NSG Exam 3

when should RN administer rapid acting insulin?

when tray is there and patient is going to eat

The nurse is completing a mini mental status examination with a patient. What should the nurse ask to evaluate remote memory?

"Where did you work in the 1970's?"

A nurse is teaching a parent of an infant who has heart failure about meeting the infant's nutritional needs. Which of the following statements by the aren't indicates and understanding of the teaching?

"I will add polycose to each of my baby bottles."

Nurse is providing teaching to a group of parents of newborns who are planning to formula feed. Which of the following statements by a parent indicates a need for further teaching?

"I will make sure my baby's feeding last 10-15 minutes."

A nurse is providing teaching to a client who has type 2 diabetes mellitus and is starting repaglinide. Which of the following statements by the client indicates understanding of the administration of this medication?

"I'll take this medicine with my meals."

A nurse is providing teaching to a client who has a prescription for pramlintide for type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? (select all that apply)

"Inject pramlintide just before a meal" "Discard open vials after 28 days"

A patient with a seizure disorder asks the purpose of staying awake all night prior to having an ECG in the morning. What should the nurse explain to this patient?

"Sleep deprivation can cause a seizure, which will be helpful during the test."

A nurse is reinforcing teaching about nutritional consideration with the parents of a toddler. Which of the following statements by the parents indicated an understanding of the teaching?

"The quality of the food is more important than the quantity"

A nurse is providing discharge teaching about nutrition to the parents of a child who has CF. Which of the following responses by the parents indicates an understanding of the teaching?

"We will give out child pancreatic enzymes with meals."

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

"move objects away from the client"

A nurse is instructing a group of clients regarding calcium rich foods. Which of the following foods should the nurse include in the teaching as the best source of calcium?

1 c milk

A nurse is providing nutritional teaching to the mother of a preschooler and is recommending food options to provide 1 oz of grains. Which of the following foods should the nurse recommend?

1 c ready to eat cereal flakes

A nurse is preparing to administer clonazepam 1.5 mg PO in 3 equally divided doses every 8 hours for a client who has seizures. The amount of available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer per dose?

1 tablet

A nurse is providing dietary teaching to the parents of a newborn who is being breastfed. The nurse should instruct that the transition to whole milk should be done at what age?

12 months

The nurse should intervene immediately if the patient has which blood glucose level above?

200 mg/dL

What is the recommended BMI range or older adults?

22-27

Which has the most carbs?

3 kit kat bars

Of the following which is the best choice for performing irrigation?

35 mL syringe with a 19 gauge angiocatheter

Which is most concerning... Blood glucose of...?

45- hypoglycemic

A nurse is caring for a client who has a mild traumatic brain injury. Which of the following manifestations should the nurse immediately report to the provider?

A change in the Glascow coma scale from 13 to 11

A nurse is caring for a client who is well hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the clients portion uptake and synthesis?

Albumin

A patient reports a change in the taste of food. Which of the cranial nerves should the nurse suspect as being affected?

CN VII Facial

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Elevate the clients bed 30-45 degrees

The patient is refusing meals because of a loss of appetite. What is a nursing intervention for this problem?

Encourage family to visit and bring favorite foods during mealtime

What is the proper approach to feed an advance dementia patient?

Feed small amounts at a time alternating with fluid

The nurse notes that an older patient sways when moving from a sitting to a standing position. What is this patient at risk for experiencing?

Hypothermia

What is the equation to calculate a patients BMI?

Kg/M^2

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

Protein

A nurse is teaching clients in an outpatient facility about the use of insulin to treat type 1 diabetes mellitus. For which of the following types of insulin should the nurse tell the clients to expect a peak effect 1 to 5 hr after administration.

Regular insulin

A nurse is assessing a client who has rea score of 6 on the glascow coma scale. The nurse should expect which of the following outcomes based on this score?

The client needs total nursing care

A nurse is receiving a transfer report for a client who has a head injury. The client has a glasgow coma scale score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken too.

When teaching a patient about the healing process of an one wound after surgery, which of the following points would the nurse make?

The patient will have more scar tissue formation that there would be for a wound closed at surgery

A nurse is instructing a group of clients about nutrition and eating foods high in iron. The nurse should include that which of the following aids in the absorption of iron?

Vitamin C

The patient was recently started on levodopa for parkinson. Which nursing intervention is a priority for this patient?

administer the patients meds as ordered and on time

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide?

alcohol increases the chance of phenytoin toxicity

The nurse is reviewing medical orders written for a patient with encephalitis. Which medication should the nurse expect to be prescribed as a priority for this patient?

antiviral

If a patient is receiving a tube feeding, what are the associated risks the nurse should watch for?

aspiration pneumonia fluid and electrolyte imbalances GI disturbances

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (select all that apply)

assess the clients airway potency remove objects from the clients bed place the client in a side-lying position

The patient returns to the unit following an operation. The nurse would do which nursing intervention first?

assess the patient vital signs

A HgbA1C (averages past 3 months of blood sugar) should be checked...

at any time of the day

The nurse suspects that a patient with a brain tumor is developing increased ICP. What assessment findings caused the nurse to make this conclusion? Select all that apply.

ataxia nausea vomiting headache

A patient is scheduled for an electroencephalogram. What pre procedure information should the nurse emphasize with this patient?

avoid caffeine for 8 to 12 hours before the test

A nurse is teaching a client who has GERD about managing his illness. Which of the following recommendations should the nurse include in the teaching?

avoid eating 3 hours before bedtime

A nurse is caring for a child who is having tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

position the child side-lying

If patient is on parenteral nutrition, what are the associated risks the nurse should watch for?

catheter related infection hyperglycemia fluid and electrolyte imbalance

Pressure ulcers are directly caused by which of the following condition at the site

compromised blood flow

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased ICP?

decreased level of consciousness

A patient is recently diagnosed with parkinson disease. The nurse understands that this patient has a deficiently of which neurotransmitter?

dopamine

What intervention would be most appropriate for a word with a beefy red wound bed?

dressing to keep the wound moist and clean

What water recommendations will the nurse are for dry mouth?

drink small mouthfuls of water frequently throughout the day

During morning care a patient with a seizure disorder asks why the room has suddenly turned green. What should the nurse do?

prepare for a seizure to begin

A client asks about recommended foods/snacks to help with dry mouth, the nurse will respond:

eat sugarless hard candy

A patient has a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment the nurse discovers a stage 1 pressure area on the patients left heel. What is the initial response

elevation of the left heel

A patient recovering from a lumbar puncture rates a headache as being 8 on a pain scale of 0-10. What should the nurse do while waiting for the health care provider to prescribe pain medication?

encourage increasing oral fluid intake

The nurse is providing care for a newly diagnosed type 1 diabetic. Which lifestyle modifications are important to include in the plan of care?

encourage regular provider visits

What are the primary differences between acute and chronic wounds?

exceed the typical healing time but acute woulds heal readily

Which lab is correlated with the diagnosis of DM?

fasting blood glucose greater than 140 mg/dL

what do carbs include- sugar, starches, and

fiber

A nurse is instructing a group of clients regarding nutrition. Which of the following a good source of Omega 3 fatty acids that the nurse should include in the teaching?

fish

The home health nurse leans that an elderly patient isn't able to get to the grocery store. She doesn't have much food in her home, and eats and drinks little. Most of her time is spent sitting in her chair watching TV, often not realizing that she has bladder leakage. Which nursing actions would we implement to limit risk of developing pressure ulcers? SATA

help her get out of her chair every 2 hours, change her clothing frequently, encourage her to wear incontinence products

Which of the following patients most at risk for nutritional imbalance

holy man who has been on water only fast for two weeks

A patient has been experiencing a tonic-clonic seizure for five minutes. What should the nurse do first?

prepare to insert an airway

Highest FiO2 in comparison to the other oxygen delivery devices

important to monitor skin integrity adding humidity can prevent mucosa from drying out

DKA (acidosis) is primarily an issue with

insulin- if patient doesn't take insulin, typically type 1 diabetes

A nurse is providing teaching to the parent of an infant about introducing solid foods. The nurse should recommend that which of the following foods be introduced first?

iron fortified cereals

A nurse is caring for a client in an outpatient facility who has been taking acarbose for type 2 diabetes mellitus. Which of the following laboratory tests should the nurse plan to monitor?

liver function tests

A patient sustains an injury to the left temporal lobe. Which body functions should the nurse expect to be affected by this injury? Select all that apply.

long term memory auditory perception receptive speech center

Which patients should the nurse consider screening for type 2 diabetes?

men and women with cardiovascular disease women who were diagnosed with gestational diabetes men who are overweight or obese women with a bmi greater than 30

Which medication should be stopped 48 hours prior to CT scan?

metaformin- risk of lactic acidosis

A patient is experiencing changes in eye movements. Which part of the central nervous system is most likely causing these changes?

midbrain

Which client does the nurse recognize a being at the greatest risk for pressure ulcers?

middle aged adult with quadriplegia

The staff development trainer is preparing orientation materials for new staff hired to care for patients with seizure disorders. Which type of seizure can occur in any age group? Select all that apply.

myoclonic tonic-clonic simple partial

Which is most concerning to RN?

patient walking barefoot

A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet?

peanut butter and jelly sandwich

Nutrition assessment of low income family. Inadequate protein intake. Which foods should nurse suggest to increase protein content with little food expenditure increase?

peas and beans

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

position the child laterally

A nurse is caring for an antepartum client who has iron deficiency anemia. When teaching the client nutrition, the nurse should emphasize the intake of what group of foods?

red meat and organ meat

What is a good way to improve oral intake in the hospital setting?

remove bed pans, urinals, and emesis basins from rooms before meal times

A nurse is caring for a client who has a traumatic brain injury. Which of the folwoing findings should the nurse identify as a vindication of increased ICP?

restlessness

A nurse is instructing a group of clients regarding nutrition. The teaching should state that which of the following groups of food contains the highest level of carbohydrates?

rice, potatoes and oranges

A man was involved in a MVA yesterday. He is to be sedated for more then 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time

risk for impaired skin integrity related to immobility

A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the would. The wound healing process is described in this situation is:

secondary intention healing

While assessing a new wound the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting?

serousangunious

A nurse is caring for a 2 year old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose?

shake the container vigorously

A nurse is caring for a client following a brief loss of consciousness. Which of the following should the nurse immediately report to the RN?

small drops of clear fluid in the left ear

A nurse is providing teaching for a client who has a new prescription for metformin. Which of the following adverse effects of metformin should the nurse instruct the client to report to the provider?

somnolence

A client developed a stage 4 pressure ulcer to his sacrum 6 weeks ago and now the ulcer appears to be shallow crater involving only partial skin loss, what would the nurse now classify the pressure ulcer as?

stage 4 pressure ulcer, healing

The nurse needs to provide a strong stimulus to illicit a response; however the patient drifts back to unresponsiveness. What term should the nurse use to document this patients level of responsiveness?

stupor

What of these four visceral proteins is not a sensitive indicator of nutritional status?

transferrin

A patient is hospitalized in a long term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx 5 cm X 3 cm. The area is covered with 100% eschar. What would the nurse identify this as

unstageable pressure ulcer

Which of the following describes the difference between dehiscence and evisceration?

with dehiscence, there is a separation of one or more layers of wound tissue, evisceration involves the protrusion of internal viscera from the incision site