Question Trainer 1 Content

The provider writes an order for a stat dose of morphine 4mg IV for px. 3 hours later the pt again reports px, and the nurse admins a second injection. Which best describes the nurse's liability?

-the nurse is liable because there is no order for a second dose of morphine. it was a one time order and she acted outside of her scope of practice.

Nurse cares for pt dx'd with T1DM reporting decreased vision. The client asks the nurse what caused the changes. the nurse response is based on which statement?

-the pt decreased vision is caused by gradual destruction and degeneration of the retinal vessels and retina.

The nurse cares for the post op pt dx'd with T2DM controlled with oral agents. the pt asks why the HCP ordered subq insulin injections after sx. The nurse;s response is based on knowing which physiological process?

Being NPO inhibits normal glucose control, sx induces metabolic changes

a 7yo child is seen in the clinic with a dx of pituitary dwarfism. Which clinical manifestation is the nurse most likely to see?

Delicate features-they will appear younger than chronological age. W- abn body proportions (small but normal), early sexual maturation (delayed), coarse, dry skin (usually fine, smooth).

The nurse cares for a 3 mo old scheduled for a barium swallow in the am. prior to the procedure, it is most appropriate for the nurse to take which action?

NPO for 3 hours prior

The nurse cares for a client dx'd with a pneumothorax resulting from an MVA 3 days ago. Pt has a chest tube connected to a 3 chamber water seal drainage system with 20 cm suction. The nurse determines the lung has re expanded if which observation is made?

The fluid in the water seal chamber does not fluctuate with respirations indicating that no more air is leaking into the pleural space.

The nurse cares for a client dx'd with gastric reflux RT a hiatal hernia. The client asks the nurse why food and fluids should be withheld just before going to bed. Which response by the nurse is most appropriate?

You are less likely to awaken during the night with heartburn if the stomach is empty. A full stomach is more likely to slide (reflux) through the hernia, causing regurg and heart burn.

In planning diet teaching for a child in the early stages of nephrotic syndrome, the nurse should discuss with the parents which dietary change?

- adequate protein and low sodium intake, if the child can tolerate the protein intake this is encouraged to speed healing; sodium is usually restricted.

Posted cataract pt is cautioned about not making sudden movements or bending over. The nurse identifies the rationale for this recommendation is to prevent what complication?

- pressure on the ocular suture line. sudden changes in position, constipation, vomiting, stooping, or bending over increase the intraocular pressure an put pressure on the suture line.

The nurse identifies which finding would have the greatest impact on the elderly pt's ability to complete activities of ADL's?

-Apraxia, the loss of purposeful movement in the absence of motor or sensory impairment. when it affects an ADL, such as dressing, the client may not be able to put clothes on properly

Nurse is caring for a pt admitted with a dx of stroked facial paralysis. Nursing care should be planned to prevent which complication?

-Corneal abrasion as they will not be able to close the eye voluntarily when the facial nerve (cranial nerve VII) is affected the lacrimal gland no longer supplies secretions to protect the eye.

The toddler dx'd with lead poisoning is admitted to the peds unit. the HCP writes an order to encourage fluids. Which fluid is best for the nurse to offer to the toddler?

-Milk contains calcium, calcium binds to lead and inhibits absorption

a client had a kidney transplant yesterday and the adult child has come to visit. The nurse should instruct the adult child to do which action?

-Perform good hand washing. -no special gear is needed, no mask or gloves or gown

Nurse cares for pt receiving a blood transfusion. after 30 mins, the nurse assesses the pt. Which symptom indicates a severe allergic reaction is happening?

-Respiratory wheezing- characteristic of an allergic reaction as well as urticaria, facial flushing and itching. W- Bounding peripheral pulses won't be caused by the transfusion in most cases. Chills and lower back discomfort would be indicative of a hemolytic transfusion reaction.

The home care nurse visits a new parent and a 2 week old infant. the client asks the nurse which solid foods to give the child first. Which response does the nurse give?

-Rice cereal is usually the first solid food and is started around 4-5 mos W- Strained fruits are not well tolerated and solids are usually started at 4-5 mos not 6

The parents of a child dx'd with hemophilia asks the nurse to explain the cause of the disease. Which response is best?

-The mother transmits the gene to her son. affected male inherits the gene from his mother and can only transmit to his daughters. it is not an autosomal recessive trait, there is a 50% chance that the mother will pas the trait to each of her children

Nurse on psych unit of the hospital declines a pt's request to organize a party on the unit for the pt's friends. The pt becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the client's behavior?

-abusive language is one of the behaviors symptomatic of the client's illness

Nurse cares for a newborn dx'd with FAS. They expect to see which characteristics?

-an infant with small head circumference, LBW, and undeveloped cheekbones. FAS babies are usually small for gestational age, may have feeding difficulties with poor sucking ability, and have small head, resp distress RT preterm birth, near damage, small trachea, floppy epiglottis

Which statement should be documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the ICU?

-constantly cries and calls for nurses, gives an objective description of the pt behavior and affect

the nurse knows that cortisol is responsible for which action?

-converting proteins and fat into glucose

A middle aged pt is admitted to an in pt psych unit. they report that a family member is trying to steal their property. the client is dx'd with paranoid disorder. the nurse suspects that the client is demonstrating which symptom?

-delusions of persecution, the client has delusions which are strongly held beliefs that are not validated by reality. the idea that a family member is trying to steal property is a believe not validated in this situation.

nurse identifies the primary reason for elderly adults to have consitpation is because of which process?

-elderly adults engage in less activity and have decreased GI muscle tone.

A pt gravida 2 para 1, is admitted with HTN. she reports her wedding band is tight. the nurse assesses for which indications of mild pre-eclampsia?

-facial swelling and proteinuria, blurred vision may appear later, epigastric pain and headache are signs of eclampsia before a seizure, oliguria is seen later with severe preeclampsia.

The nurse recognizes which symptoms are early signs of lithium toxicity?

-fine motor tremors, N and V, D

In a client with an ET tube that requires suctioning- which statement is an accurate description of how the nurse should perform the procedure?

-insert the catheter until resistance is met, then withdraw it slightly, apply suction intermittently as the catheter is withdrawn -never suction longer than 10-15 seconds, use twirling motion when withdrawing, suction is never applied when catheter is inserted

Nurse cares of ra prenatal client 8 weeks gestation with a positive VDRL. when the nurse prepares the teaching plan, it is most important for the nurse to include which info?

-instruct the client about the importance of taking all medication. communicable diseases are reportable, partners or contacts need to be found and notified so that they may be treated.

In prepping the teaching plan re colostomy irrigations, the nurse should include which info?

-it needs to be irrigated at the same time every day to assist in establishing a normal pattern of elimination - it should only be irrigated once a day, never insert the catheter more than 4 inches, the solution should be body temp, increasing the temp doesn't make the irrigation more efficient.

The nurse should caution the pt with hypothyroidism to avoid which implementation?

-narcotic sedatives, the client will be very sensitive to narcotics, barbiturates, and anesthetics.

A parent of a child with chicken pox asks why the child will not come down with it again if exposed at school. What explanation does the nurse give?

-natural active immunity occurs bc the child's body actively makes the antibodies against the chicken pox virus.

The adult pt is prepping for a plasma cholesterol screening. Which instruction does the nurse give to the client?

-only take sips of water for 12 hours before the test for accurate results.

A client comes to the out pt psych clinic for tx of a fear of heights. the nurse knows that phobias involve which behaviors?

-projection and displacement

A 6 month old is in the clinic for a well baby checkup. What findings does the nurse expect to observe?

-sitting with support -Playing peek a boo -rolling from back to abd W- a pincer grasp (9 mos), tripling of birth weight (1 year), presence of a posterior fontanelle (closes at 2-3mos) are incorrect.

The nurse performs a Rinne test on a pt. Which is an accurate statement of how this test should be started?

-stem of a vibrating tuning fork is held against the mastoid bone until the client indicates sound can no longer be heard.

the nurse preps an older client for an IVP. the pt asks the nurse to explain the reason why the procedure is performed. the nurse's response should be based on which explanation?

-the HCP is able to examine the urinary tract by x ray which helps evaluate kidney function

Which symptoms alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness?

-tremors, elevated temp, night sweats, w- depression, night sweats, decreased concentration

The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason?

Renal threshold for glucose is elevated in the elderly. The level at which glucose starts to appear in the urine increases, leading to false negative readings; results in elevated glucose levels making blood glucose monitoring more accurate.

The nurse supervises an LPN administering an enema to a client. The nurse determines the LPN's actions are appropriate if which action is observed?

The LPN positions the client in left side lying with knee flexed which allows solution to flow downward along the natural curve of the sigmoid colon and rectum and improves retention of solution. W- Placing the solution 20" above the anus could cause rapid infusion and possibly painful distention of the colon. It is not feasible to adjust the temp of the solution during the admin phase. Inserting the tube 6 inches is too far, no more than 4"