse interacting with the client interpret and respond to the use of this word? 1. Evidence of his illness and ignore it when interacting with the client. 2. A mispronunciation and indicate to the client that the staff does not understand its meaning. 3. Evidence of his illness and clarify the meaning with the client during the interaction. 4. A mispronunciation and correct the client's grammar when interacting with the client.

3. Evidence of his illness and clarify the meaning with the client during the interaction. ( 1. Evidence of his illness and ignore it when interacting with the client. 2. A mispronunciation and indicate to the client that the staff does not understand its meaning. 3. Evidence of his illness and clarify the meaning with the client during the interaction. = "evorriation." Is not a word. But it has meaning to the schizophrenic patient. 4. A mispronunciation and correct the client's grammar when interacting with the client. )

In planning a menu for a client suffering from an acute manic episode, which of the following would the nurse determine to be most appropriate? 1. Spaghetti and meat balls, salad, banana. 2. Beef and vegetable stew, bread, vanilla pudding. 3. Fried chicken leg, ear of corn, apple. 4. Fish fillets, stewed tomatoes, cake.

3. Fried chicken leg, ear of corn, apple. ( 1. Spaghetti and meat balls, salad, banana. = have to sit down to eat. 2. Beef and vegetable stew, bread, vanilla pudding. = have to sit down to eat. 3. Fried chicken leg, ear of corn, apple. = patient can hold these items while walking around. these are all foods that the patient can eat while they are walking around during their manic attack. Because when patients are in a manic stage they are not stopping to take a break. But you still have to give them their nutrition. They can walk and move around with these food items . 4. Fish fillets, stewed tomatoes, cake. )

The nursing instructor asks a nursing student about the cause of hemophilia. The student correctly responds by telling the instructor which fact about hemophilia? 1. Hemophilia is a Y-linked hereditary disorder. 2. A splenectomy resolves the bleeding disorders. 3. Hemophilia A results from deficiency of factor VIII. 4. A bone marrow transplant is the treatment of choice.

3. Hemophilia A results from deficiency of factor VIII. ( 1. Hemophilia is a Y-linked hereditary disorder. = No it an X chromosome 2. A splenectomy resolves the bleeding disorders. = there is no cure for hemophilia there's just treatments. 3. Hemophilia A results from deficiency of factor VIII. = Hemophilia A is from not having enough of factor 8 ( VIII). factor 8 ( VIII) is that coloring factor 8 is your clotting factor that helps you clot so that you don't bleed out. So those patients what have hemophilia A they don't have that Factor 8 which means they don't have those clotting capabilities which means the chance of them hemorrhaging to death is very high. 4. A bone marrow transplant is the treatment of choice. = No )

A client known for making inappropriate sexual advances toward the staff is diagnosed with an antisocial personality disorder. The nurse knows that which of the following is inconsistent with this diagnosis? 1. Grandiosity 2. Poor frustration tolerance 3. Intense guilt 4. Fighting

3. Intense guilt ( 1. Grandiosity = consistent with antisocial personality disorder. Because they think they are special and above the law. Grandiosity refers to a sense of specialness and self-importance that might lead you to: boast about real or exaggerated accomplishments. consider yourself more talented or intelligent than others. 2. Poor frustration tolerance = consistent with antisocial personality disorder. 3. Intense guilt = they have no feeling of guilt. They feel like you deserve it if you let them scam you. They feel like you should have know they were going to play/trick you. 4. Fighting = consistent with antisocial personality disorder. * patients who have antisocial personality disorders like to trick, scam, play like your friend to get what they want. They feel good about scamming and hurting people. )

The nurse cares for a teenager admitted for burns to 50% of her body. Which of the following actions by the nurse has highest priority? 1. Counsel patient regarding body image changes. 2. Maintain airborne precautions. 3. Maintain aseptic technique during procedures. 4. Encourage the teen's friends to visit regularly.

3. Maintain aseptic technique during procedures. ( 1. Counsel patient regarding body image changes. 2. Maintain airborne precautions. 3. Maintain aseptic technique during procedures. = priority is always going to be what keeps the patient alive. We need to make sure we maintain stability for this patient at all times. Why? The 3 biggest concerns about Burns are infection, shock( because of fluid shift), and pain. 4. Encourage the teen's friends to visit regularly.)

A child with cystic fibrosis (CF) is being discharged after initial diagnosis and treatment. The mother has been instructed about nutrition for the child and the need for pancreatic enzymes. The nurse is confident the mother understands about the home care of her child when stating, "I know it will be important for me to: 1. Restrict the amount of salt in our foods." 2. Limit fluids to avoid swelling and increased fluid buildup." 3. Make sure the Pancreatic enzymes are taken with all snacks and meals." 4. Prepare separate meals for my child."

3. Make sure the Pancreatic enzymes are taken with all snacks and meals." ( 1. Restrict the amount of salt in our foods." 2. Limit fluids to avoid swelling and increased fluid buildup." 3. Make sure the Pancreatic enzymes are taken with all snacks and meals." = cystic fibrosis is when the patient body creates a lot of mucus plugs.mucus plugs are thick and can clog everything up. Sometimes patient can get mucus plugs in their lungs and this can affect their breathing. Mucus plugs can sometimes clog up the patients pancreas. Remember the pancreas is responsible for releasing pancreatic enzymes. Those enzymes are supposed to go the small intestine (because digestion of food happens in the small intestine ) to break down the food. mother understands to sprinkle pancreatic enzymes onto the child's food to help the child's pancreas break down the food. 4. Prepare separate meals for my child." )

The nurse assists in developing a plan of care for the child with meningitis. Which would be the priority client problem for a child with a meningitis diagnosis? 1. Pain 2. Inadequate knowledge 3. Neurological dysfunction 4. Difficult family coping processes

3. Neurological dysfunction ( 1. Pain = the only time pain is a priority is a priority is in very few cases. Myocardial infarction, kidney stones, burns, sickle cells. 2. Inadequate knowledge 3. Neurological dysfunction = meningitis is an infection in the brain. So our priority is going to be what keeps the patient alive. 4. Difficult family coping processes)

A 78-year-old inactive client diagnosed with acute renal failure is at risk for which of the following skeletal maladies? 1. Rickets 2. Osteomyelitis 3. Pathological fractures of long bones 4. Compression fractures of the spinal column

3. Pathological fractures of long bones ( 1. Rickets = soft bones have vitamin D deficiency. 2. Osteomyelitis = infection log the bone. 3. Pathological fractures of long bones = this is another complication of a patient that's been immobile for a long time is their bones can get pores and weak. The bone is strong because of calcium, how does calcium get into the bones? By activity such as, walking, jogging, any weight bearing exercises. It pushes the calcium that was originally in the blood into the bone to make the bone strong. However when a patient is immobile that calcium that was in the bone goes out into the blood; this is what makes the bone porous and weak for fractures. 4. Compression fractures of the spinal column = happens in high impacts incidents such mva,. )

The physician orders all of the following procedures for a client diagnosed with placenta previa. Which one should the nurse questions? 1. Take vital signs every thirty minutes. 2. Auscultate fetal tones every fifteen minutes. 3. Perform vaginal checks to determine cervical dilation. 4. Assess frequency, intensity, and duration of contractions.

3. Perform vaginal checks to determine cervical dilation. ( 1. Take vital signs every thirty minutes. 2. Auscultate fetal tones every fifteen minutes. 3. Perform vaginal checks to determine cervical dilation. = placenta previa is when the cervix is weak. The cervix is supposed to be closed but when the cervix is weak it starts to open up. This could cause the baby to slip out. So do not perform cervical checks with a patient with placenta previa. 4. Assess frequency, intensity, and duration of contractions. )

The nurse cares for a client with an internal radium implant. It is MOST important for the nurse to take which of the following actions? 1. Restrict visitors with upper respiratory infections. 2. Assign the client to male caregivers. 3. Plan nursing activities to decrease time spent in the client's room. 4. Wear a lead-lined apron when caring for the client.

3. Plan nursing activities to decrease time spent in the client's room. ( 1. Restrict visitors with upper respiratory infections. =restrict all visitors time limit. No children and pregnant women allowed! 2. Assign the client to male caregivers. = males caregivers are exposed to radiation as well. So this is not the answer! 3. Plan nursing activities to decrease time spent in the client's room. = you need to cluster your activities and plan ahead when going into the patients room. Do wheat you need to do for them and get out. 4. Wear a lead-lined apron when caring for the client. = you do not need to wear a lead-lined apron for routine care. )

The client is diagnosed with an acute exacerbation of Crohn's disease. Which assessment data warrant immediate attention 1. The client's WBC count is 10.0 ( 103)/mm3. 2. The client's serum amylase is 100 units/dL. 3. The client's potassium level is 3.3 mEq/L. 4. The client's blood glucose is 148 mg/d.

3. The client's potassium level is 3.3 mEq/L. ( 1. The client's WBC count is 10.0 ( 103)/mm3. 2. The client's serum amylase is 100 units/dL. 3. The client's potassium level is 3.3 mEq/L = you should know not to play with potassium levels. Potassium has a very narrow they range. Potassium should be 3.5 - 5.0. Anything below 3.5 or above 5.0 is can kill the patient. 4. The client's blood glucose is 148 mg/d. )

Hospital administration decides the psychiatric unit will move to a former medical-surgical unit in 2 months. The psychiatric nurse manager goes to the new unit to assess its structure. Which of the following MOST concerns the nurse? 1. The lights and floor coverings in the hallways. 2. The location of the nursing station in relationship to the patient rooms. 3. The fixtures in the bathroom in-patient rooms. 4. The availability of a large central room for unit meetings and socialization.

3. The fixtures in the bathroom in-patient rooms. ( 1. The lights and floor coverings in the hallways. 2. The location of the nursing station in relationship to the patient rooms. 3. The fixtures in the bathroom in-patient rooms. = patient safety is number 1. Patient safety is going to be the nurse number one priority. When it comes to psych patients they can hang themselves from those bathroom bars or rails. Towels racks, bathroom equipment all have to be collapsible with any type of pressure so that patients cannot hang themselves. 4. The availability of a large central room for unit meetings and socialization. )

The nurse selects the Z track method to administer hydroxyzine (Vistaril) for which of the following reasons? 1. Z track slows the rate of absorption. 2. Z track is the safest and least painful way to give the injection. 3. The medication is irritating to subcutaneous and skin tissues. 4. Z track prevents the medication from seeping into the venous circulation.

3. The medication is irritating to subcutaneous and skin tissues. ( 1. Z track slows the rate of absorption. 2. Z track is the safest and least painful way to give the injection. 3. The medication is irritating to subcutaneous and skin tissues. = the medication is irritating to subq and skin tissues. Something else the z track method does is keep the medication sealed into that subq area/tissue. Iron is another medication that we use the z track method with. Because it keeps it from seeping out and can be irritating to the subq/ skin tissues. 4. Z track prevents the medication from seeping into the venous circulation. = z track method doesn't prevents the medication from seeping into the vessels. )

A client with angina complains that the angina pain is prolonged and severe and occurs at the same time each day, most often in the morning, On further assessment a nurse notes that the pain occurs in the absence of precipitating factors. This type of anginal pain is best described as: 1. Stable angina 2. Unstable angina 3. Variant angina 4. Nonanginal pain

3. Variant angina ( 1. Stable angina = it's predicable, short, not severe. 2. Unstable angina = unpredictable and Severe 3. Variant angina = predictable and severe and varies at the same times each day. in the question it says it predictable and severe 4. Nonanginal pain )

The nurse is talking with a client who had a subtotal gastrectomy 1 month ago. Which of the following statements by the client would be a priority to follow up? 1. "I occasionally take an over-the-counter (OTC) laxative.* 2. "leat several small meals each day." 3. "Tavoid drinking liquids with meals." 4. "I feel tired all the time." (key)

4. "I feel tired all the time." ( 1. "I occasionally take an over-the-counter (OTC) laxative. = it's okay to take occasionally 2. " I eat several small meals each day." = that's good anything that has to do with GI questions " several small meals each day." Is a great answer. 3. "I avoid drinking liquids with meals." = this is good to do because it avoids dumping syndrome 4. "I feel tired all the time." (key) = we're concerned about severe anemia because they are feeling tired all the time. And we are also going to be concerned about b12 level.

Which of the following tests is used most often to diagnose angina? 1. Chest x-ray 2. Echocardiogram 3. Cardiac catheterization 4. 12-lead electrocardiogram (ECG)

4. 12-lead electrocardiogram (ECG) ( 1. Chest x-ray 2. Echocardiogram 3. Cardiac catheterization 4. 12-lead electrocardiogram (ECG) = the ECG gives you a picture of the heart and how well it's doing. It shows if the patient is having any ischemia. If a patient is having angina you're expecting to see an inverted T wave. If they're having variant angina you expect to see an ST elevation )

The nurse administers a tube feeding to a patient with a baseline decreased mental status. Immediately after completing the tube feeding, it is MOST important for the nurse to place the client in which of the following positions? 1. Supine with the head of the bed elevated 45°. 2. Supine with the lower extremities elevated on pillows. 3. High Fowler's or semi-Fowler's position. 4. On the right side with the head of the bed elevated.

4. On the right side with the elevated head of the bed elevated. ( 1. Supine with the head of the bed elevated 45°. 2. Supine with the lower extremities elevated on pillows. 3. High Fowler's or semi-Fowler's position. = if choice 4 isn't available then we would pick High Fowler's position. 4. On the right side with the elevated head of the bed elevated. = You're promoting drainage from the small intestine because the head of the bed is elevated you're also preventing aspiration. So this is the best choice. )

A tornado has just leveled a large housing division near the hospital, and the disaster alarm has been announced at the hospital. The nurse caring for clients on the postpartum/pediatric unit considers which of the following clients MOST appropriate for discharge within the next hour? 1. A postpartum client who delivered over an intact perineum 12 hours ago. 2. A postpartum client diagnosed with an infection that has been receiving antibiotics for the past 24 hours. 3. A 3-year-old with newly diagnosed type 1 diabetes, diarrhea, and vomiting. 4. A 3-day-old breast-feeding infant with a total serum bilirubin of 14 mg/dL.

4. A 3-day-old breast-feeding infant with a total serum bilirubin of 14 mg/dL. ( 1. A postpartum client who delivered over an intact perineum 12 hours ago. = this is the second most stable patient. It is important for us to know that their perineum is intact because the chance of them bleeding is decreased/low. There's nothing in this that tells us that the patient is hemorrhaging. 2. A postpartum client diagnosed with an infection that has been receiving antibiotics for the past 24 hours. 3. A 3-year-old with newly diagnosed type 1 diabetes, diarrhea, and vomiting. 4. A 3-day-old breast-feeding infant with a total serum bilirubin of 14 mg/dL. = who is the most stable patient? The 3 day old with the total serum bilirubin of 14 mg/dL is most stable. Because it's been 3 days and the bilirubin is 14. We don't even consider phototherapy until a patients bilirubin is more than 15! Also breastfeeding promotes excretion of bilirubin through their stool. )

The nurse coming on duty receives the report from the nurse going off duty. Which of the following clients should the on-duty nurse assess first? 1. The 58-year-old client who was admitted 2 days ago with heart failure, BP of 126/76, and a respiratory rate of 21 breaths a minute. 2. The 88-year-old client with end-stage right-sided heart failure, BP of 78/50, and a DR order. 3. The 62-year-old client who was admitted one day ago with thrombophlebitis and receiving IV heparin. 4. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem).

4. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem). ( 1. The 58-year-old client who was admitted 2 days ago with heart failure, BP of 126/76, and a respiratory rate of 21 breaths a minute. = we would see the patient 3rd. 2. The 88-year-old client with end-stage right-sided heart failure, BP of 78/50, and a DR order. = we would see this patient last because they have a DNR and they have been there. 3. The 62-year-old client who was admitted one day ago with thrombophlebitis and receiving IV heparin. = you would see the patient second because patient came a day ago and is receiving heparin. 4. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem). = the gave us a hint " admitted 1 hour ago". Remember new clients require a lot of in-depth assessment. Another hint is " new onset of symptoms". This patient is moray unstable. )

The nurse is monitoring a client receiving glipizide (Glucotrol). Which outcome indicates an ineffective response from the medication? 1. A decrease in polyuria 2. A decrease in polyphagia 3. A fasting plasma glucose of 100 mg/dL 4. A glycosylated hemoglobin level of 12%

4. A glycosylated hemoglobin level of 12% ( 1. A decrease in polyuria = good 2. A decrease in polyphagia = good 3. A fasting plasma glucose of 100 mg/dL = good because it's between 70 - 110 4. A glycosylated hemoglobin level of 12% = this is bad this medication is not effectively working. The hemoglobin a1c is 12 that bad! For diabetics we want it to be less than seven. Patients who are not diabetic we want hemoglobin levels to be 5.7 or less )

A client is constantly pacing, talking rapidly to everyone, and always standing around the nurse's station. The client makes unreasonable demands on the staff and eats and sleeps infrequently. Which of the following best describes the manic behavior exhibited by this client? 1. Stereotypical response to anxiety. 2. A retreat into a personal inner world. 3. Blunted sensory perceptual reactions. 4. An exaggerated reaction to stimuli.

4. An exaggerated reaction to stimuli. ( 1. Stereotypical response to anxiety. 2. A retreat into a personal inner world. 3. Blunted sensory perceptual reactions. 4. An exaggerated reaction to stimuli. )

The client receiving a continuous heparin drip complains of sudden chest pain on inspiration and tells the nurse, "Something is really wrong with me." Which intervention should the nurse implement first 1. Increase the heparin drip rate. 2. Notify the health-care provider. 3. Assess the client's lung sounds. 4. Apply oxygen via nasal cannula.

4. Apply oxygen via nasal cannula. ( 1. Increase the heparin drip rate. 2. Notify the health-care provider. 3. Assess the client's lung sounds. 4. Apply oxygen via nasal cannula. * the question gave us enough information. 1. patient is receiving heparin to prevent DVT from traveling to the lungs. 2. They have sudden chest pain this could indicate pulmonary embolism. 3rd patient says something really wrong with me. When patients get pulmonary embolism they feel like they are going to die and like " something is really wrong with them". So the nurse should put their oxygen on their face and then listen to their lungs. )

A client is leaving for surgery and because of preoperative sedation needs complete assistance to transfer from the bed to the stretcher. Which of the following should the nurse do first? 1. Elevate the head of the bed. 2. Explain the procedure to the client. 3. Place the client in the prone position. 4. Assess the situation for any potentially unsafe complications.

4. Assess the situation for any potentially unsafe complications. ( 1. Elevate the head of the bed. 2. Explain the procedure to the client. 3. Place the client in the prone position. 4. Assess the situation for any potentially unsafe complications. = = remember ADPIE Assess, diagnosis, plan, implementation, evaluation )

The nurse cares for a client diagnosed with croup. The nurse should follow which of the following transmission-based precautions? 1. Standard precautions. 2. Airborne precautions. 3. Droplet precautions. 4. Contact precautions.

4. Contact precautions. ( 1. Standard precautions. = we use standard precaution for everyone. We want to make sure that we don't give our patients an infection while they are in our facility. ) 2. Airborne precautions. = this is for patient safety that have tuberculosis, measles, and chickenpox. 3. Droplet precautions. = this is for patients with pertussis( whooping cough highly contagious) , influenza, and pneumonia. 4. Contact precautions.= croup is a viral infection that we see in pediatrics. Little kids get croup it's a barking cough. Therefore we put this patient on contact precaution)

A client has a diagnosis of abruptio placentae. The nurse should assess the client's laboratory results for: 1. Increased platelet count. 2. Prolonged partial thromboplastin time. 3. Increased fibrinogen level. 4. Decreased clotting time.

4. Decreased clotting time. ( 1. Increased platelet count. = if you have increased platelet counts that means the patients clotting which means they are at a decreased risk for bleeding. 2. Prolonged partial thromboplastin time. = promotes bleeding. If a patient has abruptio placenta we are worried about that patient bleeding out we are going to be look at the lab values. If the clotting time is increased it takes longer to clot if it's decreased it takes a shorter timeframe to clot. 3. Increased fibrinogen level. = this increases clotting. So this can't be the correct answer because we are looking for something that would cause the patient to bleed. 4. Decreased clotting time. = promotes clotting not bleeding )

A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the client, the nurse is alert to a(n): 1. Increased blood pressure 2. Decreased heart rate 3. Increased urinary output 4. Decreased peristalsis

4. Decreased peristalsis ( 1. Increased blood pressure 2. Decreased heart rate 3. Increased urinary output 4. Decreased peristalsis = we are going to watch out for peristalsis which places the patient at risk for constipation. patients who are immobile needs lots of fluids and fiber to decrease constipation. When a patient is immobile and on bed rest everything in their body slows down. Blood circulation slows down patients that's immobile are at risk for blood clots, cupidus ulcers, and decrease blood pressure, decreased peristalsis (gut slows down. ) for decreased blood pressure get patient up slowly and dangle their feet to prevent orthostatic hypotension. ) ( * Peristalsis makes digestion possible. It's what moves food and fluids through each stage of the digestive process. Without peristalsis, we could neither eat nor poop. The slow but steady progress of peristalsis is also important for digestive health.)

Which of the following conditions is the predominant cause of angina? 1. Increased preload 2. Decreased afterload 3. Coronary artery spasm 4. Inadequate oxygen supply to the myocardium

4. Inadequate oxygen supply to the myocardium ( 1. Increased preload = tend to see in patients with right sided heart failure 2. Decreased afterload = it's caused by decreased cardiac output. You're going to see less oxygen, vitamins, nutrients, and blood supply going to the tissue. 3. Coronary artery spasm = usually see this is variant angina. 4. Inadequate oxygen supply to the myocardium = this is the number reason patients have chest pain. There's not enough blood, oxygen, and nutrients going to the heart. )

What would the nurse most expect to observe in a client with impulsive and acting out behavior? 1. Good problem-solving skills. 2. Commitment to long-term goals. 3. Ability to delay gratification. 4. Low tolerance for frustration.

4. Low tolerance for frustration. ( 1. Good problem-solving skills. 2. Commitment to long-term goals. 3. Ability to delay gratification. 4. Low tolerance for frustration. = patients who are impulsive and act out they have a very low tolerance for frustration. The minute they don't get their way they act on their emotions and they don't even think about the repercussions. Why? Because they want immediate gratification. )

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. Which nursing intervention related to altered nutrition should be the initial choice? 1. Weigh the client three times per week, before breakfast. 2. Explain to the client the importance of a good nutritional intake. 3. Report the nutritional concern to the psychiatrist and obtain a nutritional consult as soon as possible. 4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times. ( 1. Weigh the client three times per week, before breakfast. 2. Explain to the client the importance of a good nutritional intake. 3. Report the nutritional concern to the psychiatrist and obtain a nutritional consult as soon as possible. 4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times. = you're are killing two birds with one stone. Number 1 you're making sure he gets the nutrition and then number 2 you're also helping with that psychological aspect by letting that patient know that they are worthy of your time.

A young adult client is brought to the psychiatric hospital by the parents. The client is poorly groomed, and the parents report that the client appears to be hearing voices. During the first few hospital days, which of the following would be a priority nursing intervention: 1. See that he bathes and changes his clothes daily. 2. Complete the standardized admission assessment of the client. 3. Observe the client carefully to see if he approaches the staff. 4. Seek him out frequently to spend short periods of time with him.

4. Seek him out frequently to spend short periods of time with him ( 1. See that he bathes and changes his clothes daily. 2. Complete the standardized admission assessment of the client. 3. Observe the client carefully to see if he approaches the staff. 4. Seek him out frequently to spend short periods of time with him. = remember people over paperwork every single day of the week. The reason why you seek out the patient and spend short amount of time with client is because you're trying to build rapport. You're trying to build a trusting relationship with the client. Your first priority with that client is to build a trusting relationship. This will help you learn the client and the client to respond to you better. )

The unlicensed assistive personnel (UAP) notifies the nurse the client diagnosed with chronic obstructive pulmonary disease is complaining of shortness of breath and would like his oxygen level increased. Which intervention should the nurse implement 1. Notify the respiratory therapist (RT). 2. Ask the UAP to increase the oxygen. 3. Obtain a STAT pulse oximeter reading. 4. Tell the UAP to leave the oxygen alone.

4. Tell the UAP to leave the oxygen alone. ( 1. Notify the respiratory therapist (RT). 2. Ask the UAP to increase the oxygen. 3. Obtain a STAT pulse oximeter reading. 4. Tell the UAP to leave the oxygen alone. = tell the UAP to leave the oxygen alone and then immediately afterwards go check on your patient! This is a COPD patient where if we increase their oxygen. What are we doing? We are telling their brain tell their lungs to stop breathing. We turn off that drive for their lungs to breathe on their own. )

What is the primary reason for administering morphine to a client with an MI? 1. To sedate the client 2. To decrease the client's pain 3. To decrease the client's anxiety 4. To decrease oxygen demand on the client's heart

4. To decrease oxygen demand on the client's heart ( 1. To sedate the client 2. To decrease the client's pain 3. To decrease the client's anxiety 4. To decrease oxygen demand on the client's heart = if a patient has an MI the heart is in trouble. The heart is responsible for supply oxygenated blood through the body. Therefore you want to decrease oxygen demand on the heart. In this answering the heart is demanding oxygen therefore you want to help the heart by decreasing its demand for oxygen. You are helping the heart to rest. )

In which of the following situations would the nurse know the administration of magnesium sulfate (Epsom Salt) to be contraindicated? To: 1. Stop the onset of labor at 32 weeks gestation. 2. Reverse the effects of Pitocin hyperstimulation in a laboring client. 3. Prevent seizures in a client with pregnancy induced hypertension. 4. Treat uterine atony following vaginal delivery.

4. Treat uterine atony following vaginal delivery. ( 1. Stop the onset of labor at 32 weeks gestation. 2. Reverse the effects of Pitocin hyperstimulation in a laboring client. 3. Prevent seizures in a client with pregnancy induced hypertension. 4. Treat uterine atony following vaginal delivery. = magnesium sulfate is contraindicated for women with uterine atony. Uterine atony is when the uterine muscles are loose and boggy. The goal is for the women's uterine to be tight and constricted to decrease hemorrhage. * Magnesium sulfate relaxes the uterine muscles. We give magnesium sulfate if the patient is having too many contractions or if their contractions are too strong on their uterus. Magnesium sulfate is given to relax the uterine muscle, help soften them. )

Which of the following types of angina is most closely related with an impending MI? 1. Angina decubitus 2. Chronic stable angina 3. Nocturnal angina 4. Unstable angina

4. Unstable angina ( 1. Angina decubitus 2. Chronic stable angina 3. Nocturnal angina 4. Unstable angina = unstable angina is most closely linked to myocardial infarction because it's severe you never know when it's going to come on because it's unpredictable. And it's long lasting and progressive. Progressive means as time goes by the pain gets worse if the patient does not get any help. )

The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the nurse would provide the UAP with the best directions about the assignment? 1. "Encourage the client to increase daily fluid intake." 2. "Ambulate the client 20 ft (6.7 m) every 4 hours beginning at 0900." (key) 3. "Assist the client to perform passive range-of-motion (ROM) exercises." 4. "Reinforce physical therapy instructions about the proper use of a walker."

The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the nurse would provide the UAP with the best directions about the assignment? 1. "Encourage the client to increase daily fluid intake." = false. by how much to increase daily fluid intake? 2. "Ambulate the client 20 ft (6.7 m) every 4 hours beginning at 0900." (key) = this answer choice is objective and it's precise. 3. "Assist the client to perform passive range-of-motion (ROM) exercises." = it's not saying the type of exercises to do, it not telling us how often. not detailed enough. 4. "Reinforce physical therapy instructions about the proper use of a walker." = this is the job for the PN or VN to reinforce instruction/ education. CNA and UAP cannot reinforce teaching

Which laboratory result warrants immediate intervention by the nurse for the female client diagnosed with systemic lupus erythematosus (SLE) 1. A hemoglobin and hematocrit of 13 g/dL and 40%. 2. A erythrocyte sedimentation rate of 9 mm/hr. 3. A serum albumin level of 4.5 g/dL. 4. A white blood cell count of 15,000/mm3.

Which laboratory result warrants immediate intervention by the nurse for the female client diagnosed with systemic lupus erythematosus (SLE) 1. A hemoglobin and hematocrit of 13 g/dL and 40%. 2. A erythrocyte sedimentation rate of 9 mm/hr. 3. A serum albumin level of 4.5 g/dL. 4. A white blood cell count of 15,000/mm3. = this patient has Lupus they are already immune compromised. The normal range of WBC is 5,000 - 10,000. Therefore the patient is a risk for infection because they have an elevated WBC level.