Nur 410 Final Review
After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip at 1200 units/hr is prescribed. Several hours later, vancomycin (Vancocin) 500 mg intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take?
Start another IV line for the vancomycin and continue the heparin as prescribed.
A school-aged child is brought to the emergency department with partial- and full-thickness burns of the lower extremities. The practitioner writes multiple prescriptions. Which intervention will the nurse complete first?
Starting an intravenous line with a large-bore catheter
The nurse is caring for client on peritoneal dialysis (PD). What action by the client indicates a need for further teaching?
The client cleans the catheter while taking a bath
The nurse cares for a client following a parathyroidectomy. The nurse alerts the provider to which assessment finding?
Tingling around the mouth, fingers, and toes is reported
What is the rationale for the nurse administering docusate sodium to a client hospitalized with a traumatic brain injury?
To prevent straining which can increase ICP
The nurse reviews the health history of a female client with a new diagnosis of acute myelogenous leukemia (AML). What questions does the nurse ask to record the client's risk factors for AML?
"What types of occupations have you had?"
You are providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. What are the possible causes of autonomic dysreflexia?
-Distended bladder -Sacral pressure injury -Fecal impaction -Urinary tract infection
The nurse cares for a client with magnetic resonance imaging (MRI) scheduled for later in the day. The nurse alerts the healthcare provider of which client conditions?
-The client has a coronary artery stent -The client has had hip replacement surgery -The client has a fear of enclosed spaces
The nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of an adrenal cortex tumor. When assessing the client, which of these, if found, are signs of Cushing disease?
-Thin, translucent skin with bruising -Increased fatty deposition in the neck and back -round face -increased fatty deposition in the extremities -dependent edema in the feet and ankles
The nurse is caring for a client that has undergone a total hip replacement. The nurse recognizes which clinical manifestations indicate a pulmonary embolism. Select all that apply.
Unilateral chest pain fever
A young adult sustained a spinal cord injury at the level of T5 a week ago and is now incontinent of feces. When the nurse tries to give a bath and change the linens, the client says, "Leave me alone. It's worse having you change me than it is to lie in this mess." What is the best response by the nurse?
While I'm bathing you I'll start teaching you about bowel training."
A client with the diagnosis of Parkinson disease asks the nurse, "Why do I drool so much?" Which is the nurse's best response?
You have a loss of involuntary movements
The nurse provides education to a client with Parkinson disease and the client's family. The nurse stresses which interventions to promote client safety?
-monitor the client for difficulty eating or swallowing - encourage client to move slowly to a standing position -encourage the client to use an adaptive device when ambulating
A client with small cell carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH). What signs should the nurse expect to observe? Select all that apply.
-vomiting -seizures -oliguria
An older widow with lung cancer is now in the terminal stage of her illness. Her family is puzzled by her mood changes and apparent anger at them. The nurse explains to the family that the client is:
.Coping with her impending death
A 7-year-old child with cerebral palsy who wears leg braces has a slight sensory loss in the lower extremities. What is the most essential information for the nurse to teach the child and parents?
Examine the skin for evidence of pressure points.
The nurse educator provides information regarding established risk factors for heart disease. Which non-modifiable risk factor increases risk for cardiovascular disease (CVD) for an adult client?
Family history
nurse teaches a client who is scheduled for a kidney transplant about the need for immunosuppressive medications. The nurse determines that the client understands the teaching when the client states, "I must take these medications:
For the rest of my life
The nurse is concerned about a deteriorating client. Which signs of cardiogenic shock does the nurse expect?
Heart rate 124 beats/min
he nurse educates a client about Parkinson disease. Which statement by the client indicates further education is needed?
I will drink fruit and vegetable juice to get my calories and vitamins
The nurse educates a client scheduled to begin radioactive iodine (RAI) therapy. Which client statement indicates more education is needed?
I will use a cloth handkerchief to blow my nose
The healthcare provider is caring for a client who has septic shock. Which of these should the healthcare provider administer to the client first?
IV fluids to increase intravascular volume.
The nurse is assessing the client's apical heart rate. Identify the location on the chest to place the stethoscope.
In adults, the apical pulse is located at the fifth intercostal space at the left midclavicular line.
The nurse is applying the oxygen device seen in the picture provided. What intervention should be included as part of the plan of care?
Maintain an oxygen flow rate between 10-15 liters.
During the progressive stage of shock, anaerobic metabolism occurs. For which complication should the nurse assess the client?
Metabolic acidosis
Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is nothing by mouth (NPO) is complaining of severe thirst. The client's urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do?
Moisten clients lips with wet 4x4
A nurse cares for a client receiving a heparin infusion. The nurse observes bright red urine in the client's catheter drainage system. Which action does the nurse take first?
Notify the healthcare provider.
The nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism?
Obese client with leg trauma
The nurse infuses a 30 mL/kg 0.9% normal saline bolus for a client with severe sepsis. Which action does the nurse take next in response to this intervention?
Obtain the client's blood pressure.
A low-dose intravenous dopamine hydrochloride (Dopamine) infusion drip is prescribed for a client in acute renal failure (ARF). What is the most appropriate way for the nurse to administer this intravenous medication to the client?
Picc
A client with small-cell lung cancer is receiving chemotherapy. Identify the priority intervention based on the following chart.
Place in neutropenic precautions.
An older adult client is admitted to the hospital with a diagnosis of chronic kidney disease. The nurse reviews the client's medical record. Which clinical finding is a priority to be communicated to the primary health care provider?
Potassium level
A client has refused to eat or drink for the past three days, is confused, and hypotensive. The client's urinary output has dropped to less than 300 mL/day, and a diagnosis of kidney failure secondary to dehydration has been made; 50% glucose and regular insulin have been prescribed. What is the rationale for the ordered medications?
Prevent cardiac arrest
A client calls the nurse at the clinic, reporting an area of the right breast that looks like the peel of an orange with no other changes. The nurse takes what action for the client?Schedule the client for the next available appointment.
Schedule the client for the next available appointment.
A client with Hodgkin lymphoma is admitted to the hospital. The nurse reviews the client's medical record and identifies which characteristic of Hodgkin lymphoma?
Single, large, painless lymph node
A client has end-stage kidney disease and is receiving hemodialysis. During dialysis the client complains of nausea and a headache and appears confused. Following the prescribed protocols, the nurse should:
decrease the rate of exchange
Which intervention is most important for preventing deep vein thrombosis in a client post-operatively after a knee replacement?
enoxaparin
A nurse is caring for a client receiving continuous ambulatory peritoneal dialysis for chronic kidney disease. The nurse should monitor the client for what complication?
hepatitis B
A client arrives in the emergency department unconscious and exhibiting decerebrate posturing. When assessing the client, the nurse expects to observe:
hyperextension of both the upper and lower extremities
A nurse is caring for a client who was admitted to the hospital with a diagnosis of Addison disease. The nurse should assess the client for what signs related to this disorder?
hypoglycemia and hypotension
After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse expects that manifestations of excessive levels of antidiuretic hormone are:
hyponatremia and decreased urine output
The nurse is assessing a client admitted with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse expects which focused assessment data?
jugular vein distention
A client with hypothyroidism is three days postoperative and becomes confused, with marked hypothermia. Myxedema coma is suspected. Which action does the nurse perform first?
maintain airway patency
The nurse assesses a 5-year-old child after a shunt procedure is performed to correct increased intracranial pressure. Which finding is of most concern?
marked irritability
The nurse provides discharge instructions to a client with Cushing syndrome. The nurse advises the client to follow which instruction?
monitor for dark, tarry stools
A school-aged child is admitted to the hospital with severe burns on the arms. Therapeutic escharotomy is planned. What is the priority nursing action at this time?
monitoring radial pulses
While working in a neuromuscular clinic the nurse monitors infants for symptoms of cerebral palsy. Which statements by infants' mothers indicate the need for further evaluation for cerebral palsy?
my baby was able to turn from front to back by 2 months of age all of my other children were sitting alone by this age. this baby doesn't seem to be anywhere near sitting alone
A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
notify the health care provider
The nurse is caring for a client who sustained a partial-thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago. Which primary short-term outcome established by the nurse and client will be added to the care plan?
pain will remain a 2 or less on a scale of 0 to 10
Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and apprehensive. What is the mostimportant initial nursing action?
prepare for ng tube insertion
A teenage girl who has sustained a partial-thickness burn on the face secondary to excessive exposure to the sun states, "Prom night is only three weeks away. I will never be healed!" What is the nurse's best response?
recovery will take approximately three weeks
A client is admitted to the hospital with severe burns. What client response should the nurse anticipate when caring for the client during the acute phase of burn recovery?
stable vitals
A 6-year-old child is in the acute phase of nephrotic syndrome. The mother asks the nurse about play activities for her child. What should the nurse suggest?
stuffed animal
A child has a spinal cord injury. Which action by a nursing student should require the nurse to intervene?
taking a rectal temp
What safety instruction should a nurse teach a 10-year-old child with diminished sensation in the legs because of cerebral palsy?
test the temp of bath water
A nurse is obtaining the health history of a 5-year-old child who has been admitted to the child health unit with acute glomerulonephritis. What would the nurse anticipate to be in the history?
the child had a sore throat a few weeks ago
The nurse reviews the lab results of a client with Addison's disease. Which laboratory finding is likely for this client?
the client's serum sodium level is decrease
A client with a spinal cord injury is receiving methylprednisolone. What finding would the nurse interpret as indicating a possible complication of this therapy?
the stools are positive for blood
A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics?
topical
The nurse cares for a client following a thyroidectomy. The nurse keeps which item at the client's bedside in case of emergency?
tracheostomy equipment will be kept at the bedside
A nurse is caring for a toddler with the diagnosis of nephrotic syndrome. What is the best indicator of kidney function in this toddler?
urine output
A client develops diabetes insipidus after suffering a traumatic brain injury. Following initial treatment, a nurse assesses the client for which signs of improvement?
urine output less than 150 ml/hr
A client with end-stage kidney disease says to the nurse, "I heard that it is inevitable that I will need a kidney transplant. If so, which one of my kidneys will be removed?" Which is the best response by the nurse?
"Neither of your kidneys will be removed unless they are infected."
A client diagnosed with lung cancer is receiving chemotherapy on an outclient basis. The nurse provides what home care instruction to the client?
"Contaminated linens should be washed separately."
After prostate surgery a client's indwelling catheter and continuous bladder irrigation (CBI) are to be removed. The nurse discusses the procedure with the client. The nurse evaluates that the teaching is understood when the client states, "After the catheter is removed I probably will:
"Experience some burning on urination."
A nurse completes discharge instructions for a client undergoing radiation therapy for Hodgkin disease. Which statement made by the client indicates additional teaching is needed?
"I should apply aloe vera lotion after my treatments."
The nurse is caring for a client admitted for a severe kidney infection and hyponatremia. The health care provider prescribes ceftriaxone (Rocephin) 1 gram to be administered intravenously over 30 minutes. The intravenous (IV) piggyback contains 50 mL. The IV tubing drop factor is 15 drops/mL. At what rate should the nurse infuse the medication?
25 drops/min
A client is admitted for a traumatic brain injury. The nurse assesses dry mucous membranes and a urine output of 400 mL/hr for the past 8 hours. (Place each option in order, from first priority to last.)
1. complete a neurological assessment 2. notify the healthcare provider of the client's change in condition 3. draw laboratory samples as prescribed 4. administer IV fluids and desmopressin acetate as prescribed
A nurse notes that a child is exhibiting signs of cerebral palsy. At what age are these signs usually first noticeable?
12 months
A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.
Bradycardia Hypotension Bladder dysfunction
A client is admitted with post-traumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document? Record your answer using a whole number
3
The client on the hospital unit has experienced a seizure after a traumatic brain injury. Which test will the nurse anticipate the need to teach the patient about?
EEG
The nurse teaches an adult client diagnosed with lung cancer about the signs and symptoms of chemo-induced thrombocytopenia. Which symptom indicates thrombocytopenia?
Ecchymosis
An infant who is exhibiting signs of increased intracranial pressure (ICP) is admitted to the pediatric intensive care unit. What is the nurse's priority of care for this child?
Elevating the infants head higher than the hips
The healthcare provider is assessing a client's risk of lung cancer by calculating the pack-year history. The client has smoked two packs of cigarettes each day for 20 years. Calculate the client's pack history
40 year-pack history
A 10-year-old boy who is about to begin chemotherapy for acute myelogenous leukemia (AML) tells the nurse that he is old enough to refuse treatment. What is the nurse's most appropriate response?
A. "You seem frightened. Let's talk about it."
The nurse cares for a client who underwent a modified radical mastectomy yesterday. What interventions does the nurse include?
A. Have the client elevate the affected arm on a pillow to reduce swelling. C. Measure and record closed suction drainage on the intake and output record. E.Encourage deep breathing and coughing exercises regularly.
The nurse teaches a client recently diagnosed with hyperthyroidism. The nurse encourages which lifestyle recommendation?
Establish a relaxing bedtime routine
When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client?
Avoid leaning forward
A client who has breast cancer had postlumpectomy chemotherapy and is now scheduled for radiation on an outpatient basis. What is an important nursing intervention while the client is receiving radiation?
B. Assessing the irradiated site daily for redness or irritation
A client's absolute neutrophil count is 400/mm³ (0.4 x10E9/L). The nurse includes what instruction for the client?
B."Contact the health care provider immediately if you suspect a fever." D."Wash your hands with soap and water, especially before eating." E."Avoid contact with visitors who have communicable illness."
A client with a head injury has admission vital signs of blood pressure 114/66, pulse 110, and respirations 26. Which of these vital signs, if taken one hour after admission, would be of most concern to the nurse?
Blood pressure 156/60, pulse 55, respirations 12
When planning long-term care for a 2-year-old child with cerebral palsy (CP), it is important for the nurse to consider that:
CP is not progressively degenerative
A hospitalized 3-year-old child with leukemia is undergoing chemotherapy. The mother tells the nurse that her child is asking for fried chicken. How should the nurse respond?
Child preferences should be honored because of the need for calories.
The nurse is taking care of a client with a suspected pulmonary embolism. Which of the following tests would most likely be ordered to help with this diagnosis?
Computed Tomography
A nurse cares for a client who is post-operative splenic repair. Which finding does the nurse most likely assess in the client? See chart information below.
Dizziness
The nurse is assessing reflexes on an adult client. A positive Babinski reflex is indicated by which response:
Dorsiflexion of the great toe with fanning of the other toes
A client rescued from a burning building has partial- and full-thickness burns over 40% of the body. Which is the initial physiologic change that the nurse can expect?
an increase in serum potassium
A client who is being discharged with severe facial scarring from burns tells the nurse, "I've saved some oxycodone, and when I get home I'm going to take all of them. Don't tell anyone." What is the best response by the nurse?
are you going to kill yourself
A client with the diagnosis of Cushing syndrome has the following laboratory results: Na (sodium) 149 mEq/L; K (potassium) 3.2 mEq/L; Hb (hemoglobin) 17 g/dL; and glucose 90 mg/dL. What should the nurse teach the client? Select all that apply
avoid foods high in salt
A client has a total hysterectomy with bilateral salpingo-oophorectomy for cancer of the ovary. In addition to encouraging ambulation, what exercise should the nurse instruct the client to perform to help prevent postoperative deep vein thrombosis (DVT)?
b. Ankle pumping
A preschool child with a spinal cord injury will be on prolonged bedrest. The nurse explains to the parents that certain foods will be restricted to prevent complications associated with immobility. What food should be noted as restricted in the teaching plan?
cheese
A client is recovering from full-thickness burns and the nurse provides counseling on how to best meet nutritional needs. When which foods are selected does the nurse identify that the client understands the teaching?
cheeseburger and malt
What should the nurse emphasize when providing discharge instructions for a client with the diagnosis of Addison disease?
continue steroid replacement therapy
The nurse is monitoring a client with renal failure for signs of fluid excess. Which findings are consistent with fluid excess? Select all that apply.
crackles auscultated in lungs distended neck veins edema elevated BP
A client who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload?
crackles in the lungs