119-250
A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention?
***Allopurinol (Zyloprim)*** Aspirin, low dose Furosemide (lasix) Enalapril (vasote)
The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication?
***Antibiotics*** Anticoagulants Antihypertensive Anticholinergics
A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain?
***Cardiac rhythm and heart rate.*** Daily intake of foods rich in potassium. Hourly urinary output Thirst ad skin turgor.
A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.)
***Collect multiple site screening culture for MRSA*** ***Place the client on contact transmission precautions*** ***Place the client on contact transmission precautions*** Obtain sputum specimen for culture and sensitivity Call healthcare provider for a prescription for linezolid (Zyrovix) Rationale: Until multi-site screening cultures come back negative (A), the client should be maintained on contact isolation(C) to minimize the risk for nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infectant, is not indicated, unless the client has an active skin structure infection cause by MRSA or multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated9D) based on the client's history is a wound infection.
An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition?
***Delirium*** Depression Dementia Psychotic episode
A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care?
***Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%*** ***Evaluate heart rate for effectiveness of cardio tonic medications*** ***Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples*** ***Ensure Interrupted and frequent rest periods between procedures.*** Administer diuretics via secondary infusion in the morning only Rationale: Pulse oximetry screening supports prescribed level of O2. HR provides an evaluative criterion for cardiac medications, which reduce heart rate, increase strength contractions (inotropic effects) and consequently affect systemic circulation and tissue oxygenation. Breast milk or basic formula provide 20 calories/ounce, so frequent feedings with high energy formula. D minimize fatigue is necessary.
The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound?
***High pitched or fine crackles.*** Rhonchi High pitched wheeze Stridor
A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?
***How many departments can use this equipment?*** Will the equipment require annual repair? Is the cost of the equipment reasonable? Can the equipment be updated each year?
The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose?
***Jaundice*** Nausea Fever Fatigue
A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.
***Monitor abdominal girth*** ***Report serum albumin and globulin levels*** ***Note signs of swelling and edema.*** Provide diet low in phosphorous Increase oral fluid intake to 1500 ml daily. Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease.
An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition?
***Multiple organ dysfunction syndrome (MODS)*** Disseminated intravascular coagulation (DIC) Chronic obstructive disease. Acquired immunodeficiency syndrome (AIDS) Rational: MODS are a progressive dysfunction of two or more major organs that requires medical intervention to maintain homeostasis. This client has evidence of several organ systems that require intervention, such as blood pressure, hemoglobin, WBC, and respiratory rate. DIC may develop as a result of MODS. The other options are not correct.
The nurse is auscultating is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.)
***Murmur*** s1 s2 pericardial friction rub s1 s2 s3
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?
***Observe aspiration site.*** Assess body temperature Monitor skin elasticity Measure urinary output
Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply.
***Prepare medication reversal agent*** ***Check oxygen saturation level*** ***Apply oxygen via nasal cannula*** Initiate bag- valve mask ventilation. Begin cardiopulmonary resuscitation Rationale: Sedation, given during the procedure may need to be reverse if the client does not easily wake up. Oxygen saturation level should be asses, and oxygen applied to support respiratory effort and oxygenation. The client is still breathing so the bag- valve mask ventilation and CPR are not necessary.
The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize?
***Protect joint function*** Improve circulation Control tremors Increase weight bearing
A 56-years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse?
***Provide an opportunity for him to clarify his values related to the decision*** Encourage him to share memories about his life with his wife and family Advise him to seek several opinions before making decision Offer to contact the hospital chaplain or social worker to offer support. Rationale: When a client is faced with a decisional conflict, the nurse should first provide opportunities for the client to clarify values important in the decision. The rest may also be beneficial once the client as clarified the values that are important to him in the decision-making process.
A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective?
***Reduced level of pain*** Full volume of pedal pulses Granulating tissue in foot ulcer Improved visual acuity
At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation:
***Remove sequential compression devices.*** Apply PRN oxygen per nasal cannula. Administer a PRN dose of an antipyretic. Reinforce the surgical wound dressing. Rationale: Sequential compression devices should be removed prior to ambulation and there is no indication that this action is contraindicated. The client's oxygen saturation levels have been within normal limits for the previous four hours, so supplemental oxygen is not warranted.
A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement?
***Send stool sample to the lab for a guaiac test*** Observe stool for a day-colored appearance. Obtain specimen for culture and sensitivity analysis Asses for fatty yellow streaks in the client's stool. Rationale: Thrombolytic drugs increase the tendency for bleeding. So guaiac (occult blood test) test of the stool should be evaluated to detect bleeding in the intestinal tract.
Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider?
***Sudden dysphagia*** Blurred visual field Gradual weakness Profuse diarrhea
The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine?
***The client's previous GCS score*** When the client's stroke symptoms started If the client is oriented to time The client's blood pressure and respiration rate Rationale: The normal GCS is 15, and it is most important for the nurse to determine if it abnormal score a sign of improvement or a deterioration in the client's condition
The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?
***Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours.*** Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours. Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours is the correct procedure for collecting 24-hour urine specimen. Discarding even one voided specimen invalidate the test.
A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client's discharge teaching plan?
***Weigh every morning*** Eat a high protein diet Perform range of motion exercises Limit fluid intake to 1,500 ml daily
The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat?
***Yogurt and/or buttermilk.*** Avocados and cheese Green leafy vegetables Fresh fruits
An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)?
9 % 18 % ***36 %*** 45 % Rational: according to the rule of nines, the anterior and posterior surfaces of one lower extremity is designated as 18 %of total body surface area (TBSA), so both extremities equals 36% TBSA, other options are incorrect.
A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.)
A client must be willing to accept palliative care, not curative care. The healthcare provider must project that the client has 6 months or less to live.
A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?
A mother with an infected episiotomy
A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?
Abnormal responses for cranial nerves I and II ***Persistent coughing while drinking*** Unilateral facial drooping Inappropriate or exaggerated mood swings
After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)
Administer PRN nebulizer treatment Obtain 12 lead electrocardiogram. Monitor continuous oxygen saturation.
The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?
Administer a prescribed analgesia for pain.
A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next?
Administer antiemetic agents Bivalve the cast for distal compromise Provide high- calorie, high-protein diet ***Begin parenteral antibiotic therapy*** Rationale: The standard of treatment for osteomyelitis is antibiotic therapy and immobilization. After bond and blood aspirate specimens are obtained for culture and sensitivity, the nurse should initiate parenteral antibiotics as prescribed
A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action?
Administer naloxone (Narcan) per PNR protocol ***Initiate seizure precautions*** Obtain a serum drug screen Instruct the family about withdrawal symptoms. Rationale: Withdrawal of CNS depressants, such as Xanax, results in rebound over-excitation of the CNS. Since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the client.
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next?
Administer the analgesic as requested
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next?
Administer the analgesic as requested Rationale: Chronic pain may be difficult to describe but should be treated with analgesics as indicated.
The healthcare provider changes a client's medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement?
Administer the medication via the oral route as prescribed
The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN?
An adult female who has been depress for the past several month and denies suicidal ideations. A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium. ***A young male with schizophrenia who said voices is telling him to kill his psychiatric*** An elderly male who tell the staff and other client that he is superman and he can fly. Rationale: The RN should deal with the client with command hallucinations and these can be very dangerous if the client's acts on the commands, especially if the command is a homicidal in nature. Other client present low safety risk.
A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
Answer 83 Rationale: 1000 ml-----12hr. • Xml ---------1hr. • 1000/12 = 83.33 = 83.
The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.)
Answer: 12160 Rationale: 4ml x 67kg x 40 (bsa) =12,160 ml
In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?
Anxiety related to fear of suffocation.
When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement?
Arrange to transport the client to the hospital Instruct the client to keep a food journal, including portions size. ***Review the client's use of over the counter (OTC) medications.*** Reinforce the importance of keeping the feet elevated. Rationale: Sodium is used in several types of OTC medications. Including antacids, which the client may be using to treat his GERD. Further evaluation is need it to determine the need for hospitalization (A) A food journal (B) may help over, but dietary modifications are needed now since edema is present. (C) May relieve dependent edema, but not treat the underlying etiology.
A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take?
Ask a chemotherapy-certified nurse to administer the Zofran ***Administer the Zofran after flushing the saline lock with saline*** Hold the scheduled dose of Zofran until the client awakens Awaken the client to assess the need for administration of the Zofran. Rationale: Zofran is an antiemetic administered before and after chemotherapy to prevent vomiting. The nurse should administer the antiemetic using the accepter technique for IV administration via saline lock. Zofran is not a chemotherapy drug and does not need to be administered by a chemotherapy- certified nurse.
An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take?
Ask the UAP to take the blood pressure in the other arm Tell the UAP to use a different sphygmomanometer. ***Review the client's serum calcium level*** Administer PRN antianxiety medication. Rationale: Trousseau's sign is indicated by spasms in the distal portion of an extremity that is being used to measure blood pressure and is caused by hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.
While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?
Ask the client what he is thinking about at his time.
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take?
Ask the older brother how he felt during the incident.
An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take?
Ask the wife to stop and assess the client's swallowing reflex
Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?
Assess IV site frequently for signs of extravasation
An older male comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first?
Assess the surroundings for noise and distractions.
Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)?
Aural migraine headaches.
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan?
Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?
Be alert for possible cross-sensitivity to cephalosporin agents.
A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?
Bowel patterns Rationale: the client should be assessed for a change in bowel patterns to evaluate the effectiveness of this medication because Mesalamine is used to treat ulcerative colitis (a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum) and also to maintain improvement of ulcerative colitis symptoms. Mesalamine is in a class of medications called anti-inflammatory agents. It works by stopping the body from producing a certain substance that may cause inflammation.
The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?
Brain damage with CP is not progressive but does have a variable course
The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal?
Case management and screening for clients with HIV. Regional relocation center for earthquake victims ***Vitamin supplements for high-risk pregnant women.*** Lead screening for children in low-income housing. Rational: Primary prevention activities focus on health promotions and disease preventions, so vitamin for high-risk pregnant women provide adequate vitamin and mineral for fetal developmental.
The charge nurse in a critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit?
Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation
A male client's laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client's plan of care?
Cluster care to conserve energy Initiate contact isolation ***Encourage him to use an electric razor*** Asses him for adventitious lung sounds Rationale: This client is at risk for bleeding based on his platelet count (normal 150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for shaving, should be encouraged to reduce the risk of bleeding
When evaluating a client's rectal bleeding, which findings should the nurse document?
Color characteristics of each stool.
An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation?
Consistently applies TED hose before getting dressed in the morning. Frequently elevated legs thorough the day. Inspect the leg frequently for any irritation or skin breakdown ***Completely stop cigarette/ cigar smoking*** Rationale: Stopping cigarette smoking helps to decrease vasoconstriction and improve arterial circulation to the extremity.
While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?
Contact the medical records department supervisor.
The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?
Convey to the client that birth is imminent.
A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client?
Crutches with 2 point gait. Crutches with 3 point gait. ***Crutches with 4 point gait.*** A quad cane
A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect?
Decrease in serum T4 levels Increase in blood pressure ***Decrease in pulse rate*** Goiter no longer palpable
An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries?
Decrease prevalence of glaucoma in the population.
The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?
Decreases the amount of HCL secretion by the parietal cells in the stomach
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?
Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider
After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first?
Determine client's pulse, blood pressure, and respirations
A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?
Determine the client's vital sign.
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?
Digoxin.
The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation?
During acute illness
A woman just learned that she was infected with Heliobacter pylori. Based on this finding, which health promotion practice should the nurse suggest?
Encourage screening for a peptic ulcer
While receiving a male postoperative client's staples de nurse observe that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledgement the client's anxiety, what action should the nurse implement?
Encourage the client to continue verbalize his anxiety ***Attempt to distract the client with general conversation*** Explain the procedure in detail while removing the staples Reassure the client that this is a simple nursing procedure. Rational: Distract is an effective strategy when a client experience anxiety during an uncomfortable procedure. (A & D) increase the client's anxiety.
A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement?
Encourage the client to eat finger foods.
The nurse note a depressed female client has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?
Encourage the client's family to visit more often Schedule a daily conference with the social worker Encourage the client to participate in group activities ***Engage the client in a non-threatening conversation.*** Rationale: Consistent attempts to draw the client into conversations which focus on non-threatening subjects can be an effective means of eliciting a response, thereby decreasing isolation behaviors. There is not sufficient data to support the effectiveness of A as an intervention for this client. Although B may be indicated, nursing interventions can also be used to treat this client. C is too threatening to this client.
After administering an antipyretic medication. Which intervention should the nurse implement?
Encouraging liberal fluid intake
In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?
Ensure that no dependent loops are present in the tubing.
A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device
Ensure the transparent dressing has no tears that might create vacuum leaks
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?
Establish a structured routine for the client to follow.
A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem?
Establish trust with community leaders and respect cultural and family values
A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information?
Explain that it may take several weeks for the medication to be effective ***Confirm the desired effect of the medication has been achieved.*** Notify the health care provider than a change may be needed. Evaluate when and how the medication is being administered to the client. Rationale: Trazodone o Desyrel, an atypical antidepressant, is prescribed for client with AD to improve mood and sleep.
An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?
Explain the reason for using only non-narcotics.
Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include?
Fall prevention measures.
The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis?
Fever and dysuria.
The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement?
Give the child syringes or hospital mask to play it at home prior to hospitalization. Include the child in pay therapy with children who are hospitalized for similar surgery. ***Provide a family tour of the preoperative unit one week before the surgery is scheduled.*** Provide doll an equipment to re-enact feeling associated with painful procedures. Rationale: School age children gain satisfaction from exploring and manipulating their environment, thinking about objectives, situations and events, and making judgments based on what they reason. A tour of the unit allows the child to see the hospital environment and reinforce explanation and conceptual thinking.
A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider?
Headache Joint stiffness ***Persistent fever*** Increase hunger and thirst Rationale: Enbrel decrease immune and inflammatory responses, increasing the client's risk of serious infection, so the client should be instructed to report a persistent fever, or other signs of infection to the healthcare provider
The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness?
Hemoglobin A1C (HbA1C) reading less than 7%
After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?
Hold oral intake until swallow evaluation is done.
An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?
Identify pills in the bag.
The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care?
Increase fluid intake to 3,000 ml/daily
A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis?
Infection Increase intracranial pressure ***Shock*** Head Injury.
When implementing a disaster intervention plan, which intervention should the nurse implement first?
Initiate the discharge of stable clients from hospital units ***Identify a command center where activities are coordinated*** Assess community safety needs impacted by the disaster Instruct all essential off-duty personnel to report to the facility
The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?
Instruct the mother to change the child's diaper more often.
The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply)
Interacts with a flat affect. Avoids eye contact. Has a disheveled appearance.
The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?
Large amounts of fluid and electrolyte replacement.
A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement?
Maintain both lower extremities elevated on pillows.
A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug?
Maternal pulse rate of 162 beats per min
Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan of care?
Medicate as needed for pain and anxiety.
Which intervention should the nurse include in the plan of care for a child with tetanus?
Minimize the amount of stimuli in the room
A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?
New onset of purple skin lesions.
A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?
No wheezing upon auscultation of the chest.
Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? (Select all that apply)
Notify the food services department of the allergy. Enter the allergy information in the client's record Add egg allergy to the client's allergy arm band.
Based on principles of asepsis, the nurse should consider which circumstance to be sterile?
One inch- border around the edge of the sterile field set up in the operating room A wrapped unopened, sterile 4x4 gauze placed on a damp table top. ***An open sterile Foley catheter kit set up on a table at the nurse waist level*** Sterile syringe is placed on sterile area as the nurse riches over the sterile field. Rationale: A sterile package at or above the waist level is considered sterile. The edge of sterile field is contaminated which include a 1-inch border (A). A sterile objects become contaminated by capillary action when sterile objects become in contact with a wet contaminated surface.
A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement?
Palpate at the radial pulse site with the pads of two or three fingers.
The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement?
Perform bilateral chest auscultation
In early septic shock states, what is the primary cause of hypotension?
Peripheral vasoconstriction ***Peripheral vasodilation*** Cardiac failure A vagal response Rationale: Toxins released by bacteria in septic shock create massive peripheral vasodilation and increase microvascular permeability at the site of the bacterial invasion.
In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
Place personal religious artifacts on the body. Attach identifying name tags to the body. Follow cultural beliefs in preparing the body.
The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention?
Postmenopausal women need an intake of at least 1,500 mg of calcium daily.
A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care?
Provide daily care of tong insertion sites using saline and antibiotic ointment
A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take?
Provide the man and his mother with a copy of the Patient's Bill of Rights
A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement?
Raise the head of the bed to a Fowler's position and support his arms with a pillow
The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?
Recommend weigh bearing physical activity
An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?
Reinforce the importance of annual papanicolaou (Pap) smears
To evaluate the effectiveness of male client's new prescription for ezetimibe, which action should the clinic nurse implement?
Remind the client to keep his appointments to have his cholesterol level checked.
Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement?
Remove cigarettes for the client's room
During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?
Report weight gain of 2 pounds (0.9kg) in 24 hours
A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?
Reposition the client with the head of the bed elevated.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?
Respiratory apnea of 30 seconds
When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur?
Resume normal physical activity Drink electrolyte fluid replacement ***Give a dose of regular insulin per sliding scale*** Measure urinary output over 24 hours. Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client manifest early signs of DKA that include excessive thirst, frequent urination, headache, nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should determine fingersticks glucose level and selfadminister a dose of regular insulin per sliding scale.
A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer?
Simethicone (Mylicon)
While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first?
Submit a referral for an evaluation by a physical therapist.
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?
Supervise a newly hired graduate nurse during an admission assessment
The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply)
Take postoperative vital signs for a client who has an epidual following knee arthroplasty Collect a sputum specimen for a client with a fever of unknown origin Ambulate a client who had a femoral-popliteal bypass graft yesterday
A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care?
Teach family proper range of motion exercises
A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?
Teach tracheal suctioning techniques
A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?
Tell all their assigned clients to stay in their rooms.
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
The client's need for pain medication should be determined.
The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes?
The fating blood sugar was 120 mg/dl this morning. Urine ketones have been negative for the past 6 months ***The hemoglobin A1C was 6.5g/100 ml last week*** No diabetic ketoacidosis has occurred in 6 months. Rationale: A hemoglobin A1C level reflects he average blood sugar the client had over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the client understand long-term diabetes control. Normal value in a diabetic patient is up to 6.5 g/100 ml.
A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement?
Transfer the client to the surgical floor.
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?
Use sunblock or protective clothing when outdoors.
A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?
Ventricular arrhythmias. Rationale: adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralocorticoids and sodium excretions that is characterized by hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias are life threatening and required immediate intervention to correct critical potassium levels.
The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)
Weigh the client and report any weight gain. Report any client complaint of pain or discomfort. Note and report the client's food and liquid intake during meals and snacks.
The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.)
1. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia
