Nur221 Exam Part 1

How often do you check restraints and why? What type of restraints are preferred?

-Every 15 minutes to check circulation -Quick/Easy release

Normal HCO3

22-26

Normal CO2

35-45

Normal pH

7.35-7.45

A nurse is preparing to administer lithium to a client who has bipolar disorder. The nurse notes that the client's lithium blood level is 1.2 mEq/L. Which of the following actions should the nurse take? (Select all that apply.) A. Administer the next dose of lithium carbonate as scheduled. B. Check the client for signs of lithium toxicity. C. Notify the provider for a possible increase in the dosage of lithium carbonate. D. Request a stat repeat of the client's lithium blood level. E. Place the client on fluid restrictions.

A. Administer the next dose of lithium carbonate as scheduled. B. Check the client for signs of lithium toxicity. RATIONALE: A blood lithium level of 1.2 mEq/L is within the expected reference range. However, because it is in the upper range, it is important to check the client for signs of toxicity.

A nurse is obtaining a history from a client who has sexual dysfunction. Which of the following medications can cause this condition? (Select all that apply) A. Atorvastatin B. Paroxetine C. Cimetidine D. Potassium chloride E. Loratadine

A. Atorvastatin B. Paroxetine C. Cimetidine

A nurse is assessing a client with arterial blood gas values pH 7.49, PaO2 90 mm Hg and a PaCO2 of 31 mm Hg. What clinical manifestations may be associated with the client's arterial blood gas results? (Select all that apply.) A. Dizziness B. Tingling in hands C. Tetany D. Bradycardia E. Increased bicarbonate level

A. Dizziness B. Tingling in hands C. Tetany

When preparing a patient for wound irrigation, what intervention should the nurse implement?

Administer analgesics

A nurse in a provider's office is reviewing the laboratory reports of a client who is being evaluated for Graves' disease. Which of the following laboratory results is an indication of Graves' disease? A. Decreased thyrotropin receptor antibodies (TRAb) B. Decreased thyroid-stimulating hormone (TSH) C. Decreased thyroxine (T4) D. Decreased triiodothyronine (T3)

B. Decreased thyroid-stimulating hormone (TSH) RATIONALE: A. In the presence of Graves' disease, elevated thyrotropin receptor antibodies is an expected finding. C. In the presence of Graves' disease, an elevated T4 level is an expected finding. D. In the presence of Graves' disease, an elevated T3 level is an expected finding.

A nurse is caring for a client who received a permanent pacemaker 6 weeks ago and is experiencing dysrhythmias. Which of the following orders should the nurse clarify with the provider? A. Cardiac enzymes B. MRI of the chest C. Daily physical therapy D. Low-sodium diet

B. MRI of the chest

The nurse is caring for a client and has received the following blood gas values for this client: pH- 7.30, CO2- 65, HCO3- 30. What is the correct interpretation of these blood gasses? A. Compensated respiratory acidosis B. Partially compensated respiratory acidosis C. Uncompensated respiratory acidosis D. Partially uncompensated respiratory acidosis

B. Partially compensated respiratory acidosis

A nurse is completing a medication reconciliation for a client who is being transferred to the unit from the ICU and is to start taking propranolol. Which of the following findings in the medical history should the nurse report to the provider as a potential contraindication for taking the medication? A. The client has a history of hypothyroidism. B. The client has a history of bronchial asthma. C. The client has a history of tachycardia. D. The client has a history of migraine headaches

B. The client has a history of bronchial asthma. Some other contraindications for the administration of propranolol include: • Hypersensitivity • Pulmonary edema • Uncompensated heart failure • Cardiogenic shock • Sick sinus syndrome • Heart block

What does Heparin prevent?

Blood clots from forming

A nurse applies restraints without a prescription to a client who threatens to leave against medical advice. For which of the following intentional torts may the nurse incur liability as a result (select all that apply)? A. Malpractice B. Negligence C. Battery D. False imprisonment E. HIPAA violation

C. Battery D. False imprisonment

A nurse is working in a long-term care facility when a fire breaks out. What is the nurse's priority? A. Activate the fire alarm system B. Extinguish the flames using an appropriate fire extinguisher C. Remove any clients from the area to rescue them from immediate danger D. Open the windows and doors to allow the smoke to dissipate

C. Remove any clients from the area to rescue them from immediate danger

A nurse in an emergency department is admitting a client who is lethargic and unable to complete sentences. The client has 'a heart rate of 34 beats per minute and a blood pressure of 83/48 mm Hg. The nurse applies electrodes to the client's chest and limbs and the electrocardiogram (ECG) monitor shows complete heart block. Which of the following actions should the nurse take first? A. Transport the client to the cardiovascular laboratory. B. Prepare the client for insertion of a transvenous pacemaker. C. Activate the emergency response system and be prepared to perform CPR. D. Apply transcutaneous pacemaker pads

D. Apply transcutaneous pacemaker pads

When administering Calcium Carbonate the nurse should instruct the patient to do what?

Take medication with 8 oz of water

An HIV positive patient has a low CD4, what medications increase this?

trimethoprim-sulfamethoxazole

Normal Lithium

0.8-1.2

What can Colchicine cause?

Rhabdomyolysis

Doffing PPE order

gloves, goggles, gown, mask

When giving instructions to a patient who is taking Montelukast (Singulair) the nurse should inform the patient to?

take medication daily and it prevents asthma attacks but does not treat them

How long do you perform hand hygiene and how much soap?

2 minutes and 15 mL

A nurse is teaching a client who has a new prescription for enteric-coated aspirin as stroke prophylaxis. The client asks the nurse why the provider prescribed an enteric-coated medication. Which of the following responses should the nurse give? A. "The enteric coating allows a lower dosage to be given." B. "Enteric-coated medications have better absorption in the body." C. "Enteric-coated medications cause less gastric irritation." D. "The enteric coating provides a steady release of the medication over time."

C. "Enteric-coated medications cause less gastric irritation."

A A nurse is providing teaching to a client who has cirrhosis and a new prescription for lactulose. The nurse should instruct the client that lactulose has which of the following therapeutic effects? A. Increases blood pressure B. Prevents esophageal bleeding C. Decreases heart rate D. Reduces ammonia levels

D. Reduces ammonia levels

Cranial nerves 3, 4, 7, and 9 names and testing

III- oculomotor; motor; PERRLA, 6 cardinal positions of gaze IV- Trochlear; motor; PERRLA, 6 cardinal positions of gaze VII- Facial; sensory & motor; facial movements, taste on anterior two thirds of the tongue IX- Glossopharyngeal; sensory & motor; taste on posterior third of the tongue, swallowing, speech sounds, gag reflex

What is lithium used for?

Mood stabilizer in bipolar patients

Ciprofloxacin can cause what?

Tendon rupture

Donning PPE

gown, mask, goggles, gloves

Early manifestations of lithium toxicity include:

nausea, vomiting, fine tremor, polyuria, slurred speech, and muscle weakness.

A nurse in the emergency department is caring for a child who has severe lead toxicity. A. Administer syrup of ipecac to the child. B. Administer activated charcoal to the child. C. Administer calcium gluconate to the child. D. Administer chelation therapy.

D. Administer chelation therapy.

Live vaccines are contraindicated in what patients?

Older adult patients

If a pediatric patient overdoses on Iron, who should the nurse call?

poison control

How do H2 receptor antagonist work and what do they treat?

-reduce the amount of stomach acid released by glands in the lining of your stomach and thereby reducing symptoms of heartburn -treats GERD

A nurse is caring for a client who is experiencing an acute gout attack. The nurse should anticipate a prescription from the provider for which of the following medications? A. Colchicine B. Allopurinol C. Probenecid D. Pegloticase

A. Colchicine

A nurse is performing a community assessment in a rural setting. Which of the following types of health care is most likely to be absent in this setting? A. Tertiary care B. Primary prevention C. Chronic care D. Secondary prevention

A. Tertiary care Tertiary care, or specialized care through consultation, is usually obtained following a referral from a primary care provider. Primary prevention involves avoiding disease before it happens, such as through immunizations or wellness promotion. Chronic care is required by clients who have chronic health conditions. The focus of secondary prevention is early detection and treatment of acute illness and injury to prevent disability and mortality.

A nurse is providing teaching to the parent of an infant who has heart failure and a new prescription for digoxin elixir. Which of the following pieces of information should the nurse include? A. Withhold the medication if the infant's heart rate is less than 110/min B. Mix the medication in 120 mL (4 oz) of infant formula C. Expect the infant to vomit frequently while taking this medication D. Double the dose if the infant has increased edema

A. Withhold the medication if the infant's heart rate is less than 110/min

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? A. Excessive airway secretions B. A leak within the ventilator's circuitry C. Decreased lung compliance D. The client coughing or attempting to talk

B. A leak within the ventilator's circuitry

ACE inhibitors treat hypertension and can cause what adverse reaction?

Cough

RACE acronym

-Rescue clients from immediate danger by removing from the area of the fire -Activate the fire alarm system -Close doors and windows to contain the fire -Extinguish flames with an appropriate fire extinguisher

A nurse is performing an assessment of the heart on an adult client. Identify the area where the nurse will place the stethoscope to auscultate the heart sounds heard in the Tricuspid valve.

Left Lower Area of Sternum Tricuspid valve: left lower sternal border

Airborne precautions require:

-private room -masks/respiratory protection devices for caregivers and visitors -use an N95 if the client is know or suspected to have TB -negative pressure airflow exchange in the room -wear face protection -clients who have an airborne infection should wear a mask while outside of the room

A nurse is caring for a client who is experiencing an chronic gout attack. The nurse should anticipate a prescription from the provider for which of the following medications? A. Colchicine B. Allopurinol C. Probenecid D. Pegloticase

B. Allopurinol

A nurse has completed a wound irrigation procedure for a client who requires contact and droplet precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first? A. Gown B. Gloves C. Goggles D. Mask

B. Gloves

Isotonic exercise

movement in which muscles shorten (contract) and move involves contracting and relaxing your muscles through the full range of a joint's motion

A nurse has selected a vein to place an IV catheter for a client who will be receiving antibiotics via intermittent IV bolus. Identify the order in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) -Advance the catheter. -Clean the site with an antiseptic swab. -Flush the catheter. -Apply a tourniquet. -Insert the catheter.

1. Clean the site with an antiseptic swab. 2. Apply a tourniquet. 3. Insert the catheter. 4. Advance the catheter. 5. Flush the catheter.

A nurse is teaching a client about potassium-rich foods. Which of the following food choices by the client indicates an understanding of the teaching?(Select all that apply) A. Sliced bananas B. Baked potato C. Turkey and cheese sandwich D. Plain yogurt with peaches

A,B,D Bananas, baked potatoes, and plain yogurt with peaches are high in potassium. A client who has Addison's disease requires a diet low in potassium because this condition causes hyperkalemia A turkey and cheese sandwich is high in protein, carbohydrates, and sodium.

A nurse is teaching a client who has human immunodeficiency virus (HIV) about the early manifestations of acquired immune deficiency syndrome (AIDS). Which of the following statements should the nurse include in the teaching? A. "You can expect a persistent fever and swollen glands." B. "You can expect an elevated white blood cell count." C. "You can expect increased blood pressure and edema." D. "You can expect weight gain."

A. "You can expect a persistent fever and swollen glands."

A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement? A. Dysphagia B. Positive Babinski sign C. Decreased deep-tendon reflexes D. Ataxia

A. Dysphagia Dysphagia (difficulty swallowing) can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (vagus).

A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest X-ray. The nurse should instruct the newly licensed nurse to take which of the following actions? A. Have the client wear a surgical mask. B. Wear a gown for protection from the client's infection. C. Ask the radiology staff to perform a portable chest X-ray in the client's room. D. Place an N-95 respirator on the client.

A. Have the client wear a surgical mask. The nurse should instruct the client to wear a surgical mask. The mask will protect anyone who comes into contact with the client, including the nurse. The nurse should wear an N-95 respirator when caring for a client who has tuberculosis. The client is not required to wear an N-95 respirator.

A nurse is administering an enteric-coated tablet to a client and explaining the pharmaceutical preparation. Which of the following statements should the nurse make? A. "This coated tablet dissolves better in your stomach and intestines." B. "You are less likely to have an upset stomach with this pill because of the coating on the tablet." C. "The coating on the tablet improves the absorption of the medication." D. "The coating on the tablet allows a gradual release of the medication."

B. "You are less likely to have an upset stomach with this pill because of the coating on the tablet."

A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care? A. Protective B. Airborne C. Droplet D. Contact

B. Airborne Tuberculosis requires airborne precautions, which are protocols that prevent the spread of infections via very small droplets (e.g. measles and varicella).

A nurse is irrigating a surgical wound. Which of the following solutions will the nurse use to irrigate the wound? A. Hydrogen peroxide B. Povidone iodine solution C. Chlorhexadine D. Sterile normal saline 0.9 NS

D. Sterile normal saline 0.9 NS

A nurse is performing an assessment of the heart on an adult client. Identify the area where the nurse will place the stethoscope to auscultate the heart sounds heard in the pulmonic area.

Left Upper Area of Sternum Pulmonic valve: 2nd and third intercostal spaces close to the sternum

How does Glipizide (Glucotrol) act in T2 diabetes?

Lowers blood sugar by stimulating the release of insulin from the pancreas and increasing the sensitivity to insulin at receptor sites.

What are the 3 levels of prevention? Primary Prevention—intervening before health effects occur, through. Secondary Prevention—screening to identify diseases in the earliest. Tertiary Prevention—managing disease post diagnosis to slow or stop.

Primary Prevention—intervening before health effects occur, through. Secondary Prevention—screening to identify diseases in the earliest. Tertiary Prevention—managing disease post diagnosis to slow or stop.

A nurse is performing an assessment of the heart on an adult client. Identify the area where the nurse will place the stethoscope to auscultate the heart sounds heard in the aortic valve.

Upper Right Area of Sternum 2nd right intercostal space to the apex

What is acute radiation syndrome?

an acute illness caused by irradiation of the entire body (or most of the body) by a high dose of penetrating radiation in a very short period of time (usually a matter of minutes).

When administering Calcium Carbonate the nurse should inform the patient of what adverse effects?

constipation, nausea, arrhythmias

What do bronchodilators do?

relax bronchial smooth muscle, which causes dilation of the bronchi and bronchioles that are narrowed as a result of the disease process

isometric exercise

tightening (contractions) of a specific muscle or group of muscles. During isometric exercises, the muscle doesn't noticeably change length. The affected joint also doesn't move. Isometric exercises help maintain strength

After completing a course reviewing the principles of hand hygiene, a nurse must demonstrate the appropriate method of washing her hands. Place in order the list of events the nurse will demonstrate when washing hands. -Apply lotion or barrier cream, if needed. -Dry hands with a paper towel. -Apply an adequate amount of soap to the surface of the hands. -Wet hands with water. -Rub hands together vigorously, covering all surfaces, for at least 15 seconds. -Rinse soap from hands with water.

1. Wet hands with water. 2 Apply an adequate amount of soap to the surface of the hands. 3. Rub hands together vigorously, covering all surfaces, for at least 15 seconds. 4. Rinse soap from hands with water. 5. Dry hands with a paper towel. 6. Apply lotion or barrier cream, if needed.

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. Initiate bag-valve-mask ventilation B. Provide the client with a communication board C. Obtain a blood sample for ABG analysis D. Document the ventilator settings

A. Initiate bag-valve-mask ventilation

A nurse is teaching a group of healthy older adult clients about health screenings after age 50 years. Which of the following health screenings should the nurse recommend completing every 5-10 years? A. Cholesterol B. Colonoscopy C. Diabetes mellitus D. Visual acuity

B. Colonoscopy The nurse should recommend an annual visual acuity screening for all clients over. The nurse should recommend cholesterol screening every 3 to 5 years until age 75 years. Older adult clients should have a diabetes mellitus screening every 3 years. If a client is high-risk, the nurse should recommend more frequent screenings.

A nurse in a provider's office is providing teaching to a client with osteoporosis who has a new prescription for alendronate sodium (Fosamax). Which of the following pieces of information should the nurse include? A. Alendronate sodium can be administered by IV once yearly. B. Take alendronate sodium with a full glass of water on an empty stomach. C. Side effects of alendronate sodium include leukopenia. D. Alendronate sodium should be taken with calcium-containing foods to increase absorption.

B. Take alendronate sodium (Fosamax) with a full glass of water on an empty stomach. Alendronate sodium should be taken with at least 230 mL (8 oz) of water 30 min before ingesting foods. An upright position is recommended after taking alendronate sodium to decrease the risk of esophagitis

A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

C. Respiratory alkalosis

A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should indicate to the nurse the client is experiencing digoxin toxicity? A. Suppression of dysrhythmias B. Increased atrioventricular (AV) conduction C. Visual disturbances D. Weight gain

C. Visual disturbances The nurse should recognize that nausea, vomiting, abdominal discomfort, fatigue, and visual disturbances are common manifestations that can indicate that the client is experiencing digoxin toxicity.

A nurse is providing discharge teaching to a client who has heart failure and a prescription for digoxin 0.125 mg PO daily and furosemide 20 mg PO daily. Which of the following statements by the client indicates an understanding of the teaching? A. "I know that blurred vision is expected to happen while I'm taking digoxin." B. "I will measure my urine output each day and document it in my diary." C. "I will skip a dose of my digoxin if my resting heart rate is below 72 beats per minute." D. "I will eat fruits and vegetables that have a high potassium content every day."

D. "I will eat fruits and vegetables that have a high potassium content every day." Hypokalemia is an adverse effect of diuretic therapy. Because the client is taking digoxin, it is important to maintain a potassium level between 3.5 to 5.0 mg/dL to avoid digoxin toxicity.

A nurse is working in a pediatrician's office and receives a call from a parent whose 4-year-old child was sitting on the floor surrounded by acetaminophen tablets. The parent thinks the child might have eaten as many as 10 of the tablets. What is the most appropriate response by the nurse? A. "Make the child vomit." B. "Give the child 16 ounces of milk." C. "Monitor the child's mentation for 48 hours." D. "Take the child to the nearest emergency department."

D. "Take the child to the nearest emergency department."

A nurse must collect a random stool sample to test for fecal occult blood testing. Place the following steps in the best order for collecting a random stool sample. Tell the client to notify the nurse when he/she needs to defecate Transfer the specimen to the lab or test stool with a fecal occult blood test car Place the collected stool in the specimen container and close the lid When the client is ready, ask the client to defecate into a clean bedpan Label the specimen with the client's information Collect a small amount of stool from the sample

Tell the client to notify the nurse when he/she needs to defecate When the client is ready, ask the client to defecate into a clean bedpan Collect a small amount of stool from the sample Place the collected stool in the specimen container and close the lid Label the specimen with the client's information Transfer the specimen to the lab or test stool with a fecal occult blood test card