Rn question trainer test 1 NGN
the nurse provides care for a client just returned from an MRI of the brain. The client asks the nurse, "will you tell me the results? do I have cancer?" which response by the nurse is both therapeutic and appropriate to maintain the legal scope of practice?
" I am unable to go over the results of the MRI with u, but I will call your health care provider to come speak with you right away"
Esophagogastroduodenoscopy (EGD) prep and post procedure
- Consent - NPO at least 8 hrs b4 procedure -teach about numbness of thrat due to local anesthetic applied to posterior pharynx -sedative - side lying position for procedure -assess for gag reflex b4 -maintain NPO untill gag reflec returns -look for vomiting of blood or resp distress - expect sore throat for 3-4 days after procedure
the nurse provides care for an older adult client recieving chemotherapy for gastric cancer. The nurse recalles which helps prevent infection?
- Hand hygiene - standard precautions - private room ** antibiotics should only be given if an infection is confirmed
alcohol withdrawals
- tremors - elevated temperature - agitation - insomnia - sweating *** other s/s are mild tachycardia, anxiety, mild tachycardia
what are the 3 interventions to do when a pt is hypoglycemic?
1. provide a snack containting at least 15 grams of carbohydrates 2. order a breakfast tray for the client 3. recheck the BG q 15 mins until stable
normal ammonia level
15-45
the nurse provides oral care for a client in a long term care facility. The nurse recalls which is the purpose of oral care? SATA
- prevents tooth loss - lowers risk of cavitites - relieves oral discomfort -decreases oral bacteria -prevents gum disease
the nurse cares for a client before an esophagogastroduodenoscopy (EGD) procedure. The nurse understands which is done to prevent complications?SATA
- the client must be without foods or fluids for the past 6-8 hrs - the client must state any allergies to food or medications - the client must remove all jewelry before the EGD (all jewelry should be removed prior to any procedure that requires sedation but implanted metal is permitted) - the client must arrange for another person to drive home
the nurse notes that a client diagnosed with parkinson disease takes benztropine. The nurse recalls which adverse effect is expected? SATA
- urinary retention - constipation - blurred vision - dry mouth
aminophylline therapautic level?
10-20 mcg/ml -admin daily dose in morning, with food or full glass of water - inform that solution is strongly alkaline, incompatible with many meds (avoid OTC cough, cold, or breathing preperations)
A client diagnosed with asthma recieves an intravenous aminophylline infusion and has an aminophylline level drawn. The nurse recalls which is the therapeutic range of aminophylline?
10-20 mcg/ml - we need to monitor for toxicity with infusions of aminophylline.
hepatic encepthalopathy
brain dyfunction and damage caused by increased ammonia in the bllod and results from severe liver disease treatment to decrease ammonia: eliminate dietary protein, and admin antibiotics
early signs of lithium toxicity
fine motor tremors, nausea and vomiting, and diarrhea ***seizures are associated with severe lithium toxicity (coma, mental confusion, death ) *** fever, muscle weakness, coma and death are also toxicity s/s
a client is diagnosed with aggressive behaviors. The nurse declines the client's request to organize a party on the unit for the client's friends. The client becomes angry and uses abusivee language toward the nurse. Which statement indicates the nurse had an understanding of the client's behavior?
reflecting back the client's frustration and angry feeling will communicate the nurse's empathy and understanding.
the client has a long hx of cirrhosis with acute hepatic encephalopathy. The nurse assesses the daily lab reports. Which finding indicates the client is improving?
the clients ammonia level decreased from 110 to 75 mcg/dl
the practice of nursing is professionally guided and supported by a nationally accepted document on ethical values and conduct...
the code of ethics for nurses
A client with a diagnosis of human immunodeficiency virus (HIV) is admitted to the hospital with pneumonia. Which client behavior does the nurse expect?
Angry with the health care system
symptoms of preeclampsia
- blood pressure (greater than 140 systolic and/or 90 diastolic mmhg and occurs twice 4-6 hours apart) - proteinuria (greater than 0.3g/24 hrs and protein/creatinine ratio greater than 0.3) - platelets (greater than 100,000) - head ache -visual changes -edema -right upper epigastric pain - dizziness -anginal pain
the nurse provides care for a client who returns to the unit after a new gastrostomy tube is placed. The nurse undserstands which is expected? SATA
2.) reports of surgical site discomfort (soreness is expected for several days after placement) 4. flush tube with water b4 and after all meds 5.) admin the tube feeding at room temp (to prevent cramping and promo digestion) - elevate hob for 1 hr after feeding to prevent aspiration -provide skin care around tube -complications (aspiration, diarrhea, abd distention, hyperglycemia, impaction) - enteral feedings can be started within a few hrs of gastrostomy tube placement if prescribed
the nurse recieves a message on social media from a former client. The message reads, "I thought you were so nice and would like to be friends." Which action by the nurse is appropriate?
IGNORE the message and delete it ( in order to prevent any additional communication, the nurse should ignore and delete the message)
A client who recieves intravenous (IV) antibiotics reports redness, pain, and burning at the site. The nurse recalls which IV complication is occuring?
Phlebitis -phlebetis is characterized by redness, pain, tenderness, and warmth along the vein where the Iv is inserted. - Infiltration is characterized by taut, cool, edematous skin around the IV site
patients bill of rights
privacy confidentiaity respetful care current information informed consent refusal of treatment reasonable response to request for services knowledge of hospital/clinic regulation
a client, gravida 2 para 1, is admitted with hypertension at 32 weeks gestation. The client reports the wedding band is tight. The nurse assesses for which additional indications of preeclampsia?
proteinuria and retinal vascular constriction
Which statement is documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the intensive care unit?
the client constantly calls for nurses and cries incontrollably - this is objective and contains information that is observable.
Diabetic ketoacidois (DKA): actions to take and parameters to monitor
actions to take: - prepare to admin an IV infusion of regular insulin -immediately start an IV of 0.9% normal saline (NS) Parameters to monitor: -BG hrly and electrolytes q 2 hrs -urine output q hr(make sure the renal system is able to keep up with the change of electrolytes and fluid vo)
Naproxen (NSAID) adverse affects
***used as an analgesic -headache -dizziness -edema (fluid retention) -gastrointestinal distress -pruritis -rash -kidney and cardiovascular systems may be effected, and exaggerate the issue
metered dose inhalers (MDI)
- aerosol, pressurized inhaler. -applies directly to the site of action (lungs and airways) through mouth - enables smaller doses, rapid absorption and onset of action. - "maintenance" inhalers used daily to prevent acute resp distress - "rescue" inhalers of short-acting meds used for immediate relief of acute resp. distress - Give brochodilators first
the nurse administeres a metered dose inhaler (MDI) medication to a client diagnosed with chronic obstructive pulmonary disease (COPD). The nurse recalls which is true about MDI? SATA
- an MDI uses a propellant to deliver medication - multiple doses are available to use in MDI - Advantage for MDI is its portability
The nurse provides care for a client with a new diagnosis of herpes zoster that is diffusely spread over the abd and back. The nurse recalls which is true about the transmission of herpes zoster?
airborne and contact precautions are needed until lesions are dry -herpes zoster requrie airboen precautions with private room, negative pressure, and an N95 mask for care. Contact precautions include gown and gloves
the nurse strokes the sole of a newborn's foor and observes for dorsiflexion of the great toe. Then, the nurse holds the infant upright and allows the bottom of the foot to touch the examining surface, and observes for knee and hip flexion. Which two reflexes does he nurse assess?
babinski and stepping reflexes
the nurse provides care for several clients on a med surg floor and decides to delegate several tasks. The nurse understands which concept applies when safely delegating tasks to unlicensed assistive personnel (UAP)? SATA
- delegate tasks that are within the scope of practice of the UAP - delegate tasks that are appropriate under the circumstances - delegate the correct tasks to the correct care provider - delegate a task with clear directions and epextations - delegate tasks, but provide oversight and monitoring
the nurse cares for a gravida 1, para 1, adult client who delivered an 8-lb infant by cesarean birth. The client is one day postpartum. The nurse recalls the clients is ar risk for which potential complication?
- depression - hemorrhage - thromboembolism - incisional infection *if the patient delivered vaginally incontinence and episotomy infection are also complications
the nurse is promoted to nurse manager. The nurse is aware communication is an important part of the new position. Which element does the nurse identify as having a positive effect on communication? SATA
- encourage integrity, honesty, and accountability - convey high standards of client care to staff members -create a trusting positive work environment - promote advocacy for the health clients - develop camaraderie and an attitude of relaxation
the nurse provides care for older adult clients in ahealth care provider's office. The nurse understands that there are factors that contribute to an increased risk of poor health outcomes in certain vulnerable populations. Which factor can contribute to an older adult client's inability to manage the health? SATA
- limited income -chronic illness - tobacco use - physical inactivity - polypharmacy
Airborne infection precautions
- private room with monitored negative air pressure with 6 to 12 air changes per hour -examples of diseases: (measles/rubeola, m. tuberculosis, varicella, disseminated zoster/shingles)
The nurse observes a client with anxiety having increased wringing of hands and purposeless pacing. Which intervention will the nurse initiate to support the client?
Walk with the client WITHOUT conversation (allows the client to perform activities that may help alleviate anxiety symptoms)
The nurse will first determine ___________. If the client is incapacitated and cannot make medical decisions, those decisions can be made by __________. In the absence of an advance directive, or established domestic partner or spouse, the consent of the client's surgery would be given by________.
1. If the client has an advanced directive. 2. A durable power of attourney for healthcare 3. The client's adult children
The nurse completes care for a client on airborne precautions. In which order does the nurse remove the PPE?
1. remove contaminated gloves by grabbing the palm of one hand and removing the 1st glove 2. hold contaminated glove in gloved hand and slide it off so that one glove is inside the other 3.)discard gloves 4.)unfasten the gown ties and make sure the sleeves do note tough the clothing underneath 5.)pull gown away and touch the inside of the gown only 6.) role gown away from body 7.) discard gown 8.) remove respirator once outside the clients room 9.) discard the respirator 10.) wash hands * Gloves, Gown, Respirator, Wash hands
babinski reflexes (infant)
-stroke sole of foot from heel upward across ball of foot -causes toes to fan - reverts to usual adult reponse by 12 month
Stepping reflexes (infant)
makes stepping movements when held with toes touching a surface
6 month old milestones
-teething -rolls from back to abdomen - manipulates small objects - holds arms out to be picked up
hepatitis A,B,C,D
A- fecal-oral route via contaminated food or infected food handlers B- transmitted through infected blood or body fluids C-transmitted through blood or body fluids D- transmitted through infected blood or body fluids
a 6 mo old is brought to the clnic for a well-baby checkup. During the exam, the nurse expects to observe which assessment findings?
- sitting with support - bearing weight when held in standing position - rolling from back to abdomen
delirium tremens s/s
tremors anxiety panic disorientation hallucination vomiting tonic-clonic seizures (1st 48 hrs after withdrawal
A client is admitted to the behavioral health unit with a labile mood, laughing loudly, then curing at the staff. The client paces up and down the hallway talking about a myriad of subjected to anyone who will listen. Which disorder does the nurse recall with these attributes?
BIPOLAR disorder -bipolar disorder includes attributes of elevated behavior when in the manic state include labile mood, excessive energy, accelerated speech, thought, and movement. They talk non-stop to anyone who will listen , oten in loud tnes and may be difficult to redirect while in manic state. The other attribure of bipolar disorder is depression. the client cycle between mania and depression over hours, days, weeks,and months.
the nurse cares for a cient admitted with cerebral vascular accident (CVA) and facial paralysis. Nursing care is planned to prevent which complication?
Corneal abrasion -nursing care cannot prevent inabillity to talk, loss of gag reflex, or inability to open the affected eye, - we can prevent corneal abrasion with COOL COMPRESS AND PRESCRIBED EYE DROPS - the client cant blink the ey and no longer supply secretions to protect the eye and lead to corneal abrasions
Bipolar disorder treatment (mania and depression)
treatment: -lithium - paritcular anticonvulsant medications: (carbamazepine, valproate, lamotrigine) - psychotherapy -antidepressants