Archer Tutor 12/20
The primary healthcare provider (PHCP) prescribes a regular insulin infusion. The prescription is for 4.5 units/hr. The label on the medication reads 250 mL of 0.9% saline containing 100 units of regular insulin. How many mL/hr should the client receive? Fill in the blank. Round your answer to the nearest tenth
11.3 mL/hr
The primary healthcare provider (PHCP) prescribes 2350 mL of 0.9% saline to a client with severe hypovolemia. The PHCP prescribes the infusion over five hours. How many mL/hr will deliver the prescribed dose? Fill in the blank.
470 mL/hr
The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect? Select all that apply. A. Unilateral frontotemporal pain B. Drowsiness C. Phonophobia D. Shuffling gait E. Dysphagia F. Vomiting
A, B, C, F - Unilateral frontotemporal pain that may be described as throbbing or dull - Sensitivity to light (photophobia) and sound (phonophobia) - Nausea and/or vomiting - Altered mentation (drowsiness) - Dizziness, numbness, and tingling sensations
The nurse is assessing a client with Lyme disease. Which of the following would be an expected finding? SATA A. Lymphadenopathy B. Fatigue C. Petechial rash D. Arthralgias E. Hemoptysis
A, B, D Classic features of Lyme disease include erythema migrans which is a bullseye type appearing rash. Additional features of Lyme disease include myalgias, arthralgias, fatigue, lymphadenopathy, and conjunctivitis.
The nurse is caring for a client who reports a sexual assault. Which actions should the nurse take? Select all that apply. A. Interview the client in a private room B. Refer the client to support groups C. Allow the client to be alone to promote problem-solving D. Record verbatim statements in the medical record E. Repeat questions previously answered
A, B, D When caring for a client who has been sexually assaulted, the nurse must maintain a private environment to allow for the client to be forthcoming with their answers. Support groups are quite influential in the recovery process, and it would be wise for the nurse to provide these at discharge.
Which of the following patients would be the best candidates for total parenteral nutrition (TPN)? Select all that apply. A. A patient with inflammatory bowel disease who has intractable diarrhea. B. A patient with celiac disease who is not absorbing nutrients. C. A patient who is underweight and needs short-term nutritional support. D. A patient who is comatose and needs long-term nutritional support. E. A patient who has anorexia and refuses to take foods via the oral route. F. A patient with burns who has not been able to eat adequately for 6 days.
A, B, F Examples include motility disorders, intractable diarrhea (Choice A), impaired absorption of nutrients from the gastrointestinal tract (Choice B), and when oral intake has been inadequate for a period over seven days. TPN promotes tissue healing and is an excellent choice for a patient with burns who has an improper diet. Please note that oral intake is the best feeding method; the second best method is via the enteral route. Total parenteral nutrition (TPN) is indicated only in specific cases.
You are educating a patient newly diagnosed with hypertension about sodium and its role in blood pressure. Which of the following statements about sodium are true? Select all that apply. A. Sodium cannot be completely eliminated from the diet. B. There is no sodium in fresh fruits and vegetables. C. Canned vegetables should be avoided. D. The body needs some sodium as it plays an important role in water balance.
A, C, D There is a small amount of sodium in fresh fruits and vegetables, but there are still a good choices for a patient newly diagnosed with HTN
The nurse and two unlicensed assistive personnel (UAP) are preparing to reposition a client who requires log rolling. Which actions would be appropriate? SATA A. Place a small pillow between the client's knees. B. Places the client's arms at their side. C. Fanfold a drawsheet along the backside of the client. D. Instruct the client to laterally flex the neck during the turn. E. Roll the client as one unit in a smooth, continuous motion.
A, C, E It is appropriate for a client who is to be log rolled to have a pillow placed between the client's knees to prevent tension on the spinal column and adduction of the hip. Fanning out a draw sheet under the client enables staff to have strong handles to grip without slipping. The purpose of log rolling a client is to move the client in one smooth, continuous motion to prevent twisting of the spinal column.
You are assessing a 16-year-old female with anorexia nervosa. Which of the following symptoms and signs would you expect to find? Select all that apply. A. Lanugo B. Heavy menstrual periods C. Hypertension D. Hypothermia
A, D
You are providing discharge teaching for a 3-year-old patient with CHF. She is going home on digoxin. Which instructions are essential to teaching her parents regarding the administration of this medication? SATA A. Administer digoxin one hour before or two hours after meals. B. Mix the medication with milk or applesauce to ensure she drinks it all. C. If the child vomits after administering a dose then repeat the dose. D. Call the doctor if the child starts eating poorly and vomiting frequently.
A, D
Of the following, which conditions would the nurse recognize as potential sources of neuropathic pain? SATA A. Spinal tumor B. Arthritic joint C. Muscle strain D. Shingles E. Kidney stones
A, D Neuropathic pain describes constant inflammation or irritation of nerve cells that causes pain sensation due to oversensitive nerve cells and a decrease in opioid receptors. Examples of neuropathic pain sources include CNS lesions, stroke, tumor, multiple sclerosis, sciatica, shingles, and phantom limb pain.
The nurse is administering prescribed furosemide to a client. Which manifestations would be concerning for fluid volume deficit? Select all that apply. A. Tachycardia B. Bradypnea C. Weight gain D. Decreased urine output E. Tenting of the skin
A, D, E If the client is tachypneic, the heart is beating faster to increase the cardiac output in a low volume setting - hence, the fluid volume deficit. They have a decreased circulating blood volume. This leads to a decreased renal blood flow, causing a reduced urine output. Tenting of the skin can occur due to a lack of fluid in the tissues and is a sign of fluid volume deficit.
A nurse on the surgical floor is caring for a patient who is three days post-splenectomy. During 0700 vital signs, the CNA obtains a 100.2-degree temperature but forgets to tell the nurse about this finding. At 1500, the nurse takes the patient's temperature, and it is 101.8 degrees. After documenting the findings, the nurse should do which of the following? SATA A. Administer amoxicillin per the standing order B. Call the physician immediately C. Palpate the patient's right upper quadrant D. Administer acetaminophen E. Place the patient in the Trendelenburg position
A,B,D After splenectomy, the patient is at high risk for developing OPSI (overwhelming post-splenectomy infection) and the nurse should recognize signs of an infection early on. Administering antibiotics and antipyretics for a fever is crucial to prevent the disease from worsening. The doctor should be called immediately because further treatment may be necessary.
The nurse is teaching a group of students about renal disorders. Which statement, if made by the student, requires follow-up? Select all that apply. A. "Pyelonephritis causes a client to have massive amounts of proteinuria." B. "Acute kidney injury may be caused by nephrotoxic medications." C. "Bacterial cystitis is diagnosed using a 24-hour urine collection." D. "Polycystic kidney disease may cause hematuria after a cyst rupture." E. "Diabetic nephropathy is prevented by increasing the hemoglobin A1C."
A,C,E Acute pyelonephritis is a consequence of untreated cystitis. Massive amounts of proteinuria are a classic manifestation associated with nephrotic syndrome. urine analysis (UA), would be evaluated to determine if the client has cystitis. Diabetic. The higher the A1C equates to more complications such as diabetic nephropathy.
You are working in a community clinic. You are giving instructions to a 72-year-old man who was diagnosed today with early bilateral senile cataracts. You know that the man understood your instructions when he says: A. "I may have to quit driving until I get the cataracts treated." B. "I am going to miss being able to read the morning newspaper." C. "My wife will have to pick out my clothes since I won't be able to see the colors." D. "I will have to be careful since my eyes won't move together."
A. "I may have to quit driving until I get the cataracts treated." During the early stages of this condition, diminishing distance vision is the highest risk for older adults. The nurse must caution the patient that the ability to see signs when driving will present a significant risk.
You are caring for a client at the end of life who is terminally ill, confused, and no longer able to give informed consent. The doctor has spoken to the spouse about the need for a feeding tube because the client is malnourished and is failing to thrive. The spouse, who is the client's healthcare surrogate, states that she wants the tube feedings to begin as soon as possible so that the spouse will "not die of starvation"; however, the client's advance directive, which was written five years ago, states that the client does not want a feeding tube or any other life-saving measures. What should you say to the client's spouse about the feeding tube? A. "I understand your feelings and beliefs about the feeding tube, but your spouse has chosen not to have a feeding tube in his advance directive." B. "I agree that starvation is a bad way to die. I will contact the doctor and let the doctor know that you have agreed to place the feeding tube." C. "You cannot make that decision for your husband even though the doctor will probably give your husband the feeding tube." D. "Feeding tubes are not recommended for clients at the end of life who are affected with malnutrition and are failing to thrive."
A. "I understand your feelings and beliefs about the feeding tube, but your spouse has chosen not to have a feeding tube in his advance directive." You would respond to the client's spouse with, "I understand your feelings and beliefs about the feeding tube, but your spouse has chosen not to have a feeding tube in his advance directive." An advance directive supersedes the wishes of the healthcare surrogate.
Which of the following children would the nurse identify as a priority for having the greatest risk for choking and suffocating? A. A toddler playing with his 9-year-old brother's construction set. B. A 5-year-old eating yogurt for a snack. C. An infant asleep in her crib without a blanket. D. A 3-year-old drinking a glass of juice.
A. A toddler playing with his 9-year-old brother's construction set. A young child may place small or loose parts of toys in his mouth. A toy that is safe for a 10-year-old child could be deadly for a toddler.
An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching? A. Apply cool air under the cast with a blow-dryer B. Use sterile applicators to scratch the itch C. Apply cool water under the cast D. Apply hydrocortisone cream under the cast using a sterile applicator
A. Apply cool air under the cast with a blow-dryer
You are caring for a newly admitted obese patient in the ICU. The patient has a history of smoking. She states that her symptoms started early in life and are worse at night. She denies any history of recent fever or chills. You notice wheezing and stridor upon assessment. You expect the diagnosis for this patient will be: A. Asthma B. Bronchiectasis C. Congestive heart failure (CHF) D. Chronic obstructive pulmonary disease (COPD)
A. Asthma Asthma typically begins in early life, whereas symptoms of CHF and COPD usually develop later in life. Bronchiectasis typically presents with signs and symptoms of a recent infection, including large amounts of bronchial secretions. Asthma symptoms tend to come and go with symptoms being worse at night. There is often a family history of asthma, and it usually occurs in obese patients.
The nurse is caring for a client with hypernatremia. Which prescribed intravenous fluid (IVF) would be appropriate? A. Dextrose 5% in water (D5W) B. 3% saline C. Lactated ringers D. 0.9% Saline
A. Dextrose 5% in water (D5W) This client has hypernatremia (sodium > 145 mEq/L) and should avoid additional sodium-containing fluids. Dextrose 5% in water is used to replace water losses due to hypernatremia. It would be an appropriate maintenance fluid for this client because it contains free water with no added sodium or other electrolytes and promotes renal solute excretion.
You are admitting a new client. During your collection of data for the health history, you ask the client about the medications, including over-the-counter medications, herbs, supplements, and vitamins that they are taking at home. You are performing the: A. Medication reconciliation process as mandated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). B. Medication reconciliation process as mandated by the Institute for Healthcare Improvement. C. Unique identifier process as mandated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). D. Unique identifier process as mandated by the Institute for Healthcare Improvement.
A. Medication reconciliation process as mandated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).
The nurse is developing a plan of care for a client with an impairment to the hypoglossal cranial nerve. Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Observe the client during meals B. Keep suction at the bedside C. Provide large print education materials D. Teach the client to scan the room E. Alternate the use of an eye patch
A. Observe the client during meals B. Keep suction at the bedside The hypoglossal cranial nerve (XII) is central to the skeletal muscles of the tongue and assists with swallowing.
The nurse is caring for a group of premature infants. Which action is most important in preventing healthcare-acquired infection? A. Performing frequent hand hygiene B. Disinfecting commonly touched surfaces C. Screening visitors for illness D. Administer prophylactic antibiotics
A. Performing frequent hand hygiene The most important action a nurse can take to prevent a healthcare acquired infection is to frequently wash their hands. Hand hygiene is a proven and effective measure to decrease the transmission of pathogens. The nurse should wash their hands when they are visibly soiled, before and after contact with the client. Alternatively, the nurse may use alcohol-based sanitizers.
You are caring for a 12-year-old patient with a history of seizures. During her stay, you notice that she begins staring blankly. During this period, you are unable to get her attention, and she does not speak. You suspect that this is a: A. Petit mal seizure B. Simple partial seizure C. Grand mal seizure D. Myoclonic seizure
A. Petit mal seizure The petit mal (or absence) seizure is characterized by blank staring and an impaired level of consciousness. This type of seizure usually begins between the ages of 3 and 15 years.
The nurse is caring for a child with nephroblastoma. The nurse plans to take which action? A. Post a sign that states, "Do not palpate abdomen" B. Recommend foods low in protein C. Insert an indwelling urinary catheter D. Initiate fluid restrictions
A. Post a sign that states, "Do not palpate abdomen" Nephroblastoma (Wilms tumor) is the most common childhood cancer. Common treatments include surgical removal followed by chemotherapy. Nursing care involves minimal manipulation of the abdomen (no palpation) and a posted sign. It is essential to keep the encapsulated tumor intact.
You are planning an educational series of classes for young pregnant women. Which of the following needs should you include in a class related to nutrition during pregnancy? A. The need to increase caloric intake by about 340 calories during the second trimester of gestation. B. The need to increase caloric intake by about 370 calories during the second trimester of gestation. C. The need to increase caloric intake by about 340 calories during the third trimester of gestation. D. The need to increase caloric intake by about 370 calories during the third trimester of gestation.
A. The need to increase caloric intake by about 340 calories during the second trimester of gestation. This caloric increase is necessary to support the growth and development of the fetus. Similarly, a caloric increase of about 450 calories is indicated during the third trimester of gestation for the same reason.
A post-hemorrhoidectomy client is preparing for discharge to home. During the provision of discharge instructions, the nurse should highlight which of the following points? A. The proper technique for sitz bath B. Restricting fluid intake for 24 hours C. Laxative administration upon discharge D. Lying in a recumbent position
A. The proper technique for sitz bath It is important that the client is instructed to perform a sitz bath appropriately, understanding that the operative site must be exposed to the warm, moist heat during each sitz bath. Specifically, the nurse should educate the client to perform sitz baths three to four times daily in the immediate post-operative period following a hemorrhoidectomy.
When entering a patient's room to administer medications, what should the nurse's first action be? A. Verify the patient's full name and date of birth. B. Ask the patient to verify any medication allergies. C. See if the patient had breakfast. D. Review medications and potential side effects.
A. Verify the patient's full name and date of birth.
The nurse is caring for a child who is receiving prescribed methylphenidate. Which of the following findings should be reported to the primary healthcare provider (PHCP)? A. Weight loss of 3 kilograms B. Dry mouth C. Trouble falling asleep D. Occasional headaches
A. Weight loss of 3 kilograms Children receiving psychostimulant medications such as methylphenidate should be monitored closely for weight loss which may inhibit their ability to meet their growth milestones. This finding of a three-kilogram weight loss is necessary to report to the PHCP.
Following a pregnant client's report of persistent nighttime leg cramps over the past week, it would be appropriate for the nurse to instruct the client to increase their dietary intake of: A. Whole grains, nuts, egg yolks B. Almonds, sweet potato, avocado C. Lentils, peas, nuts D. Carrots, tomatoes, squash
A. Whole grains, nuts, egg yolks The client's complaint of nocturnal leg cramps may indicate inadequate magnesium and/or vitamin D intake. Whole grains and nuts are magnesium-rich foods, while egg yolks are a significant source of Vitamin D
While working in the surgery department, a nurse witnesses the patient signing the consent form for his gastric bypass surgery. The surgeon asks the patient if they have any further questions, and the patient says no. After the surgeon leaves, the patient begins asking the nurse questions about the surgery and the possible complications. He states, "I don't know if I should do this. What do you think?". What are the appropriate responses from the nurse? SATA A. "That is up to you, what do you want to do?" B. "It sounds like you still have some concerns about the operation, is that correct?" C. "Let me call the surgeon and have him come back in. He can go over these concerns with you so that you understand everything clearly." D. "I wouldn't do it, this surgery sounds risky!"
B, C
The nurse is caring for a client with Meniere's Disease. Which of the following assessment findings would be expected? Select all that apply. A. Presbyopia B. Tinnitus C. Vertigo D. Dyskinesia E. Hearing loss
B, C, E The cardinal features of Meniere's disease include sensorineural hearing loss, vertigo, and tinnitus. These features relapse and remit and can be debilitating.
The nurse is supervising a new graduate place an intravenous catheter. Select all the nursing interventions that have been proven effective in terms of beginning and maintaining intravenous access. Select all the apply. A. Not attempting an intravenous start more than one time B. Using the shortest length catheter as possible C. Using the smallest size catheter as possible D. Reviewing the medical history to determine any previous untoward effects of IV access E. Using the most distal hand veins when possible F. Applying warm compresses to the site for 10 minutes
B, C, F Using the shortest length catheter as possible, using the smallest size catheter as possible, and applying warm compresses to the site for 10 minutes for vasodilation are three effective nursing interventions. No more than 2 times, history of mastectomy to limp nodes, most distal arm, not the hand.
The registered nurse (RN) assigns client care to a licensed practical/vocational nurse (LPN/VN). Which of the following should the RN assign to the LPN? Select all that apply. A. A client requiring an assessment of their current medications B. A client needing a nasogastric tube (NGT) for enteral feedings C. A client with an insulin pump and is unsure of how to load the insulin D. A client with unstable blood pressure following adrenalectomy. E. A client requiring airborne isolation and bronchodilators via an inhaler
B, E Skills such as the insertion of an NGT are within the scope of an LPN/VN. The RN can delegate this to the LPN/VN. Further, LPN/VN's may care for a client in isolation as well as administer bronchodilators via an inhaler. Practical/vocational nurses should get the most stable patient assignment.
You are administering scheduled amoxicillin to your 12-year-old patient in the PICU. The order reads 750 mg/day in 3 divided doses. The tablets are each 125 mg. How many tablets do you give to your patient for their morning dose? A. 1 B. 2 C. 3 D. 4
B. 2
The nurse is caring for a client experiencing acute mountain sickness (AMS). The nurse anticipates a prescription for which medication? A. Sodium bicarbonate B. Acetazolamide C. Tamsulosin D. Dutasteride
B. Acetazolamide Acetazolamide, a carbonic anhydrase inhibitor, is commonly prescribed to prevent or treat AMS. It is preferred that this medication be taken 24 hours prior to the ascent.
The psychiatric nurse is providing care for a patient who has just calmed down after exhibiting inappropriate behaviors related to bipolar disorder. The nurse knows that which of the following is the best way to help prevent another unseemly episode? A. Identify the consequences of the behavior. B. Assist the client in understanding triggering events or feelings that may have lead to the outburst. C. Ensure that the patient's safety is upheld. D. Offer the patient clear options to deal with their current behavior.
B. Assist the client in understanding triggering events or feelings that may have lead to the outburst. The psychiatric nurse would be most effective in preventing further inappropriate episodes by assisting the client in understanding what may have triggered the event.
The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan? A. Place an eye patch over the affected eye B. Instruct the client to turn their head from side to side C. Speak slowly, clearly, and in a deeper voice D. Provide the client with ear plugs to promote rest
B. Instruct the client to turn their head from side to side Homonymous hemianopia (HH) is vision loss on the same side of the visual field in both eyes. It is appropriate for the nurse to teach the client to scan the room. Scanning the room will expand the visual field because the same half of each eye is affected.
The nurse is triaging a child with bilateral lower extremity chemical burns. The nurse suspects that the child may have been abused. The nurse should take which initial action? A. Cover the affected area with sterile dressing B. Irrigate the affected area with saline C. Report the suspected abuse D. Document the findings
B. Irrigate the affected area with saline common mnemonic to remember is "the solution to pollution is dilution." When a client has a chemical burn, the highest priority is to copiously irrigate it (dilute it) with saline or water.
The nurse in the psychiatric unit is administering fluoxetine (Prozac) together with tranylcypromine (Parnate). The nurse should watch out for which symptoms signifying an adverse reaction from the combination of both drugs? A. Low blood pressure and urinary retention B. Muscle rigidity and hyperthermia C. Shortness of breath and pink frothy sputum D. Weakness and diaphoresis
B. Muscle rigidity and hyperthermia Serotonin syndrome is a result of too much serotonin in the body due to the use of SSRI's and MAOI's. Serotonin syndrome is characterized by high body temperature, agitation, muscle rigidity, tremor, sweating, dilated pupils, and diarrhea. Upon noticing these symptoms, the nurse must report this to the physician to initiate medical intervention.
Which of the following is the most accurate education for injury prevention in the home of elderly clients? A. Use the handrail when going up and down the stairs, ensure robes or pants are held up if flowy, and wear comfortable slippers. B. Remove all throw rugs, remove furniture from all pathways, and wear comfortable/non-skid footwear. C. Use solid chairs without armrests, keep walkways clear, and use cordless phones. D. Install raised toilet seats, ensure that all sinks have throw rugs to prevent slipping on water, and use grab bars in the shower/bathroom.
B. Remove all throw rugs, remove furniture from all pathways, and wear comfortable/non-skid footwear.
The nurse is caring for a client with angle-closure glaucoma. It would be correct to place the client in which position? A. High fowler's B. Supine C. Semi fowler's D. Left lateral recumbent
B. Supine Placing the client supine, who has angle-closure glaucoma, is effective as it will assist in the lens falling away from the iris, decreasing the pupillary block.
A nurse is conducting client education regarding medication for a client receiving a monoamine oxidase inhibitor (MAOI). The client has successfully demonstrated understanding by stating, "I should avoid tyramine-containing foods, or I may go into hypertensive crisis." When asked to list specific tyramine-containing foods, the client would be correct to include which of the following? A. Cream cheese B. Swiss cheese C. Milk D. Ice cream
B. Swiss cheese
The nurse educator is giving a lecture on the different types of arthritis. Which of the following should the nurse educator emphasize distinguishes rheumatoid arthritis from gouty arthritis and osteoarthritis? A. Crepitus with range of motion B. Symmetry of joint involvement C. Elevated serum uric acid levels D. Dominance in weight bearing joints
B. Symmetry of joint involvement The distinguishing factor in all three types of arthritis is the symmetry of joint involvement. Rheumatoid arthritis is symmetrical and bilateral, while osteoarthritis and gout are unilateral.
What percussion sound is heard over most of the abdomen? A. Hyperresonance B. Tympany C. Resonance D. Dullness
B. Tympany Tympany is the percussion sound heard over hollow organs. The small intestine and colon are hollow organs; they predominate over most of the abdominal cavity. A: surface of the chest C: healthy lung tissue D: fluid, usually occurs with pneumonia
The nurse is attending to a client who is 20 weeks pregnant and has completed patient education. Which of the following statements by the client indicates that she has a good understanding of her baby's development? A. "My baby is able to breathe now." B. "My baby can open his eyes." C. "My baby is about 7 ½ inches long." D. "My baby has fully grown fingernails."
C. "My baby is about 7 ½ inches long." By 20 weeks gestation, the fetus is approximately 20 cm long or 7 ½ inches. This statement reflects a proper understanding of the mother regarding fetal development and does not require further teaching.
A client is scheduled to undergo electroconvulsive therapy (ECT). The nurse understands, which action needs to be performed prior to the ECT? A. Assess the client for contrast dye allergy. B. Administer an anti-convulsant. C. Apply a blood pressure cuff to the client's arm. D. Check if the client is on Metformin.
C. Apply a blood pressure cuff to the client's arm. A blood pressure (BP) cuff is wrapped around an ankle or arm and is inflated above systolic pressure before the NMBA is injected. This prevents NMBA from entering that foot or arm allowing the provider to visually observe the motor component of seizure activity in that foot/arm.
The UAP reports to the nurse that the patient who is on oxygen is presenting with a profusely bloody nose. The patient has been on warfarin for atrial fibrillation. Which action would be the highest priority? A. Instruct the UAP to offer oral and nasal care to help with dryness. B. Notify the physician so the scheduled warfarin can be held. C. Assess the client and look for bruising, bloody stools, and bleeding gums. D. Obtain a bubbler to humidify the oxygen.
C. Assess the client and look for bruising, bloody stools, and bleeding gums. The nurse's priority action should be to assess the patient and determine if there are any other sources of bleeding. For a patient on anticoagulation, assuming that a dry nose is the only reason for profuse nasal bleeding before assessing the patient is unacceptable.
While performing morning rounds, a nurse assesses a client's fat emulsion infusion and notes the infusion is one hour behind the scheduled time. Which of the following is the best nursing action? A. Adjust the infusion rate to make up the difference over the next hour, then revert the infusion rate back to the prescribed rate. B. Increase the infusion rate to ensure that the infusion finishes at the correct time. C. Ensure the fat emulsion infusion rate is infusing at the prescribed rate and maintain the rate at the prescribed rate. D. Stop the infusion and inform the health care provider (HCP).
C. Ensure the fat emulsion infusion rate is infusing at the prescribed rate and maintain the rate at the prescribed rate. The nurse should confirm the fat emulsion infusion is infusing at the prescribed rate and subsequently maintain the prescribed rate until the infusion is complete.
Your client has just got an epidural catheter to manage their severe, continuous pain. Which of the following is a nursing intervention that is necessary after the placement of this epidural catheter and the initiation of an opioid epidural infusion? A. Ensure the availability and immediate accessibility of Actiq to reverse any respiratory depression. B. Ensure the availability and immediate accessibility of Sublimaze to reverse any respiratory depression. C. Monitor the client at least every hour for the first 24 hours for any signs of respiratory depression and level of sedation. D. Monitor the client at least every 2 hours for the first 24 hours for any signs of respiratory depression and level of sedation.
C. Monitor the client at least every hour for the first 24 hours for any signs of respiratory depression and level of sedation. The nursing intervention that is necessary after the placement of this epidural catheter and the initiation of an opioid epidural infusion is to monitor the client for signs of respiratory depression and level of sedation at least every hour for the first 24 hours.
The nurse is taking vital signs on her patient with a diagnosis of acute lymphoblastic leukemia (ALL). His temperature is 38.7 degrees C. What is the nurse's priority? A. Place cool washcloths on the patient's head. B. Continue with her assessment. C. Obtain intravenous access on the patient. D. Assess the patient's perfusion.
C. Obtain intravenous access on the patient. It is the priority action to establish intravenous access for this patient. This patient has a diagnosis of ALL, so the nurse knows that he is immunocompromised. He is very susceptible to infections and with a fever of 38.7 degrees C (101.6 F), she has a high index of suspicion for disease.
While working in the neonatal intensive care unit, the nurse assesses the client receiving continuous nasogastric feeding. In the gastrointestinal assessment, the nurse notes: - Hypoactive bowel sounds - The abdominal girth of 32 cm increased from 30 cm at the previous assessment. - Soft abdomen, tender to palpation. - No stool x 2 days. What is the priority nursing action? A. Notify the health care provider B. Continue to monitor C. Pause the infant's feeds D. Re-evaluate the abdominal girth at your next assessment
C. Pause the infant's feeds high risk of developing necrotizing enterocolitis (NEC).
A 30-year-old male on the surgical floor is recovering after a traumatic car accident. He has a skin graft on his right lower leg that was completed one day ago. What nursing intervention should the nurse NOT perform to decrease the patient's pain? A. Give the patient PRN norco B. Elevate the extremity C. Soak the extremity D. Give the patient a PRN anti-inflammatory
C. Soak the extremity Doing this can cause the wound to reopen and the skin graft to be altered. This patient may need to go back into surgery and have another graft placed.
The patient presents to the emergency department with back pain and numbness in the extremities after experiencing a fall. The nurse assesses muscle flaccidity and hypotension. What is the nurse's highest priority regarding this patient? A. Assess for external bleeding B. Prepare the patient for intubation C. Stabilize the cervical spine D. Insert an 18g IV for fluid replacement
C. Stabilize the cervical spine The highest priority action would be to stabilize the patient's cervical spine to prevent further damage and to preserve airway patency.
The nurse is caring for a client receiving a continuous infusion of diltiazem who has the below tracing on the electrocardiogram (ECG). On assessment, the client has irregular peripheral pulses, an S3 heart sound, and 2+ pedal edema. The nurse should plan to take which priority action? See the image below. A. Assess the client for chest pain B. Perform a 12-lead electrocardiogram C. Stop the infusion D. Obtain an immediate troponin level
C. Stop the infusion This tracing reflects atrial fibrillation and diltiazem may be used as a treatment. Diltiazem is a calcium channel blocker and may cause the client to develop heart failure because of its negative inotropic and chronotropic effects. An S3 heart sound is one of the earliest manifestations of heart failure. This, combined with pedal edema, supports the nurses' decision to stop this infusion to prevent further clinical deterioration.
The 6-year-old immigrant child has been diagnosed with Hepatitis A. He was brought from Mexico by his grandparents a few days ago. You would expect that treatment for this child will include: A. Acyclovir B. Interferon C. Supportive care D. Ribavirin
C. Supportive care Hepatitis A is typically an infection that is self-limiting if the child receives the appropriate supportive care. The disease is usually transmitted by drinking water and food that is contaminated with fecal matter. Removing the source of the infection and providing a healthy diet will often help resolve the infection.
Which question would you ask to assess the family as the basic unit of society when applying the systems theory of family? A. Tell me about the traditions that your family has and practices. B. What form of discipline is used in the home? C. Tell me about your involvement in school activities with your children. D. Are you able to share home responsibilities with your spouse?
C. Tell me about your involvement in school activities with your children. Asking the family about their involvement in school activities with their children is an example of applying the systems theory to the family and its interactions with and exchanges with others outside of the boundaries of the family.
A senior RN is supervising a newly registered nurse in the emergency department. Which situation would require the senior RN to intervene? A. The new RN elevates the foot of a 13-year-old with a fractured tibia. B. The new RN calls Child Protective services for the child she suspects is being sexually abused. C. The new RN checks the tonsils of a drooling 3-year-old with a sore throat. D. The new RN gives a nebulization treatment to an 8-year-old with asthma.
C. The new RN checks the tonsils of a drooling 3-year-old with a sore throat. A child with a sore throat that is drooling may be manifesting epiglottitis. Drooling may indicate that the child is going into respiratory distress and warrants timely intervention by the healthcare team. The senior RN should step in and guide the new RN in what to do.
The nurse is auscultating bronchovesicular lung sounds on a client. The nurse understands that these lung sounds are best heard A. right second intercostal space. B. midclavicular line, in the fifth intercostal space. C. posteriorly, between the scapula. D. over the trachea.
C. posteriorly, between the scapula. Bronchovesicular sounds occur over major bronchi where there are fewer alveoli. They are moderate in pitch and amplitude and are normally equal during inspiration and expiration. Posteriorly, bronchovesicular breath sounds can be auscultated between the scapulae.
The charge nurse is planning patient care assignments for a licensed practical/vocational nurse (LPN/VN). Which of the following would be an appropriate patient assignment for the LPN? Select all that apply. A. A 67-year-old one-hour post-procedure from a cardiac catheterization. B. An 88-year-old client who was just admitted for intractable pain secondary to metastatic cancer. C. A 42-year-old being discharged following a diagnosis of type 2 diabetes mellitus. D. A 75-year-old inpatient client with colon cancer needing colostomy care. E. A 50-year-old client being treated for herpes zoster with prescribed oral antivirals.
D, E
The nurse caring for a client with cardiac arrhythmias is alerted to a new order from the health care provider (HCP) to administer an additional digoxin dose to the client. The nurse reassesses the client and the client's most recent lab values from that morning before relaying to the HCP that the client's heart rate is 40 BPM and serum potassium was 2.8 mmol/L. The HCP, however, insists and threatens, "Give the digoxin now, or I will have you fired!". The most appropriate response by the nurse would be: A. "Fine. I'll give the digoxin now, but this client will die." B. "I don't have to listen to you." C. "Don't you raise your voice at me again, or we'll see who gets fired." D. "I think we should discuss this with the pharmacist or the unit manager first."
D. "I think we should discuss this with the pharmacist or the unit manager first." This is an appropriate and assertive response that not only that accomplishes the primary goal of keeping the client safe, but does so while avoiding infringing upon the HCP's rights. Additionally, by bringing in a third party (such as a pharmacist or unit manager), not only will the issue be clarified, but the situation will likely be diffused.
The nurse is talking to an elderly client who is being discharged with digoxin as a take-home medication. The nurse should initiate further teaching when the client states: A. "I won't take the tablet when my pulse is too slow." B. "I guess I'll be eating a lot of spinach and bananas from now on." C. "So, I need to watch out for any nausea and vomiting every now and then." D. "It's good that I don't have to get my blood examined for potassium from now on."
D. "It's good that I don't have to get my blood examined for potassium from now on." This is an inaccurate statement by the client and necessitates the nurse to provide additional clarification. Hypokalemia ( low potassium level) increases the risk of digoxin toxicity, especially cardiac arrhythmias. The client needs to understand that serum potassium levels need to be monitored frequently while on Digoxin.
The cardiac nurse is evaluating cardiac markers to determine whether or not their patient's heart has suffered from muscle damage. The nurse is aware if damage has occurred, CK-MB levels will be their highest after how many hours? A. 3 to 6 B. 1 to 2 C. 48 to 72 D. 18
D. 18 CK-MB, or creatine kinase myocardial muscle, levels measure muscle cell death and are at their highest elevation 18 hours after cardiac muscle damage. CK-MB levels first begin elevating about 3 to 6 hours after a cellular injury or myocardial infarction and stay elevated for about 48 to 72 hours.
The nurse is caring for a client with Helicobacter pylori. The nurse should anticipate a prescription for which of the following medications? A. Dicyclomine B. Metoclopramide C. Valacyclovir D. Amoxicillin
D. Amoxicillin Amoxicillin is an antibiotic that is commonly used to treat Helicobacter pylori infections. When treating this infection, this medication is often coupled with a proton pump inhibitor such as esomeprazole.
Shortly after checking into the obstetrics unit, a client currently at 39 weeks gestation spontaneously ruptured her membranes when ambulating to the bathroom. After the client returns to bed, which of the following should be the nurse's initial action? A. Assess the color and quantity of the fluid. B. Perform a vaginal examination to assess the cervix for dilation. C. Inform the client she is now on strict bed rest until further notice. D. Assess the fetal heart tones.
D. Assess the fetal heart tones. The priority is for the nurse to assess the fetal status following the spontaneous rupture of the client's membranes.
Which of the following is a physiological alteration that can occur with stress? A. Decreased visual acuity B. Increased peristalsis C. Decreased glucocorticoids D. Hyperglycemia
D. Hyperglycemia Hyperglycemia is a physiological alteration that can occur during a stress response among both diabetic and non-diabetic clients. More specifically, glucose is increased by various factors, including elevated levels of cortisol, glucagon, and epinephrine (often referred to the "fight or flight" phenomena). These hormones may, in turn, lead to insulin resistance, further increasing hyperglycemia.
The nurse is developing a care plan for a client with Legionnaires' disease. Which nursing diagnosis would be appropriate? A. Disturbed body image B. Impaired skin integrity C. Risk for infection D. Ineffective airway clearance
D. Ineffective airway clearance Legionnaire's disease refers to a type of pneumonia caused by the Legionella bacteria, typically found in water or soil. An appropriate nursing diagnosis would be ineffective airway clearance, as this disease impairs the airway and lung function.
The nurse reviews a client's medical record taking prescribed isoniazid for pulmonary tuberculosis. Which laboratory data is most important to monitor? A. PT and PTT B. CBC C. BUN D. Liver enzymes
D. Liver enzymes Liver toxicity is a severe adverse effect of isoniazid. Healthcare providers should monitor for signs of jaundice, fatigue, elevated liver enzymes, and loss of appetite. Liver enzyme tests are usually performed monthly during therapy to identify early hepatotoxicity. Isoniazid is a bacteriocidal for actively growing organisms and a bacteriostatic for dormant mycobacteria. It is selective for M. tuberculosis. Isoniazid is used alone for chemoprophylaxis, or in combination with other antitubercular drugs when treating active disease.
The nurse encounters an infant with irritability from acute otitis media while working in the pediatric clinic. The nurse should know that the infant is at much higher risk than an adult for otitis media due to which of the following? A. Immature cardiac sphincter B. Feeding in a semi-Fowler position C. Introduction of solid foods D. Narrower, shorter, and more horizontal Eustachian tubes
D. Narrower, shorter, and more horizontal Eustachian tubes
You are working in the delivery room. The physician has inserted an endotracheal tube (ETT) in a newborn who did not respond to initial treatment. The most reliable method for confirming the placement of the ETT is: A. Observe for the rise and fall of the chest with ventilations B. Observe for increased heart rate C. Auscultate for bilateral breath sounds D. Observe for CO2 exhalation using a CO2 detector
D. Observe for CO2 exhalation using a CO2 detector Within 8 to 10 breaths, the sensor should begin to detect exhaled CO2. If an indicator is not available, the team should observe for an increased heart rate.
The nurse is caring for a client that was newly prescribed clozapine. It would be essential to teach the client to do which of the following? A. Maintain a healthy diet because of weight gain B. Exercise regularly and maintain hydration C. Expect excessive secretions in the mouth D. Obtain follow-up laboratory work
D. Obtain follow-up laboratory work Treat schizophrenia, Follow-up laboratory work is essential for a client taking clozapine. The medication may adversely cause neutropenia. The client will be instructed to obtain this necessary laboratory work to ensure they are not experiencing agranulocytosis, which may make the client susceptible to infection.
The nurse manager is working on a unit where his nursing staff is not comfortable taking care of patients from other cultural backgrounds. What is the most appropriate action for the manager? A. Let the staff research different articles regarding various cultures so they become more familiar with them. B. Transfer the nurses to another unit where they can't be assigned to patients from other cultures. C. Rotate the nurses' assignments so they can all have the opportunity to take care of patients from other cultures. D. Organize an activity that offers opportunities for the staff to learn about the cultures they might encounter at work.
D. Organize an activity that offers opportunities for the staff to learn about the cultures they might encounter at work. An activity like a workshop is an excellent opportunity for staff to learn about new cultures and to identify their feelings towards other religions. They also have a chance to ask questions.
A nurse in a gynecology clinic is assessing a first-time client (G1P0) who is eight weeks pregnant. Which assessment finding would alert the nurse of a high-risk pregnancy? A. The client reports nausea and vomiting four to five mornings per week. B. The client expresses her ambivalence toward the pregnancy to the nurse. C. The client reports intermittent constipation since learning she was pregnant. D. The client reports intermittent vaginal spotting and abdominal cramping.
D. The client reports intermittent vaginal spotting and abdominal cramping. The first sign of threatened abortion is vaginal bleeding, which is relatively common during early pregnancy.
You are caring for a group of psychiatric mental health clients. One of these clients, who has anger management and aggressive behavior concerns, has not yet gained telephone privileges. You notice that the nursing assistant on the unit is escorting this client to the telephone. After you talk to the client about the telephone privileges, the nursing assistant tells you that, "It is unfair for this client to not be able to use the telephone when other clients are free to do so." What should you determine about this nursing assistant's comment? A. This comment clearly shows that the nursing assistant is favoring this client. B. This comment indicates that the nursing assistant is ensuring equal rights. C. This comment indicates that the nursing assistant is preventing discrimination. D. This comment indicates a learning need relating to the therapeutic milieu.
D. This comment indicates a learning need relating to the therapeutic milieu. A milieu environment is planned and maintained in a manner that eliminates all possible stressors so that psychiatric mental health clients with emotional and behavioral issues can concentrate their energies and thoughts on the things impacting them rather than external stressors, such as changing and inconsistent rules and boundaries that have been eliminated from the environment of care.
While on your first posting at a Sleep clinic, you are reviewing the stages of sleep. Place the following steps or phases of sleep in an appropriate sequential order of the sleep cycle.
The stage of the sleep cycle that is characterized with a brief period of very light sleep. The stage of the sleep cycle that is characterized with 10 to 20 minutes duration. The stage of the sleep cycle that is characterized by delta waves. The stage of the sleep cycle that is characterized with vivid dreams.
