NCLEX Practice

The nurse provides care for a client who underwent a vagotomy with antrectomy to treat a duodenal ulcer. Postoperatively, the client develops dumping syndrome. Which client statement indicates to the nurse that further teaching is necessary? 1. "I should eat bread with each meal." 2. "I should eat smaller meals more frequently." 3. "I should lie down after eating." 4. "I should avoid drinking fluids with my meals."

"I should eat bread with each meal."

When answering a question ask yourself:

"If I could do only one thing and then leave, what would I do?"

The LPN/LVN reporting to the nurse says, "You may want to see the client recently diagnosed with pancreatic cancer. I am not sure how well things are going." The nurse enters the room and finds the client sitting quietly, looking out the window. As the nurse approaches the client, the client does not look at the nurse. Which is the most appropriate question for the nurse to ask? 1. " Sleep problems are common during times of stress. Have you had difficulty sleeping?" 2. "Tell me what you know about your diagnosis and the treatment you will receive." 3. "How would you describe your overall health status up to this time in your life." 4. "How have you handled any health problems you experienced in the past?"

"Tell me what you know about your diagnosis and the treatment you will receive?"

A client arrives at the emergency department experiencing tingling and weakness in the lower extremities that started when getting out of bed. The client reports the symptoms seem to be progressing upward. Which statement by the client is most important for the nurse to pursue during the assessment process? 1. "My grandfather had polio when he was young." 2. "I have been a vegetarian for several months now." 3. "Things have been stressful at work lately." 4. "We have been in the final preparations for a trip overseas."

"We have been in the final preparations for a trip overseas." (Immunizations may have been given

A client is admitted to the emergency department. The family reports the client had a sudden onset of left-sided facial droop and slurred speech at home. The nurse observes left-sided muscle weakness. Which is the MOST important question for the nurse to ask? 1. "What over-the-counter medications does your parent take?" 2. "What was your parent doing when the symptoms began"? 3. "when did you notice the onset of your parents symptoms?" 4. "Does your parent have a hisory of high blood pressure?"

"When did you notice the onset of your parents symptoms?" (thrombolytic therapy can only be given within a narrow window of time.)

Medication treatment for heart failure include:

*Diuretics *ACE inhibitors *ARBs *Beta Blockers *Blood thinners *Positve Inotropes *Vasodilators

A nurse evaluates the urinary output of a client weighing 210 pounds, using the guideline of 0.5 mL/kg/hr to determine minimum acceptable total urinary output for the client. How much urine must the client produce in eight hours? Record your answer rounding to the nearest whole number. _____mL

-210 lbs/2.2=95.45 kg -95.45 kg x 0.5mL= 47.73 mL/hr -47.73 mLx 8 hours= 381.82 mL -Round to 382 mL ***382 mL***

Ensuring for Safety prior to engaging with a client:

-Assess for safety prior to engaging with a client -Maintain distance and step away if threatened -Employ de-escalation techniques -assess for triggers or altered mental status.

Common NCLEX Traps

-Do not ask "why". -Do not leave the client. -Do not persuade the client. -Do not say "don't worry" -Do not pass the buck. -Do not read into the question. -Do not "do nothing."(keep things the same)

How to prevent falls:

-Fall risk wristbands, room signs -socks with traction beading -bed in lowest position and bed/chair alarms -fall mats -supervision -monitor B/P and oxygenation

Risks for falling:

-History of falling -Impaired gait -Secondary diagnosis -Sensory Deficits -Environmental factors(cords, IV and machines)

Prescriptions given for a myocardial infarction include:

-Morphine -Oxygen -Nitroglycerin every 5 min for 3 doses -Aspirin -12 lead ECG with continuous monitoring

Who Do You See First Questions?

-Unstable vs. Stable -Unexpected vs. Expected -ABC's -Acute Vs Chronic -Actual vs. Potential

Guidelines for client's in restraints: (National Standards)

-assess the reason for altered mental status -constant supervision -quick-release tie to frame of bed(NEVER to siderails)!!!! -check circulation every 30 minutes for extremity restraints. -provide food, fluid, and toileting every 2 hours.

A patient who has dumping syndrome should:

-avoid drinking fluids with meal. -eat small, frequent meals. -lie down after eating.

Third-Degree Heart Block(needs immediate attention!!!!):

-client is symptomatic -usually results in failure, ischemia, or shock -Signs and symptoms include syncope, chest pain, and lightheadedness. -IMMEDIATE ATTENTION NEEDED.

Second-Degree Heart Block: (Types 1&2)

-client may or may not be symptomatic -MI is the common cause:

Premature Supraventricular Tachycardia triggers include:

-excess alcohol consumption -stress or extreme emotions -caffeine -hyperthyroidism -digitalis toxicity -hypokalemia -coronary artery disease -myocardial infarction -cardiomyopathy -cor pulmonale(right ventricular enlargement due to pulmonary hypertension.

Indications of DKA are:

-headache, blurred vision, confusion. or drowsiness. -Polydypsia(fruity(acetone) breath -dry flushed skin with elevated temperature -tachycardia, hypotension, Kussmaul respirations -nausea and vomiting -polyuria

Third-Degree Heart Block Treatment:

-identify underlying cause -ATROPINE, DOPAMINE AND EPINEPHRINE MAY BE ADMINISTERED TO INCREASE HR AND SUPPORT THE BLOOD PRESSURE(this is temporary measure)

Second-Degree Heart Block(Mobitz 2)Treatment:

-identify underlying cause -if the ventricular rate is slow and the client is symptomatic: *atropine is administered to increase the HR *if atropine is ineffective transcutaneous pacing

Fire Hazards within a hospital:

-oxygen -frayed or damaged electrical cords -cautery equipment in operating rooms or labs -microwaves or other heating equipment

Treatment for a client with diabetic ketoacidosis(DKA) is:

-slow, deep breaths -IV 0.9% sodium chloride(increase B/P ) -correction of hypokalemia(if present) -IV insulin as long as potassium is greater than or equal to 3.3 mEq/L -monitor glucose and electrolytes -Identify and correct precipitating factors

Key Points of Safety During A Blood Transfusion include:

-the rights of administration -continual assessment of the IV site(to ensure no infiltration) -monitoring current VS against baseline VS -physically assessing the client -assessing the infusion to avoid excess "hang time" -correct documentation (right client, right medication, right dose, right route and right time)

Isotonic fluids include:

0.9 NaCl.

The treatment for DKA is to rehydrate the client with:

0.9%NaCl**Given with a regular insulin drip(pushes glucose into cell and potassium follows)

A nurse applies a cardiac monitor to a client with parozysmal supraventricular tachycardia (PSVT). Which factors can contribute to the development of this rapid rhythm? (Select all that apply) 1 Extreme emotions 2 Hyperkalemia 3 Smoking Cigarettes 4 Coronary Valve Disease 5 Hypothyroidism

1 Extreme Emotions 3 Smoking Cigarettes 4 Coronary Valve Disease(these can affect atrial tissue)

The nurse prepares a client with multiple sclerosis for discharge. Which instructions are included in the discharge paperwork? (Select All that Apply) 1 Include 25-35 grams of dietary fiber daily 2 Follow a gluten-free dietary plan 3 Establish a daily, vigorous exercise routine. 4 Avoid the use of saunas and hot tubs 5 Establish daily routines for activities.

1 Include 25-35 grams of dietary fiber daily(to prevent constipation) 4 Avoid the use of saunas and hot tubs (extreme temperatures(hot or cold) can exacerbate MS symptoms such as fatigue, diminished motor ability, and decreased visual acuity. 5 Establish daily routines for activities(MS patients suffer from cognitive impairment.

A nurse ambulates a client after an appendectomy. The client becomes unsteady and starts to fall. Which actions does the nurse take? (Place Each option in order, first to last.)

1 Puts both arms around the client's waist, or grabs ahold of gait belt 2 Provides a wide base of support and stands with feet apart. The final step is assisting the client to the floor. 3 Puts one leg out and lets the client slide against it to the ground. 4 Bends the knees and lowers down as the client slides to the ground. The third step is to allow the client to safely slide to the ground by supporting the client with one leg.

Ileostomy includes:

1 stoma at the terminal ileum(curative for ulcerative colitis)

End colostomy is:

1 stoma(curative for rectal and colon cancer).***client is taught to irrigate this stoma***

The nurse admits a client to the postpartum unit and provides instruction about the postpartum process. The nurse determines that teaching is effective if the client makes which statement? 1. " I will call for assistance the first time I want to get out of bed. 2. "I can expect to pass clots the size of golf balls for the first 24 hours." 3. "I will use lanolin on my nipples when I breast feed my baby." 4. "I will allow my baby to suck no more than 5 minutes on each breast."

1. " I will call for assistance the first time I want to get out of bed."

The client is prescribed a 50 mcg/hr dose of transdermal fentanyl. Which statement by the client indicates understanding of the instructions? 1. "I should avoid placing a heating pad over the medication patch." 2. "If I develop a fever, less medication will be absorbed through my skin." 3. "The medication patch should be folded in half and put in the trash." 4. "I will leave the old patch on for a couple of hours after putting on the new one."

1. "I should avoid placing a heating pad over the medication patch."(Heat will increase absorption of the medication)

The healthcare provider prescribes metoclopramide 2 mg/kg IV to be given to a client 30 min before the client receives cisplatin. The client asks the nurse why the metoclopramide is being given. Which response will the nurse given to the client? 1. "Metoclopramide prevents or reduces the side effects caused by cisplatin." 2. "Metoclopramide increases the effectiveness of cisplatin." 3. "Cisplatin prevents or reduces the side effects of the metoclorpramide." 4. "Cisplatin increases the effectiveness of metoclopramide."

1. "Metoclopramide prevents or reduces the side effects of cisplatin." (Metoclopramide helps GI distress, and cisplatin is a chemotherapy medication.)

The nurse assesses a client diagnosed with Meniere disease. The client states, "I take prescribed medications regularly, but I continue to have episodes of vertigo." Which response by the nurse is MOST important? 1. "Tell me about your diet." 2. "How are things going at work." 3. "When was Meniere disease diagnosed?" 4. "What were the results of your last blood test?"

1. "Tell me about your diet."

The nurse is providing care for a client with a productive cough. The client's wbc count is 16,000 mm3. Arterial blood gas results are pH 7.33, PaCo2 47 mm Hg, PaO2 75 mm Hg, and HCO3 28 mEq/L. What action does the nurse take first? 1. Administer oxygen via face mask. 2. Administer levofloxacin intravenously. 3. Obtain pulse oximetry reading. 4. Administer sodium bicarbonate intravenously.

1. Administer oxygen via face mask.

The nurse works with an LPN/LVN on a team nursing unit. Which task is MOST appropriate for the nurse to delegate to the LPN/LVN? (SELECT ALL THAT APPLY) 1. Administering an intramuscular injection. 2. Administering a blood pressure medication intravenously. 3. Administering oral medications. 4. Referring a client to a long-term care facility. 5. Obtaining a capillary blood glucose.

1. Administering an intramuscular injection. 3. Administering oral medications. 5. Obtaining a capillary blood glucose

Which disease is characterized by anxiety about and avoidance of places or situations in which the ability to escape is limited or embarassing? 1. Agoraphobia 2. Arachnophobia 3. Sociophobia 4. Trypanophobia

1. Agoraphobia

The nurse is caring for a client with measles. Which transmission-based precaution does the nurse implement when caring for this client? 1. Airborne 2. Droplet 3. Contact 4. Neutropenic

1. Airborne

An elderly client says to the Emergency department nurse, "I have no energy, and it has gotten worse in the last several weeks." the client has a history of glomerulopnephritis and has been taking aluminum hydroxide/magnesium triscilicate frequently for the past 2 months. Which are appropriate actions for the nurse to complete a focused assessment? SELECT ALL THAT APPLY. 1. Assess bilateral deep tendon reflexes 2. Assess for the presence of Trousseau and Chvostek sign. 3. Determine the client's blood pressure. 4. Ask the client if urine output has decreased during the last week. 5. Assess if family noted any hallucination events from the client. 6. Determines client's respiratory rate.

1. Assess bilateral deep tendon reflexes. 3. Determine the client's blood pressure. 4. Ask the client if urine output has decreased during the last week. 6. Determine client's respiratory rate.

The health care provider prescribes an increase in the pareneral nutrition(PN) infusion rate from 50 mL/hr to 100 mL/hr. The PN is infusing through a peripherally inserted central catheter device. Which is the PRIORITY action for the nurse to take? 1. Assess hourly urine 2. Evaluate serum total protein level. 3. Assess VS every 4 hours. 4. Evaluate aspartate aminotransferase(AST)

1. Assess hourly urine.

A client diagnosed with left-sided heart failure receives oxygen at 4 L/min per nasal cannula, oral furosemide 40 mg/daily, and oral enalapril 5 mg daily. Which action should the nurse take FIRST? 1. Auscultate lung sounds 2. Assess skin turgor over the client's hand. 3. Measure specific gravity of the urine. 4. Lightly palpate the left upper quadrants of the abdomen.

1. Auscultate lung sounds.

The nurse takes care of a client who has a chest tube and a pleural drainage system placed for right-sided pneumothorax. The suction control chamber is set at 20 cm and tubing is attached to the wall suction. Which finding will the nurse expect to observe after the insertion of the chest tube? 1. Bubbling in the water-seal chamber. 2. Serosanguinous drainage in the collection chamber. 3. Fluctuation in the suction control chamber during coughing. 4. 1 cm sterile water in water-seal chamber.

1. Bubbling in the water-seal chamber.(NOT continuous though)

The nurse assesses a client who has a distended bladder. Because the client is unable to void, the health care provider prescribes catheterization. Which action does the nurse perform IMMEDIATELY after the catheter is inserted? 1. Clamps device after 500 mL of urine is drained. 2. Keeps the client in prone position 3. Asks the client to take deep breaths. 4. Asks the client if he has had this problem before.

1. Clamps device after 500 mL of urine is drained.

The nurse on the telemetry unit is receiving a new admission from the medical-surgical unit. Which client currently on the telemetry unit should the nurse suggest be sent to the medical-surgical unit? 1. Client magnesium level 1.6 mg/dL. 2. Client scheduled for cardiac catherization the next morning. 3. Client with digoxin level 2.4 ng/mL. 4. Client who reported chest discomfort during cardiac stress test.

1. Client magnesium level 1.6 mg/dL.

When assessing the incision of a client 2 days postoperatively, the nurse notes a shiny pink area with underlying bowel visible. Which action does the nurse implement? 1. Cover the area with sterile gauze soaked in normal saline. 2. Cleanse the wound with hydrogen peroxide and apply a sterile dressing. 3. Pack the opened area with sterile 3/4 inch gauze socked in normal saline. 4. Apply antibacterial ointment and cover with clear adhesive dressing.

1. Cover the area with sterile gauze soaked in normal saline.

The nurse is delegating tasks to the UAP. For which UAP action does the nurse intervene? 1. Decreases the oxygen flow rate from 4 L/min to 2 L/min for a client being titrated off oxygen therapy. 2. Reapplies the nasal cannula for a client who displaces the oxygen tubing. 3. Reports a decrease in the client's systolic blood pressure to the health care provider. 4. Reports an abnormal blood glucose value to the nurse. 5. Assists a healthy, multiparous, postpartum client to the bathroom for the first time following childbirth.

1. Decreases the oxygen flow rate from 4 L/min to 2 L/min for a client being titrated off oxygen therapy. 3. Reports a decrease in the client's systolic blood pressure to the health care provider. 5. Assists a healthy, multiparous, postpartum client to the bathroom for the first time following childbirth.

The school nurse notices a group of children on the playground surrounding a child who appears to be choking. The nurse observes that the child is conscious and coughing, and the children report the child was eating raisins. Which action will the nurse take FIRST? 1. Encourage the child to continue coughing. 2. Instruct a teacher to call 911. 3. Ask the child to speak. 4. Begin abdominal thrusts.

1. Encourage the child to continue coughing.

The health care provider prescribes a unit of packed red blood cells. For a client admitted with lower gastrointestinal bleeding. Which step will the nurse take when administering the blood product? (SELECT ALL THAT APPLY) 1. Ensure adequate infusion access is present before obtaining blood from the blood bank. 2. Initiate the transfusion within 1 hour of removing blood from blood bank refrigerator. 3. Use a two-person verification process to match the unit of blood to the prescription and the client to the unit of blood. 4. Monitor the client closely during the first 15-30 minutes of administration. 5. Ensure the administration times does not exceed 6 hours.

1. Ensure adequate infusion access is present before obtaining the blood from the blood bank. 3. Use a two-person verification process to match the unit of blood to the prescription and the client to the unit of blood. 4. Monitor the client closely during the first 15-30 minutes of administration.

The nurse reviews a list of patients waiting to be seen in the emergency department. Which client will the nurse select to be seen immediately? (Select All That Apply). 1. Experiencing a tingling sensation in the face and arm. 2. Reporting chest heaviness. 3. Experiencing redness on the lower legs for the last week. 4. Reporting a needle stick while being medicated. 5. Demonstrating drowsiness after taking cyclobenzaprine. 6. Experiencing headache, fever and neck stiffness.

1. Experiencing a tingling sensation in the face and arm. 2. Reporting chest heaviness. 4. Reporting a needle stick while being medicated. 6. Experiencing headache, fever, and neck stiffness.

The client receives a blood transfusion and experiences a hemolytic reaction. Which assessment findings does the nurse anticipate? (SELECT ALL THAT APPLY) 1. Hypotension 2. Low-back pain 3. Wet breath sounds 4. Fever 5. Urticaria 6. Severe shortness of breath (TOPIC: signs and symptoms of a hemolytic reaction.)

1. Hypotension 2. Low-back pain 4. Fever

The nurse supervises care for a client whose blood glucose is 525 mg/dL. pH is 7.1, and serum bicarbonate level is 14 mEq/L. Ketonuria is also present. Which statement requires the nurse to intervene? (SELECT ALL THAT APPLY) 1. I should add 5% dextrose to the IV fluids when the client's blood glucose drops below 100 mg/dL. 2. The client's potassium level will increase as the blood glucose decreases. 3. The client's laboratory results are characteristic of hyperglycemic hyperosmolar syndrome. 4. The client requires a STAT electrocardiogram. 5. I should check the client's blood glucose every 2 hours.

1. I should add 5% dextrose to the IV fluids when the client's blood glucose is 100 mg/dL.(This should be done when the blood glucose drops between 250-300-to prevent hypoglycemia) 2. The clients potassium level will increase as the blood glucose decreases.(the potassium will decrease as the blood glucose decreases) 3. The client's laboratory results are characteristic of hyperglycemic hyperosmolar syndrome. (NO this is DKA) **DKA can cause a myocardial infarction(electrocardiogram STAT) 5. I should check the client's blood glucose every 2 hours. (Blood glucose should be checked every hour).

The nurse supervisor is informed that three serious safety events occurred last month between 0730 and 0800. The last serious safety event occurred because the oncoming nursing shift did not know the client was receiving an intravenous insulin drip. Which action is the PRIORITY for the nurse supervisor to take? 1. Implement mandatory bedside reporting. 2. Discuss unsafe nursing practices with local media. 3. Delay action until hospital risk manager has completed a full investigation. 4. Ask another nurse manager for suggestions.

1. Implement mandatory bedside reporting.

The nurse provides care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which finding indicates to the nurse that the client is experiencing cor pulmonale? 1. Jugular Vein Distension 2. Whitish Frothy Sputum 3. Finger Clubbing 4. Chest Tightness

1. Jugular Vein Distension

The nurse prepares discharge teaching for a client who experiences acute asthma episodes. Which medication will the nurse instruct the client to take if experiencing sudden shortness of breath? 1. Levalbuterol 2. Montelukast 3. Fluticasone propionate 4. Salmeterol

1. Levalbuterol

The nurse ambulates a client in the hallway and notes that smoke is coming from the kitchen area. Which action does the nurse take next? 1. Move the client away from the kitchen area, pull the fire alarm, close all client room doors. 2. Pull the fire alarm, close all client room doors, move the client away from the kitchen area. 3. Notify the charge nurse, obtain a fire extinguisher, extinguish the fire. 4. Move the client away from the kitchen area, close the kitchen door, begin evacuating all clients.

1. Move the client away from the kitchen area, pull the fire alarm, and close all client doors.

The nurse provides care to a client with an epidural catheter for pain control with fetanyl after spinal fusion surgery. Which action will the nurse include when providing post-operative care to this client? (SELECT ALL THAT APPLY) 1. Perform peripheral neurovascular checks every 2 hours. 2. Ambulate the client around the hallway. 3. Assess for bowel and bladder distention 4. Keep the client at nothing by mouth status. 5. Monitor client for nausea and vomiting.

1. Perfrom peripheral neurovascular checks every 2 hours. 3. Assess for bowel and bladder distention. 5. Monitor client for nausea and vomiting.

A client returns to the recovery area after a colonnscopy procedure. Intravenous midazolam was administered during the procedure. The procedure was completed by 11:15. The recovery room nurse reviews the sedation chart below. Based on this information, which is the MOST important action for the nurse to take? 1. Recheck blood pressure in 15 minutes. 2. Administer ordanestron 4 mg IV. 3. Obtain a 12-lead electrocardiogram(ECG) 4. Assist client to get dressed.

1. Recheck the blood pressure in 15 min.

The new nurse learns during orientation that Magnet hospitals are known as high performance organizations. Which statement is MOST accurately characterizes why this is true of Magnet hospitals? 1. Recognize the importance of attracting and retaining talented employees. 2. Experience high employee turnover 3. Maintain the status quo and as a result they do not experience chance or turmoil. 4. Hire a lower percentage of baccalaurate-prepared nurses.

1. Recognize the importance of attracting and retaining talented employees.

The nurse administers and incorrect dose of medication to the client. Which actions are appropriate for the nurse to take in this situation? (SELECT ALL THAT APPLY). 1. Record the dose of medication administered. 2. Document in the health record that an incident report was completed. 3. Perform an assessment of the client. 4. Contact the Health Care Provider. 5. Document any adverse reaction that the client experienced. 6. Submit an incident report to the risk manager within 48 hours of the event.

1. Record the dose of medication administered 3. Perform an assessment of the client. 4. Contact the health care provider. 5. Document any adverse reaction that the client experienced.

The nurse is providing teaching on safety to a class of 17-year-old students. Which topic is most important for the nurse to discuss? 1. Safety during driving 2. Safety during swimming. 3. Tobacco and substance use. 4. Safe sexual practices.

1. Safety during driving

The nurse cares for a 55-year-old client diagnosed with Type 1 diabetes. The client's blood glucose level is 750 mg/dL, and ketones are present in the blood and urine. The client is given 0.9% normal saline infusions and a continuous insulin(regular) IV infusion. The nurse determines that treatment is effective if which finding is observed? 1. Serum hematocrit 48%(0.48) 2. B/P 118/78, apical pulse 110 bpm, respirations 25. 3. Arterial blood serum bicarbonate 13 mEq/L 4. Blood Urea Nitrogen 22 mg/dL.

1. Serum hematocrit 48%(0.48)

The nurse provides care for a client receiving chemotherapy and radiation who has several bruises. Which nursing intervention will be part of the care plan to prevent further injury?(SELECT ALL THAT APPLY) 1. Shave with an electric razor. 2. Allow the client to be up without supervision as tolerated. 3. Avoid enemas and suppositories. 4. Administer stool softeners. 5. Place an indwelling catheter.

1. Shave with an electric razor. 3. Avoid enemas and suppositories. 4. Administer stool softeners.

The client is diagnosed with heart failure. The nurse receives a new prescription to administer IV chlorothiazide. The nurse questions this prescription based on what laboratory results? (Select All That Apply). 1. Sodium 128 mEq/L 2. Serum Calcium 12 mg/dL 3. Serum Potassium 5.3 mEq/L 4. Serum pH 7.48 5. BUN 15 mg/dL 6. Urine Specific Gravity 1.022

1. Sodium 128 mEq/L 2. Serum Calcium 12 mg/dL 4. Serum pH 7.48

The nurse provides care for a client who is provided assist-control mechanical ventilation with positive end-expiratory pressure (PEEP) of 5 cm H2O. Which actions will the nurse include in the client's plan of care?(SELECT ALL THAT APPLY). 1. Strict handwashing before suctioning 2. Brushing every 12 hours. 3. Elevating the head of the bed 20 degrees. 4. Administering pantoprazole 40 mg intravenous daily. 5. Changing client position every 2 hours.

1. Strict handwashing before suctioning 4. Administering pantoprazole 40 mg intravenous daily(helps prevent aspiration) 5. Changing client position every 2 hours.

The nurse is explaining potential reasons to file an incident report to a new graduate nurse. When does the nurse file an incident report? (SELECT ALL THAT APPLY) 1. The nurse administers one tablet of medication when two tablets were prescribed. 2. The nurse holds the prescribed blood pressure medication because the client's blood pressure is too low. 3. The nurse notes that an IV pump has not delivered the amount of fluid it was set to deliver. 4. The nurse obtains O positive blood from the blood bank for transfusion and identifies that the patient is O negative. 5. the nurse administers insulin lispro to a client and the food tray is delivered 45 minutes later.

1. The nurse administers one tablet of medication when two were prescribed. 3. The nurse notes that an IV pump has not delivered the amount of fluid it was set to deliver. 4. The nurse obtains O positive blood from the blood bank for transfusion and identifies that the client is O negative. 5. The nurse administers insulin lispro to a client and the food tray is delivered 45 minutes later.

The nurse provides care for a client diagnosed with type 1 diabetes mellitus. Which assessment finding alerts the nurse to a hypoglycemic(blood sugar below 70) reaction? (SELECT ALL THAT APPLY) 1. Tremors 2. Hot, dry skin 3. Nervousness 4. Slurred Speech 5. Muscle cramps 6. Headache

1. Tremors 3.Nervousness/Anxiety 4. Slurred speech/confusion 6. headache *perspiration*

A client diagnosed with rheumatoid arthritis(RA) is prescribed 50 mg etanercept subcutaneous weekly. The client reports joint swelling, symmetrical joint pain, and deformities of both hands. Which finding does the nurse report to the health care provider? 1. WBC count 14,000 mm 2. C-reactive protein 1.2mg/dL 3. Serum hemoglobin 9 mg/dL. 4. Sedimentation rate 22 mm/hr.

1. WBC count 14,000 mm (infection)

Normal Urine Specific gravity is:

1.010-1.030

A therapeutic value for a PTT are usually:

1.5-2 times the normal value

Magnesium

1.5-2.5

Normal BUN levels are:

10-20 mg/dL

Sodium

135-145

If a patient suffering from hypoglycemia is conscious have them consume:

15-20 grams of glucose or simple carbohydrates. (check after 15 min and repeat if still hypoglycemic).

A normal platelet count is:

150-450,000 mm

A pediatric client is diagnosed with pneumonia and prescribed ampicillin 50 mg/kg oral suspension every 6 hours. The child weighs 18 lbs(8.181818 kg). The ampicillin is available in 125 mg/5mL. How many mL will the nurse administer for each dose? (Record your answer rounding at the end of your calculations to the nearest whole number.) __________________mL

16 mL

A nurse mentors a nursing student who is designing an education board for decreasing risk factors for gastric cancer. The student nurse exhibits an understanding of the risk factors with which statement? 1 "Gastric cancer occurs most often in middle adulthood" 2 "Switching to mostly plant-based diet can reduce the risk of gastric cancer." 3 "Weight is unrelated to the occurrence of gastric cancer." 4 "Dietary intake of Vitamin C has been shown to increase gastric cancer risk."

2 "Switching to mostly plant-based diet can reduce the risk of gastric cancer."

A client returns to the surgical unit after undergoing transurethral resection of the prostate (TURP). The nurse prepares for continuous bladder irrigation (CBI) using which solution? 1 Sterile Water 2 0.9% Nacl 3 Lactated Ringers Solution 4 Dakin solution

2 0.9% Nacl(ideal for irrigations)***does not cause fluid shifts***

The nurse admits a client with suspected acute myocardial infarction (MI). How soon after the onset of chest pain does the nurse expect elevation of blood levels of creatine-kinase-MB(CK-MB)? 1 8-12 hours 2 4-6 hours 3 0.5-1.5 hours 4 1-2 hours

2 4-6 hours (CK-MB levels peak within 24 hours)

The nurse provides care to a client diagnosed with acquired immunodeficiency syndrome (AIDS). Two weeks earlier the client was prescribed nevirapine, a non-nucleoside reverse transcriptase inhibitor (NNRTI). For which adverse reactions does the nurse assess? (Select all the apply) 1 Raised pink or brown lesions on the legs and trunk 2 A pH of 7.33 found on ABG analysis 3 Increased bacteria in the urine 4 White patches in mouth 5 Yellowing of the sclera and palms

2 A pH of 7.33 found on ABG analysis 5 Yellowing of the sclera and palms

A nurse writes a care plan for a client with symptomatic Paget disease of bone. What interventions does the nurse include for symptom management during the client's hospitalization? (Select all that apply) 1 Prepare the client for bone scan 2 Administer alendronate as prescribed 3 Use heat therapy 4 Administer ibuprofen as prescribed. 5 Advise client to increase intake of Vitamin D.

2 Administer alendronate as prescribed(targets the osteoclast-the cell responsible for Paget disease.) 3 Use heat therapy (reduces pain and increases mobility) 4 Administer ibuprofen as prescribed (to manage pain)

A nurse instructs a client with gastroesophageal reflux disease (GERD) on potential complications if the disease is left untreated. The nurse includes which complications in the teaching plan? (Select all that apply) 1 Hiatal Hernia 2 Barrett's esophagus 3 Chronic cough 4 Esophagitis 5 Ulcers

2 Barrett's esophagus 3 Chronic cough 4 Esophagitis 5 Ulcers

While assessing a client with aortic regurgitation, the nurse notes Corrigan's pulse. What characterizes this finding upon examination? 1 Narrow Pulse Pressure 2 Bounding pulse, with rapid rise and fall 3 Weak pulse with prolonged peak 4 Weak, thready pulse

2 Bounding pulse, with rapid rise and fall (associated with increased stroke volume and peripheral resistance)

A nurse counsels a client with anemia on iron-rich foods. Which foods does the nurse encourage the client to eat? (Select all that apply) 1 Bananas 2 Chicken liver 3 Whole Milk 4 Pistachios 5 Baked Beans

2 Chicken Liver 4 Pistachios 5 Baked Beans

The nurse receives report on a client status post frontal craniotomy. Which nursing actions does the nurse implement once the client arrives on the unit? 1 Infuse intravenous fluids at a rate of 150 mL/hr 2 Elevate the head of the bed to 30 degrees. 3 Cluster routine nursing care activities. 4 Apply intermittent sequential pneumatic devices. 5 Give dexamethasone as prescribed.

2 Elevate head of the bed to 30 degrees. 4 Apply intermittent sequential pneumatic devices. 5 Give dexamethasone as prescribed.

Before administration of the influenza vaccine, the nurse informs the client about which common side effects? 1 Tinnitus 2 Fever with myalgia 3 Blurred vision 4 Injection site pain 5 Constipation

2 Fever with myalgia 4 Injection Site Pain

A client with a sodium level of 116 mEq/L and a potassium level of 2.5 mEq/L resulting in severe hypotonic dehydration requires IV fluids. The nurse performs which action to safely correct the client's fluid balance? (Select All that apply) 1 Encourage client to drink 500 mL every 4 hours. 2 Give the client 100 mL of 3% saline over one hour. 3 Administer client's 25 mg hydrochlorothiazide orally. 4 Give the client dextrose 5% normal saline 0.9% at 125mL/hr. 5 Initiate a heart-healthy, 2 g sodium diet.

2 Give the client 100 mL of 3% saline over one hour. ***3% saline=High Alert Medication)*** Frequent serum sodium labs to ensure sodium is not rising more than 4-6 mEq/L in 12 hours and no more than 8 mEq/L in 24 hours.

INR(therapeutic value)is:

2-3

A client who is diagnosed with end-stage kidney disease is prescribed hemodialysis treatments three times a week. After two weeks of treatment, the client states, "I have a headache when the dialysis finishes. Is this normal?" What is the MOST appropriate response by the nurse? 1. "I have seen this a lot in clients, don't worry much about it." 2. "Headaches may occur at the beginning of treatment and should improve over time. 3. "Have you experienced any headaches similar to these in the past?" 4. "Why are you so worried about this? It is a common side effect."

2. "Headaches may occur at the beginning of treatment and should improve over time."

A client is diagnosed with sickle cell crisis has received multiple blood transfusions. Which client statement MOST concerns the nurse? 1. "My skin looks more yellow today." 2. "My heart has been skipping beats frequently today. 3. "My stomach has been hurting today." 4. " I'm so tired after doing simple household chores."

2. "My heart has been skipping beats frequently today."

At a rehabilitation center for clients with spinal cord injuries (SCIs), the nurse conducts an orientation session for a group of unlicensed assistive personnel(UAP). Which statement is most important for the nurse to include? 1. "The clients may appear angry at times." 2. "Obtain the client's permission before touching the client." 3. "Most clients arrive believing they will walk out of here." 4. "Personnel in this environment often need counseling."

2. "Obtain the client's permission before touching the client."

The nurse provides car for a client who was just informed about a cancer diagnosis. Which statement by the nurse demonstrates empathy? 1. "Tomorrow will be better." 2. "This must be difficult news to hear." 3. "What are your fears about this diagnosis?" 4. "I believe you can overcome this."

2. "This must be difficult news to hear."

The nurse receives report on the client care area. Which client should the nurse see FIRST? 1. A 13-year-old boy with a tracheostomy is turning relentlessly in bed. Vital signs are: blood pressure 110/64, pulse 104, and respirations 24. 2. A 16-year old boy in balanced suspension traction for a left fractured femur appears pale. The client reports severe muscle spasms in the left leg. 3. A 52-year-old woman on a ventilator is attempting to talk. The peak airway (inspiratory) pressure has gradually increased over the last 2 hours. 4. A 68-year-old man returned form a total laryngectomy 12 hours ago. The client requires suctioning every 30 minutes to 1 hour for large amounts of serosanguinous secretions.

2. A 13-year-old boy with a tracheostomy is turning relentlessly in bed. Vital signs are 110/64(low b/P), pulse of 104(high), and respirations 24(high)

The nurse receives new admissions. Which patient should be placed in a private room? 1. A client diagnosed with Pneumocystis Jeroveci Pneumonia. 2. A client diagnosed with group A streptococcus cellulitis. 3. A client diagnosed with Guillain-Barre Syndrome. 4. A client diagnosed with cutaneous anthrax.

2. A client diagnosed with group A streptococcus cellulitis.

The nurse cares for a client 12 hours after a gastrectomy procedure. The client is pale, diaphoretic, and confused. Vital signs are: B/P-100/46, apical pulse 130 bpm, and respirations 24 per minute. Which action does the nurse take first? 1. Administer noepinephrine by continuous IV infusion. 2. Administer oxygen by non-rebreather mask. 3. Insert an indwelling urinary catheter. 4. Administer 5% dextrose in water @ 150 mL/hr.

2. Administer oxygen by non-rebreather mask.

The nurse provides care for a client at risk for urinary incontinence. Which client care activity does the nurse delegate to a nursing assistive personnel (NAP)? (SELECT ALL THAT APPLY). 1. Perform a bladder scan with nurse supervision 2. Clean the client after an episode of incontinence. 3. Teach the client to perform pelvic floor exercises. 4. Determine the type of incontinence the client has. 5. Assist the client in using the bathroom or commode.

2. Clean the client after an episode of incontinence. 5. Assist the client in using the bathroom or commode.

The nurse delegates care of a client diagnosed with osteoporosis to a nursing assistive personal (NAP). Which instruction is MOST important for the nurse to include? 1. Monitor the urinary output. 2. Clean up clutter in the room. 3. Encourage client to bathe independently. 4. Perform passive range-of-motion exercises.

2. Clean up clutter in the room.

The nurse coordinates care on the medical-surgical unit. Which client indicators, if assigned by the nurse to the LPN/LVN, suggest professional negligence? (Select all that apply) 1. Client with wbc count of 7,000. 2. Client with hemoglobin 6 g/dL. 3. Client with BUN 80 mg/dL. 4. Client with prothrombin time of 10 seconds. 5. Client with glucose 130 mg/dL. 6. Client with platelet count of 22,000mm.

2. Client with hemoglobin of 6 g/dL. 3. Client with BUN 80 mg/dL. 6. Client with platelet count of 22,000mm.

A client experiences a transient ischemic attack(TIA). The nurse informs the client upon discharge that which factor is associated with an increased risk of stroke after a TIA? 1. Clear Speech 2. Diabetes Mellitus 3. Symptoms lasting less than 10 minutes. 4. Younger age.

2. Diabetes Mellitus

Upon assessment of a client admitted for dehydration, the nurse observes that the client appears restless and reports difficulty breathing. Upon auscultation of the client's lungs, the nurse notes bilateral basilar crackles. Which actions will the nurse take FIRST? 1. Place the client on 2 L of oxygen by nasal cannula and auscultate the lungs. 2. Elevate the head of the bed and stop the IV infusion. 3. Decrease the IV flow rate and administer furosemide as prescribed. 4. Stop the IV infusion and notify the health care provider.

2. Elevate the head of the bed and stop the IV infusion.

The nurse provides care for a client diagnosed with cutaneous Kaposi sarcoma lesions. The nurse notes the lesions are open and draining small amounts of serous fluid. Which personal protective equipment(PPE) does the nurse use when bathing and changing the linens for this client? 1. Gloves. 2. Gown and Gloves. 3. Gown, gloves and mask. 4. Gown and gloves to change the linens; gloves when bathing.

2. Gown and gloves

The nurse is preparing to administer Ibuprofen 800 mg to a client. Which information is MOST important for the nurse to obtain prior to administration? 1. Pain level 2. History of allergy to aspirin 3. Liver Enzymes 4. Hemoglobin level

2. History of allergy to aspirin (Priority)

The nurse is preparing to adminster lisinopril 10 mg and furosemide 20 mg to a client. The client's B/P is 150/89 mm Hg. The client's serum potassium level is 5.2 mEq/L and serum sodium level of 136 mEq/L. Which action should the nurse take NEXT? 1. Obtain an ECG. 2. Hold the lisinopril and notify the health care provider. 3. Administer a potassium supplement along with medications. 4. Administer both medications.

2. Hold the lisinopril and notify the health care provider.

The nurse provides care for a client who takes digoxin for heart failure. Which finding is a PRIORITY for the nurse to communicate to the health care provider(HCP)? 1. Presence of 1+ edema in the ankles 2. Intermittent nausea and loss in appetite 3. Serum potassium level of 3.8 mEq/L. 4. Weight gain of 2 lbs in one week.

2. Intermittent nausea and loss of appetite.

A client is admitted for regulation of insulin dosage. The client takes 15 units of isophane insulin at 0800 daily. At 1600, which nursing observations indicate a complication from the insulin? 1. Fruity breath, polyuria, and flushed skin. 2. Irritablity, tachycardia, and diaphoresis 3. Headache, nervousness, and polydipsia. 4. Tenseness, tachycardia, and anorexia.

2. Irritablity, tachycardia, and diaphoresis.

The nurse plans to teach a group of nursing assistive personnel(NAP) about measures to prevent catheter-associated urinary tract infections. Which measure does the nurse include?(SELECT ALL THAT APPLY) 1. Perform meticulous perineal care with soap and water every 48 hours. 2. Secure the catheter to prevent movement. 3. Maintain a closed drainage system. 4. Perform hand hygiene before and after contact with the client. 5. Encourage the client to drink 8-10 classes of fluid daily, if permitted.

2. Secure the catheter to prevent movement. 3. Maintain a closed drainage system. 4. Perform hand hygiene before and after contact with the client. 5. Encourage the client to drink 8-10 glasses of fluid daily, if permitted.

The nurse evaluates the progress of a client recently diagnosed with type 1 diabetes mellitus. As part of the treatment plan the client receives 32 units of intermediate-acting insulin and 8 units of short-acting insulin each morning. Which action, if performed by the client while preparing the morning insulin injection requires INTERVENTION by the nurse? 1. After drawing up 8 units of short-acting insulin, the client adds intermediate-acting insulin to the syringe for a total of 40 units. 2. The client draws up 32 units of the short-acting insulin followed by 8 units of intermediate-acting insulin for a total of 40 units. 3. Initially, the client injects air into the intermediate-acting insulin vial without drawing up any insulin. 4. The client injects air into each bottle of insulin equal to the amount of insulin to be withdrawn.

2. The client draws up 32 units of short-acting insulin followed by 8 units of intermediate-acting insulin for a total of 40 units.

The nurse performs a home care visit with a client diagnosed with a spinal cord injury at the level of T1. Which observation MOST concerns the nurse? 1. There is a reddened area on the client's right heel. 2. The client reports severe nasal decongestion. 3. The client reports a weak cough. 4. The client reports a "stinging needle" sensation when the feet are touched.

2. The patient reports severe nasal congestion. (a weak cough would be expect for a patient with a T1 spinal cord injury)

The nurse plans care for a 1-week old infant diagnaosed with tetralogy of Fallot(hole in heart). It is MOST important for the nurse to take which action? 1. Offer the client water every 4 hours. 2. Use high-flow soft nipple for feeding. 3. Position the infant on the abdomen after bottle-feeding. 4. Use only a gavage NG tube for feedings.

2. Use high-flow soft nipple for feeding.

Which are considered complementary and/or alternative therapies? (SELECT ALL THAT APPLY) 1. Digoxin(Lanoxin) 2. Zone Diet 3. Tai chi 4. Reiki

2. Zone Diet 3. Tai Chi 4. Reiki

An adult diagnosed with type 1 diabetes contacts the home care nurse. The client reports nausea and vomiting. Which is the MOST appropriate statement for the nurse to make? 1. "Do not take your usual dose of insulin." 2. "Check your blood glucose level every 3-4 hours." 3. "Increase your consumption of fruit juices and yogurt." 4. "You should eat six small meals a day with a bedtime snack."

2."Check your blood glucose level every 3-4 hours."

Phosphorus

2.5-4.5

Partial thromboplastin time(PTT) is:

20-39 seconds.

For a non-diabetic client the blood glucose should never exceed:

200 mg/dL.

The nurse assesses a client suspected of having glomerulonephritis. Which finding the nurse expect? 1 24-hour urine output of 2,200mL 2 WBC's present on urinalysis 3 2+ Generalized Edema 4 Blood pressure of 102/64 mm Hg

3 2+ generalized edema (generalized edema is expected in this condition-including edema in the face and periorbital area.)

A client recovers from a laryngectomy and is mechanically ventilated. Which action does the nurse take when caring for the client? 1 Suction the tracheostomy every 30 minutes. 2 Initiate the client's clear liquid diet. 3 Determine the tracheostomy minimal leak. 4 Determine the client's position of comfort.

3 Determine the tracheostomy minimal leak.

A nurse assists a health care provider with the application of a cast to a client with a fractured ankle. Which instruction takes priority? 1 Never scratch under the cast with a foreign object. 2 Elevate the affected ankle above the heart for 24 hours. 3 Report leg numbness to the healthcare provider immediately. 4 Weight-bearing instructions are given during a follow-up appointment.

3 Report leg numbness to the healthcare provider immediately. (Numbness is a sign of arterial insufficiency ****which can cause ischemia and cell death****)

A nurse cares for a client who sustained multiple fractures and a spinal injury from a motor vehicle collision. What action does the nurse prioritize to prevent complications when caring for this client on bed rest? 1 Perform vital signs every hour 2 Monitor Urine output closely 3 Reposition client every 2 hours. 4 Cluster Care to conserve energy

3 Reposition client every 2 hours(***Prevent Skin Breakdown***)

The client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow aspiration and biopsy. The client says, "I am frightened. I have never had this test before, and I don't know what to expect." Which statements will the nurse include when responding to the client's concerns? (SELECT ALL THAT APPLY) 1. "We will move you to the operating room where the test is always performed." 2. "The bone in the front of your chest will be used for the biopsy specimen." 3. "A tight pressure dressing will be placed over the test site after the procedure." 4. "You will not feel any discomfort as the local anesthetic is injected." 5. "There is a risk of bleeding, so we will monitor the test site frequently."

3. "A tight pressure dressing will be placed over the test site after the procedure." 5. "There is a risk of bleeding so we will monitor the test site frequently."

The home care nurse instructs a client diagnosed with multiple sclerosis(MS). The nurse notes that the client's speech is slow and slurred. Which client statement indicates to the nurse that further teaching is necessary? 1. "I will sit up straight when I talk and will feel confident." 2. "I will turn off the TV when speaking and look at the person with whom I am talking." 3. "During a conversation, I will carefully build up to my most important points." 4. "If words fail me, I will draw a picture."

3. "During a conversation, I will carefully build up to my most important point."

A client diagnosed with a Second-Degree Heart Block Type 1(Wenkebach) reports chest pain. Which prescription will the nurse question? 1. Morphine sulfate 4 mg IV STAT 2. Nitroglycerin 0.4 mg sublingual PRN every 5 min with a max of 3 doses. 3. 250 mL boluses of dopamine and 0.9% sodium chloride 4. 12-lead ECG and continuous ECG monitoring.

3. 250 mL boluses of dopamine and 0.9% sodium chloride(DO NOT GIVE, QUESTION This prescription!)

The nurse provides care for a client diagnosed with diastolic heart failure. The nurse observes the recent onset of the above rhythm. Which is the MOST appropriate action for the nurse to take? 1. Administer digoxin 0.25 mg IV 2. Instruct the client to take a deep breath and hold it. 3. Assess level of consciousness and orientation. 4. Auscultate posterior chest.

3. Assess level of consciousness and orientation.

The nurse in the emergency department assesses a client diagnosed with tonic-clonic epilepsy. The client's spouse states that the client has been taking phenytoin as prescribed, but has not been feeling well lately. Which client observation MOST concerns the nurse? 1. Reddish-brown urine, and the client reports constipation. 2. Acne, hirsutism, and gingival hyperplasia 3. Ataxia, slurred speech and nystagmus 4. The left arm is in a sling and the client walks with a limp. (TOPIC=complications from phenytoin)

3. Ataxia(lack of muscle control), slurred speech, and nystagmus.

The nurse is assessing a neonate born at 44 weeks gestation. Which finding does the nurse document as consistent with the newborn's gestational age? 1. Slow recoil of the pinna 2. Absence of plantar creases. 3. Cracked, peeling skin. 4. Abundant vernix

3. Cracked, peeling skin.

The parent of a 22-month old toddler plans to begin toilet training the child. Which is the MOST important factor for the nurse to stress to the mother? 1. Consistency in method 2. Maintain an positive attitude 3. Developmental readiness of the child. 4. Avoid comparing the child to peers.

3. Developmental readiness of the child.

The nurse knows that risk factors for glaucoma include: 1. Asian American Race 2. Decreased intraocular pressure 3. Diabetes 4. Younger age

3. Diabetes Other risk factors include: high intraocular pressure, older age, African American, family history of glaucoma, myopia, and hypertension.

The nurse provides care for a client with severe hypothermia. Which assessment will the nurse perform first? 1. Determine presence of shivering 2. Assess the skin for mottling 3. Examine cardiac monitor for dysrhythmias. 4. Review laboratory values for low calcium level.

3. Examine cardiac monitor for dysrhythmias.

The nurse delegates tasks to nursing assistive personnel(NAP). Which statement will the nurse make that indicates adherence to the rights of delegation? (SELECT ALL THAT APPLY) 1. "I gave Mr. Smith nausea medication 20 min ago. Can you go see if he feels better?" 2. "I am heading to lunch. Check with Mr. Jones in 15 min to see if the enema helped." 3. "I placed an indwelling catheter in Mr. John. Empty the urinary bag in 15 minutes and let me know how much he had for urine output." 4. "Mr Jackson can ambulate @ 0800 starting in his room with a walker. Once you are done, report to me how he did." 5. "I notice Mr. Johnson's temperature is not documented. Can you tell me what it is?"

3. I placed an indwelling catheter in Mr. John. Empty the urinary bag in 15 min and let me know how much he had for urine output. 4. "Mr Jackson can ambulate @ 0800 starting in his room with a walker. Once you are done, report to me how he did." 5. "I notice Mr. Johnson's temperature is not documented. Can you tell me what it is?"

The nurse provides teaching for an older client diagnosed with osteoporosis. Which instruction regarding exercise is MOST important for the nurse to provide to the client? 1. Avoid any exercise activities because they increase the risk of fracture. 2. Increase the intensity of exercise to lose weight. 3. Include weight-bearing activities in the exercise plan. 4. Exercise to strengthen muscles and improve muscle tone.

3. Include weight-bearing activities in the exercise plan.

The nurse cares for a client diagnosed with a head injury. The nurse notes the urinary output is 1,000 mL in 3 hours. Which action by the nurse is MOST appropriate? 1. Contact the health care provider 2. Administer 0.9% sodium chloride IV infusion @ 100 mL/hour. 3. Measure the urine specific gravity. 4. Obtain the client's weight.

3. Measure the urine specific gravity. ***(this will validate and confirm the client's diagnosis of diabetes insipidus(DI).***

The nurse provides care for a client who is recovering from DKA. The nurse teaches the client stratagies to prevent recurrence of this condition. Which preventative strategy is appropriate for the nurse to include in the teaching plan? 1. East six small meals per day. 2. Maintain appropriate follow-up care. 3. Monitor blood glucose levels frequently. 4. Test urine for ketone levels.

3. Monitor blood glucose levels frequently.

The nurse provides care for a client who has undergone detoxification of long-term opioid use. The nurse plans discharge teaching for the client. Which medication does the nurse include in the discharge teaching? 1. Diazepam 2. Vareninclin 3. Naltrexone 4. Disulfiram

3. Naltrexone

The nurse auscultates crackers throughout all lung fields and measures a heart rate of 132 bpm, a respiratory rate of 30, and blood pressure of 102/54 mm Hg in a client recovering from an esophagectomy. Which action will the nurse take FIRST? 1. Place the client on continuous pulse oximetry. 2. Monitor the client for changes in blood pressure. 3. Notify the health care provider. 4. Assist the client to use the incentive spirometer.

3. Notify the health care provider.

The nurse determines that the client's tracheostomy requires suctioning. Which action does the nurse take FIRST? 1. Elevate the head of the bed to 90 degrees. 2. Quickly insert the suction catheter. 3. Preoxygenate the client. 4. Put on clean gloves.

3. Preoxygenate the client.

The nurse caring for a client with an acute myocardial infection and chest pain delegates 5-minute vital sign assessments to nursing assistive personnel (NAP). The charge nurse intervenes and changes the assignment. Which right of delegation does the charge nurse following in this situation? 1. Right direction 2. Right communication 3. Right circumstance. 4. Right supervision.

3. Right Circumstance

A client diagnosed with malnutrition is prescribed continuous enteral feedings through a newly placed gastrostomy tube. Which actions will the nurse include in the plan of care?(SELECT ALL THAT APPLY) 1. Cover the insertion site with an adhesive blockage. 2. Add 8 hours of feeding to the bag at a time. 3. Rotate the gastrostomy tube 360 degrees once daily. 4. Auscultate for a whoosh through the gastrostomy tube. 5. Check for slight in-and-out movement of the gastrostomy tube.

3. Rotate the gastrostomy tube 360 degrees once daily.(prevents skin breakdown) 5. Check for slight in-and-out movement of the gastrostomy tube. (indicates tube is not embedded into stomach wall.)

The nurse provides care for a client diagnosed with hyperemesis gravidarum. The nurse assists the client to fill out a menu. Which menu selection would cause the nurse to intervene? 1. Banana and cereal 2. Pasta and Bread 3. Sausage and Cheese 4. Rice and potatoes

3. Sausage and Cheese

The terminally ill client reports to the nurse that a do-not-resusicitate(DNR) prescription has been initiated. The client is concerned that family members do not accept this wish. Which is the BEST action made by the nurse? 1. Reassure the client that things will work themselves out. 2. Allow the next of kin to make final health care decisions. 3. Schedule a meeting with the client and family. 4. Contact the hospital social worker.

3. Schedule a meeting with the client and family.

During a urinary bladder catheter insertion, with a size 16 French catheter on an older adult male, the nurse feels increased resistance. Which is the MOST appropriate action for the nurse to take? 1. Withdraw the catheter and apply more lubricant. 2. Instruct the client to take a deep breath and bear down. 3. Stop the insertion and instruct the client to take deep breaths. 4. Withdraw the catheter and notify the health care provider.

3. Stop the insertion and instruct the client to take deep breaths.

The nurse preceptor observes the novice nurse obtain blood through a peripherally inserted central catheter(PICC). Which observation requires an intervention by the nurse preceptor? 1. The nurse discards 1 mL of blood prior to obtaining the blood sample. 2. The nurse uses a 10 mL syringe to flush through the port of the catheter. 3. The nurse applies clean gloves prior to beginning the procedure. 4. The nurse uses the push-pause technique to flush the catheter..

3. The nurse discards 1 mL of blood prior to obtaining the blood sample. (it should be 3-5 mL of blood to prevent contamination)

A client diagnosed with cushing syndrome is hospitalized in preparation for transsphenoidal hypophysecotomy surgery. Which nursing intervention is most important for the client at this time? 1. Place the client on seizure precautions 2. Discourage intake of potatoes, orange juice, and bananas. 3. Use a lift sheet to reposition the client. 4. Ask how client has coped with physcial changes of the disease.

3. Use a lift sheet to reposition the client(to prevent pathological fractures)

The nurse has taught a female client who is pregnant about expected physiological changes. The nurse should follow-up if the client states that which of the following is a normal finding during pregnancy? 1. Constipation 2. painful leg cramps 3. enlargement of moles 4. a line of pigmentation on the abdomen.

3. enlargement of moles

The nurse is caring for assigned clients. Which of the following clients may be experiencing a complication that the nurse should recognize? 1. The client with COPD who is performing pursed lip breathing while sitting in a chair. 2. the client who had a ileostomy created 6 hours ago and has a small amount of blood in the ileostomy drainage bag. 3. the client who had a vaginal hysterectomy 2 days ago and has saturated 1 perineal pad in the past 3 hours. 4. the client with hepatic cirrhosis who has spider angiomas on the nose and cheeks and has clay colored stools.

3. the client who had a vaginal hysterectomy 2 days ago and has saturated 1 perineal pad in the past 3 hours.

The nurse has received information about assigned clients. The nurse should first assess the client. 1. whose respirations decreased to 16 one hour after paracentesis 2. who has expectorated blood-tinged mucus 6 hours after bronchoscopy. 3..whose left leg is cool to the touch 2 hours after a cardiac catherization via the left femoral artery. 4..who has shoulder pain rated 5 on a scale of 0(no pain) to 10 (severe pain) 4 hours after a laparoscopic cholecystectomy.

3. whose left leg is cool to the touch 2 hours after cardiac catherization via the left femoral artery.

The nurse meets with the parent of an adolescent male who presents for an annual health maintenance visit. The parent voices concern that the child has recently become clumsy and uncoordinated. Which response by the nurse is correct? 1. "Your son might have attention deficit hyperactivity disorder." 2. "I'll talk with the health care provider about assessing for subtle motor dysfunction." 3. "Your son's clumsiness is expected at this age." 4. "This may be an early sign of depression."

3."Your son's clumsiness is expected at this age."

A gastric ulcer will cause pain:

30-60 minutes after eating.

A nurse develops a plan of care for acute pain control in a client who is one-day post knee replacement surgery. What short-term goal does the nurse establish for this client? 1 Client will be able to mobilize 25 feet without discomfort in 24 hours. 2 Client will report being pain-free after 12 hours of intervention. 3 Client will not require narcotic pain medication for next 8 hours. 4 Client will report pain level of less than 6 on 0-10 scale within 8 hours.

4 Client will report pain level of less than 6 on a 0-10 scale within 8 hours. (***GOALS***=specific and realistic)

A nurse examines a client for a suspected peptic ulcer rather than a gastric ulcer? 1 Hematemesis occurs more than melana. 2 Atrophic gastritis also occurs. 3 Pain occurs within one hour of eating. 4 Pain is relieved by eating food.

4 Pain is relieved by eating food.(Pain resumes 2-3 hours after a meal)

A transfusion should NEVER last more than:

4 hours!!!(Increased risk for infection after 4 hours)

HbA1c normal level is:

4-6%

The nurse instructs a client on advance directives. Which client statement indicates to the nurse a need for further education? 1. " Advance directives should be completed long before a medical crisis develops." 2. "I decide who will make health care decisions for me if I chose a Health Care Proxy." 3. "A living will means my family will know what life-sustaining measures I want taken." 4. "A power of attorney for health care prevents my children from selling my home."

4. "A power of attorney for health care prevents my children from selling my home."

A client of Asian decent receives information about a recommended surgery from the health care provider, yet refuses to sign the consent form. Which response by the nurse is best? 1. "Did you understand what the health care provider said to you about the surgery?" 2. "Why won't you sign the form after the health care provider recommend the surgery?" 3. "I will have to call the surgeon and have your surgery cancelled until you can make a decision?" 4. "Are there other people that you want to talk with before making this decision?"

4. "Are there other people that you want to talk with before making this decision?"

The nurse has attended a staff education program about infection control guidelines. Which of the following statements by the nurse would indicate a correct understanding of the program? 1. "I will wear a particulate respirator mask (N95) when feeding a client with influenza" 2 :I will wear a surgical mask when checking the pulse of the client with pulmonary tuberculosis (TB). 3. "I should wear a protective gown when entering the room of a client with meningococcal meningitis." 4. "I should wear clean gloves when bathing a client with atopic dermatitis(eczema) who has draining lesions."

4. "I should wear clean gloves when bathing a client with atopic dermatitis(eczema) who has draining lesions."

The nurse is providing safety education to a new parent about infant safety. Which is the MOST important statement for the nurse to include? 1. "The infant should be placed in a forward-facing car seat in the back seat." 2. "Place safety locks on all cabinet doors and toilet." 3. "Ensure that pot handles are turned away from the front of the stove." 4. "Place the infant to sleep on his or her back in a bare crib."

4. "Place the infant to sleep on his or her back in a bare crib."

The nurse receives a call from the adult child, who reports, "I just got here to see my elderly parent, who I think has had heat stroke. I think the air conditioning is not working, and the house is very hot." The adult child reports the parent is confused, very thirsty, nauseated, and in pain. Which is the MOST appropriate response for the nurse to make? 1. "If perspiration is present, heat stroke has not occurred." 2. "Give your parent cool fluids to drink immediately." 3. "What medications does your parent take daily?" 4. "Remove any excess clothing immediately."

4. "Remove any excess clothing immediately."

The nurse reviews medical records to identify clients who require fall risk precautions. Which client is at the highest risk for falls? 1. A young adult client diagnosed with appendicitis is receiving 0.9% sodium chloride IV. 2. An older adult client diagnosed with Parkinson Disease is receiving carbidopa/levodopa PO. 3. An adult client diagnosed with pneumonia and altered mental status is receiving amoxicillin PO. 4. An older adult client diagnosed with a stroke and hemiplegia is receiving heparin IV.

4. An older adult client diagnosed with a stroke and hemiplegia is receiving heparin IV.

A client takes a statin as prescribed. Which action does the nurse implement to identify if the client is experiencing any side effects of the medication? 1. Measure height and weight 2. Check recent cholesterol level 3. Inquire about the consistency of stool. 4. Assess for muscle tenderness

4. Assess for muscle tenderness.

The nurse teaches a client with stomatitis about the foods to help improve the health problem. Which menu selection by the client indicates to the nurse that teaching has been effective? 1. Hot tea 2. Oranges 3. Spicy Nuts 4. Bananas

4. Bananas

A client is brought to the emergency department by friends reporting a dry mouth, frequent urination, extreme thirst and no fluid intake in the last 8 hours. The friends report the client may not have taken insulin during the last couple of days. The nurse reviews prescriptions from the health care provider. Which prescriptions does the nurse implement FIRST? 1. Administer 20 mEq potassium chloride orally. 2. Begin regular insulin at 0.1 units/kg/hour. 3. Obtain a 12-lead electrocardiogram. 4. Begin infusion of 0.9% NaCl at 1 L per hour.

4. Begin infusion of 0.9% NaCl at 1 L per hour.

The critical care nurse cares for a client diagnosed with septic shock. Which observation MOST concerns the nurse? 1. Serum glucose 120 mg/dL 2. WBC count 15,000/mm3 3. Skin is warm, dry and flushed. 4. Bleeding noted around venipuncture site.

4. Bleeding noted around venipuncture site. (sign of DIC)***DIC can happen in any kind of shock.***clients bleed out from every orphis.

The nurse provides care for a client diagnosed with systemic lupus erythematosus(SLE). Which finding will the nurse find MOST concerning? 1. Pallor observed on fingers of the right hand. 2. Blood pressure reading of 152/90 mm Hg. 3. Pain reported as severe in the left knee and ankle. 4. Blood Urea Nitrogen (BUN) level of 40 mg/dL.

4. Blood Urea Nitrogen (BUN) level of 40 mg/dL.

A client is diagnosed with hemophilia A develops mild epistaxis and bleeding gums while receiving a transfusion of frozen fresh plasma(FFP). Which action does the nurse take first? 1. Call a Code 2. Obtain a STAT platelet count 3. Obtain a STAT prothromin time(PT). 4. Check the IV site.

4. Check the IV site.

The nurse provides care for a client with type A blood who is scheduled to receive 1 unit of packed red blood cells(RBCs). One unit of packed RBC's, type B is received on the unit. Which action should the nurse take NEXT? 1. Prime the Y-tubing with 0.9% sodium chloride. 2. Measure the client's vital signs. 3. Instruct the client to report itching or chills. 4. Contact the blood bank

4. Contact the blood bank

The nurse provides care for the client immediately after arrival in the emergency department. Emergency personnel report that the client was involved in a head-on collision with immediate loss of consciousness. Which is the FIRST action taken by the nurse? 1. Determine Glasgow Coma Scale (GCS) score. 2. Assess bilateral blood pressure. 3. Check bilateral pupillary response to light. 4. Determine Oxygen Saturation Levels.

4. Determine Oxygen Saturation Levels

A client reports chest pain during deep inspiration and shortness of breath to the nurse. The client's ABG result is pH 7.33, pCO2 48 mm Hg, and HCO3 mEq/L. Which action does the nurse take FIRST? 1. Administer 10 mL acetycysteine 10% solution every 2 hours. 2. Give oxygen at 7 L/min with a simple face mask for 10 minutes. 3. Perform nasotracheal suctioning every 10 minutes for 30 seconds. 4. Instruct the client to take slow, deep breaths and cough three times every 5 minutes.

4. Instruct the client to take slow, deep breaths and cough three times every 5 minutes.

A client reports chest pain during inspiration and shortness of breath to the nurse. The client's arterial blood gas(ABG) result in pH 7.33, PCO2 48 mm Hg, and HCO3 23 mEq/L. Which action does the nurse take FIRST? 1. Administer 10 mL acetylcysteine 10% solution every 2 hours. 2. Give oxygen at 7 L/min with a simple face mask for 10 minutes. 3. Perform nasotracheal suctioning every 10 minutes for 30 seconds. 4. Instruct the client to take slow, deep breaths and cough three times every 5 minutes.

4. Instruct the client to take slow, deep breaths and cough three times every 5 minutes.(Get oxygen in and let carbon dioxide out to resolve respiratory acidosis)

A family member of a client with a pneumothorax states, "I think something is wrong with that drainage device. It just got very noisy." The nurse observes that bubbling in the underwater seal is continuous compared to several hours ago. Which action does the nurse take FIRST? 1. Clamp the chest tube at the insertion site. 2. Add sterile water to the underwater seal chamber 3. Notify the health care provider 4. Observe the connections of the drainage system.

4. Observe the connections of the drainage system.

Furosemide 40 mg IV is prescribed for a client. The client reports shortness of breath at rest, and the nurse notes bilateral 2+pitting edema. It is most important for the nurse to take which action after administration of the medication? 1. Check the serum potassium levels. 2. Weigh the client. 3. Measure the client's urine output. 4. Obtain the client's blood pressure.

4. Obtain the client's blood pressure.

The nurse reviews the medical record of a client recently diagnosed with Guillan-Barre syndrome. The client has flaccid paralysis of both legs, a history of coronary artery bypass surgery 3 weeks ago, and a 20-year history of hypertension and hypercholesterolemia. The client was also recently diagnosed with type 2 diabetes mellitus(DM). The nurse prepares to apply anti-embolism stockings to both legs. Which priority action does the nurse implement? 1. Assess for bilateral pretibial edema. 2. Palpate both calves for pain. 3. Ask the client the reason for application of anti-embolism stockings. 4. Palpate bilateral pedal pulse strength.

4. Palpate bilateral pedal pulse strength.(determine circulatory status prior to applying anti-embolism stockings)

The client is diagnosed with a stroke is admitted to the rehabilitation center. The client has left-sided pronator drift and decreased dorsiflexion strength of the left extremity. The nurse notes the client bumps into the left wall when ambulating with a walker. The client leans to the left sitting in a chair or wheelchair. Which is the MOST appropriate action for the nurse to take? 1. Place the client's favorite watch on the left wrist. 2. Provide a written list for the client during morning care. 3. Instruct the client to choose a dress for the day. 4. Position the client to the right side faces the door of the room.

4. Position the client to the right side faces the door of the room.

The nurse answers a call light for a client who reports pain at the IV site. Upon assessment the nurse notes the IV insertion site is pale, cool to the touch, and mildly swollen. It is MOST important to the nurse to take which action? 1. Slow the infusion rate and monitor for the client's response. 2. Stop the infusion and notify the healthcare provider. 3. Remove the IV catheter and apply pressure dressing. 4. Remove the IV catheter and place the client's arm on a pillow.

4. Remove the IV catheter and place the client's arm on a pillow.

The nurse cares for a client with an endotracheal tube and positive pressure mechanical ventilation. Which observation requires an immediate interventions by the nurse? 1. The LPN/LVN reports that the client's weight has increased 3 pounds over 72 hours. 2. The client gags and bites the endotracheal tube. 3. The endotracheal cuff pressure is 22 mm Hg. 4. The LPN/LVN drains ventilator condensation toward the endotracheal tube connection.

4. The LPN/LVN drains ventilator condensation toward the endotracheal tube connection. (*****draining the condensation toward airway****)

The nurse is supervising four UAP. The nurse will immediately intervene and provide assistance if which scope of practice violation is observed? 1. The UAP performs a routine blood glucose test on a client. 2. The UAP performs a point of care urine pregnancy test. 3. The UAP assists an older adult with feeding. 4. The UAP restarts the client's IV fluids.

4. The UAP restarts the client's IV fluids.

The nurse visits the home of a client with a newly inserted pacemaker. Which observation indicates that the nurse needs to provide additional teaching to the client? 1. The client's left arm is kept at the level of the client's waist. 2. The client stores pacemaker information in a wallet. 3. The client wears a medical-alert bracelet on the right wrist. 4. The client carries a cell phone in a chest shirt pocket.q

4. The client carries a cell phone in a chest shirt pocket.

The nurse reviews the record of a client diagnosed with acute kidney injury. Which lab value is MOST important for the nurse to review? 1. Fasting blood sugar 2. Serum uric acid 3. Serum protein 4. Urine specific gravity

4. Urine specific gravity

The nurse is instructing a young adult client diagnosed with Addison Disease how to adjust the dose of hydrocortisone and fludrocortisone. The nurse should explain that an increased dose may be needed in which situaiton? 1. When getting engaged to be married. 2. After gaining 4 lb in a week 3. When ingesting a large amount of fluids 4. When having wisdom teeth extracted

4. When having wisdom teeth extracted

The nurse has been made aware of laboratory test results for assigned clients. Which of the following test results would require follow-up? 1. urinalysis that is negative for protein for the client who has diabetes mellitus(type 2) and is receiving insulin therapy. 2. international normalized ratio(INR) of 2.9 for the client who has a deep vein thrombosis(DVT) and is receiving anticoagulation therapy. 3. Serum potassium level of 4.2 mEq/L for the client who is receiving prescribed furesomide. 4. sputum specimen that is positive for acid-fast bacillus for the client who is receiving prescribed prophylactic isoniazid.

4. sputum specimen that is positive for acid-fast bacillus(AFB) for the client who is receiving prescribed prophylactic isoniazid.

WBC(White Blood Cells) levels:

5,000-10,000

Fasting glucose should be:

60-110 mg/dL

The nurse provides care for a client diagnosed with a hypertensive emergency. The client is prescribed sodium nitroprusside 0.3 mcg/kg/min. The client weighs 176 lb(80 kg). The concentration of the sodium nitroprusside is 50 mg/250 mL. What rate will the nurse set for the per hour amount on the micro infusion pump? (RECORD YOUR ANSWER ROUNDING AT THE END OF THE CALCULATION USING ONE DECIMAL PLACE.) _____________mL/hr

7.2 mL/hr

Before drawing up insulin, inject air in the amount you will be drawing up into the vial. If you are drawing up 8 units, ___ units of air should be drawn up and injected into vial.

8

Calcium

8.5-10.5

For a TRALI reaction the provider may prescribe:

ABG's be drawn, human leukocyte antigen or anti leukocyte antibodies, a STAT chest xray, supplemental oxygen and corticosteroids would also be prescribed.

Types of Reactions to blood transfusions are:

ABO(hemolytic) Febrile(non-hemolytic) Allergic or immunity Transfusion-related acute lung injury(TRALI) Massive blood transfusion reaction

Potassium is impacted by:

ACE inhibitors, ARBS, diuretics and insulin.

Diagnostic Tests for Addison Disease:

ACTH Stimulation Test(little or no increase in cortisol if Addison Disease is present.) CRH suppression test (ACTH high, but not cortisol) Urine cortisol and aldosterone CT scan/MRI (can detect adrenal calcification, fungal infections, tuberculosis and tumors.

Cushing syndrome is caused by:

ACTH-secreting pituitary adenoma, hypothalamus dysfunction, or steroid overuse(prednisone), or an adrenal tumor.

Lactated Ringers solution will not cause fluid shifts, but has:

Added electrolytes.

LPN/LVN Assignment:

Assign stable clients with expected outcomes.

High magnesium causes:

CNS depressants/slow everything down.

Metabolic Acidosis develops in:

DKA(Diabetic Ketoacidosis)

Type 1 Diabetes poses a high risk for a patient to develop:

DKA(Diabetic Ketoacidosis)

Therapeutic Communication Tips:

DO: respond to feeling tone. provide information. focus on the client. use silence. use presence DON'T: ask "why" questions. ask yes/no questions(except in case of self-harm) focus on the nurse. explore say "don't worry".

UAP Assignment:

Delegate standard, unchanging procedures.

Gas forming and high residue foods should be limited if you have an:

End colostomy

Type 2 diabetes is diagnosed with a __________________test.

HgbA1c(normal 4-6%)

Symptoms of Cushing syndrome include:

Hyperglycemia Buffalo Hump Moon Face Immunosuppression Bone Demineralization (Osteoporosis) Integumentary changes Thinning of Skin, Easy Bruising, and Striae Muscle Wasting Gastrointesinal Ulceration

Trypanophobia is the fear of:

INJECTIONS

Thrombocytopenia can occur in patients with:

Lupus, Rheumatoid Arthritis, and client's receiving chemotherapy. (Thrombocytopenia can sometimes be idiopathic)

Normal Creatnine levels are:

M: 0.6-1.2 F: 0.5-1.1

Hemoglobin Levels:

M:14-18 F:12-16

Hematocrit levels:

M:42-52 F: 37-47

A nurses interventions during a hemolytic reaction include:

Maintaining IV fluids to keep the blood pressure up Taking samples from the unit of blood Monitoring coagulation and kidney function

During a plateletpheresis the nursing interventions include:

Maintaining then integrity of the rate Monitoring the insertion site Watch for reactions(can result in a bad reaction because platelets infuse quickly)

Post-op Nursing Care after a Transphenoidal hypophysectomy(Pituitary Resection):

Monitor Vital Signs Urine Output monitoring(Diabetes Insipidus can occur due to manipulation of pituitary gland) Monitor for Infection/Meningitis Positioning HOB 30 degrees to reduce intracranial pressure, promote drainage and reduce the chance of bleeding. Seizure precautions Mustache bandage(monitor for constant drip, sweet taste=possible CSF leak) Good mouth care, but NO TOOTHBRUSH in mouth for 2 weeks after. Teach Deep Breathing (BUT NO COUGHING) Avoid sneezing, bending over, coughing, blowing nose or constipation. Lifelong Hormone Replacement(Hydrocortisone, Fludrocortisone)

If a transfusion reaction occurs, obtain a new bag of ________saline and not the one connected to the y-tube.

NORMAL

The diet a patient with pancreatitis will include:

NPO, TPN

First-Degree Heart block:

No emergency treatment is needed, but can progress into second and third degree heart block.

Always think PEOPLE before:

Paperwork

Nursing Interventions for Addison's Disease:

Prevent hypoglycemia monitor blood glucose frequently recognize symptoms of hypoglycemia promptly Provide Fluid Balance, Monitor Intake and output (Push fluids) Restrict excessive potassium and Promote Sodium Intake Monitor for orthostasis(Safe transfer) Stress Dosing for steroids(Increase when excessive stress is taking place) Increase sodium in hot weather

Second-Degree Heart Block Type 2(Mobitz 2):

QRS is dropped without progressive PR lengthening.

Fire Safety(RACE):

R-Rescue A-Alarm C-Contain(Close doors, contain fire) E-Extinguish or Evacuate

An infant should be placed in a ______-facing car seat in the back seat and on placed on their______to sleep.

REAR, BACK

Medication Rights:

Right Client-two unique identifiers Right medication Right Dose Right Route(Always double check route) Right Time Right Frequency Right Reason Right History and Assessment Right Consent Right Documentation

Five Rights of Delegation:

Right task(scope of practice, stable client.) Right Circumstance (workload) Right Person(scope of practice) Right Communication (Specific Task to be Performed, expected results, follow-up communication) Right Supervision (clear directions, intervene if necessary)

If a blood transfusion reaction occurs:

SAVE tubing and blood to return to the blood bank, draw a blood sample for hemoglobin, culture and retype and cross, collect a urine sample for hemoglobin determination, and continue to monitor patient closely.

Always include allergies in:

SBAR report!!!!

If symptoms of a transfusion reaction occur, the nurses action should be to:

STOP TRANSFUSION IMMEDIATELY!!!!

AS SOON as an ABO reaction is expected:

STOP TRANSFUSION!!!

Types of shock include:

Septic, Neurogenic, Hypovolemic, Hemhorrhagic, and Cardiogenic.

Kaplan's RN Decision Tree

Step 1: Can you identify the topic of the question? Step 2: Are the answers assessment or implementation? Step 3: Apply Maslow: Are the answers physical psychosocial? Step 4: Are the answer choices related to ABC's? Step 5: What is the outcome of each of the remaining answers?

Treatment for Adrenal Crisis is:

Sugar(IV Glucose) Salt(IV sodium chloride) Steroid(IV hydrocortisone) Support(ABC's, correct electrolytes, INsulin in dextrose to reduce hyperkalemia) Search(underlying cause)

Treatment for Cushing syndrome:

Transphenoidal hypophysectomy(pituitary resection) To remove pituitary gland when tumor is present Incision made between the upper lip and the nose.

During a blood transfusion ___-set tubing is used to______________out any particulate.

Y

RN Assignment:

You cannot delegate: assessment teaching nursing judgement.

Restraints are always:

a LAST resort!!!!

4 side rails up is considered:

a RESTRAINT.

First-Degree Heart Block is characterized by:

a constant but prolonged PR interval(greater than 0.20 sec). Atria are conducting very slowly.

The allergic or immunity reaction occurs due to:

a hypersensitivity to the antibodies in the donor's blood. (usually occurs by mislabeling or not identifying the client)

Thrombocytopenia is:

a low platelet count

Weak, thready pulse is:

a sign of low blood pressure or reduced cardiac output.

A pacemaker allows:

a stronger AV conduction and a faster ventricular rate. (Improves cardiac output)

Pulsus tardus is:

a weak pulse with a slow upstroke and prolonged peak. (seen in aortic stenosis)

If a non-hemolytic(Febrile) reaction occurs a provider may prescribe:

acetaminophen

If a pH level is less than 7.35 it is considered __________ and more than 7.45 it is _____________.

acidosis, alkalosis

Results of Adrenal Crisis are:

acute hypotension, hypoglycemia, hyperkalemia, and weakness.

Nursing care for Cushing Syndrome:

address hyperglycemia/diabetes mellitus reduce carbohydrates, promote exercise, monitor glucose levels, weight monitoring and control. immune suppression(hand washing, monitor for signs of infection, teach proper hygiene) Bone demineralization(increase calcium and Vitamin D and encourage weight bearing exercises) Avoid Injury Skin Changes: Avoid adhesive tape Avoid medications/herbs that interfere with clotting Monitor fluid status, reduce sodium in diet and increase potassium in diet Avoid Caffeine and Alcohol

Addison's disease is caused by:

adrenal insufficiency(Hypoadrenalism)

AVOID or decrease intake of:

alcohol, caffeine, chocolate, fatty foods, peppermint, tight-binding clothes, and no bending and stooping.

Left-sided heart failure(Lungs):

all fluid backs up into the lungs.

Right-sided heart failure(venous side):

all fluid backs up into the venous side.****Symptoms include JVD, ascites, peripheral edema.

Test to diagnose cushing's syndrome include:

an electrolyte panel, cbc to assess for evidence of infection, ACTH levels, cortisol levels, urine levels, CT scan and MRI of adrenal and pituitary glands, and bone density scanning(DEXA scan) to check for osteoporosis.

Acute glomerulonephritis is most often caused by:

an infections such as strep or mononucleosis.

Hematocrit indicate:

anemia or dehydration

Hemoglobin is an indication of:

anemia.

Symptoms of acute glomerulonephritis include:

anorexia, nausea, fatigue, and uremia. (patients will be put on fluid restriction)

If an allergic reaction occurs during a blood transfusion a provider may prescribe:

antihistamine, corticosteroids, and/or epinephrine.(infusion may be restarted if the symptoms are mild and transient)

Vital Signs should be monitored frequently during a blood transfusion, prior to the infusion then:

at 15 min, every hour until transfusion is complete, and then every hour for 3 hours after transfusion ends.

Onset of a hemolytic reaction can occur:

at any time during a transfusion or after the blood has infused.

Colostomy's should be irrigated:

at the same time daily.

Plateletpheresis is when:

blood is extracted and the platelets are filtered out, blood is then returned back to the client.

During plateletpheresis, platelets tend to:

bunch up in filter and slow the infusion rate.

Abdominal thrusts should only be used if a client:

cannot cough, talk or breathe.

Narrow pulse pressure is noted in:

cardiogenic shock(pulse pressure equals the systolic BP minus the diastolic BP)

Before a transfusion:

check history of past transfusion and reactions.

Second-Degree Heart Block Symptoms:

chest pain, arm or jaw pain, nausea/vomiting, dyspepsia, fatigue and lightheadedness.

Multiple Sclerosis is a:

chronic inflammatory disease of unknown etiology that affects the brain and spinal cord.

Furosemide given intravenously moves fast and can cause:

circulatory collapse.(client loses too much fluid!!!***DEADLY****)

Bounding peripheral pulse indicates:

circulatory overload.

The diet a patient with diverticulitis will include:

clear liquids and fiber.

DIC=

client can die/Life threatening!!!!!*****

Cryoprecipitate is used to replace

clotting factors(specifically factor VIII, von Willebrand factor, and fibrinogen)

Red blood cell transfusion do not contain:

clotting factors, albumin or platelets.

Adrenal Crisis:

critically low adrenal hormones.(hypoadrenalism)

A dexamethosone suppression test is used to diagnose:

cushing's syndrome

To treat hemochromatosis, we may use:

deferzsirox, or deferiprone

Symptoms of Addison Disease include:

deficient cortisol levels, hypoglycemia, weight loss, anorexia, fatigue, melanin deposits(brassy tan skin with hyperpigmentation.), dehydration, hypotension, hyperkalemia(body retains potassium), arrythmias, ECG changes, decreased androgens(decrease libido for women, but no effect on men) and infertility.

High urine specific gravity is an indication of:

dehydration

DKA(Diabetic Ketoacidosis) can result in:

diabetic coma.

Licorice can increase potassium loss and may cause:

digoxin toxicity and arrhythmias.

If the urine specific gravity is low, urine will be ____________. If the urine specific gravity is high, urine will be _______________.

diluted, concentrated

Signs and symptoms of Hypoglycemia are:

dizziness sweating blurred vision tachycardia

Signs and symptoms of thrombocytopenia are:

easy bruising and petechiae.

During a transfusion reaction a patient's vital signs should be checked:

every 5 minutes and monitor urine for hematuria.

Clinical manifestations of Cushing Syndrome are:

excessive cortisol, edema, heart failure, hypokalemia, excessive sex hormones(androgens), hirsutism, acne and hyperpigmentation, women:oligomenorrhea, enlargement of clitoris men: gynecomastia, testicular atrophy

Symptoms of an acute hemolytic reaction include:

fever dyspnea facial flushing severe low back pain hypotension tachycardia hematuria DIC shock (occur when ABO-incompatible blood is infused)

Signs and symptoms of a TRALI reaction include:

fever, chills, hypotension, tachycardia, frothy sputum, dyspnea, hypoxia, hypoxemia, respiratory failure and noncardiogenic pulmonary edema.

Big BUN=BAD....High BUN means that:

fluid volume is low. (High BUN=dry)

Dakin solution is made:

from diluted household bleach(hypochlorite) ***can damage healthy tissue***

Albumin is prepared:

from plasma.

It is normal for a client with an endotracheal tube to:

gag and bite the tube.(patient may need more sedation)

Medications for Type 2 diabetes include:

glipizide, and metformin. (oral anti-diabetic agents).

WBC's are transfused for a patient who:

has a very low wbc count and an active severe infection that has been unresponsive to antibiotics.

RA can cause a low __________ level.

hemoglobin

The PTT is examined when the client is taking:

heparin

Causes of GERD include:

high levels of estrogen/progesterone, hiatal hernia, CCB, diazepam, decongestants, and smoking.

Hematocrit measures:

hydration status. (blood volume decreases hematocrit will go up/blood volume increases hematocrit will go down.)

Antihypertensives can mask the signs of:

hypoglycemia.

A massive blood transfusion will cause:

hypothermia and cardiac dysrhythmias. They can develop citrate toxicity, hypocalcemia, hyperkalemia.

Albumin can be used to treat:

hypovolemic shock and hypoalbuminaria.

Signs and symptoms of anemia include:

hypoxia dizziness fatigue shortness of breath

A patient suffering from confusion can be a symptom of:

hypoxia (poor perfusion to brain)

WBC's are transfused as:

immature cells(stem cells)

If a client on a ventilator attempts to speak it will:

increase the inspiratory pressure.

WBC are an indication of:

infection.

Type 1 Diabetes is:

insulin dependent. Polyuria, polyphagia and polydypsia. (thirsty, hungry and frequent urination)

Supraventicular tachycardia is:

is an atrial tachycardia caused by an abnormal impulse above the bundle of HIS, near the AV node.

To manage shock use:

isotonic fluid.(will stay in the vascular space).

Assess the client continually after the transfusion monitoring for:

itching, shortness of breath and pulmonary edema.

When using skeletal traction:

keep affected body part in alignment with traction, pull, and countertraction) ***NO TWISTING****

Creatinine and BUN measure:

kidney function.

When there is circulatory compromise, eventually it will effect the ___________, and can cause kidney ______________.

kidneys, failure

If a patient is allergic to banana's, the client will require a:

latex free operating room

Total cholesterol goal is:

less that 200 mg/dL.

DKA(Diabetic Ketoacidosis) is a:

life-threatening condition caused by inadequate insulin levels.(breaks fat into glucose and ketone bodies)

Nevirapine is associated with:

liver failure, especially within the first month. (patient must be monitored for signs of hepatotoxicity)

Second-Degree Heart Block Type 1(Wenckebach):

longer, longer, longer, drop(now you got a wenckebach) P wave gets longer and longer then QRS drops. Atiral rate is normal but ventricular rate may be slow.

Signs and symptoms of shock include:

low B/P, high H/R or low H/R, altered mental status, uticaria, bronchospasms(if analphylactic)oliguri, and back pain.

Cardiogenic Shock may have a:

low heartrate

A patient with diabetic ketoacidosis(DKA) will have a:

low pH and low HCO3.

Left-sided heart failure is:

lungs.

HCO3 is related to:

metabolic acidosis.(think DKA)

Impaired kidney function increased risk of lactic acidosis with:

metformin use.

If someone is suffering from lead poisoning, __________ should be encouraged, because _______binds to lead and inhibits absorption.

milk intake, calcium

During a WBC transfusion a nurse should:

monitor vital signs and treat the condition(fever).

If a massive blood transfusion occurs the provider may prescribe:

monitoring of clotting factors and electrolyte levels.

When assessing for hyperpignmentation pay close attention to the:

mucous membranes, knuckles, knees and elbows.

Signs and symptoms of hyponatremia include:

muscle cramps nausea confusion weakness convulsions

Signs and symptoms of hypokalemia:

muscle weakness ECG changes Paresthesias Nausea

Signs and symptoms of hyperkalemia:

muscle weakness ECG changes dysrhythmias nausea

Third-Degree Heart Block(Complete Heart Block):

no relationship between the P waves and QRS exist.

Type 2 diabetes is:

non-insulin dependent(control blood sugars through diet and exercise.)****Symptoms: vision changes, fatigue, recurrent infections, delayed wound healing.****

During a blood transfusion ONLY:

normal saline is used(dextrose and lactated ringers will cause RBC hemolysis)

Hemoglobin tells you the:

oxygen carrying capactiy of the blood.

ABG normal values are:

pH 7.35-7.45 PaCO2 35-45 HCO3 21-28 PaO2 80-100 SaO2 95-100

Potassium is altered with:

pH changes(acidosis or alkalosis) and renal failure.

Fresh Frozen Plasma(FFP) is given to:

people with bleeding problems, such as hemophilia, liver disease, ,vitamin K deficiency and excess certain levels of warfarin may require a plasma transfusion.

A decrease in the level of consciousness and orientation is an early sign of:

poor cardiac output.

A patient who has cushing disease is encourage to consume foods that contain:

potassium

Barrett's Esophagus refers to a:

premalignant condition with abnormal changes in the epithelium cells lining the esophagus. This condition places the client at a higher risk for esophageal cancer.

During a TRALI reaction it causes:

pulmonary inflammation and capillary leakage. (occurs within 1-6 hours of the transfusion.

Creatinine is an indication of:

renal failure.

PACO2 and PaO2 is related to:

respiratory distress.(think COPD and pneumonia)

During suctioning the patient should be in a _____________position.

semi-fowlers.

Non-hemolytic(Febrile) reaction occurs due to:

sensitization to the the donors wbcs, platelets or plasma proteins.

When drawing up short-acting and intermediate-acting insulin, always draw ________-_________insulin first and ________-_______ next.(Don't forget the air injection)

short-acting(clear), intermediate-acting(cloudy).

Packed RBC transfusion should be started:

slowly

Furosemide(Lasix) should be pushed through the IV:

slowly.

Sociophobia is the fear of:

social evaluation

Signs and symptoms of GERD include:

sore throat, cough, dyspepsia, heartburn, nausea, abdominal pain(mid-epigastric)

When documenting the information should be:

specific and objective.

Adrenal Crisis can be triggered by:

stress, autoimmune processes, TB, AIDS and sudden discontinuation of steroid therapy.

Right-sided heart failure is:

systemic.

Heart blocks can occur at the level of:

the atrioventricular (AV) node, bundle of His, or the bundle branches.

During plateletpheresis monitor:

the drip chamber and use gravity infusions when possible. A nurse should watch closely for signs of bleeding.

Gavage feedings are only used after:

the infant suckled, but didn't have enough intake.

If the HCO3 is high it means:

the kidneys are trying to compensate.

Fresh Frozen Plasma(FFP) is:

the liquid of blood that is left over after cells have been removed. (clotting factors and other blood components are still present without platelets).

TRALI (transfusion related acute lung injury) occurs when:

there is a reaction between the transfused antileukocyte antibodies and the recipient leukocytes.

The massive blood transfusion reaction occurs when:

there is a replacement of ten or more Red Blood Cell units given within 24 hours. (RED BLOOD CELL TRANSFUSIONS TO NOT CONTAIN CLOTTING FACTORS, ALBUMIN OR PLA

Signs and symptoms of hypernatremia include:

thirst dry tongue confusion

Platelets indicate:

thrombocytopenia.(Consider heparin induced)

Blood should be handled with care:

to prevent cells from being damaged.

O- blood is considered:

universal donor.

AB+ blood is the:

universal recipient

Loop colostomy is:

usually temporary with 2 openings(relieves obstruction distal to site***proximal and distal stoma drainage***)SKIN IRRITATIONEd

Signs and symptoms of an allergic reaction during a blood transfusion include:

uticaria(itching), flushing, potentially anaphylaxis, hypotension, dyspnea and hypoxia

An ileostomy is:

very irritating and destructive to the skin.

During a FFP transfusion, a nurse should monitor:

vital signs, coagulation tests and signs of bleeding.

PT and INR are examined when the client is taking:

warfarin.