..

a. A patient is being evaluated for possible atopic dermatitis. The nurse will review the patient's laboratory values for the level of a. IgE. b. IgA. c. basophils. d. neutrophils.

a. IgE.

1. Seizure prophylactics for preeclampsia manifestation SATA

a. Magnesium sulfate (CNS depressant) prevents preeclampsia from advancing to eclampsia b. Urinary output, LOC, respiratory depression

1. Post-delivery, post-bleeding. Most important nursing action?

a. Methergine if Pitocin isn't working. Check blood pressure before giving (no high BP) Can give Hemabate if BP is high

1. Breastfeeding, she thinks she does not need birth control. Nurse's best response

a. This is not a form of contraception!

b. An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. The nurse will plan to a. apply wet sheets and a fan to the patient. b. provide O2 at 2 L/min with a nasal cannula. c. start lactated Ringer's solution at 1000 mL/hr. d. give acetaminophen (Tylenol) rectal suppository.

a. apply wet sheets and a fan to the patient.

b. The nurse is caring for a child with a diagnosis of Kawasaki disease. The child's parent asks the nurse, "How does Kawasaki disease affect my child's heart and blood vessels?" The nurse's response is based on the understanding that: a. inflammation weakens blood vessels, leading to aneurysm. b. increased lipid levels lead to the development of atherosclerosis. c. untreated disease causes mitral valve stenosis. d. altered blood flow increases cardiac workload with resulting heart failure.

a. inflammation weakens blood vessels, leading to aneurysm.

62. Tylenol OD in ER what to give?

actelysysteline

a. The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."

c. "I will lie down someplace dark and quiet when the headaches begin."

a. Which child with asthma should the nurse see first? i. A 12-year-old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 93%. ii. A 5-year-old who is speaking in complete sentences, is pink in color, is wheezing bilaterally, and has an oxygen saturation of 93%. iii. 9-year-old who is quiet, is pale in color, and is wheezing bilaterally with an oxygen saturation of 92%. iv. A 16-year-old who is speaking in short sentences, is wheezing, is sitting upright, and has oxygen saturation of 93%.

i. A 12-year-old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 93%.

a. A child with a repaired myelomeningocele is in the clinic for a regular exam. the child has frequent constipation and has been crying at night because of pain in the legs. after an MRI the diagnosis of a tethered cord is made. which should the nurse tell the parents? i. A tethered spinal cord is a post-surgical complication ii. A Tethered spinal cord occurs during times of slow growth iii. Release of the tethered cord will be necessary only once iv. Offering laxatives and acetaminophen daily will help control these problems

i. A tethered spinal cord is a post-surgical complication

a. The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? (SATA) i. Ballottement ii. Chadwick's sign iii. uterine enlargement iv. positive pregnancy test v. fetal heart rate detected by a non electronic device vi. outline a fetus via radiography or ultrasonography

i. Ballottement ii. Chadwick's sign iii. uterine enlargement iv. positive pregnancy test

a. The patient, who is 41 week's gestation, has just had a biophysical profile with a score of 2. Which of the following nursing interventions would be most appropriate?

i. Consult with the physician as this score indicates a probable need for immediate delivery

b. A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following are contraindications? (SATA) i. Hypospadias ii. Hydrocele iii. Familiar history of hemophilia iv. Hyperbilirubinemia v. Epispadias

i. Hypospadias iii. Familiar history of hemophilia v. Epispadias

a. A patient has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the patient will present with what alteration in laboratory values? i. Increased eosinophils ii. Increased neutrophils iii. Increased serum albumin iv. Decreased blood glucose

i. Increased eosinophils

b. The nurse is creating a plan of care for a 2 year old admitted to the pediatric unit with confirmed bacterial meningitis. Which of the following are included? SATA i. Isolation precautions ii. Analgesia as ordered for pain iii. Elevate head on one pillow iv. Cluster nursing care. v. Television as a distractor

i. Isolation precautions ii. Analgesia as ordered for pain iv. Cluster nursing care.

a. A nurse is called to the delivery room to assist with the assessment of a newborn who was born at 32 weeks gestation. The newborns weight is 1,100 grams. Which of the following are expected findings n the newborn? SATA

i. Lanugo ii. Weak grasp reflex iii. Translucent face

a. The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. i. Loosening restrictive clothing ii. Restraining the client's limbs iii. Removing the pillow and raising padded side rails iv. Repositioning the client to the side, if possible, with the head flexed forward v. Keeping the curtain around the client and the room door open so when help arrives, they can quickly enter to assist.

i. Loosening restrictive clothing iii. Removing the pillow and raising padded side rails iv. Repositioning the client to the side, if possible, with the head flexed forward

a. A macrosomic infant is born after a difficult forceps assisted delivery. After stabilization the infant is weighed, and the birthweight is 4550 G. The nurse is most appropriate action is to?

i. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia

a. A patient's cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first? i. Perform immediate defibrillation. ii. Give epinephrine (Adrenalin) IV. iii. Prepare for endotracheal intubation. iv. Give ventilations with a bag-valve-mask device.

i. Perform immediate defibrillation.

a. Which of the following lab values should the nurse report to the position as being consistent with HELLP syndrome?

i. Platelets 75,000

a. A nurse is caring for a newborn infant with myelomeningocele. Which of the following nursing actions are most appropriate? SATA i. Position the infant in prone position. ii. Maintain appropriate body temperature. iii. Keep the sac covered with sterile moist dressings. iv. Rectal temperature checks every two hours. v. Turn the infant's head to the side for feedings.

i. Position the infant in prone position. ii. Maintain appropriate body temperature. iii. Keep the sac covered with sterile moist dressings.

a. A client sustains a brain injury. The client is being treated with desmopressin acetate. What would indicate a positive outcome from the medication? i. Reduction in urine output ii. Increase in urine output iii. Decrease in reabsorption of water in the renal tubules iv. Elevation of the client's heart rate

i. Reduction in urine output

a. Level C personal protective equipment has been deemed necessary in response to an unknown substance. The nurse is aware that the equipment will include what? i. self-contained breathing apparatus ii. A vapor-tight, chemical-resistant suit iii. A uniform only iv. An air-purified respirator

iv. An air-purified respirator

a. A workplace explosion has left a 40-year-old man burned over 65% of his body. His burns are second- and third-degree burns, but he is conscious. How would this person be triaged? i. Green ii. Yellow iii. Red iv. Black

iv. Black

1. Post stroke how would you know the patient is adapting a. The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? i. Gets angry with family if they interrupt a task ii. Experiences bouts of depression and irritability iii. Has difficulty using modified feeding utensils iv. Consistently uses adaptive equipment in dress self

iv. Consistently uses adaptive equipment in dress self

a. The risk manager informs the nurse manager of the orthopedic unit that her unit has had an increase in incident reports of pts falling during the 11-7 shift. The nurse manager knows that the best way to resolve this problem is to: i. Use creativity. ii. Obtain support from the 7-3 shift. iii. Use institutional research. iv. Identify the problem.

iv. Identify the problem.

b. An epidural block is ordered for a woman in labor. Which nursing action is essential because the client has epidural anesthesia? i. Monitoring the uterus for uterine tetany ii. Giving oxytocin to counteract the effect of the epidural in slowing contractions iii. Having the woman lie flat in bed to avoid post-anesthesia headache iv. Monitoring blood pressure for possible hypotension

iv. Monitoring blood pressure for possible hypotension

a. A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? a. Auscultate heart sounds. B. Auscultate breath sounds. C Palpate peripheral pulses. d. Check mental orientation.

B. Auscultate breath sounds.

a. The nurse is caring for a patient hospitalized with an acute episode (relapse) of MS. Which agent is the preferred treatment during relapse? A. Interferon beta-1a [Avonex] IM B. Methylprednisolone [Solu-Medrol] IV C. Glatiramer acetate [Copaxone] subQ D. Natalizumab [Tysabri] IV infusion

B. Methylprednisolone [Solu-Medrol] IV

a. The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently "coughed up some blood." What is the nurse's most appropriate action? A) Assess the patient for additional signs and symptoms of Kaposi's sarcoma. B) Review the patient's most recent viral load and CD4+ count. C) Place the patient on respiratory isolation and inform the physician. D) Perform oral suctioning to reduce the patient's risk for aspiration.

C) Place the patient on respiratory isolation and inform the physician.

a. A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage? A) Rinsing the ears with normal saline after swimming B) Avoiding loud environmental noises C) Instilling antibiotic ointments on a regular D) Avoiding the use of cotton swabs

D) Avoiding the use of cotton swabs

a. A patient's rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary care provider has added prednisone to the patients drug regimen. What principle will guide this aspect of the patient's treatment? A) The patient will need daily blood testing for the duration of treatment. B) The patient must stop all other drugs 72 hours before starting prednisone. C) The drug should be used at the highest dose the patient can tolerate. D) The drug should be used for as short a time as possible.

D) The drug should be used for as short a time as possible.

1. Probable signs of pregnancy SATA

Goodell sign -softening of vaginal portion of cervix (Cervical tip) Chadwick Sign - increased blood flow to cervix, causes tissue to become purple. Hegar sign - Softening of uterus so that uterus and cervix can be distinguishable. + pregnancy test (serum) + pregnancy test (urine) Braxton Hicks contractions Ballottement - feeling for a movable object (baby)

a. What is a clinical manifestation of a cluster headache? i. Weakness ii. Lacrimation iii. Photophobia iv. Food cravings

Lacrimation

a. A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement? a. "I'll take salt tablets when I work outdoors in the summer." b. "I should take acetaminophen (Tylenol) if I start to feel too warm \."c. "I need to drink extra fluids when working outside in hot weather."\\ d. "I'll move to a cool environment if I notice that I'm feeling confused"

\."c. "I need to drink extra fluids when working outside in hot weather."\\

a. When assessing an older patient admitted to the ED with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate? a. "Do you feel safe in your home? "b. "You should not return to your home." c. "Would you like to see a social worker?" d. "I need to report my concerns to the police."

a. "Do you feel safe in your home?

Nursing action indicates correct understanding of cardiac dysrhythmias

a. Adenosine is for SVT

1. Radical mastectomy SATA, what indicates pt is experiencing complications a. Arm edema (elevate arm) b. Surgical site infection c. abd cramps d. Gas

a. Arm edema (elevate arm) b. Surgical site infection

1. Circumcision SATA if parents understand teaching,

a. Contraindicated: epispadias, hypospadias, hemophilia

1. G1P0 ER labor, chlamydia, 3cm 50% effaced. Contractions, small amounts of bleeding. Doctor's orders meds, what priority of information to give to patient

a. Give betamethasone for fetal lung maturity (want at least 2 doses)

a. Hr 120, flexed extremities, strong cry, grimacing, acrocyanosis

a. Okay result, repeat in 5 minutes

a. A client in the emergency department develops the following cardiac rhythm. The nurse performs an immediate assessment and finds the client unresponsive and pulseless. Which of the following actions is considered the priority of care? b. Defibrillation c. Chest compressions d. Assess breath sounds Administration of amiodarone

b. Defibrillation

a. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness. d. Examine the patient for any external bleeding.

b. Observe the patient's respiratory effort.

a. The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a. Teach the patient about how to use tissues to dispose of respiratory secretions. b. Stock the patient's room with all the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patient's family members the reason for the use of airborne precautions.

b. Stock the patient's room with all the necessary personal protective equipment.

b. Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. Hemoglobin is within normal limits. b. Urine output is 65 mL over the last hour. c. Pulmonary artery wedge pressure (PAWP) is normal. d. Mean arterial pressure (MAP) is 65 mm Hg.

b. Urine output is 65 mL over the last hour.

a. The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a. A patient with no pedal pulses b. A patient with an open femur fracture c. A patient with bleeding facial lacerations d. A patient with paradoxical chest movement

d. A patient with paradoxical chest movement

a. During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent and the entire leg is swollen. Which action will the nurse take next? a. Send blood to the lab for a complete blood count. b. Assess further for a cause of the decreased circulation. c. Finish the airway, breathing, circulation, disability survey. d. Start normal saline fluid infusion with a large-bore IV line.

d. Start normal saline fluid infusion with a large-bore IV line.

How to oxygen sat on peds pt?

finger

a. A nurse is revieing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses. Which of the following statements indicates an understanding of teaching?

i. "A patient should avoid consuming undercooked meats while pregnant"

a. A nurse is assessing pain in a patient with trigeminal neuralgia. Which patient response describes classic pain with trigeminal neuralgia?

i. "The pain is excruciating, sharp, and shooting."

a. Which of the following patients would be expected to benefit from a moist to dry dressing (mechanical debridement)? (select all that apply) i. 24-year-old with an open infected wound from a spider bite ii. 7-year-old with an abrasion on bilateral knees iii. 50-year-old with a post operative knee replacement incision iv. 30-year-old who had a large cyst removed and now has some necrotic tissue present in the crater type wound

i. 24-year-old with an open infected wound from a spider bite iv. 30-year-old who had a large cyst removed and now has some necrotic tissue present in the crater type wound

a. The woman comes to the doctors office for her routine checkup. She is 34 weeks gestation. The nurse notes all of the following. Which is of greatest concern to the nurse?

i. Blood pressure 150/94 ii. Complaints of intermittent headache and blurred vision

a. An infant is being treated for jaundice using photo therapy. Which of the following interventions would the nurse take in preparation for this procedure? SATA

i. Make sure the infants ours are covered to prevent eye damage ii. Ensure adequate hydration iii. Cover the genital area and monitor for skin irritation and breakdown iv. Assess bilirubin levels

Medication's that are used to induce labor are:

i. Oxytocin (Pitocin) ii. Misoprostol (Cytotec)

a. Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? i. Use aseptic technique when caring for invasive lines or devices. ii. Ambulate postoperative patients as soon as possible after surgery. iii. Remove indwelling urinary catheters as soon as possible after surgery. iv. Advocate for parenteral nutrition for patients who cannot take oral feedings. v. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

i. Use aseptic technique when caring for invasive lines or devices. ii. Ambulate postoperative patients as soon as possible after surgery. iii. Remove indwelling urinary catheters as soon as possible after surgery. v. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

a. The client has been prescribed an antihistamine anticholinergic medication. The nurse anticipates that the client will need a teaching plan regarding management of: i. drowsiness and dry mouth. ii. bradycardia and fatigue. iii. tachycardia and dyspnea. iv. abdominal cramps and nausea.

i. drowsiness and dry mouth.

a. Who is the highest priority to receive the flu vaccine? i. A healthy 8-month-old who attends day care. ii. A 3-year-old who is undergoing chemotherapy. iii. A healthy 7-year-old who attends public school. iv. An 18-year-old who is living in a college dormitory.

ii. A 3-year-old who is undergoing chemotherapy.

a. The nurse is assessing the patient for possible use of narcotic analgesics. Which of the following fetal assessments would contraindicate the use of narcotic analgesics? i. FHR 140 ii. Absence of long-term variability iii. Accelerations with fetal movement iv. 38 weeks' gestation

ii. Absence of long-term variability

a. The nurse is caring for a child with Kawasaki disease in the acute phase. Which of the following clinical manifestations would the nurse expect to observe? i. Osler nodes ii. Cervical lymphadenopathy iii. Strawberry tongue iv. Chorea v. Erythematous palms vi. Polyarthritis

ii. Cervical lymphadenopathy iii. Strawberry tongue v. Erythematous palms

a. Which of the following problems is most often associated with myelomeningocele? i. Biliary atresia ii. Hydrocephalus iii. Craniostenosis iv. Tracheoesophageal fistula

ii. Hydrocephalus

a. Two nurses approach their manager about a conflict regarding the next month's schedule. The nurses are talking loudly and at the same time. The manager most effectively uses communication skills to resolve the conflict by: i. Taking both nurses aside, separately and then together, and charging them with resolving the problem without her direct intervention. ii. Listening to each nurse speak to the other without interruption and asking clarifying questions to help them resolve the issue themselves. iii. Separating the nurses, instructing each to decide how the problem can be resolved, and meeting with them the next day. iv. Calling an emergency scheduling committee meeting and asking volunteers to resolve the conflict between the two nurses.

ii. Listening to each nurse speak to the other without interruption and asking clarifying questions to help them resolve the issue themselves.

b. The nurse should recognize a patient's risk for impaired immune function if the patient has undergone surgical removal of which of the following? i. Thyroid gland ii. Spleen iii. Kidney iv. Pancreas

ii. Spleen

b. A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site? i. Forearm ii. Thigh iii. Deltoid muscle iv. Abdomen

ii. Thigh

a. The most common complication associated with myelomeningocele is: i. Learning disability ii. UTI iii. Hydrocephalus iv. Decubitus ulcers and skin breakdown

ii. UTI

a. Which instruction will be included when teaching a patient with possible allergies about intradermal skin testing? i. "Do not eat anything for about 6 hours before the testing." ii. "Take an oral antihistamine about an hour before the testing." iii. "Plan to wait in the clinic for 20 to 30 minutes after the testing." "Reaction to the testing will take about 48 to 72 hours

iii. "Plan to wait in the clinic for 20 to 30 minutes after the testing."

a. A pediatric nurse is providing discharge instructions to the parents of an infant with a history of hypoxemia. The nurse teaches the parents about the signs and symptoms associated with hypoxemia. Which signs and symptoms prompt the parents to notify practitioner immediately? i. Weight loss or gain ii. Excessive crying iii. Dehydration and respiratory infection iv. Not achieving developmental milestones

iii. Dehydration and respiratory infection

a. A few minutes after you have given an intradermal injection of an allergen the patient who is undergoing skin testing for allergies the patient complains about feeling anxious, short of breath, and dizzy. Which of the actions included in the emergency protocol should you take first? i. Start oxygen at 4 L/min using a nasal cannula. ii. Obtain IV access with a large-bore IV catheter. iii. Give epinephrine (Adrenalin) 0.3 mL intramuscularly. iv. Administer 3 mL of nebulized albuterol (Proventil) 0.083%.

iii. Give epinephrine (Adrenalin) 0.3 mL intramuscularly

b. The physician is performing an amniotomy on a woman in labor. What is the most important nursing action during this procedure? i. Assist the physician ii. Keep the mother informed iii. Monitor fetal heart tones iv. Encourage slow chest breathing

iii. Monitor fetal heart tones

a. A patient with Guillain-Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? i. Administer bronchodilators as ordered. ii. Remind the patient of the importance of deep breathing and coughing exercises. iii. Prepare to assist with intubation. iv. Administer supplementary oxygen by nasal cannula.

iii. Prepare to assist with intubation.

a. carotid endarterectomy is being considered as treatment for a patient who has had several TIAs. What should the nurse explain to the patient about this surgery? i. it involves intracranial surgery to join a superficial extracranial artery to an intracranial artery ii. it is used to restore blood circulation to the brain following an obstruction of a cerebral artery iii. it involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke iv. it is used to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation

iii. it involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke

patient is being brought into the ED who is probably infected with anthrax. The nurse should ensure what level of personal protective equipment to wear for everyone who will come into contact with the patient? i. Level A ii. Level B iii. Level C iv. Level D

iv. Level D

a. As part of a teaching session, a client with myasthenia gravis and her family are receiving instructions from the nurse. The nurse teaches the client that overdosing of cholinesterase inhibitor may result in cholinergic crisis. The client is taught about which signs and symptoms of cholinergic crisis? i. Decreased muscle strength in the lower extremities ii. Increased salivation and sweating iii. Muscle weakness and increased salivation iv. Muscle weakness; difficulty in breathing and swallowing

iv. Muscle weakness; difficulty in breathing and swallowing

a. An emergency department nurse is assessing a pediatric client suspected of having acute pericarditis. Which assessment finding should the nurse conclude supports the diagnosis of acute pericarditis? i. Bilateral lower extremity pain ii. Pain on expiration iii. Pleural friction rub iv. Pericardial friction rub

iv. Pericardial friction rub

a. The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for patients. Which statement, if made by the nurse, would be the most accurate? i. Inferences from clinical research studies are used as a guide. ii. Patient care is based on clinical judgment, experience, and traditions. iii. Data are evaluated to show that the patient outcomes are consistently met. iv. Recommendations are based on research, clinical expertise, and patient preference

iv. Recommendations are based on research, clinical expertise, and patient preference

36. Pt comes to ER with hemiparesis and dysarthria that started 2 hours before. Have hx of TIA, nurse anticipates preparing pt for what? (Clot buster?? Alteplase????) a. A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for i. surgical endarterectomy. ii. transluminal angioplasty. iii. intravenous heparin administration. iv. tissue plasminogen activator (tPA) infusion.

iv. tissue plasminogen activator (tPA) infusion.

1. Why would u head circum. With myelomeningocele

to assess icp

a. When you ask your patient to open up and say AHHHH you are assessing which nerve?

vagus

a. A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to: i. Respect the patient's desire and arrange for privacy at mealtimes. ii. Offer the patient liquid nutritional supplements at frequent intervals. iii. Discuss the patient's concerns with visitors who arrive at mealtimes. iv. Teach the patient to chew food on the unaffected side of the mouth.

i. Respect the patient's desire and arrange for privacy at mealtimes.

b. The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? i. Taking medications as scheduled ii. Eating large, well-balanced meals iii. Doing muscle strengthening exercises iv. Doing chores early in the day while less fatigued

i. Taking medications as scheduled

a. An adolescent is admitted to the hospital with a diagnosis of bacterial meningitis. Which of the following actions, if observed by the nurse, would require an intervention? i. The LPN/LVN enters the patient's room and leaves the door open. ii. The nursing assistant leaves the patient's room with the lights dimmed. iii. The student nurse washes his hands and dons gloves and a mask. iv. The patient's mother stands away from the patient while talking to him

i. The LPN/LVN enters the patient's room and leaves the door open.

a. The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate? i. The carotid endarterectomy involves surgical removal of plaque from an artery in the neck. ii. The diseased portion of the artery in the brain is removed and replaced with a synthetic graft. iii. A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed. iv. A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque.

i. The carotid endarterectomy involves surgical removal of plaque from an artery in the neck.

a. A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor which finding indicates that preterm labor is occurring?

i. The cervix is a facing and dilated to 2 cm

a. A nurse is creating a teaching plan for a patient who has a recent diagnosis of scleroderma. What topics should the nurse address during health education? Select all that apply. i. The importance of vigilant skin care ii. Managing Raynaud's-type symptoms iii. Smoking cessation iv. Surgical treatment options v. Weight loss

i. The importance of vigilant skin care ii. Managing Raynaud's-type symptoms iii. Smoking cessation

a. A nurse is assessing a PP patient for fundal height, location, and consistency. Th fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions is the cause of uterine atony?

i. Urinary retention

a. A nurse in a providers office is obtaining a health history from a client who has cluster headaches. Which of the following are expected findings? SATA i. Pain is bilateral across the posterior occipital area ii. Client experiences altered sleep-wake cycle iii. Headache occurs approximately 1-8 times daily iv. Client describes the headache pain as dull and throbbing v. Nasal congestion and drainage occurs

ii. Client experiences altered sleep-wake cycle iii. Headache occurs approximately 1-8 times daily v. Nasal congestion and drainage occurs

a. Which action by a new registered nurse (RN) who is orienting to the telemetry unit indicates a good understanding of the treatment of heart dysrhythmias? i. Prepares defibrillator settings at 360 joules for a patient whose monitor shows asystole. ii. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia iii. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation iv. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block

ii. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia

a. The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest? i. Taking a hot bath at least once daily ii. Resting in an air-conditioned room whenever possible iii. Increasing the dose of muscle relaxants iv. Avoiding naps during the day

ii. Resting in an air-conditioned room whenever possible

a. A nurse enters a patient's room at the beginning of the shift. The nurse looks around the room for potential sources for infection. Which of the following options pose a potential risk for infection for this client? Select all that apply i. A bottle of saline irrigation solution which is tightly closed and a label identifying that it was opened 10 hrs. earlier. ii. The clients abdominal dressing has 3 different areas of moist drainage saturating the dressing and soiling the client's gown. iii. An opened package of gauze sponges in present on the windowsill. iv. The tubing of the client's IV fluids is not labeled with the date of the last tubing change.

ii. The clients abdominal dressing has 3 different areas of moist drainage saturating the dressing and soiling the client's gown. iii. An opened package of gauze sponges in present on the windowsill. iv. The tubing of the client's IV fluids is not labeled with the date of the last tubing change.

a. Which should the nurse administer to provide quick relief to a child with asthmawho is coughing, wheezing, and having difficulty catching her breath? i. Prednisone. ii. Singulair (montelukast). iii. Albuterol. iv. Flovent (fluticasone).

ii. albutetrol

b. Over the last week an infant with repaired myelomeningocele has had a high-pitched cry and been irritable. length, weight and head circumference have been at the 50th percentile. today length is at the 50th percentile, weight is at the 70th percentile and head circumference is at the 90th percentile. the nurse should do which of the following? i. tell the parent this is normal for an infant with a repaired myelomeningocele ii. tell the parent this might mean the baby has increased ICP iii. suspect the baby's ICP is low because of a leak iv. refer the baby to the neurologist for follow up care

ii. tell the parent this might mean the baby has increased ICP

a. A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include? i. How to differentiate between hemorrhagic and ischemic stroke ii. Risk factors for ischemic stroke iii. How to correctly modify the home environment iv. Techniques for adjusting the patients medication dosages at home

iii. How to correctly modify the home environment

a. A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient? i. All at one time, to provide a longer rest period ii. Before meals, to stimulate her appetite iii. In the morning, with frequent rest periods iv. Before bedtime, to promote rest

iii. In the morning, with frequent rest periods

a. The nurse is caring for a 39-year-old woman with a family history of breast cancer. She requested a breast tumor marking test and the results have come back positive. As a result, the patient is requesting a bilateral mastectomy. This surgery is an example of what type of oncologic surgery? i. Salvage surgery ii. Palliative surgery iii. Prophylactic surgery iv. Reconstructive surgery

iii. Prophylactic surgery

a. A nurse is caring for an infant with myelomeningocele who is going to surgery later today for closure of the sac. Which would be a priority nursing diagnosis before surgery? i. Alteration in parent-infant bonding ii. Altered growth and development iii. Risk for infection iv. Risk for weight loss

iii. Risk for infection

a. A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors? i. The nurse wears face protection, gloves, and a gown when irrigating a wound. ii. The nurse washes the hands with a waterless antiseptic agent after removing a pair of soiled gloves. iii. The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure. iv. The nurse places a used needle and syringe in the puncture-resistant container without capping the needle.

iii. The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.

a. A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? i. The patient meets the criteria for a diagnosis of an acute HIV infection. ii. The patient will be diagnosed with asymptomatic chronic HIV infection. iii. The patient has developed acquired immunodeficiency syndrome (AIDS). iv. The patient will develop symptomatic chronic HIV infection in less than a year

iii. The patient has developed acquired immunodeficiency syndrome (AIDS).

a. While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? i. Insert an oral airway during the seizure to maintain a patent airway. ii. Restrain the patient's arms and legs to prevent injury during the seizure. iii. Time and observe and record the details of the seizure and postictal state. iv. Avoid touching the patient to prevent further nervous system stimulation.

iii. Time and observe and record the details of the seizure and postictal state.

c. A newborn with a repaired myelomeningocele is assessed for hydrocephalus. which would the nurse expect in an infant with hydrocephalus? i. low pitched cry and depressed fontanel ii. low pitched cry and bulging fontanel iii. bulging fontanel and downwardly rotated eyes iv. depressed fontanel and upwardly rotated eyes

iii. bulging fontanel and downwardly rotated eyes

b. A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? i. cool, clammy skin. ii. shortness of breath. iii. heart rate of 45 beats/min iv. BP of 82/40 mm Hg.

iii. heart rate of 45 beats/min

c. The nurse is assessing a child admitted with possible Kawasaki's disease. A characteristic sign or symptom that the nurse should observe and document would be: i. cardiac dysrhythmia ii. decreased urine output iii. peeling skin on fingers iv. decreased level of consciousness

iii. peeling skin on fingers

a. A pregnant 16-year-old asks the nurse if she should have an abortion. How should the nurse respond initially? i. "You should ask your parents for advice." ii. "Abortion is the deliberate killing of a human being." iii. "An abortion would let you finish growing up before you have children." iv. "What are your feelings about abortion?"

iv. "What are your feelings about abortion?"

a. What is the most important piece of information that the nurse must ask the parent of a child in status asthmaticus? i. "What time did your child last eat?" ii. "Has your child been exposed to any of the usual asthma triggers?" iii. "When was your child last admitted to the hospital for asthma?" iv. "When was your child's last dose of medication?"

iv. "When was your child's last dose of medication?"

a. The nurse notes that the client has dyspnea and red blotches on the face and arms and appears anxious following exposure to latex. The nurse calls the ART, who initates emergency treatment. Of all the emergency treatments available, which action should be taken first by ART? i. Start oxygen at 1 liter per minute via nasal cannula ii. State IV access with a large-bore catheter iii. Administer diphenhydramine 25 mg IM iv. Administer epinephrine hydrochloride 0.4 mL SQ

iv. Administer epinephrine hydrochloride 0.4 mL SQ