PNE FINAL
A 3-year-old client has been hospitalized for 1 week with her mother rooming-in; however, the mother has gone home to tend to other family responsibilities for a few days. After being inconsolable for the first 24 hours after the mother's departure, the nurse notes the child is now lying quietly in bed sucking her thumb. Which response should the nurse prioritize in this situation?
"Are you feeling sad? Your mom didn't want to leave, but she will be back after two more breakfasts."
During a well-child visit, the caregiver expresses concern that the 3-year-old child often stutters when speaking. Which response should the nurse prioritize to best assist this family?
"Children of this age may stutter while they search for just the right word."
The nurse has been caring for a 12-year-old boy during his 5-day hospitalization. The child's IV has infiltrated, and the RN is getting ready to change the intravenous line site. Which statement made by the nurse would be appropriate in supporting the child?
"The client is left-handed and likes to draw; an IV site in his right arm would be best."
The father of a 4-year-old is concerned his child is not telling the truth and blaming others for things that have happened. Which response should the nurse prioritize after the father shares that the child is blaming someone named 'Andrew' for a broken tool, and they have no idea who this is?
"Your son may have a friend named Andrew, but it could be an imaginary friend."
Nurse is monitoring anticoagulant therapy by assessing prothrombin time (PT) laboratory values anticipated for a PT level therapeutic levels?
1.5-2.5 times the control value
Normal HCO3
22-26
Normal PaCO2
35-45
normal PH
7.35-7.45
Normal PaO2 levels
80-100 mmHg
The nurse is preparing a child for surgery and is demonstrating and evaluating the child for using a patient-controlled analgesia device after surgery. The nurse would determine which client would be most appropriate to use this device?
A 7-year-old who has told the nurse about using the control button
The diagnosis of AIDS includes?
A CD4 count below 200 mm3
Buerger's disease
A condition in which the blood vessels, especially those supplying the legs, are constricted whenever nicotine enters the bloodstream, the ultimate result being gangrene and amputation.
The nurse is obtaining data regarding the medication that the client is taking on a regular basis. The client states he is taking duloxetine (Cymbalta), an antidepressant for the treatment of neuropathic pain. What type of therapy does the nurse understand the client is receiving?
Adjuvant drug therapy
Select the correct nursing implementations for Heparin administration.
Administer SQ injection in the abdomen around the umbilicus
What is a blood disorder that results in pancytopenia, due to bone marrow depression. This may be a result of radiation exposure, insecticides, medications or mononucleosis.
Aplastic Anemia
When assessing the blood pressure of a patient receiving pentazocine (Talwin) 30 mg orally for pain control two days after surgery, the reading is 166/100, which is much higher than the patient's presurgical blood pressure. What is your best action?
Assess the patient for other cardiac changes.
The nurse is taking a class on chemical disasters with the local emergency response team. What toxins would the nurse be learning about?
Blistering agents Cyanide Nerve agents
While the nurse is taking a blood pressure on a 4-year-old, the child states that the blood-pressure cuff is too tight and angrily says, "That hurt, you big poo-poo head." What is the most appropriate response by the nurse?
Calmly explain that you don't mean to hurt her, loosen the cuff, and tell her that is isn't nice to call you names.
treatment for crohns disease
Corticosteroids, oral aminosalicylates
The nurse is caring for a victim of a chemical disaster. Medications given in the treatment of this client include amyl nitrite, sodium nitrite, and sodium thiosulfate. What chemical agent does the nurse know this client has been exposed to?
Cyanide
Mr. Smith has experienced a blood transfusion reaction, shortly after the reaction, his IV site started oozing, blood and he has a severe nose bleed. His labs reveal a prolonged PT and PTT. You, as the nurse suspect what disorder.
Disseminated intravascular coagulation (DIC)
what is pica
Eating non-food items including ice, paper, dirt, hair.
The nurse is helping assist the care provider in doing a lumbar puncture on a 9-month-old infant. Which method will be the safest and most appropriate method of restraining the child?
Hold the child snugly against the chest, pass one arm below the child's legs; with the other arm, hold the child's hands.
The nurse is caring for several clients on the pediatric unit. When interacting with the preschooler, which action will the nurse predict to occur?
Insists doing something and the next moment reverts to being dependent
The nurse is documenting the blood type of a newborn as "type O." Which statement describes the antigens and antibodies related to this blood type?
It does not have the A or B antigen, but it does have the anti-A and the anti-B antibody.
A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?
Naturally acquired active immunity
You are caring for an elderly patient in a long-term care facility who has been prescribed a cephalosporin. Which adverse effect should you monitor the patient for while taking this drug?
Nephrotoxicity
The nurse observes that a client who had an arterial blood gas performed 30 minutes ago is still oozing blood from the puncture site. Pressure was held to the site for 5 minutes after the puncture and another 5 minutes when the site was still oozing. What factor does the nurse know will participate in the ability for the blood to clot?
Platelets
The nurse is presenting an in-service training to a group of pediatric nurses on the topic of play. The nurse determines the session is successful when the group correctly chooses which example as best displaying toddlers playing?
Playing independently and are side by side
The nurse knows that interferon agents are used in association with chemotherapy to produce which effects in the client?
Shorten the period of neutropenia
The nurse is caring for a 14-year-old child who is scheduled to have surgery the next day. What would be the most appropriate intervention for the nurse to implement to help prepare this child for surgery?
Show the child models of the body that include the organs or parts of the body the child will be having surgery on.
what is rifampin used for
TB and to prevent meningitis adverse effects can include flu like symptoms
Which client does the nurse identify as in a state of alkalosis from hyperventilation?
The client with a pH of 7.55
A client has received a diagnosis of Lyme disease. What does the nurse understand about the transmission of infection resulting in this disease?
The disease is spread by arthropods.
The nurse is administering a gavage feeding through a nasogastric feeding tube. Which nursing intervention is the highest priority?
The nurse positions the child in a sitting position.
A nurse is caring for a client diagnosed with Von Willebrand Disease. What is the correct statement related to this disease?
The patient will have a shorten APTT.
A client has been involved in an automobile accident and is assessed to have an enlarged spleen. What does the nurse understand is the significance of attempting to prevent unnecessary removal of the spleen for this client?
The spleen is a lymphatic structure and assists with phagocytosis.
Thalassemia is an inherited autosomal recessive gene that causes a mutation in the DNA that makes hemoglobin. Select the best answer related to Thalassemia.
The treatment for thalassemia major includes frequent transfusions of PRBC, and iron chelating agents
The nurse is preparing an injection of ceftriaxone sodium 500mg IM for a 9-month-old client. When assessing the best site for injection, which landmarks are determined in preparation for injection?
Trochanter and knee joint
Positive Chvostek's sign
Urgent report to physician, indicates acute pancreatitis
The antidote to warfarin (coumadin) is___________, and the antidote to Heparin is __________?
Vitamin K and Protamine Sulfate
Raynaud's phenomenon
a peripheral arterial occlusive disease in which intermittent attacks are triggered by cold or stress
classification of scopolamine
anticholinergics
therapeutic action of nifedipine
calcium channel blocking agent that decreased blood pressure by relaxing vascular smooth muscle in the cornary artery and systemic arteries leading to decreased peripheral resistance
Virchow's triad
catergoies that contribute to thromobsis
Crohn's disease
chronic inflammation of the intestinal tract
Atherosclerosis
condition in which fatty deposits called plaque build up on the inner walls of the arteries
rule to follow when admistering digoxin
count pulse for full minute and hold is apical rate is lower than normal
immediate care for client with PE
dissolve cloth and restore cardio function
dumping syndrome
dumping large amounts of hypertonic chyme into the jejunum
troponin lab tests, when does it elevate and what does it dx
elevates 4-6 after MI and confirms MI
organisms that can cause pneumonia
group b strep, staphylococcous, iv drug use
arteriosclerosis
hardening of the arteries
methimazole treats what
hyperthyroidism
Glaucoma
increased intraocular pressure
cystic fibrosis and what organ does this effect
major mucous secretion which causes lung infections pancreas exocrine disease
what is tetany
muscles spams cause by malfunction of the parathyroid glands and consequent of deficiency of calcium
how is a fat embolism developed
occurs after fracture to femur, tibia, or pelvis
infective endocarditis
organism comes from break in the skin and travels to the heart (per carol)
ss of a DVT
pain in calf, foot, or leg swelling, tenderness, warm skin, redness, warmth to effected area, worsening pain when moving extremity, bluish or which discoloration
Simmonds disease
pathological condition in which complete atrophy of the pituitary gland causes loss of function of the thyroid, adrenals, and gonads
classification of promethazine
phenothiazines
classificatioin of metoclopramide
promotility drug
how does blood circulate through the heart
right atrium tricuspid right ventricle pulmonary artery lungs pulmonary veing left atrium bicuspid valve left ventricle aorta body
classification of ondansetron
serotonin receptor antagonists
why would we prescreen for herbal supplements
these can cause excessive bleeding (per carol)
why do we not want to stimulate the vagus nerve when ambulating a patient
this nerve controls a part in heart rate, bp, and cause them both to bottom out
thyrotoxic crisis
toxic condition characterized by hyperthermia, tachycardia, nervous symptoms, and rapid metabolism; also known as thyroid storm.