NURS 495 Review

A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which statement by the client indicates understanding of the teaching? a. "I will notify the airport screeners about my pacemaker" b. "I will expect to have occasional hiccups" c. "I will have to disconnect my garage door opener" d. "I will take my pulse every 2 to 3 days"

a

A student nurse is observing a cardioversion procedure and hears the team leader call out "Stand Clear." The student recognizes which rationale is most appropriate for this announcement? a. The cardioverter is being charged to the appropriate setting b. They should initiate CPR due to pulseless electrical activity c. They cannot be in contact with equipment connected to the client d. A time-out is being called to verify correct protocols

c

An older patient is admitted with heart failure. What observation by the nurse indicates the patient's condition is getting worse? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a ABG shows a increase in pH and decrease in PCO2 b Blood pressure of 150/90 and pulse of 90 c Urinary output increase to 60 ml/hr and crackles are heard in the base bilaterally d. Irritability and confusion

d. Irritability and confusion

A patient with a known history of panic disorder comes to the emergency department and states to the nurse, "Please help me. I think I'm having a heart attack." What is the priority nursing action? a Check the client's vital signs. b Encourage the patient to use relaxation techniques. c Identify the manifestations related to the panic disorder. d Determine what the patient was doing when the pain started.

a

A client with a large fetus is to have a pudendal block during the second stage of labor. The nurse plans to instruct the client that once the block is working she: a. May lose bladder sensation b. Will not feel an episiotomy c. May lose the ability to push d. Will no longer feel contractions

b

A client at 36 weeks gestation attends the prenatal clinic for a routine exam. The nurse identifies that the client's blood pressure has increased from 102/60 to 134/88 and is concerned she may be developing mild preeclampsia. The nurse should also assess the client for: a Proteinuria b Mild ankle edema c Episodes of faintness on arising d Weight gain of two pounds in two weeks

a

A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which clients as being at risk for the development of a dysrhythmia? (Select all that apply) a. A client who has metabolic alkalosis b. A client who has a serum potassium of 4.3 mEq/L c. A client who has an SaO2 of 96% d. A client who has COPD e. A client who underwent stent placement in a coronary artery

a, d, and e

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care? a Surgical mask and gloves b Particulate respirator , gown and gloves c Particulate respirator and protective eyewear d Surgical mask, gown and protective eyewear

b

Which food should the nurse teach a client with heart failure to limit when following a 2-g sodium diet? a. Apple b. Canned tomato juice c. Whole wheat bread d. Hamburger

b. Canned tomato juice Rationale: Anything canned is usually high in salt.

The mental health nurse is caring for the client diagnosed with a schizoaffective disorder. Which type of malpractice has the nurse committed when telling a co-worker, "That patient is crazy and may kill someone."? a. Libel b. Slander c. Battery d. Invasion

b. Slander

The nurse is teaching the patient with iron deficiency anemia about foods that should be included in the diet. Which item selected by the patient best indicates an understanding of the dietary needs? a Nuts and milk b Coffee and tea c Cooked oats and fish d Oranges and green vegetables.

d

Furosemide is administered intravenously to a patient with heart failure. How soon after administration should the nurse begin to see evidence of the drug's desired effect? a 5 to 10 minutes b 30 to 60 minutes c 2 to 4 hours d 6 to 8 hours

a

A child is admitted to the hospital with a diagnosis of nephrotic syndrome. The nurse reads the child's medical record and expects to note documentation of which manifestations of this disorder? Select all that apply. a. Edema b. Proteinuria c. Hypertension d. Increased weight e. Abdominal pain

a, b, d, and e

What is a side effect of MAOI medications when tyramine containing food is ingested? a. Hypertensive crisis b. Coma c. Neuroleptic malignant syndrome d. Ketoacidosis

a. Hypertensive crisis

An elderly patient, suspected of being physiologically dependent on diazepam (Valium), is admitted to the psychiatric unit for evaluation. During the first several days following admission the nurse's actions should be directed toward: a involving the patient in the unit treatment program and activities. b observing the patient for agitation, tremors and seizures. c encouraging the patient to discuss effects of substance abuse on life situation. d monitoring the patient for hypotension, tachycardia and depressed respirations

b

The patient has received a prescription for lisinopril (Prinivil). The nurse teaches the patient which side effect may occur? a Polyuria b Cough c Hypokalemia d Increase in blood pressure

b

A nurse is providing teaching to a client who has a prescription for methotrexate (Trexall) for severe psoriasis. Which information should the nurse include? Select all that apply a Drink a glass of wine daily b Monitor for evidence of infection c Monitor kidney function tests d Expect increased bruising

b and c

The nurse correctly calculates the EDC of a client with a last menstrual period of April 11 as: a. January 4 b. January 25 c. January 18 d. February 14

c

A cardiac nurse educator is reviewing the use of a fixed rate mode pacemaker with a group of newly hired nurses. Which statement by a newly hired nurse indicates understanding of the review? a. "This means the pacemaker fires in an asynchronous pattern" b. "This means the pacemaker fires only when the heart rate is below a certain rate" c. "The pacemakers can automatically adjust to a client's increased activity level" d. "The pacemaker activity is triggered by heart muscle activity"

a

A hospitalized patient tells his evening nurse that he has received pain medication at 10:00 am and again at 2:00 pm and that the medication provided no relief from the pain. The patient says to the nurse, "Whenever that daytime nurse takes care of me and give me pain medication it never works! I am so glad that you are here so that I get some relief from this pain." The nurse has observed this same occurrence with other patients who were care for by the same daytime nurse and suspects that the daytime nurse is self-abusing drugs. The nurse implements which action? a Reports the information to the nursing supervisor. b Calls the impaired nurse organization and reports the daytime nurse. c Talks with the daytime nurse who gave the medication to the patient. d Reports the information about the daytime nurse to the police department.

a

A multigravida patient at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The patient's contractions are 20 minutes apart, lasting 20 to 30 seconds. Their cervix is dilated to 2 cm. The nurse reviews the physician's orders. Which of the following orders should the nurse initiate first?Physician ordersContinuous external fetal and contraction monitoringIV of D5LR @ 125mL/hI & O catheterization for urinalysis and culture and sensitivityBetamethasone 12 mg IM daily x 2 days a. Continuous external fetal and contraction monitoring b. IV of D5LR @ 125mL/h c. I & O catheterization for urinalysis and culture and sensitivity d. Betamethasone 12 mg IM daily x 2 days

a

A nurse applies an external fetal monitor and tocotransducer to monitor the fetal heart rate (FHR) and contractions of a client in labor. The FHR is in the 140s. Contractions are every 5 min and 45-50 seconds in duration. The nurse performs a vaginal exam and finds the cervix is 2cm dilated, 50% effaced, and the fetus is -2 station. One hour later the dilation is still 2 cm, but now the effacement is 80%. Which stage and phase of labor is this client experiencing? a. The first stage, latent phase b. The first stage, active phase c. The first stage, transition phase d. The second stage of labor

a

A nurse is caring for a client with CAD in a clinic who asks the nurse why her provider prescribed 1 aspirin tab (80 mg) per day. Which is an appropriate response by the nurse? a "Aspirin reduces the formation of blood clots that could cause a heart attack" b "Aspirin relieves the pain due to myocardial infarction" c "Aspirin dissolves clots that are forming in your coronary arteries" d "Aspirin relieves headaches that are caused by other medications"

a

A patient is brought to the emergency department with chest pain, diaphoresis, elevated pulse, respiration and blood pressure, dry mouth and nausea. The patient refuses to lie down, paces and says, "I am going to die." After testing, the client is diagnosed with an anxiety reaction. The nurse planning care for this patient should give priority to which nursing action? a Offer support and reassurance until his anxiety level is reduced. b Educate the patient and family members on means to prevent anxiety attacks in the future. c Encourage the patient to verbalize the concerns that set off the attack. d Teach the patient and family members to use relaxation to ward off future attacks.

a

A patient who has schizophrenia is scheduled to begin an activity group. Which statement by the patient indicates that he is ready to participate? a "I would like to learn some new activities to fill my time and relieve stress." b "I believe that my illness is mostly the fault of my parents and teachers." c "I want to learn to manage my illness without using medications." d "I think group would be a good chance to show that I am not as ill as everyone thinks I am."

a

A patient's electrocardiogram strip shows atrial and ventricular rates of 110 beats per minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse interpret this rhythm? a Sinus tachycardia b Sinus bradycardia c Sinus dysrhythmia d Normal sinus rhythm

a

During active labor, a client's membranes rupture and her cervix is 5 cm dilated and 50% effaced. The fluid is clear and the fetal heart rate is stable. The nurse should anticipate that: a. Birth of the fetus will occur within 24 hours. b. The second stage of labor will be prolonged. c. An oxytocin infusion will be required to stimulate labor. d. The delayed effacement will result in a difficult delivery

a

Magnesium Sulfate is being administered intravenously to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates Magnesium Sulfate toxicity? a Respirations less than 12/min b Urinary output less than 50mL/hour c Hyper-reflexic deep tendon reflexes d Flushing and sweating

a

Metoprolol is added to the pharmacologic therapy of a diabetic female diagnosed with stage 2 hypertension who has been initially treated with furosemide and ramipril. The nurse should evaluate the client for which expected therapeutic effect? a Decrease in heart rate b Lessening of fatigue c Improvement in blood sugar levels d Increase in urine output

a

TPN is prescribed for a patient with Crohn's disease. What indicates to the nurse that the TPN has been effective? a Has met nutritional needs b Is not in metabolic acidosis c Is hydrated d has a weight decrease

a

The RN nurse educator is discussing delegation guidelines to a group of new graduates (GN). Which statement from the GN indicates a need for additional teaching? a "The UAP will be practicing on my brand new nursing license." b "I will still remain accountable for what I delegate to the UAP." c "I will make sure the UAP to whom I delegate is competent to perform the task." d "When I delegate, I must follow-up with the UAP and evaluate the task."

a

The nurse evaluates a 29-year-old gravida 2 para 1 patient in the labor and delivery unit. Which of the following would determine that the patient is in true labor? a. Her cervix has dilated an additional 2 cm in the last 3 hours. b. Fetal heart tones have remained in the range of 130-140 beats per minute. c. Her contractions have remained every 10 minutes lasting 25 seconds for the past 4 hours. d. The presenting part has remained at -1 station for the past 3 hours

a

The nurse instructs the patient with chronic renal disease receiving dialysis about dietary modifications. The nurse determines that patient understands the dietary needs when the patient selects which items from the dietary menu? a Cream of wheat, blueberries and coffee b Sausage and eggs, bananas, orange juice c Bacon, cantaloupe, tomato juice d Cured pork, grits, strawberries orange juice

a

The nurse is caring for a patient with suspected iron deficiency anemia and instructs the patient on dietary therapy. Which lab values suggest that dietary management has been effective? a Increased ferritin and decreased TIBC (total iron binding capacity) b Increased ferritin and increased TIBC c Decreased ferritin and decreased TIBC d Decreased ferritin and increased TIBC

a

The nurse is caring for the newborn infant of a mother who received large amounts magnesium sulfate. Which newborn finding can the nurse anticipate? a Hypotonia b Tachypnea c Polycythemia d Hyperreflexia

a

The nurse teaching a new mother about breastfeeding is correct in including which of the following statements? a "Encourage baby to pull most of the areola into his mouth." b "Schedule your feedings for every 4 hours." c "Minimize the length of feedings if your breasts become engorged." d "Position baby supine with her head rotated toward your breast."

a

The nursing student approaches the instructor after being stuck by a bloody needle. Which instructor statement is most accurate knowing the patient was HIV-positive? a "Wash with soap and water and see the doctor now; treatment should begin within 1 to 2 hours." b "The first HIV antibody testing is completed in 6 weeks and then completed in 3 months." c "Wash with soap and water now. At the end of the clinical shift notify your position." d "Flush immediately with water for 10 minutes and then cover with a bandage and glove."

a

The patient has a potassium level of 6.2 mEq/L hemolyzed. Which actions are most appropriate by the nurse? a Assess the patient and redrawn the blood b Check urine output and administer KCL 20 mEq oral tabs c Administer Kayexalate 15g oral tabs and check sodium level d Administer IV regular insulin in D5 1/4NSS and place on cardiac monitor

a

The post-op patient is receiving morphine via the patient controlled analgesia pump (PCA). The nurse finds the patient drowsy, with Temp 97.2 F, pulse 52, RR 11, BP 101/58 and pulse ox 93% on 2L of oxygen. Which action should the nurse take first? a Attempt to arouse the patient b Contact the health care provider c Check the PCA pump setting and history d Document the findings e Administer Narcan

a

Which of these actions by the nurse takes priority when the nurse discovers a prolapsed cord in a laboring woman? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Lift the fetal head up with gentle pressure. b Administer oxygen. c Check for cord pulsation. d Insert a foley catheter.

a

A nurse is providing primary prevention to a local community group about psychiatric-mental health disorders. Which of the following would the nurse include as protective factors? Select all that apply a Flexibility b Absence of recreational activities c Adequate economic resources d Limited social relationships

a and c

The patient is taking Gentamycin 80 mg IV q 8hr. for an infection. Which are appropriate interventions regarding this medication? (Mark all that Apply) Multiple answers: Multiple answers are accepted for this question Select one or more answers and submit. For keyboard navigation...SHOW MORE a After the 3rd dose of the medication blood is drawn minutes before the infusion and 60 minutes after the infusion. b Observe the patient for tinnitus c Monitor the creatinine level d Advise the patient that diarrhea is a common side effect.

a, b, and c

The patient with Alcoholism has a magnesium level of 1.2 mEq/L. Which foods would be most appropriate for the nurse to recommend? Select all that apply. a. Peanut Butter b. Dark Chocolate c. Pineapples d. Apples e. Coffee

a, b, and c Rationale: Nuts and grains have a very high magnesium content. Dark chocolate and pineapples also contain Mg.

A nurse manager is explaining the use of incident reports to a group of nurses in an orientation program. Which statements should the nurse manager include in this teaching? (Select all that apply) a A description of the incident should be documented in the client's health care record. b Incident reports should not be shared with the client. c Incident reports include a description of the incident and the actions taken. d A copy of the incident report should be placed in the client's health care record. e The risk management department investigates the incident.

a, b, c, and e

A nurse manager is observing the actions of a nurse she is supervising. Which actions by the nurse requires the nurse manager to intervene? (Select all that apply) a. Reviewing the health care record of a client assigned to another nurse b. Making a copy of a client's most current laboratory results for the provider during rounds c. Providing information about a client's condition to hospital clergy d. Discussing a client's condition over the phone with an individual who has provided the client's information code e. Participating in walking rounds that involve the exchange of client-related information outside the client's room

a, b, c, and e

A nurse employed in a well baby clinic is preparing the scheduled recommended immunizations to a 2 month old infant. The nurse reviews the infant's immunization schedule and notes documentation that the infant received the first dose of hepatitis B (HepB) vaccine at birth. The nurse should prepare to administer which vaccines at this time? Select all that apply. a. Pneumococcal (PCV-13) b. Inactivated poliovirus (IPV) c. Hepatitis B (Hep B) d. Haemophillus Influenza type b conjugate (HIB) e. Varicella f. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) g. Measles mumps and rubella (MMR)

a, b, c, d, and f

The nurse is coassigned with a licensed practical nurse (LPN) to care for 20 patients on a skilled, long-term care facility. When working as a team, which nursing duties would the nurse delegate to the LPN? Select all that apply. a Administer morphine sulfate 30mg intramuscular every b Hang 2 units of packed red blood cells c Inject furosemide 40 mg intravenously daily d Place a nasogastric tube for gastric decompression e Calculate output every 8 hours and report to the health care provider f Insert a 20-French Foley catheter

a, d, e, and f

A patient with the diagnosis of bipolar disease disorder, depressed type, is found lying on the floor in his room in the psychiatric unit. The patient states, I don't deserve a comfortable bed; give it to someone else." Which is the most appropriate response by the nurse? a. "Everyone has a bed and this one is yours." b. "You are not allowed to sleep on the floor." c. "I don't understand why you are on the floor." d. "You're too valuable a person to be lying on the floor."

a. "Everyone has a bed and this one is yours."

A nurse is providing teaching for a client who has a new diagnosis of hypertension and a prescription for a low-sodium diet. Which statement indicates a need for further teaching? a. "I should select organic canned vegetables" b. "I need to read food labels when grocery shopping" c. "I will stop eating frozen dinners for lunch at work" d. "I know that deli meats are usually high in sodium"

a. "I should select organic canned vegetables" Rationale: Remember that canned foods are high in sodium. The other statements are correct.

A patient is brought to the alcohol detoxification unit by his wife. He is lucid and cooperative with the nurse during the initial interview. Which of these questions is most important to ask during the first interview? a. "When did you take your last drink?" b. "Do you usually drink at home or in a bar?" c. "Is it your decision to get help or is it your wife's decision?" d. "Have you ever been to an AA meeting?"

a. "When did you take your last drink?"

The following patients are waiting to be seen in the ER. Which patient should the nurse assess first? a. A patient who abuses cocaine with chest pain. b An intoxicated patient with a long history of alcoholism. c A patient who recently experienced a "bad trip" from LSD. d A patient who thinks she has been given flunitrazepam (Rohypnol)

a. A patient who abuses cocaine with chest pain.

A patient with a recent diagnosis of deep vein thrombosis (DVT) has sudden onset of shortness of breath and chest pain that increases with a deep breath. What should the nurse do first? a. Assess the oxygen saturation b. Call the health care provider c. Administer morphine sulfate 2 mg IV d. Perform range of motion exercises in the involved leg

a. Assess the oxygen saturation

The graduate nurse notices a distinct odor of alcohol on the precepting nurse's breath. Which action is most appropriate and should be taken by the graduate nurse? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a. Immediately inform the charge nurse of the nurse's breath odor b Discuss the situation with another colleague and formulate a plan c Research the state's peer assistance program and discuss the program with the nurse d Ask the impaired nurse to go home or the incident will be reported to the manager

a. Immediately inform the charge nurse of the nurse's breath odor

The physician orders a paracentesis. Which instructions immediately before the procedure is most appropriate by the nurse? a. Instruct the patient to void b. Administer a laxative c. Hold all patient medications d. Administer an enema

a. Instruct the patient to void Rationale: A paracentesis involves draining fluid from the abdomen. If the patient doesn't void prior to the procedure, there is a risk of puncturing the bladder.

The patient with cardiac disease has the following serum lab results: potassium 4.5 meq/L, blood glucose of 150 mg/dl, increased CK-MB, BUN is 10, LDL is 180 and urine specific gravity is 1.030. Which actions are the most appropriate by the nurse? a. Keep in bed and assess for chest pain b. Recommend a low fat diet and encourage exercise c. Place the patient in Semi-Fowler's position and increase the patient's fluids d. Repeat blood sugar and notify the doctor

a. Keep in bed and assess for chest pain Rationale: CK-MB is a cardiac enzyme that detects MI. This is the most concerning abnormal value. Keep the patient in bed to decrease oxygen demand.

A patient is admitted with fluid overload. Which is a priority nursing action? a. Listen to lungs b. Check for hypertension c. Monitor intake and output d. Assess vital signs

a. Listen to lungs Rationale: B and D are saying the same thing, you are checking blood pressure. A is the priority as we are concerned with pulmonary edema. This follows the ABC model for prioritization.

The child recovering from foot surgery is advanced to a full liquid diet. Which item should the nurse offer to the child? a. Pudding b. Chicken noodle soup c. Applesauce d. Lemon Gelatin

a. Pudding Rationale: The patient is advancing from a clear liquid diet to a full liquid diet. Lemon gelatin is a see-through clear liquid. Pudding is a full liquid because it is made of milk and it is not see through. The other two options are solid foods.

The patient has a sodium level of 150mEq/L. Which item should be the nurse implement first? a. Water b. Salty peanuts c. Processed cheese d. IV solution: D5W

a. Water Rationale: Water is the first choice as it is not invasive. Isotonic fluids would be given before D5W, a hypotonic solution.

A college student was hospitalized following onset of a severe case of pertussis and treated with an antibiotic. In preparing for discharge, the nurse would correct which patient statement that indicates a misunderstanding about post discharge care? a "Irritants that I breathe such as smoke or dust could make me have coughing spells again." b "I will try to avoid being around people for a full 2 weeks after going home so I don't spread this to others." c "I will be very careful to wash my hands often." d "It will still be important to try to drink a lot of fluids when I go home."

b

A nurse administers a fatal dose of morphine sulfate to a patient. During the subsequent investigation of error, it is determined that the nurse did not check the patient's respiratory rate before administering the medication. Failure to adequately assess the patient is addressed under which function of the nurse practice act? a Defining the specific educational requirements for licensure in the state. b Identifying the process for disciplinary action if standards of care are not met. c Describing the scope of practice of licensed and unlicensed care providers. d Recommending specific terms of incarceration for nurses who violate the law.

b

A nurse is caring for several clients in an extended care facility. Which client is the highest priority to observe during meals? a A client who has decreased vision b A client who has Parkinson's disease c A client who has poor dentition d A client who has anorexia

b

A nurse is working on a cardiac unit caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate that which management strategy will be used for this client? a. Defibrillation b. Pacemaker insertion c. Synchronized cardioversion d. Administration of IV Lidocaine

b

A nurse received report on four patients. Which patient would the nurse see first? a A patient with congestive heart failure who gained 2 pounds overnight b A patient with tuberculosis who raised 50mL of sanguineous sputum over the past 2 hours c A patient with C. Difficile who continues to have loose, fouling smelling stools d A patient with chronic obstructive pulmonary disease (COPD) whose last report of oxygenation saturation was 91%

b

A patient is in the first hour of their recovery after a vaginal delivery. 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 patient's vital signs remain at their baseline. Based on this information, the nurse would implement which of the following actions? a. Recheck the admission hematocrit and hemoglobin levels. b. Report the findings to the health care provider. c. Document the findings as normal. d. Increase the IV rate.

b

A patient is recovering from a spinal cord injury which left her with quadriplegia. She often is tearful, and, when referral to a rehabilitation hospital is suggested, she says, "What's the use - I'll never be good for anything anyway." Which response by the nurse is most appropriate? a Accept the patient's right to make her own treatment decisions. b Encourage the patient to talk about her feelings of worthlessness. c Remind the patient that all persons have worth in the eyes of God. d Educate the patient on the importance of rehabilitation in self care.

b

A patient with heart failure is taking furosemide, digoxin, and potassium chloride. The patient has nausea, blurred vision, headache, and weakness. The nurse notes that the patient is confused. The telemetry strip shows first-degree atrioventricular block What other signs should the nurse assess next? a Hyperkalemia b Digoxin toxicity c Fluid deficit d Pulmonary edema

b

A woman who is taking clomiphene citrate (Clomid) calls the infertility clinic and says that she has some nausea each morning and frequency of urination. She suspects that she may be pregnant. Which instruction should the nurse provide to the woman? a Tell her that pregnancy cannot be determined until she misses her next period. b Have her come to the clinic promptly for a sensitive pregnancy test. c Have her continue taking the drug until she completes this cycle and then have a pregnancy test. d Reassure her that her symptoms are commonly seen in women who take this drug.

b

As a young patient is receiving a dialysis treatment, the nurse notes the patient is not talking with the other patients and was tearful. The nurse states, "You look discouraged." The patient replies, "I'm a bother. Not much good to anyone anymore. My partner would at least get some insurance money if I died." Which is the most therapeutic response by the nurse? a "I can understand how you feel." b "You feel so bad you wish you were dead." c "We all have days we feel like that. Let's talk about your diet." d "I know it's hard, but don't let it get you down or let your wife hear you."

b

Emergency Medical Service brings a woman into the emergency room on a stretcher. She is in active labor and on physical examination, crowning is noted. The nurse is aware that the priority action is to: a. get the patient to the labor unit as quickly as possible. b. provide gentle pressure on the fetal head. c. maintain a sterile environment for the delivery. d. go to the phone and call the doctor immediately.

b

Five minutes after a spontaneous vaginal delivery, a full-term newborn presents with the following: apical heart rate: 120; respirations: 24 and shallow; position: partial flexion; cry when suctioned; bluish extremities. The nurse would determine that the APGAR score is: a 5 b 7 c 9 d 10

b

In assessing a client receiving chemotherapy, which would require further evaluation by the nurse? a Dry mucous membranes b Areas of ecchymosis c Complaints of fatigue d Hair loss on scalp

b

The charge nurse is planning hospital bed placements for the five male clients identified below. Two double rooms and one private room are available. Which room assignments should be made by the charge nurse?Client A - Has infected abdominal wound, cultured positive for methicillin-resistant Staphylococcus aureusClient B - Admitted with ketoacidosis, history of chronic hepatitis CClient C - Has history of bloody sputum, night sweats; airborne precautions currently in placeClient D - Had vascular surgery; leg ulcers cultured positive for methicillin-resistant Staphylococcus aureusClient E - 1 day postoperative small bowel resection; had postoperative hypotension a Client B - private room; Clients C and E in same room; Clients A and D in same room b Client C - private room; Clients A and D in same room; Clients B and E in same room c Client E - private room; Clients B and C in same room; Clients A and D in same room d Client C - private room; Clients A and B in same room; Clients D and E in same room

b

The patient received regular insulin at 7am. At 10am the patient is irritable, feels shaky and sweaty. Which action should the nurse take first? a Have patient lie down and rest b Administer glucose c Administer insulin d Check serum glucose level

b

The patient with suspected renal calculi is admitted to the medical unit. Which intervention should the nurse implement first? a. Request the patient to urinate and strain urine b. Assess the patient's pain c. Increase the patient's oral fluid intake d. Encourage the patient to ambulate

b

The patient with tuberculosis is to be started on Rifampin as one of the 4 medications to treat this condition. Which is an appropriate instruction by the nurse? a "Yellow-colored skin is common" b "Wear glasses instead of soft contact lenses" c "Always take the medication with food" d "As soon as the cultures are negative, the medication will be stopped".

b

A patient has a history of chronic constipation. Which medications prescribed for the patient would alert the nurse to be especially vigilant in observing for constipation and teach the client about preventive measures? Select all that apply. a Antibiotics b Iron c Laxatives d Opioids

b and d

The nurse is caring for several patients scheduled to start on Lipitor (atorvastatin). Which patient should the nurse question the use of Lipitor? (Mark all that apply) a A 45 year old male with a LDL of 189 and a history of hypertension b A 30 year old female with a LDL of 210 and is planning a family within the year. c A 58 year old male with metabolic syndrome with an ALT of 35 d A 60 year old female with an LDL of 190 an AST of 80 a family history of CAD

b and d

A client who is 29 weeks pregnant comes to the labor and delivery unit. She states that she's having contractions every eight minutes. The client is also 3cm dilated. Which treatments can the nurse expect to administer? Select all that apply. a. Folic Acid (Folvite) b. Procardia (Nifedipine) c. Betamethasone d. IV fluids e. Meperidine (Demerol)

b, c, and d

A nurse is reinforcing teaching with a client who has a new prescription for levothyroxine to treat hypothyroidism. Which information should the nurse include in the teaching? (Select all that apply) a Weight gain is expected while taking the medication b Medication should not be discontinued without the advice of the provider c Follow-up serum TSH levels should be obtained d Take the medication on an empty stomach

b, c, and d

A nurse on the telemetry unit is caring for a client who was admitted 2 hours ago and has chest pain. The client becomes angry and tells the nurse that there is nothing wrong with him and that he is going home immediately. The nurse should base her actions on which factors? (Select all that apply) a To avoid legal issues the nurse should notify the risk manager immediately. b Clients leaving without a discharge order the nurse should document the client left the facility "against medical advice" (AMA) c It is the nurse's responsibility to explain to the client the risks involved if he chooses to leave. d Most facilities have a form that clients are asked to sign if they leave the facility prior to discharge. e A nurse who tries to prevent a client from leaving the hospital may be faced with legal charges.

b, c, d, and e

The nurse is at the scene of a train crash. Which patients should be coded as emergent? Select all that apply. a Patient is asystolic with no respirations b Patient complains of chest pain c Patient with a leg sprain d Patient with a chest wound e Patient with several fractures of extremities f Patient with full thickness burns on at least 20% of body g Patient with head injury producing loss of consciousness

b, d, f, and g

The patient with Alzheimer's disease becomes increasingly agitated and states, "I must go and clean out the barn!" Which nursing response is most therapeutic? a. "What makes you think the barn needs to be cleaned?" b. "So you've cleaned a barn. Tell me did you live on a farm?" c. "It's awfully hot today; maybe you should wait until tomorrow." d. "There are no barns around here. Would you like something to eat?"

b. "So you've cleaned a barn. Tell me did you live on a farm?" Rationale: This question allows the patient to talk about their past, which can be good.

A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 diabetes mellitus. Which action should the nurse implement? a. Check blood glucose immediately after breakfast b. Administer insulin when breakfast arrives c. Hold breakfast for 1 hr after insulin administration d. Clarify the prescription because insulin should not be administered at this time

b. Administer insulin when breakfast arrives Rationale: Aspart is a short-acting insulin with a quick onset. If it is given too far ahead of breakfast, the patient can become hypoglycemic.

Spironolactone (Aldactone) is prescribed for the patient. When teaching the patient about this medication, what does the nurse instruct the patient to limit when making dietary choices? a. Red meats b. Citrus Fruits c. Whole grains d. Dairy products

b. Citrus Fruits Rationale: Spironolactone is a potassium-sparing diuretic, so we want the patient to limit their consumption.

A nurse is observing a new nursing graduate insert a nasal trumpet airway into a patient. The nurse would intervene if the new nursing graduate did which of the following? a. Checks the nose for septal deviation. b. Uses a nasal trumpet that is slightly larger that the nares. c. Inserts the nasal trumpet gently following the contour of the nasopharyngeal passageway. d. Lubricates the nasal trumpet with water-soluble lubricant jelly containing a local anesthetic.

b. Uses a nasal trumpet that is slightly larger that the nares.

A client, 34 weeks gestation, is admitted with profuse vaginal bleeding; she expresses no discomfort or cramping. To assess this client further the nurse should: a ask client about any precipitating event. b perform vaginal exam to note source of bleeding. c prepare client for an ultrasound. d assess for a "board like" abdomen.

c

A mother is planning on bottle-feeding her newborn. The nurse should include which of the following breast care options in the care plan? a Tight binder, restrict fluids, administer oxytocin (Pitocin). b Express milk, apply ice, analgesics. c Support bra, ice packs, no nipple stimulation. d Pump breasts, apply heat, restrict fluids.

c

A nurse is caring for a client who is being prepared for surgery. The client hands the nurse information about advance directives and states, "Here, I don't need this. I am too young to worry about life-sustaining measures and what I want done for me." Which action should the nurse take? a Return the papers to the admitting department with a note stating that the client does not wish to address the issue at this time. b Explain to the client that you never know what can happen during surgery and that he should fill the papers out "just in case." c Contact a client representative to talk with the client and offer additional information about the purpose of the advance directives. d Inform the client that surgery cannot be conducted unless he completes the advance directives forms.

c

A nurse is caring for a patient after a cardiac catheterization. The patient suddenly reports a feeling of wetness in the groin at the catheter insertion site. The nurse checks the site, notes that the patient is actively bleeding, and take which best action? a Contacts the physician. b Checks the patient's peripheral pulse in the affected extremity. c Dons a sterile glove and places pressure on the insertion site using sterile gauze. d Dons a clean glove and places pressure on the insertion site with the gloved hand.

c

A nurse is instructing a client who has been prescribed oral contraceptives about danger signs that are indicative of negative side effects. The nurse evaluates that the client understands the teaching regarding side effects if the client states the need to report which manifestation? a Breast tenderness b Weight gain c Swelling or pain in one of her legs d Mild hypertension or headache

c

A nurse is observing a nursing student auscultating the breath sounds of a patient. The nurse would intervene if the nursing student did which of the following? a Use the diaphragm of the stethoscope. b Placed the stethoscope directly on the patient's skin. c Asked the patient to lie flat on the right side and then on the left side. d Asked the patient to breathe slowly and deeply through the mouth.

c

A patient is being discharged after spending six days in the hospital, due to depression with suicidal ideation. The psychiatric-mental health nurse knows that an important outcome has been met when the patient states: a "I can't wait to get home and forget that this ever happened." b "I feel so much better. If I continue to feel this way, I can probably stop taking my medications soon." c "I have a list of support groups and a crisis line that I can call, if I feel suicidal." d "I have to leave here soon, if I want to make it to the shelter before they run out of beds."

c

A pregnant woman at 32 weeks of gestation comes to the emergency room because she has begun to experience bright red vaginal bleeding. She reports that she is experiencing no pain. The admission nurse suspects: a Abruptio placentae b Disseminated intravascular coagulation c Placenta previa d Preterm labor

c

A term primigravida was involved in a car accident 3 hours ago. They are having labor contractions every 4 minutes and their cervix is 3/100/-1. The patient is crying uncontrollably and states their pain is constant and severe rating it at 10/10. The priority action by the nurse is to: a. Reassure the patient and assist with nonpharmacologic pain interventions. b. Assess intensity of contractions and determine if the patient would like an epidural. c. Notify the provider of the pain and request an assessment for potential abruption. d. Perform a vaginal exam and coach the patient with breathing exercises for pain control.

c

An older adult client who is on fall precautions is found lying on the floor of his hospital room. Which action should the nurse take first? a Call the client's provider. b Ask a staff member for assistance getting the client back in bed. c Inspect the client for injuries d Ask he client why he got out of bed without assistance.

c

The hospice nurse is triaging phone calls from patients. Which patient should the nurse contact first? a The patient whose family reports the patient is not eating b The patient who wants to rescind the out-of-hospital DNR c The patient whose pain is not being controlled with the current medications d The patient who urinary incontinence has caused a stage 1 ulcer

c

The nurse has just received the change of shift report on the following patients on the labor and delivery unit. Which of these patients should the nurse assess first? a. An 18- year-old single primigravid patient, in labor for 9 hours, with cervical dilation at 6 cm, 0 station, contractions occurring every 5 minutes, and receiving epidural anesthesia. b. A 24- year-old primiparous patient who delivered a 7-lb, 3-oz boy vaginally 1 hour ago, has a firm fundus and scant lochia rubra, and is attempting to breast-feed. c. A 26-year-old multigravida patient, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station, contractions every 3 to 4 minutes, and receiving no anesthesia. d. A 30-year-old multipara who delivered a 6- lb., 5-oz girl by cesarean birth owing to fetal distress 3 hours ago, has a firm fundus and scant lochia, and is receiving morphine by patient controlled analgesia (PCA).

c

The nurse is assessing a patient who had a cesarean birth 12 hours ago. Findings include a distended abdomen with faint bowel sounds x 1 quadrant, fundus firm at the umbilicus, lochia scant, rubra, and pain rated 2 on a scale of 1 to 10. The IV and Foley catheter have been discontinued and the patient received pain medication 3 hours ago. The patient can have pain medication every 4 hours. The nurse should first: a. Give the patient pain medication. b. Have the patient use the incentive spirometry. c. Ambulate the patient from the bed to the hallway and back. d. Encourage the patient to begin caring for their baby.

c

The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month, five clients were diagnosed with pressure ulcers. What should the nurse manager do? a Use the benchmarking procedures to compare the findings with other nursing units in the hospital. b Ask the staff education department to conduct an educational session about preventing pressure ulcers c Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes d Conduct a chart audit to determine which nurses on which shifts were giving nursing care to the clients with pressure ulcers

c

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable P waves, no definable QRS complexes, and a coarse wavy lines of varying amplitude. How should the nurse interpret this rhythm? a. Asystole b. Atrial fibrillation c. Ventricular fibrillation d. Ventricular tachycardia

c

The patient has a pH of 7.51 with a HCO3- of 35meq/L. The nurse prepares to administer which medication? a Sodium bicarbonate b Furosemide (Lasix) c Acetazolamide (Diamox) d Spironolactone (Aldactone)

c

The patient is diagnosed with asthma and the health care provider wants to start salmeterol (Serevent) as an inhaler. Which should the nurse include in the patient teaching? a It should be taken at the first sign of bronchospasm b The dosage is two puffs every 4 hours as needed for asthma attacks c It is intended for long-term maintenance. d Rinse mouth after use

c

The patient taking famotidine (Pepcid) asks the home care nurse what would be the medication to take for a headache. Which medication should the nurse recommend to the patient? a Aspirin (ASA) b Ibuprofen (Motrin) c Acetaminophen (Tylenol) d Naproxen (Naprosyn)

c

Upon assessment of third-degree heart block on the monitor, what should the nurse do first? a. Call a code b. Begin cardiopulmonary resuscitation (CPR) c. Place transcutaneous pacing pads on the patient. d. Prepare for defibrillation

c

Which patient requires immediate intervention by the nurse? a. The patient with colon cancer reporting bloody stools and abdominal pain b. The patient diagnosed with dyspepsia who has eructation and bloating c. The patient with diverticulosis with left lower quadrant pain and fever d. The patient with pancreatitis reporting steatorrhea and diarrhea

c

Which patient would not warrant an order for an antibiotic? a Emergency Cesarean Section b Surgical debridement of wound from an animal bite c Fever of unknown origin and cold like symptoms in a healthy patient d A report of a sore throat by the patient with neutropenia following chemotherapy

c

Choose the nursing responses that indicate the use of therapeutic communication techniques. Select all that apply. a " I know how you feel." b "You will do just fine just wait and see." c "You are feeling anxious because of the conversation that you had with your boss yesterday." d "Why do you still smoke when you know that you have cancer?" e "Let's talk more about the reasons you are not following your diet."

c and e

A nurse is monitoring a client who received opioid analgesia for adverse effects of the medication. Which effects should the nurse anticipate? (Select all that apply) a Urinary incontinence b Diarrhea c Bradypnea d Orthostatic hypotension e Nausea

c, d, and e

The patient is brought into the emergency room complaining of chest pain. The vitals signs are BP: 150/90, Pulse: 88, resp. rate: 20. The nurse administers nitroglycerin 0.4 mg SL. To evaluate the effectiveness of this medication, the nurse assesses for the relief of chest pain and expects to note which change in vital signs? a. BP 160/100, P 120, RR 16 b. BP 150/90, P 70, RR 24 c. BP 100/60, P 92, RR 20 d. BP 100/60, P 70, RR 24

c. BP 100/60, P 92, RR 20 Rationale: Remember that with the administration of nitro, we always check the BP because we expect it to drop. When blood pressure drops, the heart rate increases to compensate.

A nurse is completing the admission physical assessment of a client who has mitral valve insufficiency. Which is an expected finding when the patient is experiencing complications of this condition? a. Hoarseness b. Petechiae c. Crackles in the lung bases d. Splenomegaly

c. Crackles in the lung bases

The nurse is told by the alert and oriented hospitalized patient that an unidentified female entered the patient's room and search through the patient's personal possessions. After calming the patient, which action should be the nurse's priority? a. Notify the police b. Complete an incident report c. Notify the hospital security officer d. Inventory the patient's possessions

c. Notify the hospital security officer

The nurse is explaining the anatomy and physiology of ventricular septal defect (VSD) to the parents of an infant recently diagnosed with the condition. The nurse should base the explanation of the condition on which statement? A VSD is a cardiac defect: a. Related to the persistence of one of the fetal shunts b. Causing obstruction to right ventricular flow c. Resulting in increased pulmonary blood flow d. Associated with hypoxemia and cyanosis

c. Resulting in increased pulmonary blood flow

A 25 year old primigravida at 40 weeks gestation is in the active stage of labor. She is being monitored with an internal transducer and a fetal scalp clip. Upon reviewing the monitoring strip, the nurse notices decelerations of the fetal heart rate. Which pattern will most likely indicate fetal hypoxia and acidosis? a Decelerations that are mirror images of the uterine contractions. b Mild decelerations that occur at variable times and have a rapid return to baseline. c Decelerations that occur in response to fetal head compression. d Decelerations that have a delayed onset and have a very slow return to baseline well after the end of the uterine contraction.

d

A client is progressing in normal labor when her membranes rupture; the nurse notes that the fluid is greenish-brown in color. The nurse caring for this client would give highest priority to: a helping the client in to the knee-chest position. b preparing the client for a cesarean section. c observing for signs of a precipitate birth. d continuous assessment of the fetal heart rate.

d

A client who is undergoing a non-stress test asks the nurse to explain why she is using an acoustic vibration device. The nurse states that the device is used to: a. Stimulate uterine contractions b. Relax uterine contractions c. Soothe the baby to sleep d. Awaken the sleeping fetus

d

A nurse is reviewing a client's health care record and discovers that the client's do-not -resuscitate (DNR) order has expired. The client's condition is not stable. Which action should the nurse take next? a Assume that the client does not want to be resuscitated, and take no action if he experiences cardiac arrest. b Write a note on the front of the provider order sheet asking that the DNR order be reordered c Anticipate that CPR will be instituted if the client goes into cardiopulmonary arrest. d Call the provider to determine whether the order should be immediately reinstated.

d

A nurse is teaching a client the importance of remaining still following cardiac catheterization (with groin catheter insertion site). Which is an appropriate statement by the nurse? a. "Moving in bed raises your blood pressure" b. "Too much activity increases your risk for infection" c. " Moving in bed increases your risk of complications due to anesthesia" d. "Too much activity places you at risk for bleeding"

d

A patient has been admitted to the psychiatric unit with a diagnosis of obsessive compulsive disorder. The patient's hands are cracked and peeling due to frequently washing hands. Which is a realistic short term goal for this patient? a The patient will describe how anxiety precipitates obsessive handwashing. b The patient will limit handwashing to before meals and after toileting. c The patient will recognize that handwashing is excessive and irrational d The patient will use appropriate lotions to protect skin from further trauma.

d

A pregnant woman with 4 children reports the following obstetric history: a still birth at 32 weeks of gestation, triplets (2 sons and a daughter) born via cesarean section at 30 weeks gestation, a spontaneous abortion at 8 weeks ,and a daughter born vaginally at 39 weeks of gestation. Which of the following accurately expresses this woman's current obstetric history using the 5 digit system? a. 5-1-4-1-4 b. 4-1-3-1-4 c. 5-2-2-0-3 d. 5-1-2-1-4

d

A woman brings her 75 year old father to the clinic. She tells the nurse that he has become more forgetful and is "not like himself." She states that she is fearful that he may be developing Alzheimer's disease. Which is most essential in the nurse's assessment of the client? a Ask if he has abused drugs or alcohol in the past. b Find out if there is a family history of Alzheimer's or Downs Syndrome. c Evaluate the daughter's support system and her ability to serve as caregiver. d Look for signs that the client may have a treatable medical problem.

d

The Home Health Nurse makes a visit to the patient with COPD, right sided lung cancer and who is undergoing chemotherapy . Upon assessment, the nurse notes right side decreased breath sounds, poor oral intake, signs of dehydration, skin pale and dry and a temperature of 101. The HCP suggest an ER visit for the patient. Which information is most important for the nurse to communicate to the ER? a The patient has lung cancer and decreased breath sounds b The patient appears dehydrated and is has poor intake c The patient is pale and the HCP requests a CBC to be drawn d The patient is undergoing cancer treatment and has a fever

d

The client with peripheral artery disease has been prescribed Cardizem (diltiazem). To determine the effectiveness of this medication, the nurse should assess the client for which intended outcome? a Decreased anxiety b Prolonged sleep c Decrease in blood pressure d Improved blood flow

d

The nurse assesses the patient with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding should the nurse consider an indication of progressive hepatic encephalopathy? a An increase in abdominal girth. b Hypertension and a bounding pulse. c Decreased bowel sounds. d Difficulty in handwriting

d

The nurse finds an unlicensed assistive personnel (UAP) massaging the reddened bony prominences of a patient on bed rest. What action should the nurse take? a Reinforce the UAP's use of this intervention over the bony prominences. b Explain that massage is effective because it improves blood flow to the area. c Inform the UAP that massage is ev.en more effective when combined with lotion during the massage d Instruct the UAP that massage is contraindicated because it decreases blood flow to the area.

d

The nurse in the outpatient renal center is initiating the morning dialysis run. Which patient should the nurse see first? a. The patient with a hemoglobin of 9.0 mg/dL and hemocrit of 26% b. The patient with a A/V fistula and does not have a palpable thrill or auscultated bruit c. The patient reporting a 3.6 kg. weight gain and is refusing dialysis d. The patient on peritoneal dialysis is complaining of rigid abdomen and stomach pain

d

The nurse is admitting a patient to the hospital who has a diagnosis of Guillain-Barre syndrome. During history-taking, the nurse asks the family member if the patient has recently experienced which condition? a Meningitis b Seizures or head trauma c Back or spinal cord trauma d Respiratory or GI infection

d

The nurse is called to the patient's room by another nurse. When the second nurse arrives at the room, she discovers that a fire has occurred in the patient's waste basket. The first nurse has removed the patient from the room. What is the second's nurse next action? a. Evacuate the unit b. Extinguish the fire c. Confine the fire d. Activate the fire alarm

d

The nurse is discharging a patient who has been hospitalized for preterm labor. The patient needs further instruction when she says: a. "If I think I have a bladder infection, I need to see my doctor." b. "If I have contractions, I should contact my health care provider." c. "Drinking water may help prevent early labor for me." d. "If I travel on long trips, I need to get out of the car every 4 hours."

d

The nurse is preparing to care for a child diagnosed with intussusception. The nurse expects to assess which sign in this child? a Watery diarrhea b Ribbon-like stools c Profuse projective vomiting d Bright red blood and mucous in stools

d

The patient is post partum day 5 and reports her vaginal discharge has gone from brown-pink to red and is increasing in volume. What question would the triage nurse want to ask? a Have you had a fever? b What have you been eating? c Are you breast feeding? d Have you been physically active?

d

The patient is scheduled for an arteriogram. Which item is essential for the nurse to assess before the procedure? a. Intake and output b. Vital signs c. Pedal Pulses d. Allergies

d

The patient is scheduled to start a high fiber diet. Which food has the highest amount of fiber to recommend to the patient? a Whole wheat bread b Raw vegetables c Dried fruit d Baked beans

d

The patient morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema and moist crackles bilaterally. Which physician order takes priority at this time? a. Weigh patient every morning b. Maintain accurate intake and output c. Restrict fluid to 1500 mL per day d. Administer furosemide (Lasix) 40 mg IV push

d

Using the gravida and para system, how would the nurse record the obstetric history of a client who is currently pregnant, has 7-year-old twins, a 2-year-old son, and had a spontaneous abortion at 12 weeks gestation last year? a. Gravida 3, Para 3 b. Gravida 3, Para 2 c. Gravida 4, Para 3 d. Gravida 4, Para 2

d

Which nursing diagnosis is priority for the patient who has undergone a transurethral resection of the prostate (TURP)? a Potential for sexual dysfunction b Potential for altered urinary elimination c Potential for infection d Potential for hemorrhage

d

The nurse should suspect Cystic Fibrosis when the parents report which manifestation in their child? a. Wheezing b. Musty smelling urine c. Right lower quadrant pain d. A salty taste when kissed

d. A salty taste when kissed

A child with hemophilia comes to the emergency room after bumping his knee. The knee is rapidly swelling. What is the first nursing action? a. Initiate an IV site to begin administration of cryoprecipitate b. Type and cross-match for possible transfusion c. Draw blood for determination of hemoglobin and hematocrit values to monitor bleeding d. Apply ice pack and compression dressings to the knee

d. Apply ice pack and compression dressings to the knee

The patient requires a partial bed bath. The nurse gives instructions to a nursing assistant about the partial bed bath and tells the nursing assistant to: a. Just wash the patient's hands and face. b. Provide mouth care and perineal care only. c. Let the patient decide what they want washed. d. Be sure to bathe the patient's body parts that would cause discomfort or odor if left unbathed.

d. Be sure to bathe the patient's body parts that would cause discomfort or odor if left unbathed.

A nurse is observing a nursing assistant measuring the blood pressure (BP) of a patient. The nurse intervenes if which action was observed that would interfere with accurate measurement of the BP? a. Positions the patient's arm at heart level. b. Exposes the extremity fully by removing constricting clothing. c. Explains the procedure to the patient and asks the patient to rest for 5 minutes. d. Palpates the radial artery and places the cuff of the sphygmomanometer 1 inch above the brachial artery.

d. Palpates the radial artery and places the cuff of the sphygmomanometer 1 inch above the brachial artery. Rationale: You should palpate the brachial artery.

The nurse learns that a hospitalized patient has a history of chronic hepatitis C. Which precaution should the nurse plan to implement? a. Airborne b. Contact c. Droplet d. Standard

d. Standard

The patient is receiving digoxin for treatment of her congestive heart failure. Which physiological response indicates that digoxin is having the desired response? a Decrease myocardial contraction force b Increase urine output c Decrease heart rate d Fewer heart palpitations

b

The patient with migraines is prescribed Imitrex (sumatripin). Which condition should the nurse question the use of Imitrex? a Hypotension b Prinzmental Angina c Uncontrolled hyperlipidemia d Stress and Anxiety

b

A patient admitted to the telemetry unit with new diagnosed atrial fibrillation has been started on warfarin. Which are appropriate instructions by the nurse? Select all that apply. a Avoid injury to prevent bruising b Report any change in color of urine or stool c Floss the teeth deep into the gums d Do not take the medication if the pulse is below 60

a and b

A nurse is admitting a client to the coronary care unit following placement of a temporary pacemaker. Which nursing actions should the nurse use to promote client safety? (Select all that apply) a. Wear gloves when handling pacemaker leads b. Ensure electronic equipment has three-pronged grounding plugs c. Minimize the client's shoulder movements d. Hold the lead wires taut when turning the client e. Keep extra pacemaker batteries at least 300 ft away from the client

a and c

A nurse is caring for a client following for insertion of a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. Which findings should the nurse report to the provider? (Select all that apply) a. Cool and clammy foot with capillary refill of 5 seconds b. Observed pacing spike followed by QRS c. Persistent hiccups d. Heart rate 84/min e. Blood pressure 104/60 mmHg

a and c

A nurse is providing information to a client who has a new diagnosis of type 1 diabetes mellitus. Which information should the nurse include? (Select all that apply) a. It is triggered by a viral infection b. Alpha cells in the pancreas are damaged c. It usually occurs before age 30 d. It is treated with antiglycemic medications e. Blood glucose is controlled by diet and exercise

a and c

The patient is scheduled to receive Fe+ supplements for anemia. Which instructions are appropriate by the nurse? Select all that apply. a Bowel movements might appear darker in color b Increase fluids and avoid orange juice c Mix liquid form with water and drink through a straw d Take with food on a full stomach

a and c

The nurse is caring for a patient with Diabetes Mellitus who has an open wound on the left heel. Which assessment findings should the nurse associate with a wound infection? Select all that apply. a Oral temperature 100.6 o F (38 o C) b Heel feels warm when touched c Yellow and purulent drainage d Reduced sensation in the left foot e Elevated white blood cell count

a, b, c, and e

The patient with prostate cancer is scheduled to be treated with brachytherapy as an outpatient. The nurse is providing discharge instructions. Which statements by the patient warrants intervention by the nurse? Select all that apply. a. "I will use condoms during intercourse especially for the first two weeks" b. "I am looking forward to feeling better when my next child is born in 3 months". c. "It is so nice to be home during treatment and spending time with my family." d. "I will call the doctor if I experience any rectal bleeding or urinary burning or impotence."

a, b, and c

Typical signs of withdrawal in opiate-dependent newborns usually begin within 24 hours after birth. The nurse should observe newborns of suspected drug abusers for which manifestations? Select all that apply a Dehydration b Hyperactivity c High pitch cry d Prolonged periods of sleep

a, b, and c

A nurse in a provider's office is planning care for a client who has a new diagnosis of Graves' disease and a new prescription for Tapazole (methimazole). Which interventions should the nurse include in the plan of care? (Select all that apply) a Monitor CBC b Monitor triodothryonine (T3) c Instruct client to increase consumption of shellfish d Advise the client to take the medication at the same time every day e Inform the client that an adverse effect of this medication is iodine toxicity

a, b, and d

A patient with a history of severe depression and anxiety is in the hospital after attempting suicide. Which symptoms would be expected to be observed upon admission? Select all that apply. a The patient is withdrawn b The patient reports not being able to sleep for the past few nights c The patient smiles throughout the interview d The patient is not able to concentrate

a, b, and d

The nurse manager is discussing situations in which the staff nurse risks disciplinary action related to licensure. Which nurse's actions risk disciplinary action related to licensure? Select all that apply. a Inserting a central venous catheter under the supervision of the HCP. b Intentionally documenting incorrect information in the patient's medical record c Arriving at work with clothing smelling of tobacco smoke d Recently convicted of a felony for drug possession e Detailing all previous work experience when applying for a nursing position.

a, b, and d

A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of the procedure? (Select all that apply) a. Follow-up ECG b. Energy settings used c. Urinary output d. IV fluid intake e. Skin condition under electrodes

a, b, and e

A nurse is performing a nutritional assessment on a client. Which clinical findings are suggestive of malnutrition? (Select all that apply) a Poor wound healing b Dry hair c Blood pressure 130/80mg Hg d Weak hand grips e Impaired coordination

a, b, d, and e

The nurse is planning care for a group of elderly clients who are affected by orthostatic hypertension. Which actions should the nurse take? Select all that apply. a Assist the clients to stand to help prevent falls b Teach clients how to gradually change their position c Request a prescription for antihypertensive medications for clients at high risk d Conduct fall risk assessments e Consider use of sequential compression devices (SCDs) for high risk clients f Place clients on bed rest

a, b, d, and e

The unlicensed assistive personnel (UAP) reports to the nurse that the patient is "feeling short of breath." The patient's blood pressure was 124/78 mm Hg 2 hours ago with a heart rate of 82 bpm; the unlicensed assistive personnel reports that blood pressure is now 84/44 mm Hg with a heart rate of 54 bpm, and the patient stated, "I just don't feel good." What actions should the nurse take? Select all that apply a Confirm the patient's vital signs and complete a quick assessment b Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team c Make a quick check on other assigned patients before spending time required to take care of this patient d Position the patient in semi-fowlers position e Stay with the patient and reassure the patient f Call the health care provider (HCP) and report the situation using SBAR format.

a, b, d, e, and f

A nurse is teaching a client about high-fiber foods that can assist in lowering LDL. Which foods should be included in the teaching? (Select all that apply) a Beans b Cheese c Whole grains d Broccoli e Yogurt

a, c, and d

Which actions should the nurse take for the patient arriving to the clinic with a newly acquired sprain of the lower extremity? Select all that apply. a Rest b Heat application c Compression d Elevation

a, c, and d

A nurse is performing health screenings of clients at a health fair. Which clients are at risk for osteoporosis? (Select all that apply) a A 40-year-old client who takes prednisone (Deltasone) for asthma b A 30-year-old who jogs 3 miles daily c A 45-year-old client who takes phenytoin (Dilantin) for seizures d A 65-year-old client who has a sedentary lifestyle e A 70-year-old who has smoked for 50 years

a, c, d, and e

A nurse is providing information to a group of clients at a local community center about tuberculosis. Which clinical manifestations should be included in the teaching? (Select all that apply) a Persistent cough b Weight gain c Fatigue d Night sweats e Purulent sputum

a, c, d, and e

Three days after successful resuscitation after a myocardial infarction (MI), the patient states to the nurse, "I'm all washed up. I don't think I'll ever be the same person again." Which is the most appropriate response by the nurse? a "Most patients who have been as ill as you feel that way." b "How do you feel you have changed from before your illness?" c "Getting depressed won't help you get better." d "Maybe not, but tell me more how you feel."

b

Which assessment data should be collected first from the patient admitted to the emergency room with a lacerated artery? a Information about the next of kin b History of current medications c History of tobacco use d Events that resulted in the patient's condition

b

Which dietary component should the nurse teach the patient with renal calculi to limit? a Low phosphorus diet b High calcium intake c High fluid intake d Low protein diet

b

Which drug would be used in the treatment of status epilepticus? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Phenobarbital b Diazepam c Valproic acid d Phenytoin

b

Which woman should receive RhoGAM immune globulin after birth? a. Rh negative mother, Rh positive infant, positive indirect Coombs' test b. Rh negative mother; Rh positive infant; negative indirect Coombs' test c. Rh negative mother; Rh negative infant; positive direct Coombs' test d. Rh positive mother; Rh positive infant; positive direct Coombs' test

b

A nurse is preparing to administer a varicella immunization to a client. Which questions by the nurse are appropriate? Select all that apply a " Are you allergic to eggs?" b "Are you allergic to gelatin products? c " Are you pregnant?" d "Do you have a history of Guillain-Barré syndrome?

b and c

A nurse is completing an assessment of a client who has hemolytic anemia. Which is an expected finding? a. Absent turgor b. jaundice c. Shiny, hairless legs d. Bradycardia

b. jaundice

A nurse is instilling prophylactic eye treatment for ophthalmia neonatorum. Which of the following is the medication of choice to treat ophthalmia neonatorum? a Gentamycin b Nystatin c Erythromycin d Vitamin K

c

A nurse is providing discharge teaching to a client who has COPD and has a new prescription for albuterol (Proventil). Which statement made by the client indicates an understanding of the teaching? a "This medication can lower my blood sugar levels" b "This medication can decrease my immune response" c "I can have an increase in my heart rate while taking this medication" d "I can have mouth sores while taking this medication"

c

A nurse is working on a cardiac unit is admitting a client who is to undergo a cardioversion and is reviewing the health record. Which data requires that the nurse notify the provider to cancel the procedure? MAR: Ferrous sulfate 200mg BID, Diazepam 2mg BID, Isosorbide 2.5 mg 4 times a day . VS: T 99° BP 142/86mm/Hg HR 88 and irregular Respirations 20. H&P: Bariatric surgery 10 years ago, Dyspnea with exertion, Atrial fibrillation for 3 years. Client reports taking the following medications for the past six weeks: iron supplement multivitamin antilipemic and nitroglycerin a. Respiratory history b. Vital signs c. Medication history d. Medications to be administered

c

A nurse is working on a postpartum unit. Which of the following patients should the nurse assess first? a A patient who is 1 day post spontaneous vaginal delivery and complaining of pain upon urination. b A patient who is 1day post forceps assisted vaginal delivery with an estimated blood loss of 500 ml. c A patient who delivered vaginally with vacuum assist 3 days ago and a Hgb 7.2g/dL. d A patient who is 3 days post C-birth with complaints of firm and painful breasts.

c

A patient discloses to the nurse having thoughts of using the sharp edges on the bed to cut his wrists because he feels no one cares about him. Which of the following is the priority nursing intervention? a Chart the conversation and report it to the physician the next day. b Inspect the patient's room and remove anything with sharp edges. c Place the patient on 1:1 observation and notify the physician. d Tell the patient that such attention-getting tactics will not be tolerated.

c

A patient is admitted to the emergency department with severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. What is the nurse's primary goal at this time? a Maintain circulation b Manage pain c Prepare the patient for emergency surgery Your answer d Teach postoperative breathing exercises

c

The child with aortic stenosis is being in the clinic. Which manifestations can the nurse expect to find in this child? Select all that apply. a Pallor b Hyperactivity c Activity intolerance d Slow weight gain e Chest pain

c, d, and e

The school nurse is providing instructional sessions to parents on the topic of impetigo. Which parent statement indicates a need for further instruction? a. "It is highly contagious and can spread." b. "It is most common in humid weather." c. "Lesions most often are located on arms and legs." d. "It might show up in an area of broken skin such as an insect bite." e. "Important to keep child home from school, usually 24 hours after antibiotics begin."

c. "Lesions most often are located on arms and legs."

The patient with a history of aggressive behavior toward staff and peers states to the nurse, "Everyone is just so touchy; I don't see where I'm being too aggressive." Which nursing action should be included in the therapeutic plan of care to best effect a difference in perceptions? a. Refamiliarize the patient with the rules of the unit. b. Introduce nonaggressive interpersonal behaviors. c. Promote dialogue between the staff and patient to discuss the staff's perceptions of aggressive behavior. d. Encourage the staff to show patience because the patient may have poor aggression control.

c. Promote dialogue between the staff and patient to discuss the staff's perceptions of aggressive behavior. Rationale: The question is specifically in regards to perceptions.

A patient is recovering from an exacerbation of left-sided heart failure has a nursing diagnosis of Activity Intolerance. The nurse determines that the patient best tolerates mild exercise if the patient exhibits which of the following changes in vital signs during activity? a. Pulse rate increased from 80 to 104 beats per minute b. Oxygen saturation decreased from 96% to 91% c. Respiratory rate increased from 16 to 19 breaths per minute d. Blood pressure decreased from 140/86 to 110/68 mm Hg

c. Respiratory rate increased from 16 to 19 breaths per minute Rationale: The pulse rate should not increase that much for mild exercise.

A 21 year old gravida 1 para 0 is in labor. The nurse observes that the patient is having intense contractions 2-3 minutes apart lasting 80-90 seconds. She says she has an urge to push sometimes and feels like she is going to vomit. The nurse would expect to find her: a. dilated 3-4 cm and 100% effaced. b. dilated 5-6 cm and 75% effaced. c. dilated 7-8 cm and 50% effaced. d. dilated 8-9 cm and 90% effaced.

d

A 27 year old primigravida is experiencing regular uterine contractions. They are moderate to strong, 3 - 5 minutes apart and last for 40 - 70 seconds. Her cervix is 4 cm dilated and the fetus is at a station of +2. She is becoming more serious and inner directed. The nurse would analyze that she is exhibiting symptoms of what phase of the first stage of labor? a Latent phase b Pushing phase c Transitional phase d Active phase

d

The nurse is caring for the patient with a urinary catheter. Which interventions should the nurse implement to prevent a catheter-acquired UTI? Select all that apply. a. Rubbing for 10 seconds when using alcohol based hand rubs b. Changing urinary catheters and drainage bags once a week c. Using the smallest numbered catheter with intermittent catheterizations d. Properly securing the catheter on the patient's thigh to prevent movement e. Keeping a urinary drainage bag below the level of the patient's bladder

d and e Rationale: Every time you insert a new catheter, there is a potential to introduce new bacteria so we wouldn't want to change it every week.

A patient who has schizophrenia and has paranoia tells the nurse, "I'm here on a secret mission for the government. Don't blow my cover." Which response by the nurse would be most therapeutic? a. "Let's talk about something other than your mission for the government." b. "Your admission papers do not list you as a government employee." c. "You have lost touch with reality, which is a symptom of your illness." d. "It sounds like you have some concerns about your privacy. "

d. "It sounds like you have some concerns about your privacy. "

After a patient's hemodialysis treatment, the nurse would expect to find which improved lab value? a. Hgb/HCT b. Calcium c. Ammonia d. Potassium

d. Potassium

A patient is admitted with tremors, cramps and spasms. Which lab value best supports the patient's condition? a. K+ 4.0 b. Mg+ 4.8 c. Na+ 135 d. Ca+ 6.5

d. Ca+ 6.5 Rationale: A and C are normal values for their respective electrolytes. High magnesium is associated with respiratory depression

The nurse in the clinic is caring for the child with Croup (larygnotracheobronchitis). Which assessment finding warrants immediate action by the nurse? a. Barking cough b. Temperature 100 F c. Hoarse voice d. Drooling with sore throat

d. Drooling with sore throat

The client was found lying on the floor next to the bed. Once urgent care is provided, the nurse completes an incident report. Which statements would be inappropriate to include in the report. Select all that apply. a. The client fell out of bed b. No bruises or injuries are noted on the client c. The client apparently climber over the side rails when the nurse was out of the room d. The physician was notified that the client was found lying on the floor next to the bed e. The client is alert and oriented and stated that he needed to "go to the bathroom and didn't want to bother the nurse"

a and c

Trauma-informed care philosophical approach that includes which of the following principles? (Select all that apply) a. Nurses need to be aware of the potential for trauma in any patient and provide care that minimizes the risk of re-victimization and re-traumatization. b. Medications need to be given before any other interventions are considered. c. Trauma-informed care highlights the importance of providing care that protects the physical psychological and emotional safety of the patient. d. Trauma-informed care is based on the principles that traumas are not considered with depression or increased risk of suicide.

a and c

A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Select all that apply. a. Developing culturally appropriate outcomes b. Using the standardized outcomes on the clinical pathway c. Choosing the best outcome for the patient regardless of the cost d. Involving the patient and family in formulating the outcomes

a and d

The nurse is developing a post operative plan of care for the child who had a tonsillectomy and adenoidectomy. Which nutritional interventions should be included in the plan? Select all that apply. a. Provide noncarbonated fluids to drink b. Offer milk products once diet is advanced to full liquids. c. Instruct the child to drink through a straw d. Provide non-citrus fluids to drink e. Offer the child's favorite fluid: cherry punch

a and d Rationale: Major concerns w/ tonsillectomy is bleeding, pain, and irritation to the throat. Consumption of milk will lead to increased mucus production, which can lead to coughing. Citrus is irritating. Using a straw can cause trauma. The patient should not consume drinks colored red.

The pregnant woman is seeking dietary information regarding prevention of myelomeningocele in the fetus. In addition to recommending prenatal vitamins, which foods should the nurse recommend? Select all that apply. a. Leafy green vegetables b. Beans c. Oranges d. Ground Beef

a, b, and c Rationale: These foods are high in folic acid, which is necessary in preventing neural tube defects

The nurse is caring for patients in a hospital setting. Which observations made by the nurse require intervention? Select all that apply. Multiple answers: Multiple answers are accepted for this question Select one or more answers and submit. For keyboard navigation...SHOW MORE a The patient's infusion pump is noted to have a cut in the center of the cord. b The patient's bed is in the high position after a NA left the room. c The patient's battery-operated CD player does not an agency inspection tag. d The patient's bed exit alarm is beeping and another nurse just left the room. e The patient's bedside table is placed in front of the chair where the patient is sitting.

a, b, and d

The nurse is planning an educational session for a group of parents with toddlers. Based on the leading causes of death in toddlers, the nurse should make which topics priority? Select all that apply. Multiple answers: Multiple answers are accepted for this question Select one or more answers and submit. For keyboard navigation...SHOW MORE a Water safety and methods to prevent drowning b Use of age- and weight-appropriate car seats c Nutrition guidelines and age-appropriate foods d Use of labels and safety devices on poisonous substances e Safety when outdoors and crossing the street

a, b, and d

A nurse is teaching the parents of a toddler about appropriate snack foods. Which items should be included in the teaching? (Select all that apply) a. Graham crackers b. Apple slices c. Raisins d. Jelly beans e. Cheese slices

a, b, and e

The nurse is working in a busy ED with multiple admissions. For which patients should the nurse ensure that mandatory reporting is completed? Select all that apply. Multiple answers: Multiple answers are accepted for this question Select one or more answers and submit. For keyboard navigation...SHOW MORE a The patient has a gunshot wound b The patient has pertussis c The child who has a cigarette burn d The vulnerable patient who is emaciated e The adult patient who has a broken hip from a fall

a, b, c, and d

What strategies do you use if involved in an active shooter situation? Select all that apply. a. Call 911 stay on phone b. Run c. Hide d. Fight

a, b, c, and d Rationale: Additionally, when you leave the building you should do so with your hands up.

A nurse has been assigned to care for the following six patients. Which patients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply a. A patient who is on complete bed rest following extensive spinal surgery b. A patient who has a large venous stasis ulcer on the right ankle area c. A patient who has recently been admitted with a broken femur and is awaiting surgery d. A patient who has pleural effusion secondary to infection e. A patient who is receiving supplemental oxygen following shoulder surgery f. A patient who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy

a, b, c, and f Rationale: The patient with a venous stasis ulcer has poor circulation. Long bone fractures put patient's at risk for PE. Post-op patients with movement restrictions are also at risk.

The patient has a newly placed left forearm internal arteriovenous (AV) fistula for hemodialysis. Which interventions should the nurse plan to implement? Select all that apply. Multiple answers: Multiple answers are accepted for this question Select one or more answers and submit. For keyboard navigation...SHOW MORE a Tell the NA to take the BP on the right arm b Palpate for a thrill over the left forearm fistula c Aspirate blood from the fistula for blood tests d Check the left radial pulse finger movement and sensation e Instruct about the hand exercises that start in about a week

a, b, d, and e

The nurse determines that a patient receiving a unit of packed red blood cells (PRBCs) is experiencing a transfusion reaction. After stopping the blood transfusion, what actions should the nurse promptly take next? Select all that apply a. The healthcare provider should be notified b. Obtain a white blood cell count c. Run normal saline at keep vein open (KVO) rate d. Infuse normal saline bolus e. Obtain vital signs every 5 minutes

a, c, and e Rationale: You always want to stop the transfusion immediately and notify the provider. The vein should be kept open and vital signs checked frequently. You would want to collect a urine sample because it will be bloody.

Two staff nurses in an elevator are discussing the patient. The new nurse on the same unit, , but not assigned to the patient, overhears the conversation. Which is the new nurse's best course of action? a. Confront the staff nurses about discussing confidential information b. Report the breach of patient confidentiality to the agency security officer. c. Discuss the situation with the patient to inform the patient of the breach. d. Ignore the discussion because only hospital staff were on the elevator.

a. Confront the staff nurses about discussing confidential information

The school nurse discusses optimal pregame meals with the high school track team. Which suggestion would be best for the nurse to provide to the students? a. Cheeseburger, fries, and diet cola b. Spaghetti and meatballs, bread and milk c. Eggs, bacon, toast and orange juice d. Fish and chips, coleslaw, and coffee

b. Spaghetti and meatballs, bread and milk Rationale: You want to provide a meal with carbs and protein. Avoid caffeine.

The patient who recently emigrated from another country to the U.S. has been placed in seclusion. The nurse assesses that the patient is now calm and ready to be assimilated back into the mental health milieu. Which action by the nurse demonstrates cultural insensitivity? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a. Gives the thumbs-up gesture b Avoids looking at the clock or a watch c Has the NA bring the patient a cup of tea d Offers to get a book that the patient chooses

a. Gives the thumbs-up gesture

A patient with the diagnosis of schizophrenia watches the nurse pour juice for the morning medication from an almost empty pitcher and screams, "That juice is no good! It's poisoned." Which action is most appropriate by the nurse? a. Remark, "You sound frightened." b. Assure the client that the juice is not poisoned. c. Pour the client a glass of juice from a full pitcher. d. Take a drink of the juice to show the client that it is okay.

a. Remark, "You sound frightened." Rationale: The other answer choices feed in to the patient's delusion.

A relative brings a patient who has schizophrenia to an outpatient unit in a disheveled state. The patient is inappropriately dressed and inattentive to the staff due to visual and auditory hallucinations. The patient is started on haloperidol (Haldol). At the follow-up visit to the clinic, which is the best indicator that the Haldol is having the desired effect? The patient: a. arrives independently at the clinic by bus 15 minutes late for the appointment. b. glances off into the corner of the room. c. takes a bath and wears clean, appropriate clothing with the family's constant urging. d. walks restlessly when awake and sleeps almost twelve hours every day.

a. arrives independently at the clinic by bus 15 minutes late for the appointment. Rationale: Being independent is a better indicator of success.

A patient is receiving a loop diuretic. Which foods should the nurse encourage the patient to consume? Select all that apply a. Angel food cake b. Banana c. Dried fruit d. Orange juice e. Hot Peppers

b, c, and d Rationale: Loop diuretics (like Lasix) are not potassium-sparing so the patient will need to consume foods high in potassium.

The patient on the mental health unit is becoming increasingly short-tempered with others' the patient approaches the nurse's desk and, pounding on the counter, yells "I want out of here now!" Select the patient's behaviors for each behavior exhibited. a. Confusion b. Irritability c. Boisterousness d. Verbal threats e. Attacks on objects

b, c, and e

The nurse surveys the patient's hospital room. Which findings require the nurse's immediate attention to remove possible sources of infection.? Select that all apply. a. A capped bottle of saline with the notation "opened 10 hours ago." b. The bed has bloody drainage from the saturated abdominal dressing. c. An infusing IV tubing has no notation of the date when it was last changed. d. An empty container in the bathroom that is labeled urine and has the patient's initials. e. Opened packages of gauze and abdominal pads sitting on the window sill. f. An covered cup of figs on the bedside table brought by a family member.

b, c, and e Rationale: Remember that opened saline can be kept at the bedside for 24 hours.

The nurse is preparing to document the patient's violent episode. Which statements should be included specifically about the violent episode? Select all that apply a. The patient's wife called during the escalation cycle b. The patient refused to voluntarily enter into seclusion c. The patient stated "All of you are just evil people." d. Attempts to identify the cause of the patient's agitation failed e. Five staff members responded to "Emergency Code" f. The patient asked to leave the seclusion room after 30 minutes

b, c, d, and f Rationale: The nurse should only document things directly related to the violence episode.

A nurse is performing an assessment on a 16 year old patient who has been diagnosed with anorexia nervosa. Which statement by the patient would the nurse identify as a priority requiring further assessment? a. "I check my weight every day without fail." b. "I exercise 3 to 4 hours every day to keep my slim figure." c. "I've been told that I am 5% below my ideal body weight." d. "My best friend was in the hospital with this disorder a year ago."

b. "I exercise 3 to 4 hours every day to keep my slim figure." ???

The nurse is addressing the nutritional needs of several patients. Which patient statement requires further action by the nurse? a. "I was recently diagnosed with heart failure and now limit my intake of processed lunch meats." b. "I have filtered well water and encourage my children to drink plenty of water." c. "I eat shellfish, turkey and spinach to increase my iron." d. "Since I am on a lactose restricted diet, I try to increase my intake of green vegetables."

b. "I have filtered well water and encourage my children to drink plenty of water." Rationale: Filtered well water does not contain fluoride. The nurse should ask if they supplement fluoride.

The competent 90-year-old patient admitted to the ED with an MI declines treatment and wishes to be discharged home. Which statement best supports the patient's right to refuse care? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a "I have lived a full life: I want to go home to die." b. "I understand that without treatment I could die." c "It's too expensive to stay in the hospital." d "My family wants me to go home; I will be okay."

b. "I understand that without treatment I could die."

A nurse has provided home care instructions to a patient who is taking lithium carbonate (Eskalith). Which patient statement indicates an understanding of the prescribed regimen? a. "I will restrict my salt intake." b. "I will make sure my diet contains a balanced amount of salt." c. "I stop taking this medication when I feel better." d. "I will be careful to avoid foods high in protein."

b. "I will make sure my diet contains a balanced amount of salt." Rationale: Remember, if you're low in Sodium, Lithium levels increase. If you take too much sodium, Lithium levels decrease.

To help the child with mild to moderate intellectual developmental disorder develop satisfying relationships with others, which of the following nursing interventions is the most appropriate? a. Interpret the child's behavior for others. b. Set limits on behavior that is socially inappropriate. c. Allow the child to behave spontaneously because he or she has no concept of right or wrong. d. The child is not capable of forming social relationships.

b. Set limits on behavior that is socially inappropriate.

The patient will be discharged to home tomorrow on an antidepressant medication that will be taken once daily in the morning. He asks, "Do I have to take the medication every day?" How will I be able to sleep when I go home?" Do you think I'll be able to work, too, even though I have been in the hospital this long? Which is the best response by the nurse? a. "The best approach is to take it one step at a time, so that everything will work out." b. "Let's sit down and talk about your concerns and I will support you in developing a plan." c. "I understand you're worried but you and your wife will decide tomorrow when you get home." d. "I'll do my best to set up a plan for discharge that you can take home with you and refer to later."

b. "Let's sit down and talk about your concerns and I will support you in developing a plan." Rationale: It is important to include the patient in their care plan.

The RN listens to report from the previous shift. Which patient should the nurse see first? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a 4-year-old with diabetes needing a blood sugar this morning b. 2-month-old with pertussis on 3L oxygen via mask c 1-month-old with gastroenteritis with 3 stools the past shift d 9-month-old with dehydration and IV decreased last shift

b. 2-month-old with pertussis on 3L oxygen via mask

The home health nurse in the office is notified that the patient on warfarin has an International Normalized Ratio (INR) of 3.8, Which action(s) should the nurse implement first? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Document the results of the INR in the patient's EHR b. Contact the patient and inquire about any abnormal bleeding c Notify the HCP and request an order to adjust the warfarin dose d Schedule and appointment to re-draw another INR

b. Contact the patient and inquire about any abnormal bleeding

The patient is placed in seclusion for exhibiting violent behaviors. Which should be the nurse's primary goal of this seclusion? a. Assist the patient in regaining self-control b. Ensure the safety of the patient and others c. Regain control over the unit's environment d. Provide a consequence for the patient's behavior.

b. Ensure the safety of the patient and others

The nurse determines an IV site is red along the course of the vein and is slightly swollen. The patient denies pain and refuses an IV start because of "terrible veins." Which action is most appropriate by the nurse? a. Explain since IV is essential, it will not be removed unless an new one is inserted. b. Explain the IV catheter must be removed and the patient can refuse a new catheter insertion c. Maintain the IV catheter and notify the health care provider d. Recheck the IV in 30 minutes and document the patient wishes.

b. Explain the IV catheter must be removed and the patient can refuse a new catheter insertion Rationale: The patient is experiencing phlebitis. Remember that infiltrations are cool to touch.

The nurse assesses a patient with pneumonia and observes the patient is experiencing shortness of breath with a pulse ox of 90%. Which action should the nurse take first? a. Notify the doctor b. Increase the head of the bed c. Order a chest X-ray to assess for degree of pneumonia d. Check the patient's respiratory rate and lungs sounds

b. Increase the head of the bed Rationale: The patient is having problems with breathing and oxygenation. The first action should be doing something to help improve the condition. We would notify the doctor after providing interventions. The other options are delaying treatment.

The nurse notices that the patient's temperature over the past 24 hours has risen from 98.8°F (37.1°C) to 101.6°F (38.7°C). The nurse completes a head to toe assessment and documents the following nursing note:Progress Notes: 6/26 1400. Temp 101.6°F (38.7°C), Pulse 88, Resp -24, Blood Pressure 132/78. Lungs clear. Harsh cough noted. No sputum. Denies chest pain. Abdomen soft. Positive bowel sounds. Voiding dark amber urine. Last bowel movement this morning. Gait steady on ambulation. No lower extremity edema noted. R. Brown, RN. What would the nurse's next nursing action? a. Pass on the data to the next shift b. Notify the health care provider c. Apply oxygen at 2L per nasal cannula d. Obtain an urine culture

b. Notify the health care provider Rationale: We are concerned with a potential infection and should contact the health care provider first. The nurse would need an order to obtain a urine culture.

A 3-year-old has arrived in the emergency department. The nurse documents the following assessment findings in the patient's chart, knowing that they are consistent with which disease process?5/15 1100 Patient admitted to ER with Temp of 103.6° F (39.8°C), HR 120, RR 28. Respirations are shallow and breath sounds are decreased with rales auscultated on the right side. Patient has a harsh cough and mother states he has had a discolored productive cough at home. S. Jones, RN a. Bronchiolitis b. Pneumonia c. Asthma d. Pertussis

b. Pneumonia

Which factor puts an older adult at the greatest risk for impaired wound healing after abdominal surgery? a. Age over 75 years b. Poorly controlled diabetes c. History of a myocardial infarction d. Chronic peripheral vascular disease

b. Poorly controlled diabetes

The patient with DM is receiving care in the home for a foot ulcer. The home health nurse documents the narrative note. Which problem should be the nurse's priority on the return visit?Progress Notes 0900 July 15 2021 Patient visited in home. Left foot ulcer showing signs of healing with granulation tissue. Wet-to-damp dressing change completed. Instructed on wearing nonskid slipper on left foot and shoe on right after noting patient wearing white socks for ambulation. BP 140/86 mm Hg; states has not yet taken morning dose of medication: "Can't stomach breakfast if eaten before the dressing change." Plan to return in a.m. for further assessment. B. Green, RN a. Impaired skin integrity related to left foot ulcer b. Potential for injury related to improper footwear c. Potential for altered nutrition: less that body requirements related to nausea d. Ineffective therapeutic regimen management related to not taking medications as prescribed

b. Potential for injury related to improper footwear Rationale: A big concern with diabetic patient's is that they have neuropathy and should always be wearing shoes to prevent injury.

The patient with Chronic Bronchitis is admitted with possible Pneumonia and Cor-Pulmonale. Which dietary item should the nurse provide to the patient? a. Offer 3L per day of fluid b. Scrambled egg whites and raspberries c. Linguini and tomato sauce d. Fried Chicken with broccoli

b. Scrambled egg whites and raspberries Rationale: Remember that Cor-Pulmonale is right-sided heart failure. They will be on fluid restrictions. COPD patients should have a diet low in carbs because it breaks down to produce carbon dioxide. A patient with heart problems should not eat fried food.

The nurse is assessing a hospitalized older patient for the presence of pressure ulcers. The nurse notes that the patient has a 1" by 1" (3cm by 3cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? a. Stage I pressure ulcer b. Stage 2 pressure ulcer c. Stage 3 pressure ulcer d. Stage 4 pressure ulcer

b. Stage 2 pressure ulcer

Which patient arriving at the oncology clinic should the nurse see first? a. The patient with leukemia who is afebrile and white blood cell count of 25,000 b. The patient undergoing chemotherapy reports fatigue and sore throat c. The patient with possible breast cancer has a negative biopsy report his morning d. The patient with anal cancer, receiving external radiation, continues to report diarrhea and skin irritation

b. The patient undergoing chemotherapy reports fatigue and sore throat

Disulfuram (Antabuse) is prescribed for a patient who is seen in the psychiatric health care clinic. The nurse is collecting data from the patient and providing instructions regarding the use of this medication. Which data is important for the nurse to obtain before beginning the administration of this medication? a. When the last full meal was consumed. b. When the last alcoholic drink was consumed. c. If the patient has a history of diabetes insipidus d. If the patient has a history of hyperthyroidism.

b. When the last alcoholic drink was consumed.

Staff are debriefing following a patient's violent episode. What information should be included in the debriefing session? Select all that apply. Multiple answers: Multiple answers are accepted for this question Select one or more answers and submit. For keyboard navigation...SHOW MORE a The patient's coping mechanisms post event b The client's history of violent behavior c Adherence to instructional policies and procedures d The staff's feelings regarding the effectiveness of the team e The staff's ability to respond to the patient therapeutically postevent

c, d, and e

The nurse is instructing the patient with Cystic Fibrosis on nutritional snacks. Which statement by the patient warrants intervention by the nurse? a. "I always pack pretzels and potato chips with my lunch." b. " I add butter to my muffins and chocolate syrup to my fruit." c. " I am limiting my fat intake since I have difficulty digesting fat because of my condition." d. " I make sure I take my Vitamins A-D-E-K along with my enzymes."

c. " I am limiting my fat intake since I have difficulty digesting fat because of my condition." Rationale: People with CF lack pancreatic enzymes and supplement them. These patients are deficient in sodium chloride and need salt in their diet. It is okay for them to add butter and syrup because they need extra calories. They need to supplement fat soluble vitamins like ADEK.

The nurse is conducting an initial assessment interview with a newly admitted patient who is diagnosed with schizophrenia with paranoia. The patient says the following, " The voices are talking with me now. They won't go away." What is the most appropriate response by the nurse? a. "I don't hear the same sounds that you are hearing." b. "Does what you're hearing seem real to you?" c. "Are you receiving a message from what you are hearing?" d. "What you're hearing aren't really voices of people. They're thoughts in your head."

c. "Are you receiving a message from what you are hearing?"

A 40-year-old patient presents to the triage area of the ER with uncontrollable crying and anxiety. The patient states her partner of 18 years has recently asked for a divorce. The patient is observed fidgeting in a chair and wringing her hands. Which response by the nurse is most therapeutic? a. "You must stop crying so we can discuss your feelings about the divorce." b. "Once you find a job, you will feel better and more secure in your new life." c. "I can see how upset you are. Let's sit here and talk about how you're feeling." d. "Once you have a lawyer looking out for your interests, you will feel better."

c. "I can see how upset you are. Let's sit here and talk about how you're feeling."

The spouse of a dying patient says to the nurse, " I don't think I can come anymore and watch my partner die. It's chewing me up too much!" The nurse should make which therapeutic response to the spouse? a. "Focus on your partner's pain rather than yours. I know it's hard, but this isn't about what's happening to you, you know." b. "I know it's hard for you, but your partner would know if you're not there, and you would feel very guilty all of the rest of your days." c. "It's hard to watch someone you love die. You've been here with your partner every day. Are you taking any time for yourself?" d. "I think you're making the right decision. You don't have to come every day. I'll take care of your partner."

c. "It's hard to watch someone you love die. You've been here with your partner every day. Are you taking any time for yourself?"

A RN returns to the pediatric unit from dinner break and receives the following report from the LPN . Which child should the registered nurse attend to first? a. A child with epiglottis and a tracheosteomy with a neck dressing that is soiled. b. A child with acute glomerulonephritis whose urine is bloody. c. A child with sickle cell anemia crisis whose PCA medication cassette is empty. d. A child with pyloric stenosis who has vomited.

c. A child with sickle cell anemia crisis whose PCA medication cassette is empty.

A patient with acute kidney failure becomes confused and irritable. The nurse understands that the most likely cause of this behavior is which imbalance? a. Hyperkalemia b. Hypernatremia c. Elevated BUN d. Limited fluid intake

c. Elevated BUN

A 4-year old child presents with possible rheumatic fever. Which findings will the nurse observe in this patient? a. Macular rash that is pruritic b. Decreased antistreptolysin O titer c. Elevated C-reactive protein d. Decreased erythrocyte sedimentation rate

c. Elevated C-reactive protein

The nurse returns to evaluate a patient whose blood transfusion has been infusing for 30 minutes. Upon assessment, the nurse notes that the patient is dyspneic and auscultates the presence of crackles in the lung bases with an apical heart rate of 110 beats per minute. What complication should the nurse suspect that the patient is experiencing? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a Immune response to transfusion b Hypovolemia c. Fluid overload d Polycythemia vera

c. Fluid overload

After receiving TPN at 84mL/hr continuously for 5 days, the patient with confusion pulled out the central line. Prior to notifying the health care provider and providing urgent care, the nurse starts a peripheral line. Which is an appropriate action by the nurse? a. Place the peripheral line to KVO until orders are received from health care provider. b. Change the TPN tubing and infuse via the peripheral line c. Infuse D10 into the peripheral line at 84 mL/hr. d. Notify the pharmacy for a new TPN bottle.

c. Infuse D10 into the peripheral line at 84 mL/hr. Rationale: TPN has a high glucose content and when it is abruptly stopped, we are concerned for hypoglycemia. The patient should be given D10 until TPN is resumed.

A 4-year-old pediatric patient resists going to sleep. Which is the most appropriate action by the nurse? a. Adding a daytime nap b. Allowing the child to sleep longer in the morning c. Maintaining the child's home sleep routine d. Offering the child a bedtime snack

c. Maintaining the child's home sleep routine

A nurse is assigned to care for the patient scheduled for a renal biopsy. Which lab is of immediate concern? a. BUN:40 mg/dl b. Serum creatinine: 3.0 mg/dl c. Prothrombin time 20 seconds d. Potassium: 4.9 mEq/L

c. Prothrombin time 20 seconds Rationale: Although A and B are abnormal values, they are expected in a patient undergoing a renal biopsy. PTT level is elevated so the patient would be at increased risk for bleeding with the procedure.

The nurse is caring for a patient in the first 24 hours following a burn injury. When assessing the patient which sign indicates adequate fluid replacement therapy? a. BUN 22 mg/dL b. Urinary output of 15 to 20 mL/hr. c. Slowing of a previously rapid pulse d. Hematocrit level rising from 50% to 55%

c. Slowing of a previously rapid pulse

The nurse is supervising a nursing assistant performing mouth care on an unconscious patient. The nurse would intervene if the nurse noted the nursing assistant doing which of the following? a. Turning the patient's head to one side. b. Using small volumes of fluid to rinse the mouth. c. Using a gloved hand to open the patient's mouth. d. Placing an emesis basin under the patient's mouth.

c. Using a gloved hand to open the patient's mouth. Rationale: Never put your hand in a patient's mouth.

When assessing the suicide potential of a newly admitted patient, the nurse would recognize which statement by the patient as indicating the greatest risk of suicide at this time? a. "I wish I would just go ahead and die in my sleep some night." b. "I think about suicide almost every day; I can't get those thoughts out of my head." c. "I keep a gun in my nightstand at home; some night I will wake up and use it on myself." d. "I can't stop thinking about suicide; it would be so easy to wrap strips from my sheet around my neck."

d. "I can't stop thinking about suicide; it would be so easy to wrap strips from my sheet around my neck." Rationale: This is the greatest risk because the patient could carry this out in the hospital. The gun would have to be addressed before a patient is discharged.

The nurse receives report on four patients. Which patient should the nurse see first? Select an answer and submit. For keyboard navigation, use the up/down arrow keys to select an answer. a 50-year-old woman scheduled for a breast biopsy this morning and is presently crying. b 85-year-old man admitted during the night because of increased confusion who remains disoriented this morning. c 65-year-old woman who had a thoracotomy 2 days ago and has two midline chest tubes d. 40-year-old man complaining of chills and is scheduled for a colon resection in 1 hour.

d. 40-year-old man complaining of chills and is scheduled for a colon resection in 1 hour.

Screening for substance use and suicide risk should be conducted in which of the following settings? a. Emergency Departments b. Primary Care Settings c. Medical Units d. All of the Above

d. All of the Above

Which patient in the ER should the nurse assess first? a. The child with a dog bite on left hand who is bleeding b. The child with a laceration on the right side of forehead c. The child with a fractured tibia who will not move the foot d. The child who ingested prenatal vitamins

d. The child who ingested prenatal vitamins

A nurse is preparing to feed a patient via NG tube. Which is the nurse's highest priority before initiating the feeding? a. Check the feeding container for expiration b. Confirm the patient does not have diarrhea c. Make sure the client is alert and oriented d. Verify placement of the NG tube

d. Verify placement of the NG tube

Patient is admitted from the Emergency Department with a temperature of 101.2o, shaking and chills, a positive swab for influenza. What type of precautions does the patient require and what type of PPE for the Health Care Providers (HCP)? Choose the appropriate selections. a. Standard Precautions b. Contact Precautions c. Protective Precautions d. Airborne Precautions e. Droplet Precautions f. HCP - Gloves when handling body fluids or wounds g. HCP - Gloves gown surgical mask h. HCP - Gloves surgical mask i. HCP - Gloves N95 mask

e and h