211 test 5
Newly dx cardiac dysrhythmia what should the nurse monitor?STAT (1-7) anybody know the right answers it was number 29 on the test???? 1)Ca+ 8.5 2) K+ 3.1 3)Na 124 4)PT 12 w/ INR 1 5)HBG 14 6)HCT 40% 7)BUN 20
123
Least restrictive to most restrictive 1 Telling someone to stop yelling 2 Quiet indoor garden 3Put patient in quiet room 4 Put patient in room with UAP sitter 5 Restrain patient 6 Chemical restraint
123456
The nurse is caring for a substance use disorder (SUD) client who has the potential of experiencing violent episodes. The nurse should implement which intervention(s)? Select all that apply 1. Speaking slowly to the client. 2. Moving slowly when approaching the client. 3. Loudly instructing the client to remain calm to avoid being restrained 4. Projecting an attitude of calmness when caring for the client. 5. Encouraging the client to talk out feelings rather than act on them.
1245
A pt is receiving ___ at 10mL/h. The ____ is 50mg/500mL of 0.9% NS. calculate the micrograms per minute. Round to the nearest 10th.
16.7
A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of teaching? A. "I will administer prophylactic treatment for sexually transmitted infections, like chlamydia." B. "I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence." C. "I can expect manifestations of rape‑trauma syndrome to be similar to bipolar disorder." D. "I should use narrative documentation when documenting subjective data."
A
A nurse is providing discharge teaching to a client who has a Plaster of Paris walking cast on his left lower leg. Which of the following instructions should the nurse include? Select one: A Report any numbness or pain in your toes. B There is no need to cover the cast when showering. C Apply ice to your foot after walking. D A musty odor is normal as the cast ages
A
A patient taking glipizide asks the nurse, "How does my insulin pill work, anyway?" Which information will the nurse provide to the patient regarding the mechanism of action of glipizide? a. "It increases insulin production." b. "It helps the body use insulin." c. "It decreases the amount of glucose made by the liver." d. "It decreases the amount of glucose the body takes in from food
A
The nurse is caring for a client during the induction phase of hypothermia. which of the following is an appropriate consideration for this phase? A. Shivering is most likely to occur
A
The nurse is caring for a client that is physically aggressive. What would be the nurse's initial priority when managing this client? Select one: A Clear the immediate area of other clients to prevent harm to others. V B Place the client on 1-1 supervision or observation. C Restrict the client to his or her room to restore the therapeutic milieu. d. Restore the client's self-control to help prevent further loss of control.
A
The nurse is planning care for a client with a femoral fracture who is in balanced suspension traction. Which nursing care can be included in the plan of care? A) Using a fracture bedpan when the client is in the trapeze to raise hips B) turning the client side decide to give back care C) raising the head of the bed to 90° to set the client up D) giving the client a complete bed bath
A
DKA signs and symptoms A. Deep and fast respirations B. Ortho hypo C. tachycardia D. Bradycardio E. Hypertension
ABC
The child has a newly applied fiberglass hip-spica cast. Which interventions should the nurse implement? Select all that apply A. Place pillows to support the child's lower extremities B. Turn the child every 2 hours and monitor skin integrity C. Petal the perineal area and other edges of the cast
ABC
A nurse is preparing to assess an infant. Which of the following is an expected finding of shaken baby syndrome? A. Respiratory distress B. Retinal hemorrhage C. Altered level of Consciousness D. Increase in head circumference E. Sunken fontanels
ABCD
Eight hours into the shift the nurse who is monitoring a hospitalized client obtains a CIWA-ar score of 12. The patient was admitted 48 hours prior with a blood alcohol level of 250 mg/dL. What other findings should alert the nurse to the potential of alcohol withdrawal delirium or delirium tremens? A. Hypertension B. Disorientation C. hallucinations D. anorexia
ABCD
The question about fibromyalgia and what findings do expect, don't remember question but I found this A. Present on both sides of the body B. Present above and below the waist, C. Present for at least the last 3 months, D. Pain is noted on at least 11 of 18 trigger point
ABCD
The nurse is delivering a plan of care for a client with Chronic Fatigue Syndrome (CFS). Which of the following are areas that need to be addressed for this client? A. Memory issues B. Depression C. Dizzeness D. Sleep E. Pain
ABCDE
Client discharge home with an inhaler that has a spacer. Remove the caps from the inhaler and the spacer. Shake the whole unit vigorously three or four times. Fully exhale and Place the mouthpiece into your mouth, over your tongue, and seal your lips tightly around it. Press down firmly on the canister of the inhaler to release one dose of medication into the spacer. Breathe in slowly and deeply. Remove the mouthpiece. Hold your breath for at least 10 seconds after Wait at least 1 minute between puffs.
ABCDEFG
A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations • b. Orthostatic hypotension c Decreased urine output • d. Tachycardia • е. Dependent pulmonary crackles
ABD
The nurse is caring for a client with a new onset of Fibromyalgia. Which of the following could be considered in the beginning stages to treat this condition? Select all that apply. a. Tai chi b. Yoga v c. Oxycodone D Acupuncture e Low-impact aerobics w
ABDE
Which does the nurse recommend in the early stages of fibromyalgia? All except the medications!! A. Yoga B. Walking C. Acetaminophen D. Gabapentin E. Acupuncture F. Tai chi G. Amitriptyline
ABEF
for which prescriptions, does the nurse need to seek Clarification from the health care provider? A. Ms. A is a 35-year old female admitted for an acute episode of cholelithiasis. Prescribed: Morphine 1 to 15mg IV every 2 hours PRN pain B. Mr. B is 75 year old male Prescribed: Morphine 2 to 3 mg IV every 2 hours PRN pain C. Mr. C is a 55 year old male with acute pancreatitis. He has a history of alcohol and substance abuse. Prescribed: Morphine 1 to 3 mg IV every 4 hours PRN Pain D. Mr. D is an 83 year-old female with an ankle fracture. She has dementia and is unable to maintain elevation of the ankle. Prescribed: Meperidine 25 to 50 mg PO PRN Pain E. Mr. E is a 46 year oldPrescribed: Codeine 15 mg PO 1-2 tablets every 4 to 6 hours PRN Pain F. Mr. F is a 25 year old male. He has extensive abrasions on the left side of the body sustained in a motorcycle accident. No other obvious trauma was detected in the emergency d
ACDFGH
A client with fibromyalgia is prescribed a serotinin-norepinephrine reuptake inhibitor. Which side effect of the medication should the nurse include when teaching the client about this medication? SATA A) Dry mouth B) Diarrhea C) Increased sleepiness D) Nausea E) Dizziness
ADE
The nurse is providing discharge teaching to a client newly diagnosed with Fibromyalgia. The client has a history of Hypertension, Depression, and Chronic Obstructive Pulmonary Disease. Which of the following is true? Select all that apply. Select one or more: a. Amitriptyline will help promote rest. B Milnacipran should be taken at a regular time each day. C Acupuncture is effective in promoting pain relief for individuals with Fibromyalgia D Limit the intake of caffeine. E Narcotics may be added after other treatment options have failed
ADE
The nurse is caring for a client who is taking Disulfiram. The nurse would caution the client to avoid which of the following items? SATA A. Aftershave Lotion B. Yogurt C. Aged Cheeses D. Pickles vinegar in pickles! E. Liquid cough medicines F. Mouthwash
ADEF
Heat Stroke:
Absent perspiration. Hot, dry skin.
he nurse is caring for a 73 year old patient who was admitted for dehydration and observation for compartment injury. The patient fell between the toilet and the wall. His right arm was pinned underneath his body, for several hours before he was discovered by a neighbor. Fractures and other obvious injuries were ruled out in the emergency department. Patient received 400 mg ibuprofen for pain in the right arm. Which nursing actions would the nurse take for suspicion of compartment syndrome?
Anticipated: Assess the location, quality, and intensity of pain Assess for 5ps (pain, pallor, pulselessness, paralysis, paresthesia)Assess urine color and output, Notify health care provider for unrelieved pain and paresthesia Nonessential: Obtain an xray Contraindicated: Elevate right arm above the level of the heart, Apply an ice pack wrapped in a towel,Wrap the forearm with an elastic bandage,
The nurse is caring for a client newly diagnosed with Fibromyalgia. Which of the following is true concerning pain with this condition?
Antidepressants are utilized to help with pain relief.
Risperidone
Antipsychotic, used to treat schizo bipolar disorder
A clinic nurse is providing discharge teaching to an athlete for heat cramps. Which of the following statements best illustrates appropriate teaching for heat cramps? "You should avoid strenuous activity for a few days" "When exercising you should drink a sports drink in addition to water" V "Stretching before and after a workout will significantly reduce heat cramps" "Exercise indoors and avoid the outdoors when it is hot outside
B
A nurse is caring for an 87-year-old Mexican-American female patient who is in end-stage renal disease. The physician has just been in to see the patient and her family to tell them that nothing more can be done for the patient and that death is not far. The physician offers to discharge the patient home to hospice care, but the patient and family refuse. After the physician leaves, the patient's daughter approaches you and asks what hospice care is. What would this lack of knowledge about hospice care be perceived as? Select one: A Lack of an American education of the patient and her family B A barrier to hospice care for this patient v C Inability to grasp American concepts of health care D A language barrier to hospice care for this patien
B
A question about a patient with systolic heart failure BP 138/82 HR 65 meds are captopril, furosemide, lol(beta blocker) and a potassium of 6.8. A. hold med lol, B. hold med captopril C give meds or D. Notify the provider. (due to critical lab value)
B
The nurse is caring for a client who is a victim of interpersonal violence/ rape or assault. What should be the priority nursing action? Select one: A Encourage the client to verbalize feelings about the event. B Assess the client for injuries and physical trauma. c. Provide privacy for the client during the psychiatric interview. d. Help the client identify resources and support systems at discharge.
B
The nurse is caring for a client with visceral pain. Which of the following is true regarding this pain? A. Skin and muscle pain B. Responds best to opioid tx C. Shoulder pain during a myocardial infarction D. Nerve fibers from two different regions converge in spinal cord
B
The nurse is providing care to a client suffering a heat stroke. After reducing the temp the client begins to shiver. Which medication takes priority. A. Meperidine B. Chlorpromazine C. Depakote D. Dantrolene
B
The nurse is working on a psychiatric unit. Which of these clients should be evaluated first? Select one: a Manic client talking and laughing with unseen others. b Bipolar PTSD client pacing the unit with clenched fists. V c Depressed client sitting on the floor rocking back and forth. d Schizophrenic client laughing and waving hands up in the air. e Psychotic client who is having a delusion that she is the Queen of England.
B
The nurse is preparing a client for induced hypothermia. Which of the following statements are true about the induced hypothermia? Select all that apply. Select one or more: A Protocol should be used in all clients who suffer cardiac arrest. B Rewarming too quickly can cause hyperkalemia. C Involves induction, maintenance and rewarming. D Improves neurological outcome. E Shivering is treated with neuromuscular blockers.
BCDE
The nurse is working with a psychotic patient who exhibits a sudden increase in body temperature, muscular rigidity and an altered mental status after taking Thioridazine. The nurse suspects the client is experiencing signs and symptoms (S/S) of neuroleptic malignant syndrome. Which priority actions should the nurse take first? Select All That Apply A Reassess heart rate and blood pressure at least every two hours. B Treat as a medical emergency, call a rapid response as indicated. C Administer antipyretics for fever and attempt to cool the patient. D Administer dantrolene (Dantrium) as per order to promote muscle relaxation E Report the S/S to the physician and request a stop order for the medication
BCDE
Which of the following are true regarding a child's response to pain? A. Children usually have tachycardia, tachypnea, and HTN with pain B. Children experience more anxiety with pain than adults C. The first sign is change in behavior D. Pediatric clients will tell you if they are in pain E. Opioids are safe to use with pediatric clients
BCE
The nursing is developing a plan of care for a client with Chronic Fatigue Syndrome. Which of the following are areas that need to be addressed for this client? Select all that apply. Select one or more: A Nutrition B Dizziness C Memory issues. D Thromboembolism prevention E Pain F Sleep G Depressio
BCEFG
The nurse is providing education to parents on their newborn. Which of the following are methods a newbor has to generate heat? Select all that apply. A The moro reflex B Cold stress C Shivering D Decreased surface area e. Brown fat thermogenesis
BE
The nurse is caring for a client with schizophrenia. Which educational piece is appropriate to provide to the client for taking Aripiprazole? Select one: A Recommend that the client reduces his alcohol intake to one drink a day. B Advise the client to exercise more in order to optimize the drug's action. C Advise the client to take the mediation at bedtime since it causes sedation. D Instruct the client to take the medication with water only before meals.
C
The nurse on an inpatient psychiatric unit has just completed the change of shift report. The nurse should give priority to assessing the client: Select one: A On call, for a scheduled electroconvulsive therapy procedure. B Receiving chlorpromazine with a WBC of 7,500 per microliter. C With a newly reported lithium level of 2.0 meg/L D With schizophrenia having auditory hallucinations.
C
Case study about total mastectomy it was 51 on the test A. Avoid placing purse on affecting arm. B. Avoid raising above waist level (how do you keep something that is above waist level already, below waist level??) good point C. Elevate on pillow. D. Wear a medical alert bracelet notifying of arm restriction. E. Remove restrictive clothing or jewelry.
CD
A nurse is explaining the purpose of palliative care to the student. Which of the following statements are true? Select all that apply. Select one or more: a. "Palliative care is responsible for procuring organ donation" b "Palliative care should only be involved when a client is terminal" c "The team can consist of a social worker, nurse, chaplain, physician or a personal care aid" V d "Palliative care's primary purpose is support of the family and the client" e "Palliative care focuses on comfort rather than treatment"
CDE
When caring for a client with a newly diagnosed cardiac dysrhythmia, which laboratory values are the priority for the nurse to monitor? Select all that apply. A. blood urea nitrogen (BUN) of 20 mg/dL B hematocrit of 40% C. sodium of 124 mEq/L D. potassium of 3.1 mEq/L E. hemoglobin of 14 g/dL F. calcium of 8.5 mEq/L G. prothrombin time of 12 seconds with INR of 1
CDF
The nurse is providing care to the client who is suffering from Superficial Frostbite. Which of the following interventions would be appropriate? Select all that apply. Select one or more: a. Elevate extremity after warming. •b. Provide blankets or extra clothing. 1 c. Debride blisters and apply sterile dressing. d. Gently massage affected areas. e. Administer analgesia for pain.
CE
Pt with heat stroke Ensure Airway Fan the Patient Remove from hot environment Remove clothing Place ice in cloth or bags, position packs on their body Immersion in cold water if possible
Correct answers to pick on test all expect move pt from the scene Ensure the client has a patent airway., Pour cold water over the client's body and scalp., Encourage everyone around the client to fan the client., Remove the client's clothing
A client with fibromyalgia asks why a selective serotonin and norepinephrine reuptake inhibitor is prescribed for the health problem. Which should the nurse explain as the rationale for this medication? A.Reduce neuropathic pain B.Relax the client and promote sleep C.Decrease joint pain and swelling D.Increase levels of dopamine and serotonin
D
A nurse in a mental health clinic is planning care for a client who has new prescription for Olanzapine. Which of the following interventions should the nurse identify as the priority? Select one: a Consult a dietitian for a calorie-controlled diet plan b Recommend that the client exercise regularly. c Advise the client to take frequent sips of water d. Instruct the client to avoid driving during the initial therapy
D
A nurse is admitting a toddler who has RSV. Which following actions should the nurse make? A. Initiate droplet precautions B. Encourage time in the common room C. Place toddler in a room that has negative pressure D. Keep a stethoscope in the toddlers room
D
A nurse on a medical-surgical unit assesses a client who sustained injuries 12 hrs ago in a motor vehicle accident. The client's admission blood alcohol level was 325 mg/di and CIWA-Ar score is down to 15. Which of the following findings should indicate to the nurse that the client is experiencing withdrawal? Select one: A Somnolence B Pinpoint pupils C Blood glucose level of 350 mg/dL D Blood Pressure of 174/96 mm H
D
The nurse is caring for a 82 year old client that is receiving palliative care for an inoperable brain tumor. The client is requesting medication for pain. The nurse notes that the client received a dose of scheduled q4 hr tramadol 3 hours ago. What is the best action by the nurse? A. Contact the physician and request an increase in tramadol B. Administer the ordered 2mg lorazepam C. Give next dose of tramadol early D. Contact the physician and request a stronger analgesic
D
Which patient is at greatest risk for respiratory depression when receiving opioids for analgesia? A. Older adult patient with chronic pain related to joint immobility B. Patient with a heroin addiction and back pain C. Young female patient with advanced multiple myeloma D. Opioid-naive adolescent with an arm fracture and cystic fibrosis
D
The nurse is providing care to the client who is suffering from superficial frostbite. Which of the following interventions would be appropriate? SATA A.Elevate the extremity after warming. B Gently massage affected areas. C Provide blankets or extra clothing. D Administer analgesia for pain. E Debride blisters and apply a sterile dressing.
DE
50. Empty medication bottles and smell of alcohol, what's priority?
Get empty medicine bottles from EMT and notify provider
Loss of deep tendon reflexes on mag sulfate
Give calcium gluconate
Hospice
Good death for patients near end pf their lives
Cocaine
Hypertension Tachycardia tremor
51. Dantrolene with malignant hyperthermia, what to monitor ?
Liver function test
38. What was the mechanism of actions for Glipizide?
Lowers blood glucose levels by stimulating the release of insulin from the pancreas and increases sensitivity of insulin at receptor sites, decreases hepatic glucose production.
Antipsychotics
Primarily used to manage delusions, hallucinations
EPS
Refereed to as drug induced movement disorders
The nurse is caring for a client who is on hypothermia protocol. The family ask the nurse why they are doing this. which response is the best?
This treatment has a chance to improve neurological outcomes
Clonidine
Used to decrease anxiety attacks and "psychic" symptoms.
Heat Exhaustion:
Weak, thready pulse. Excess perspiration
Chlordiazepoxide
a Benz used to treat anxiety disorders or alcohol
SSRI
a class of drug that are typically used as antidepressants
Cheyne-Stokes
apnea breathing with rapid breathing
Paroxetine patient education, take in morning, notify provider before getting pregnant, notify about some side effects, stop if rash develops (Steven Johnson Syndrome??)
avoid ALL otc medications Answer was report fever or mental confusion, take in the morning, notify is plan to become pregnant
Epidural
bolus lactated ringers , moni
heroin and Mary j
class I
morphine and codeine
class II
oxycodone and fentanyl
class II
Benzodiazepines
class IV
second degree frostbite
clear to milky fluid filled blisters
Miosis
constriction of the pupil
3rd degree frostbite
dark fluid filled blisters
Kussmual respirations
deep rapid breathing
mydriasis
dilation of the pupil
Tetanic contractions
discontinue oxytocin
first degree frostbite
increased blood flow and edema
apathy
lack of interest
PCP Intoxication-haloperidol-primary nursing intervention
monitor vs especially bp
Heat Cramps:
muscle spasms that result from a loss of large amounts of salt and water through perspiration
The nurse is caring for a client who is undergoing the hypothermia protocol. The client begins shivering. The nurse should prepare to administer what medication?
neuromuscular blocker
fourth degree
no blood flow
pt having numbness/tinglingness in hands and feet
place in 104 degree water
bright red painless vaginal bleeding
place on bed and hook up to monitor no vaginal exam
Late d cells
place on left side
palliative care
relief of symptoms experienced by the dying client
What best describes milieu therapy?
safe and effective environment
Frostnip
superficial
Signs and symptoms of a person experiencing alcohol withdrawal- tremors, vomiting, inability to sleep (all the ones EXCEPT the vital signs options)
tremors, vomiting, inability to sleep
