4: Comp exam 2 ATI questions

ASO titer for child with suspected rheumatic fever

"This test will confirm if your child had a recent streptococcal infection" a blood test that measures anti-streptolysin O antibodies in the blood

D

A nurse is assessing a client who is on long-term omeprazole therapy. Which of the following findings should indicate to the nurse the medication is effective? A. increased appetite B. regular bowel movements C. Absence of headache D. reduced dyspepsia

A nurse is developing a plan of care for a client who has a new ileal conduit. The nurse should include that the client is at risk for which of the following?

Anxiety Disturbed body image Impaired skin integrity Infection

​A nurse is caring for a client who is admitted to the unit for self-mutilation. What type of behavioral therapy would the nurse expect to be ordered for this client?

Dialectical behavioral therapy which is a form of cognitive behavioral therapy

The client with Klebsiella in the urine is ordered the medication ciprofloxacin. Identify three (3) complications associated with this medication the client can develop with administration of this medication.

GI upset, rupture of the Achilles tendon and superinfection

A nurse is preparing to administer the MMR immunization to a client. What are two (2) contraindications for this vaccine?

Gelatin allergy Neomycin allergy Pregnancy

A nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions should the nurse take?

Keep familiar personal items at the bedside

A school nurse is performing a routine health assessment for a school-age child. Which of the following findings indicates the nurse should investigate further for pediculosis capitis?

Pruritus of the scalp

A nurse is planning a stage education session regarding biological weapons of mass destruction. Which of the following should he plan to include in the session?

Smallpox Anthrax Botulism

A nurse is caring for a client involved in a suspected bioterrorism event involved in a suspected bioterrorism event involving exposure to cutaneous anthrax. Which of the following manifestations should the nurse anticipate?

Skin lesions with pruritus

A nurse is assessing a client who has rea score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

The client needs total nursing care

A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching?

Vitamin A Vitamin B12 Vitamin C Vitamin K

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neuromuscular status of the client's affected extremity?

Color Temp Sensation

A nurse is assessing a client who has a suspected diagnosis of Gullian-Barre syndrome. Which of the following questions should the nurse ask the client?

"Have you had a recent influenza infection?"

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?

-Loosen restrictive clothing -Place a pillow under the client's head

A 52-year-old client is admitted for severe gastritis secondary to alcohol consumption. Identify labs and diagnostics the nurse will monitor.

CBC, AST, ALT, BUN, Creatinine, H, pylori and the doctor will likely order and endoscopy

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Talk the client through the tasks one step at a time

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side

RACE

rescue, alarm, contain, extinguish

What are three (3) points the nurse should teach parents of an epileptic client on post-seizure management?

​Reinforce the need for rest Reinforce adherence to medication regimen Encourage parents to provide developmental stimulation

A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include?

"Use contraception while taking this medication"

A nurse is providing staff education about smallpox as a bioterrorism threat. Which of the following statements indicates an understanding of this agent?

-"Smallpox is transmitted person to person" -"Naturally occurring smallpox has been eradicated from the world" -"Smallpox is often confused with varicella"

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement?

-Administer magnesium sulfate IV -Provide a dark, quiet environment -Ensure that calcium gluconate is readily available

A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take?

-Apply pressure to the nares -Place ice to the bridge of the client's nose -Move the client into high-Fowler's position

A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints?

-Assist the client with toiling at frequent intervals -Use an electronic position-sensitive device -Provide diversionary activities for the client -Involve the family in the client's care

A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should prepare the protocol based on which of the following information?

-Botulism can produce paralysis within 12 to 72 hr following exposure -Vomiting and diarrhea are expected findings following exposur

A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take?

-Check on the client hourly -Instruct the client in the use of the call light -Apply an ambulation alarm to the client's leg

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via nasal cannula. Which of the following should the nurse include in the teaching?

-Check the cannula position on a regular basis -Check the tops of the ears for skin breakdown -Post "no smoking" signs in a prominent location in the home

A nurse is educating community members about how to prepare for a disaster. Which of the following supplies should the nurse instruct the clients to include in a disaster preparedness kit?

-Clean clothing -Personal identification -Matches -Prescription medications

A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier?

-Client's full name -Facility-assigned identification number

A nurse is providing teaching to a client who has a new diagnosis of testicular cancer. Which of the following information should the nurse include in the teaching?

-Close male relatives are at an increased risk of developing testicular cancer -Testicular cancer typically occurs between ages 15 to 35

A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include?

-Count your pulse for 1 min each morning -Do not wear tight clothing over the insertion area

A nurse is caring for a client wh has questions concerning the various treatment options for his diagnosis of basal cell carcinoma (BCC). Which of the following treatments should the nurse include in the discussion?

-Cryosurgery -Electrosurgery -Radiation therapy -Micrographic surgery

A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan?

-Document restraint checks and client status every 2 hr -Educate the client's family about restraint use -Implement passive range-of-motion exercises

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications?

-Elevate the HOB to at least 30 -Administer pantoprazole as prescribed -Reposition the endotracheal tube to the opposite side of the mouth daily

A nurse is planning care for a client who has become increasingly anxious and confused. Which of the following actions should the nurse include to avoid the use of physical restraints?

-Ensure effective pain management -Attend to the clients needs for toileting -Assign the client to a room near the nurses' station -Orient client frequently to the environment

The nurse is assessing a client with a left-sided stroke. What clinical manifestations can the nurse anticipate?

-Expressive and receptive aphaia -Agnosia -Agraphia -Right extremity paralysis -Depression and anger -Visual changes

A nurse is caring for a client who has experienced a mild traumatic brain injury. Describe the manifestations of increased intracranial pressure the nurse should be alert fo

-Headache -Vomiting -Altered LOC -Back Pain -Papilledema

A client is diagnosed with Addisonian Crisis. List the lab values that will be affected by this disease process.

-Hyperkalemia -Increased BUN and creatinine -Decreased cortisol -Hyponatremia -Increased WBC -Hypercalcemia -Hypoglycemia

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment?

-Irrigating a client's abdominal wound -Suctioning a client's new tracheostomy tube

A hospitalized client with a sealed radioactive implant asks the nurse, "can my family visit me?" What education should the nurse provide regarding visitors?

-Limit visits to 30 minutes and have visitors maintain a six foot distance

A nurse is caring fora. client 4 hr postoperative following a kidney biopsy. Which of the following interventions should the nurse take?

-Monitor for hematuria -Check for flank pain

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect?

-Muscle distortion -Pain behind the ear -Impaired taste

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI?

-Nausea -Tachycardia -Diaphoresis

A community health nurse is providing a community education program about disaster preparedness. Which of the following should the nurse recommend that clients include in their family's disaster readiness supply kit or "go bag"?

-Pencil and paper -Whistle -Copies of insurance cards -Household bleach

What actions to take with a patient with active pulmonary tuberculosis

-Protective mask -Closed door sign -Puncture-proof sharps container -Hand hygiene

A nurse teaching the parents of a 10-month old infant about home safety. Which of the following information should the nurse include in the teaching?

-Serve the food in small, non-circular pieces -Tie plastic bags in knots before discarding hem -Fit the mattress so that it is snug against the sides of the crib

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take?

-Teach the client to use the call light -Keep the client's bed in the lowest position -Place a fall-risk ID band on the client's wrist

A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in incident/variance report?

-The date of the incident -The time the client was to receive the medication -The clients vital signs

A nurse is caring for a client who has been admitted with renal calculi. List three (3) nursing interventions necessary to manage renal calculi in this client's care.

-The nurse must strain the urine, manage pan, and increase their daily fluid intake.

a client has been diagnosed with tuberculosis and has been prescribed rifampin. What should the nurse include in teaching about this medication?

-Urine and other secretions may turn orange -Immediately report pain or swelling or joints -Report loss of appetite -This medication can interfere with oral contraceptives

Continuous bladder irrigation after prostate resection

-Use sterile technique when preparing the irrigation solution -Ensure the drainage tubing is patent and without obstruction or kinks -Notify the surgeon if the urine is bright red in appearance or has large clots

An occupational health nurse is interacting workers at an industrial facility about emergency procedures to take in the event of a traumatic amputation of a finger. Which of the following guidelines should the nurse include for preserving an amputated part for possible surgical reattachment?

-Wrap the amputated finger in dry sterile gauze -Put the amputated finger in a sealed, waterproof plastic bag. -Prevent the amputated finger from contacting water.

A nurse is admitting a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions? 1. "Has your son had a sore throat recently?" 2. "Was your son born with this cardiac defect?" 3. "Has your child had any injuries recently?" 4. "Have you given your child aspirin in the past 2 weeks?"

1. "Has your son had a sore throat recently?" Rheumatic fever typically develops 2-6 wks after an untreated or ineffectively treated strep infection Although rheumatic fever is not a CHD, it can progress to rheumatic heart disease, which involves cardiac valve damage Although nurses should screen child for injuries, it is not an essential question for this child at this time. Aspirin is associated with Reye syndrome

A nurse is caring for an 8-yr-old child who has rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission? 1. Auscultating the rate and characteristics of the child's heart sounds 2. Using a pain-rating tool to determine the severity of the joint pain 3. Identifying the degree of parental anxiety related to diagnosis 4. Assessing the client's erythematous rash

1. Auscultating the rate and characteristics of the child's heart sounds Tachycardia and cardiac murmur indicate cardiac involvement, which can result in serious, life-threatening, and life-long complications

A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.) 1. Check peripheral pulses in the affected extremity. 2. Place the client in high Fowler's position. 3. Measure the client's vital signs every 4 hr. 4. Keep the client's hip and leg extended. 5. Have the client remain in bed up to 6 hr

1. Check peripheral pulses in the affected extremity. 4. Keep the client's hip and leg extended. 5. Have the client remain in bed up to 6 hr Pt should remain flat or with HOB < 30 for 2-6 hrs post procedure Measure vitals frequently, w/ each check of the affected extremity

A nurse is conducting a primary surgery of a client who has sustained life-threading injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take.

1. Open the airway 2. Determine effectiveness of ventilator efforts 3. Establish IV access 4. Perform a Glasgow-Coma Scale assessment 5. Remove clothing

A nurse is assisting the provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution?

1. Perform hand hygiene 2. Remove the bottle cap 3. Place the bottle cap face-up on a clean surface 4. Pick up the bottle with the label facing toward the palm 5. Pour 1 to 2 mL into a receptacle 6. Pour the solution onto the gauze.

A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow.

1. Perform hand hygiene 2. Place package on work surface 3. Open outermost flap away from self 4. Open side flap, pulling to the side 5. Open innermost flap toward self 6. Use inner surface of package as sterile field

Steps for cleaning/irrigating wound

1. Place a waterproof pad under the client's leg 2. Don clean gloves and remove the client's dressing 3. Clean the wound using a circular motion 4. Open a sterile dressing set and supplies 5. Irrigate the wound until the solution becomes clear

Steps of pouring sterile saline ?

1. Remove the bottle cap 2. Place the bottle cap face up on a clean surface 3. Pick up the bottle with the label facing his palm 4. Pour 1 to 2 mL into a receptacle 5. Pour the solution onto the gauze

A nurse is caring for a client who reports a new onset of chest pressure severe epigastric distress. The physician prescribes monitoring of creatinine kinase (CK) isoenzymes. When should the nurse anticipate the CK isoenzymes will begin to rise if the client has had a myocardial infarction (MI)? (Select all that apply)

2 hr and 3 hr

A nurse is teaching a parent of an infant who has HF about meeting the infant's nutritional needs. Which of the following statements indicates understanding of teaching? 1. "I will feed my baby on a schedule every 4 hrs" 2. "I will add Polycose to each of my baby's bottles" 3. "I will allow my baby to take as much time as needed to finish bottle" 4. "I will limit my babies crying to 15 mins prior to each feeding:

2. "I will add Polycose to each of my baby's bottles" Feed infant w/ HF every 3 hrs

A nurse is preparing to measure an infant's VSs. The nurse should use which site to assess a HR? 1. Carotid artery 2. Apex of the heart 3. Brachial artery 4. Radial artery

2. Apex of the heart

A nurse is caring for a client who has heart failure and is receiving iv furosemide. The nurse should monitor the client for which of the following electrolyte imbalances? 1. Hypernatremia 2. Hyperuricemia 3. Hypercalcemia 4. Hyperchloremia

2. Hyperuricemia

A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus (PDA). Which of the following findings should the nurse expect? 1. Cyanosis w/ crying 2. Systolic murmur 2. Weak pulses 4. Chronic hypoxemia

2. Systolic murmur PDA = failure of the artery connecting the aorta & pulmonary artery to close after birth, causing left-to-right shunt. Bounding pulses, wide pulse pressure

C

A charge nurse is teaching a group of nurses about clients who report using garlic, ginger, and ginkgo biloba. The charge nurse should identify which of the following as an adverse effect of the supplements? A. decreased effects of anti-rejection medication B. decreased effects of anti-anxiety medication C. Increase effects of oral anticoagulants D. increased effects of antidepressant medication

C

A nurse at a family practice clinic received a call from a client who is prescribed oral contraceptives but forgot to take one dose. The client reports she is in the first week of the 28 day cycle pack. Which of the following instruction should the nurse provide? A. Do not have vaginal intercourse until after your next period B. Stop taking the pills and switch to a different contraceptive method C. Take the missed dose now and then continue the medication as ordered D. Take a home pregnancy test

C

A nurse is admitting a client who states he takes ginkgo biloba every day to improve his memory. The nurse should identify a potential interaction with which of the following medication the client is taking? A. Ranitidine B. Levothyroxine C. Warfarin D. Loratadine

D

A nurse is assessing a client after administering IV vancomycin. Which of the following findings is the nurses priority to report to the provider? A. localized redness of the catheter insertion site B. Client report of a headache C. Client report of tinnitus D. Audible inspiratory stridor

C

A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and tachycardia, which of the following actions should the nurse take? A. document the client experienced an anaphylactic reaction to the medication. B. change the IV infusion site C. Decrease the infusion rate on the IV D. apply cold compresses to the neck area.

A

A nurse is assessing a client who is taking levothyroxine. The nurse should recognize that which of the following findings is a manifestation of levothyroxine overdose? A. Insomnia B. Constipation C. Drowsiness D. Hypoactive deep-tendon reflexes

A

A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider? A. Amoxicillin-clavulanate B. Gentamicin C. Erythromycin D. Amphotericin B

C

A nurse is caring for a client who has a bacterial infection and is receiving gentamicin. Which of the following action should the nurse take to minimize the risk of an adverse effect of the medication? A. limit the clients fluid intake B. Instruct the client to report agitation C. Monitor the serum medication levels D. Administer the medicine with food

B

A nurse is caring for a client who has type one diabetes mellitus. The nurse misread the clients morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the clients breakfast. Which of the following actions is the nurses priority A. give the client 15 to 20 g of carbohydrates B. Monitor the client for hypoglycemia C. Complete an incident report D. Notify the nurse manager

C

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. The nurse should plan to administer the clients PRN bethanecol with the client reports which of the following manifestations? A. Bladder spasms B. severe pain C. Inability to void D. frequent episodes of painful urination

B

A nurse is caring for a client who is taking sucralfate. Which of the following outcomes indicates a therapeutic effect of the medication? A. Alleviate Heliobacter pylori B. Relief of GI pain C. Prevention of opportunistic infections D. Improvement of impaired vision.

B

A nurse is caring for a client who reports taking bisacodyl to promote a daily bowel movement. Which of the following assessment question should be the nurses priority? A. What do your bowel movements look like? B. How long have you been taking the bisacodyl? C. Do you take the bisacodyl with a glass of milk? D. how often do you have a bowel movement?

C

A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times? A. 0720 B. 0730 C. 0745 D. 0815

A

A nurse is caring for a school age child who has a systemic disorder and is receiving antibiotics, immunosuppressants, and corticosteroids. Both of the child's parents have a smoking history. The child reports soreness in his mouth and refuses to eat. Inspection of his mouth reveals a white, milky plaque that does not come off with rubbing. The nurse should suspect which of the following conditions? A. candidiasis B. dermatitis C. Herpes simplex D. squamous cell carcinoma

B

A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make? A. irregular bowel movements are an indication of poor intestinal health. B. excessive laxative use may cause an electrolyte imbalance C. Chronic use of laxatives can lead to a tear in the rectal mucosa D. decrease your intake of foods high in fiber

C

A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis about the use of anti-tubercular medications. Which of the following information should the nurse include in the teaching? A. medication will need to be taken for the rest of the clients life, even if the client feels better. B. medication's will need to be taken until the Mantoux test is negative C. A typical course of treatment involves 6 to 9 months of consistent medication used D. the clients family will also need to take medications to prevent infection

C

A nurse is observing an LPN preparing to administer a 2 mL penicillin G injection to a client. Which of the following actions by the LPN requires intervention by the nurse? A. the LPN determines if the client has a history of allergies to cephalosporin B. the LPN selects a 21 gauge, 1 & 1/2 inch needle C. The LPN plans to inject a needle to inches below the acromion process D. the LPN states that she will aspirate for blood prior to inject in the medication

A

A nurse is preparing a presentation about ginkgo biloba to a group of clients which of the following information should the nurse include in the teaching? A. ginkgo biloba can help reduce feelings of restlessness. B. Ginkgo biloba but may enhance wound healing. C. Ginkgo biloba can improve senile dementia D. ginkgo biloba relieves pain and inflammation of the mouth

B

A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes mellitus. When mixing the two types of insulin, which of the following action should the nurse take first? A. Inject 10 units of air into the regular insulin vial B. Inject 20 units of air into the NPH insulin vial C. Withdraw 10 units of insulin from the regular insulin vial D. Replace the needle for withdrawal with a safety needle

A

A nurse is preparing to administer cephalexin oral suspension to an older adult who has difficulty swallowing pills. Which of the following action should the nurse take? A. check the client for a penicillin allergy B. Monitor the client for constipation C. Store the medication at room temperature D. avoid shaking the medication before administering

A

A nurse is providing teaching to a client who has a skin infection and a new prescription for gentamicin topical cream. Which of the following instruction should the nurse provide? A. Wash the affected area was soap and water before applying cream B. increase intake of fluids while using this medication C. This medication might cause temporary blurred vision D. Apply the cream to large areas around the infection

D

A nurse is providing teaching to a client who has gastroesophageal reflux disease and a new prescription for omeprazole. Which of the following instruction should the nurse provide? A. Take NSAIDs if headaches occur B. Decrease intake of Vitamin D C. Expect muscle cramps for several weeks. D. Report diarrhea to the provider

B

A nurse is providing teaching to a client who has peptic ulcer disease and a new prescription for sucralfate tablets which of the following information should the nurse provide? A. An antacid may be taken with the medication if indigestion occurs. B. Take sucralfate one hour before meals C. Take the tablets whole D. Store sucralfate in the refrigerator

A

A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching? A. It might take up to three days for the medication to work. B. I will take the medication for diarrhea C. I should drink 4 ounces of water when I take the medication D. I can take this medication along with mineral oil

D

A nurse is reviewing contraception options for four clients the nurse should identify that which of the following clients has a contraindication for receiving oral contraceptives? A. A 26-year-old client who has migraine headaches at the start of each menstrual cycle B. a 28 year old client who has a history of pelvic inflammatory disease C. A 32-year-old client who has benign breast disease D. A 38-year-old client who reports smoking one pack of cigarettes every day

B

A nurse is teaching a client about the uses of aloe vera. Which of the following information should the nurse include in the teaching? A. aloe vera can cause drowsiness when taken with an anti-depressant B. aloe vera can act as a laxative C. Aloe vera can help decrease moderate blood pressure D. aloe vera can be taken to prevent migraine headaches

D

A nurse is teaching a client how to draw up regular insulin and NPH insulin into the same syringe. Which of the following instructions should the nurse include? A. Draw up the NPH insulin into the syringe first B. Inject air into the regular insulin first C. Shake the NPH insulin until it is well mixed D. Discard regular insulin that appears cloudy

D

A nurse is teaching a client who has a new prescription for NPH insulin. Which of the following instruction should the nurse include? A. Discard the medication if it is cloudy B. Briskly shake the medication before filling the syringe C. Take this medication 15 minutes before meals D. Eat a snack eight hours after taking this medication

C

A nurse is teaching a client who has a new prescription for amoxicillin-clavulanate to treat pharyngitis. Which of the following statements by the client indicates an understanding of the teaching? A. I will take this medication until my sore throat goes away B. I should take this medication on an empty stomach between meals C. I will stop taking this medication if I develop itching D. I will double my dose, if I miss one.

B

A nurse is teaching a client who has a new prescription for docusate. Which of the following information should the nurse include in the teaching? A. Do not take this medication before bedtime B. take the medication with a full glass of water C. Expect abdominal pain with this medication D. Take this medication on an empty stomach

C

A nurse is teaching a client who has a new prescription for esomeprazole to manage his GERD. Which of the following statements by the client indicates an understanding of the teaching? A. I won't pass gas as often now that I'm taking his medication. B. I will take this medication each morning with my breakfast. C. I have an increased risk of getting pneumonia while taking this medication. D. I will need to take a daily stool softener while taking this medication.

1, 6

A nurse is teaching a client who has a new prescription for ranitidine to treat peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching select all that apply. 1. I can take this medication with or without food 2. I will take this medication in the morning 3. I should expect my stools to turn black 4. I will take this medication with an antacid 5. I will take this medication when I need it for pain 6. I will eat five small meals each day

A

A nurse is teaching a client who has a new prescription for regular insulin and NPH insulin. Which of the following instruction should the nurse include in the teaching? A. Keep the open vial of insulin at room temperature B. Inject insulin into a large muscle C. Aspirate the medication prior to administration D. Administer the insulin and two separate injections

D

A nurse is teaching a client who has a new prescription for sucralfate to treat a gastric ulcer. Which of the following statements by the client indicates an understanding of the teaching? A. I will take this medication as needed to reduce pain B. I will reduce my fluid intake with this medication C. I will take this medication with an antacid D. I will take this medication one hour before meals and at bedtime.

B

A nurse is teaching a client who plans to take St. Johns wort to treat her depression. Which of the following information should the nurse include in the teaching? A. You should avoid driving by and taking St. John's wort because it can cause drowsiness. B. You may experience vivid dreams while taking St. John's wort. C. St. Johns wort may increase your risk of developing oxalate kidney stones. D. St. Johns wort may cause gastrointestinal irritation.

A

A nurse is teaching a group of clients about St. Johns wort. Which of the following information should the nurse include in the teaching? A. St. Johns wort can be used to treat mild depression B. St. Johns wort increases estrogen levels in the body C. St. Johns wort can reduce the effectiveness of oral contraceptives D. St. Johns wort can lower prostate specific antigen levels

B

A nurse is teaching about levothyroxine with a client who has primary hypothyroidism. Which of the following statements should the nurse use when teaching the client? A. take this medication until your symptoms are gone and then discontinue B. Tremors, nervousness, and insomnia may indicate your dose is too high. C. Symptoms improve immediately after starting the medication D. The medication decreases the overproduction of the thyroid hormone thyroxine

D

A nurse manager is providing an educational program an antibiotic sensitivity to bacterial infections. The nurse include in the teaching that vancomycin is indicated for which of the following infections? A. Pseudomonas aeruginosa B. Klebsiella C. Candida D. Methicillin-resistant Staphylococcus aureus

D

A nurse working on a medical unit is completing the admission of a client who reports severe allergy to penicillin. Which of the following actions should the nurse take? A. have the client purchased a medication alert bracelet to wear in the hospital. B. notify dietary services to adjust the clients diet. C. Remove all objects that contain latex from the clients room. D. verify the clients medication prescriptions do not include cephalosporin.

A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?

A private room

A nurse is caring for a client who has dementia. When performing a mental status examination the nurse should include which of the following data?

Ability to perform calculations Recall ability Long-term memory level of orientation

What type of respiratory failure is caused by Guillain-Barre' syndrome?

Acute respiratory failure

​A 10-year-old presents in status asthmaticus complaining of chest tightness and has audible wheezing. Name three (3) priority actions and steps the nurse should take.

Administer beta-agonists, corticosteroids and theophylline Fluid replacement Place on 02

A client has a new prescription for an albuterol inhaler and a beclomethasone inhaler. What instructions should the nurse include concerning use of these inhalers

Administer the albuterol inhaler prior to the beclomethasone inhaler

A nurse in the emergency department is preparing to care for a client who received multiple injuries during a fight. The nurse should plan to base his primary survey on which of the following?

Airway Cervical spine Disability Exposure

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication?

Ask the client to take a few sips of water

A nurse is caring for a client with placenta previa. What interventions should be completed for this client?

Assess bleeding and leakage Assess fundal height Refrain from vaginal exams Admin Iv fluids, medications and blood products. Betamethasone may be ordered to promote fetal lung growth Have 02 equipment at bedside

A nurse in the emergency room is assessing a client who was brought in following seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Assess the cranial nerves

​The nurse is performing discharge teaching to the caregivers for a child who had a cardiac catheterization. What are three (3) teaching points the nurse should include?

Avoid baths for a few days and showers for 24 hours Drink fluids Report fevers of any tingling in legs

A nurse is obtaining vital signs from 2-month-old infant. The infants heart rate is 190/min and his temperature is 40 C. The father asks the nurse why the babies heart is beating so fast. Which response by the nurse is appropriate? A. "This is within expected range for your baby." B. "The fever is causing an increase in your baby's heart rate." C. "As your baby begins to fall asleep, his heart rate will decrease." D. "Your baby's heart is beating fast in an attempt to cool down his body."

B. "The fever is causing an increase in your baby's heart rate."

A nurse is completing discharge teaching for a client receiving disulfiram as a deterrent to drinking. What information will the nurse provide to the client regarding how it works and precautions to take?

Blocks the breakdown of alcohol in the body, which leads to a toxic alcohol-related compound that can cause people who drink alcohol while taking this medication to become very sick. Side effects associated with this are metallic taste in mouth, , headache, drowsiness and tiredness.

Digoxin toxicity

Blurred and yellow vision Weight loss, diarrhea, bradycardia, dysrhythmias, N/V, anorexia, dizziness, confusion, weakness

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understanding the teaching when he identifies which of the following as manifestations of hypoglycemia?

Blurred vision Tachycardia Most, clams skin

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia

Cardiac cath

Bruising and a small hematoma at the incision site are expected Dressing should be left in place for at least 1 day Parent should offer acetaminophen or ibuprofen not aspirin Avoid tub baths for at least 3 days

​Identify three (3) clinical manifestations of hydrocephalus in an infant client

Bulging fontanel Poor feeding Rapid increase in head circumference

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Conjunctivae

A nurse is caring for a client who has a new prescription for raloxifene. What are contraindications for this medication that the nurse should discuss with the client?

Contraindications are pregnancy, history of DVT and must stop three days prior to menstruation

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?

Cover the area with a sterile dressing moistened with 0.9% sodium chloride irrigation

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. the nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?

Cover the wound with a moist sterile gauze dressing

A nurse is caring for a client who has refused his morning medications. How should the nurse respond to the client?

Determine why they don't want to take it and if they understand what the medication if for and the potential side effects of not taking the medication.

A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis?

Developing a respiratory infection

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Dispose of the dressing in a biohazardous waste container

adverse effects of amitriptyline

Drowsiness; Dry mouth; Blurred vision; Constipation; Urinary retention; Dizziness; Delayed orgasm and low sex drive, particularly in men; Increased heart rate; Disorientation or confusion; Low blood pressure, which can cause lightheadedness; Increased appetite; Weight gain; Fatigue; Headache; Sensitivity to sunlight; Nausea; Seizures (particularly with maprotiline)Some cyclic antidepressants are more likely to cause particular side effects. For example, desipramine and protriptyline are more likely to make you sleepy than do other cyclic antidepressants. Amitriptyline and doxepin are more likely to cause weight gain than do other cyclic antidepressants. Choosing one particular cyclic antidepressant over another may help you avoid particular side effects.

A nurse is administering albumin to a client. What are three (3) clinical manifestations of circulatory overload?​

Dyspnea, orthopnea, increase in BP, peripheral and pulmonary edema and wheezing.

​The nurse is developing a teaching plan for the upcoming discharge of a child who has a resolving sickle cell crisis. While developing the plan the nurse knows it is imperative to include what information?

Educate the child and family about the importance of consuming adequate nutrition and promoting rest. Teach them about genetic counseling. Educate them to keep the immunizations up-to-date. Encourage the child to wear medical identification tags or wristband. Teach parents and child to promote good hand hygiene and avoid people who have virus/infection/cold.

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?

Evaluate the client's neurological status

A nurse is caring for a client who has a new prescription for alosetron. What are the expected therapeutic effects of this medication?

Expected side effects are increased firmness in stool, decrease in urgency and decreased frequency of defecation.

A nurse is assessing for strabismus in a 7-year-old client. Identify three (3) clinical findings noted with strabismus.

Eyes that appear crossed or an eye that seems to wander. Uncoordinated eye movements. Asymmetric corneal light reflex

A couple is being evaluated for infertility after attempting to conceive naturally for 2 years. What are three (3) risk factors for males and three (3) risk factors for females that can affect fertility?​

Female: Age greater than 35 years old, past hx of spontaneous abortion, more than 1 year of coitus without contraceptives Male: Hx of STI, substance abuse, exposure to hazardous teratogenic

The nurse is providing education to a client with phenylketonuria who is planning her pregnancy. What foods should the nurse teach the client to consume?

Foods low in phenylalanine Foods such as fish, poultry, meat, eggs and dairy products.

A nurse is wearing person protective equipment and is preparing to leave a client's room after providing care. After untying the ties at the waist of the gown, which of the following actions should the nurse take?

Gloves Eyewear Gown Mask

Order of removing PPE for pt with MRSA

Gloves Eyewear Gown Mask Perform hand hygiene

A nurse is preparing to exit the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room.

Gloves Goggles Gown Mask Perform hand hygiene

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

Grilled salmon

A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution?

Hand hygiene Remove bottle cap Place cap on a clean surface Palm label against the hand Pour 1 - 2 mL of solution into a receptacle Pour solution onto sterile gauze

Bipolar disorder is primarily managed with mood-stabilizing medications, such as lithium carbonate. List three (3) important teaching points to provide to the client regarding the possible adverse effects of lithium.​

Hand tremor, increased thirst and increased urination

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2 degrees celsius, Which of the following neurologic disorders should the nurse suspect?

Hemorrhagic stroke

What are risk factors for iron deficiency anemia in toddlers? Name three (3) dietary sources of iron.

High intake of cows milk before 1 Breastfeeding beyond six months-not introducing solids Vegetarian diet

What are two (2) contraindications for the administration of terbutaline during labor?

History of gestational DM, cardiac disease, preeclampsia, gestational HTN Discontinue if client cannot tolerate adverse effects

​A client receiving the chemotherapeutic agent, leuprolide for treatment of prostate cancer. What is one (1) important point to discuss with the client to prevent musculoskeletal complication

Increase calcium and vitamin D intake and increase bone mass with weight-bearing exercises

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Increase fluid intake

Coarctation of the aorta

Increased BP in the arms w/ decreased BP in legs

A nurse is assessing a client who as fluid overload. Which of the following findings should the nurse expect?

Increased heart rate Increased blood pressure Increased respiratory rate

Withhold digoxin if pulse is less than ______ /min?

Infant: 90 Child: 70 Adult: 60

​A client with hypokalemia is ordered potassium chloride. Identify three (3) points to teach the client about prior to the first dose.

Instruct client to avoid salt substitutes, explain the purpose of the medication and correct administration.

A 14-year old client has been prescribed risperidone for autism spectrum disorder. What should the nurse instruct the parent of the client on how to administer the medication

It can be taken with or without food and at the same time daily

A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client?

Levdopa/carbidopa

McBurney's point

Lower right abdomen

What is the priority action for a client experiencing a seizure?

Lower the patient to floor or bed Protect head Remove any nearby furniture Provide privacy Lay patient on their side with neck flexed Loosen clothing Notify HCP

List the pertinent information that should be in a transfer repor

Medical diagnosis, demographic information, overview of health status, alterations that could cause immediate concern, last set of vital signs, medication (including PRN), diet, activity, any specific equipment they may require, advanced directive and families involvement in care

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?

Muscle contractions become progressively stronger

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect?

Muscle distortion Pain behind the ear Impaired taste

​The 24-year-old client inquires about use of the diaphragm for birth control. What five (5) instructions would be provided by the nurse to explain use of the diaphragm?

Must be fitted by provider Replace every 2 years Apply spermicidal jelly on the cervical side Diaphragm can be in place up to 6 hr before intercourse but cannot stay in longer than 24hrs Empty the bladder prior to insertion Diaphragm can be washed with soap and water

A nurse is a providers office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis?

Night sweats Low-grade fever Blood in the sputum

A school nurse is teaching a group of nurses newly hired to work in the school system about pediculosis capitis (head lice). Which of the following information is appropriate to include in the teaching?

Nits that are shed into the environment are capable of hatching for up to 10 days.

What are the expected clinical manifestation associated with a herniated lumbar disk?

Numbness and weakness in the foot, leg and/or toes. Foot drop can also occur.

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care?

Obtain IV access

​A 37-year-old pregnant client in her 3rd trimester reveals she has incontinence. What are three (3) points to discuss with the client to help her manager her incontinence?

Perform Kegel exercises Schedule bathroom breaks Monitor weight gain

A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow.

Perform hand hygiene Place package on work surface Open outermost flap away from self Open side flap, pulling to the side Open innermost flap toward self Use inner surface of package as sterile field.

A nurse is preparing to perform wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation.

Place a waterproof pad on the bed under the client's leg The nurse should apply clean gloves and remove old dressing Clean the puncture site in a circular motion Open sterile dressing set and supplies Irrigate the wound until the solution becomes clear

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

Place the child in isolation

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Place the client on his side

A nurse is instructing a client who has a new prescription for nitroglycerin transdermal patch about the administration. What instructions should the nurse include?

Place the patch on a hairless area of skin (chest, back, or abdomen) and rotate sites. Remove old patch, wash skin with soap and water, and dry thoroughly before applying new patch. Remove the patch at night to reduce the risk of developing tolerance to nitroglycerin. Be medication-free between 10 and 12 hrs daily.

A client is receiving home O2. What patient teaching should the nurse provide

Post a no smoking sign or a 02 in use sign Know where the closest fire extinguisher is Have client wear cotton clothing Ensure all electric machinery is in working order and grounded Do not use flammable material

What is an indication for taking tamoxifen

Prevent breast cancer in women with high risk of developing it

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

Protein

A client who has chronic kidney disease (CKD) should restrict what nutrients?

Protein Phosphorus Sodium

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Provide client supervision

A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following actions should the nurse take?

Provide mittens for the client to wear at night

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include?

Relief of urinary retention, measurement of residual, an open perineal wound

Nurse should follow when pouring solution....

Remove the bottle cap Place bottle cap face up on a clean surface Pick up the bottle with the label facing palm Pour 1 - 2 mL of solution into a receptacle Pour solution onto the gauze

​The nurse is assessing the fetus during labor and notes recurrent variable decelerations with minimal baseline variability. What is the priority nursing intervention for recurrent variable decelerations with minimal baseline variability?

Reposition pt from side to side or knee to chest DC oxytocin Admin 02 at 8-10L via nonrebreather Preform vaginal exam Assist with an amnioinfusion if prescribed

A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make?

Respite care

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure. Which of the following assessment findings by the nurse supports this suspicion?

Restlessness

A pediatric client was diagnosed with Reye Syndrome. Which of the following statements by the parent indicate understanding of this diagnosis? (select all that apply) "Reye Syndrome typically follows a viral illness.""There is no association between using aspirin for fevers and development of Reye Syndrome.""My son's liver function may return to full function.""His symptoms of irritability, confusion, and lethargy are expected with this diagnosis.""There is no known treatment for Reye Syndrome and its symptoms

Reyes syndrome typically follows a viral illness, most commonly the flu or chickenpox. Signs are irritability, confusion and lethargy It caught early liver function may return to full function

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority?

Schedule a follow-up visit by a home health nurse for dressing changes

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing?

Serum albumin 3.2 g/dL

A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose?

Shake the container vigorously

The nurse is assessing paternal adaptation and bonding with a newborn infant. What are three (3) ways the nurse can facilitate bonding between the newborn and father?

Skin-to-skin contact, holding the infant and eye contact Talking, singing and reading to the patient

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Take the client to the bathroom every 2 hrs

A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse is appropriate?

Tell me what you like to cook for dinner

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advanced directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed concent?

The client

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to

What is the role of the nurse when a client refuses treatment?

The nurse must be understanding and ask the patient what they believe the procedure entails. The nurse may also teach about the patient's current condition and educate on how the treatment will help the patient. Finally notify their health care provider.

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

The partner has lost 20 lbs in the past 2 months

A nurse has provided education to a client with hypothyroidism who has a new prescription for levothyroxine. What statements by the client would indicate they understand the instructions

The patient must understand that they will be on this medication for the rest of their lives. This medication must be taken on an empty stomach and do not discontinue use without talking to your HCP.

A client is admitted for suspected meningitis. What priority interventions will be most important for the nurse to initiate

The priority intervention is to limit environmental stimulus

A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching?

The signs of dementia are progressive and irreversible

CBG order

To check a glucose level, place the steps in the correct order: Check expiration date on the test strips. Perform a quality control test. Perform hand hygiene. Cleanse puncture site. Apply blood sample onto test strip. Document results.

​The nurse is caring for a child with epiglottitis. What are three (3) expected findings during the assessment of this client? List three (3) nursing interventions the nurse will be expected to carry out

Tongue protruding, inspiratory stridor, anxiety with respiratory distress, sore throat, highfever, restlessness, sit with chin pointing out, and mouth open. The nurse should not examine throat or use tongue blade. Use oxygen and high humidity, maintain hydration, and maintain upright position. Use postural drainage and CPT.

A nurse is caring for a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse plan to apply?

Transparent dressing

​What are the guidelines that nurses should follow when considering whether or not a client requires restraints?

Use a restraint when there is no other option and use the least restrictive restraint first.

A nurse is planning to care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Use a transfer device to lift the client up in bed.

​The nurse is teaching a group of parents about infant car seat safety. What are two (2) discharge teaching points the nurse should include in the parent's discharge plan on car seat safety?

Use an approved rear-facing car seat in the back seat Keep in rear-facing car seat until age 2 or until pt reached max height and weight for that seat

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client?

Water heater temp Throw rugs

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Weakness