NSC 378 Final

The nurse is reviewing assessment data of clients who may be at risk for developing malignant lymphoma. Which client would be at highest risk?

A 22-year-old man with a history of mono

A client who uses alcohol tells the nurse, "I feel so depressed about what I've done to my family that I feel like giving up." It is most important to assess the client for...

A plan for self-harm

A client with pneumonia has developed dyspnea, has a RR of 32, and is having difficulty expelling secretions. The nurse auscultates the lung fields and hears bronchial sounds in the lower left lobes. Which action should the nurse take first?

Apply oxygen

What is the priority of nursing care for a client experiencing depression?

Ask if the client has thoughts of hurting themselves and if they have a plan

A client receives morphine for postoperative pain. The nurse should...

Assess UOP every 8 hours

While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, "I think my water just broke." What should the nurse do first?

Assess the fetal heart rate pattern

What is the priority nursing action for a client with generalized anxiety disorder who is working to develop coping skills?

Assist the client to identify coping mechanisms used in the past

A female client with anorexia nervosa is receiving care from her family after successfully completing the refeeding stage of treatment. Which nursing intervention takes priority at this time?

Assisting the family to work on the issues of autonomy and separation

What are the common known side effects of atypical antipsychotics?

BBW for development of DM due to hyperglycemia and hyperlipidemia Acute extrapyramidal symptoms can occur Chronic tardive dysknesia

The nurse has just admitted a client to the ER for evaluation of a possible MI. Which diagnostic intervention by the nurse would be priority?

ECG

The nurse is developing a plan of care for a new postpartum mother and her neonate. When developing the care plan, for which of the following should the interventions be directed?

Family

Which lab value is the most reliable to monitor renal function?

GFR < 15

What intervention is needed to restore equilibrium of inadequate thyroid function?

Levothyroxine for thyroid replacement therapy

The nurse is preparing a treatment plan for a child with sickle cell anemia in a so-occlusive crisis. What is the most important nursing intervention to include?

Managing pain

For what type of patients should benzos and TCAs be avoided?

Older adults and/or individuals with potential or known respiratory and/or cardiac disorders

A client with HF develops pink, frothy sputum and restlessness. Which of the following are the priority actions by the nurse? Select all that apply.

Place the client in high Fowler's Notify the physician of the clients change in status Auscultation bilateral lung sounds for crackles

A nurse should be prepared to manage complications following AAA resection. Which complication is most common?

Renal failure

What lab data is used to monitor the status of an individuals thyroid function?

TSH, T3, and T4

A physician decides to artificially rupture a client's membranes. After this procedure, the nurse checks the fetal heart tones to:

assess for fetal bradycardia

A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN), 100 mg/dL, serum creatinine 6.5 mg/dL, potassium 6.1 mEq/L, and lethargy. Which of the following is the priority nursing assessment?

cardiac rhythm

The nurse should assess the client with left-sided heart failure for which findings? Select all that apply.

dyspnea oliguria crackles decreased O2 sats

A nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:

fine crackles

When teaching a multigravid client diagnosed with mild preeclampsia about nutritional needs, the nurse should discuss which type of diet?

regular diet

A client with a diagnosis of depression is started on imipramine, 75 mg by mouth at bedtime. The nurse should tell the client that:

this medication may initially cause tiredness, which should becomes less bothersome overtime

A client is admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to find during a nursing assessment?

wheezing, tachycardia, restlessness

A nurse is teaching a client, newly diagnosed with chronic obstructive pulmonary disease (COPD), about the use of a respiratory inhaler. Which statement demonstrates understanding of the medications?

"Albuterol followed by beclomethasone is the correct administration."

The nurse administers lactulose to an adult client hospitalized with liver cirrhosis. Which finding would indicate that the medication was effective? A. Increased stool output B. Normal serum amylase C. Decrease in abdominal girth D. Alert and oriented mental status

Alert and oriented mental status

What is the priority nursing measure for a client with von Willebrand's disease who is having epistaxis?

Apply pressure to the nose

The nurse is instructing the client who is at risk for PAD how to use knee-length elastic stockings (support hose). What instructions should the nurse include in the teaching plan? Select all that apply

Apply the elastic stockings before getting out of bed Remove the stockings every 8 hours, elevate the feet, and reapply in 15 minutes

The nurse is caring for a client with a third heart sound. Which action is indicated?

Assess the clients lungs for crackles

A client is diagnosed with pancreatitis. Which assessment would be of most concern to the nurse?

Bluish discoloration in the periumbilical area

The nurse has 5 client assignments on a medical surgical unit. Place in order the priority which the nurse will assess the clients.

Client admitted with renal failure receiving a unit of packed RBC for the last 30 minutes Client admitted with uncontrolled HTN with last BP of 160/95 mmHg Client admitted with fever with last temp of 100.2F Client admitted with end stage bladder cancer receiving oral morphine for pain control every 2 hours Client admitted with arm cellulitis after a cat bite

The nurse is caring for a client in early labor. The client reports sudden abdominal pain and is noted to have bright red bleeding. What would the nurse include in the client's plan of care? Select all that apply.

Examine the fetal heart monitoring tracing. Call the healthcare provider. Administer oxygen to the client.

A client with gastrointestinal hypertension is experiencing abdominal pain and vaginal bleeding. Which assessment should the nurse perform first?

Fetal heart tones

Four clients each gave birth 12 hours ago. Based upon report and assessment, which client should the nurse see first?

Gravida 2, Para 2002, cesarean birth, incisional site intact, hemoglobin level 9.8

A teenage client with heart failure is prescribed carvedilol. She asks the nurse, "What is this drug supposed to do?" Which responses by the nurse are correct? Select all that apply.

Improve the way your heart works Lower your BP Slow your HR

The nurse in the emergency department is caring for a 12-year-old child with full-thickness, circumferential burns to the chest, and has difficulty breathing. What is the priority intervention?

Intubation

What should the nurse expect to find while assessing the vital signs of a client with HF who has abruptly stopped taking his beta blocker drug? A. Low BP B. Irregular pulse C. Low grade fever D. Decreased RR

Irregular pulse

A child has ingested poisonous hydrocarbons. Which is the most important nursing intervention?

Keep the child calm and relaxed

A neonate returns from the operating room after surgical repair of a tracheoesophageal fistula and esophageal atresia. Which is the nurses priority intervention?

Maintain a patent airway

What is the treatment teams priority in planning care for a client with an eating disorder?

Meeting daily to discuss manipulation and countertransference

A client receiving thyroid replacement therapy develops influenza and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication puts the client at risk for developing which life-threatening complication?

Myxedema coma

A 79-year-old client has been admitted to the unit. The client is diagnosed with a left hip fracture secondary to a fall, and is scheduled for a left total hip replacement (LTHR). The client's comorbidities are hypertension and diabetes. The client is a full code with no known allergies (NKA). What is the nurse's priority action for this client?

Pain management

A laboring client brings a doula with her to the labor room. When working with the doula, which of the following actions can a doula perform with a laboring client? Select all that apply.

Serve as a support person and coach during labor Function as a resource person in the perinatal time

A client with chronic obstructive pulmonary disease (COPD) develops signs of cor pulmonale. What assessment data would alert the nurse to this condition?

edema of the extremities and distended neck veins

An emergency cesarean birth is planned for a pregnant client who begins to experience excessive vaginal bleeding soon after admission. When developing this client's plan of care, which action would be the priority?

ensure availability of replacement blood

A client is receiving epoetin alfa. Which findings indicate the effectiveness of the drug?

increase in RBC

The nurse is caring for several clients on the respiratory unit who are receiving the β-adrenergic agonist bronchodilator albuterol in the prescribed nebulizer treatments. Which side effects would the nurse expect to assess following administration? Select all that apply.

irritability and nervousness tachycardia insomnia anxiety

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

positioning the client on the side with the knees flexed

A primiparous client at 4 hours after a vaginal birth and manual removal of the placenta voids for the first time. The nurse palpates the fundus, noting it to be 1 cm above the umbilicus, slightly firm, and deviated to the left side, and notes painless dark red bleed mixed with clots. The nurse notifies the health care provider based on the interpretation that the assessment indicates which problem?

retained placental fragments

The nurse is administering intravenous magnesium sulfate as prescribed for a client at 34 weeks' gestation with severe preeclampsia. What are desired outcomes of this therapy? Select all that apply.

temp 98F, HR 72, RR 14 DTR's 2+ Mag level = 5.6

A client with a history of heart failure is receiving a lidocaine I.V. infusion at 2 mg/minute to treat runs of ventricular tachycardia. The client experiences hypotension, dyspnea, and irregular heartbeats. Which action can the nurse expect the physician to take first?

Decreasing the lidocaine infusion to 1 mg/minute

A client with a history of liver cirrhosis is in the emergency department with nausea, vomiting, and acute confusion, the client is positive for right upper quadrant tenderness and ascites. BP 104/58, HR 108, RR 22. Which order does the nurse question for this client? Select all that apply. A. Morphine sulfate 2-6mg IV every 1 hour PRN pain B. Insert NG tube to low intermittent suction C. LR's IV at 75 mL/hour D. Nothing by mouth E. Electrocardiogram

Morphine sulfate 2-6mg IV every 1 hour PRN pain Insert NG tube to low intermittent suction LR's IV at 75 mL/hour

Which findings should lead the nurse to suspect that a client who had a cesarean birth 8 hours earlier is developing disseminated intravascular coagulation (DIC) and report to the health care provider (HCP)? Select all that apply.

Petechiae on the arm where the blood pressure was taken Heart rate of 126 bpm Abdominal incision dressing with bright red drainage Platelet count of 80,000/mm3 (80 X 109/L)

A client is admitted with shortness of breath, a brain natriuretic peptide (BNP) level of 615 pg/mL, and pedal edema. Which of the following actions should the nurse take next? Select all that apply.

IV diuretic therapy give O2 with mask

An alert and oriented client comes to the emergency department after hitting his head in a motor vehicle accident. What should the nurse do first?

Immobilize the clients head and neck

The nurse is assessing a 17-year-old client with a seizure disorder. Driving privileges were suspended for failure to comply with anti-epileptic medications. The parents express concern because the client is withdrawn, not completing schoolwork, and spends increased time sleeping. Which is the nurse's best response?

"Further evaluation is needed for a mood disorder"

What is the most serious complication that can occur if the client does not receive adequate treatment for hypothyroidism?

Myxedema coma

A client is in the first hour of her recovery after a vaginal birth. During an assessment, the lochia is moderate, bright red, and is trickling from the vagina. The nurse locates the fundus at the umbilicus; it is firm and midline with no palpable bladder. The client's vital signs remain at their baseline. Based on this information, the nurse would implement which action?

Report the findings to the healthcare provider (HCP)

The nurse is caring for a client with atelectasis. Which is the nurses most important intervention?

Implement chest physiotherapy

A client is receiving treatment for severe depression. When evaluating this client for suicidal ideation, a nurse checks for:

suicidal thoughts or plans

The nurse is assigned to care for four clients. Which client should the nurse assess first?

A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem

Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test?

A client infected with human papillomavirus (HPV)

What is the priority action that a nurse should take after omitting an ordered medication?

Notify the prescriber

A primigravida states, "I think my water just broke." What should the nurse do? Select all that apply.

Perform a nitrazine test to confirm that the membranes are ruptured. Monitor the fetal heart rate and pattern. Assess maternal temperature.

A client displays signs associated with a possible ruptured AAA. What is priority nursing intervention?

Prepare the client for surgical intervention

A child is hospitalized with infective endocarditis. Which nursing intervention is most appropriate?

Provide diversional activities

A client is a gravida 1, para 0. During the first 24 hours after birth, she doesn't show consistent interest in her neonate. What should the nurse do next?

Document these expected behaviors of the taking-in period

The nurse should assess the client with left HF for which findings? Select all that apply. A. Dyspnea B. Jugular vein distinction C. Crackles D. Right upper quadrant pain E. Oliguria F. Decrease oxygen saturation

Dyspnea JVD Crackles Oliguria

What should the nurse teach a client about how to avoid the dumping syndrome? Select all that apply.

Reduce fluids with meals, but take them between meals Obtain adequate amounts of protein and fat in each meal Eat in a relaxing environment

What diet should be implemented for a client who is in the early stages of cirrhosis?

High calorie and high carb

A client is admitted with paranoia and visual hallucinations related to progressive dementia. The client continues to be restless and have hallucinations. The nurse calls the health care provider (HCP) and, after explaining the situation, background, and assessment, recommends that the HCP consider writing a prescription for which medication?`

sertraline

Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first?

a client at 32 weeks gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain

After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first?

a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular

A client with major depression and psychotic features is admitted involuntarily to the hospital. He will not eat because his "bowels have turned to jelly," which the client states is punishment for his wickedness. The client requests to leave the hospital. The nurse denies the request because commitment papers have been initiated by the health care provider. The nurse understands this client legally committable based on which criterion?

being gravely disabled

A nurse is assisting in developing a teaching plan for a client who is about to enter the third trimester of pregnancy. The teaching plan should note that which symptom should be reported immediately?

blurred vision

A client diagnosed with leukemia is now experiencing neutropenia. Which assessment is a priority for the nurse?

Breath sounds

A nurse is explaining the risk factors associated with a client's postpartum depression. Which statements from the nurse are accurate about postpartum depression? Select all that apply.

"Symptoms often begin around 4 weeks postpartum." "Symptoms present for two weeks or more." "A risk factor is an unplanned pregnancy."

A home care nurse is preparing for the next day by reviewing his/her home visit assignments. In which order should the nurse visit the clients based on priority interventions?

A client injecting insulin for daily BG coverage, day 2 A client as a new admission requiring daily morning dose of vancomycin A client requiring lab study for warfarin evening dosing A client receiving a monthly injection of cobalamin A client with a final visit for ostomy teaching

A client is diagnosed with pancreatitis. Which assessment finding would be of most concern to the nurse? A. Increased serum amylase B. Moderate right upper quadrant pain C. Low grade fever D. Bluish discoloration in periumbilical area

Bluish discoloration from periumbilical area

The nurse is caring for a multigravida in active labor with a fetus in a frank breech presentation. The nurse should notify the primary care provider if the nurse observes:

Fetal bradycardia at any time during the laboring process

The nurse is caring for a client receiving digoxin. Which symptoms would the nurse anticipate with a digoxin level of 2.3 ng/dl (0.08 nmol/l)? Select all that apply.

Nausea Drowsiness Photophobia Seeing halos around bright objects

What action should the nurse take first when a client is coughing up pink, frothy sputum?

Place the client in high Fowler's position

A client with chronic obstructive pulmonary disease (COPD) tells the home care nurse that he fell asleep in his car, while parked in the garage, with the engine running. A neighbor discovered the man an hour later. The client explained that he does this to keep warm in the winter months sometimes because his house is cold. What is the nurse's priority action?

Refer the client for a psychiatric evaluation

An adolescent with moderate depression has become increasingly introverted. The client reports to the nurse that the social withdrawal has left him/her isolated and lonely. Which of the following nursing interventions would be appropriate for this client?

Referral to an after-school social recreation program

What nutritional guideline is a priority for a patient diagnosed with COPD?

Smaller, more frequent meals due to being out of breath and aspiration risk. Increase fruits and vegetables as well as a diet with high fat and low carbs

Pancreatic enzyme replacements are prescribed for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect?

with each meal and snack

A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the clients score has changed from 11 to 15. Which responses did the nurse assess in this client? Select all that apply

Orientation to person, place, thing Spontaneous eye opening

When teaching a multigravida client diagnosed with mild preeclampsia about nutritional needs, the nurse should discuss which type of diet? A. High residue B. Low sodium C. Regular D. High protein

Regular

When teaching a multigravida client diagnosed with mild preeclampsia about nutritional needs, the nurse should discuss which type of diet?

Regular diet

A client reports severe pain in the back and joints. Upon reviewing the client's history, the nurse notes a diagnosis of depression and frequent hospitalizations for somatic illnesses. What should the nurse encourage this client to do?

Tell the physician about the pain so that its cause can be determined

The nurse is administering IV magnesium sulfate as prescribed for a client at 34 weeks gestation with severe preeclampsia. What are the desired outcomes of this therapy? Select all that apply. A. Temp 98F, HR 72, RR 14 B. UOP less than 30 mL/hour C. FHR with late decelerations D. BP less than 140/90 mmHg E. Deep tendon reflexes 2+ F. Magnesium level = 5.6 mg/dL (2.8 Mmol/L)

Temp 98F, HR 72, RR 14 DTR's 2+ Mag level = 5.6 mg/dL