ATI Level 3 Practice B Review
nurse is planning to administer recommended immunizations to a 65 year old client. which of the following immunizations should the nurse plan to administer? - influenza (yes) - HPV (no, given b/w 9-26 y/o) - herpes zoster (shingles) vaccine (yes) - pneumococcal vaccine (yes) - inactivated polio virus (IPV) vaccine (no, given @ 2mos, 4 mos, & 12 mos + age 4-6y/o)
- influenza (rec. for pts over the age of 50, pts w chronic illness, pt living in an institution, & all pts in who work in healthcare setting should get) - herpes zoster (65 y/o or older should get this) - pneumococcal vaccine (pt should have received one or two b/w age 19-64 and then one more dose at 65 or older)
diagnostic criteria for gambling disorder
- making repeated but unsuccessful attempts at controlling/cutting back/or stopping this addictive behavior over last 12 months - the client has gamble when feeling distressed over the past 12 months. This can include times when client experiences feelings of depression, anxiety, guilt, or helplessness. - the client experiences a need to increase the amt of money gambled to achieve the same lvl of enjoyment over the past 12 months.
nurse is assessing a client who has schizophrenia. which of the following manifestations should the nurse identify as positive symptoms of schizophrenia? -magical thinking (yes) -clang association (yes) - auditory hallucinations (yes) - flat affect (no, this is a negative symptom) - emotional ambivalence (no, this is a negative symptom)
-magical thinking (or belief that one's thought affect others) - clang association (choosing words based on their sounds) - auditory hallucinations (hearing voices/sounds that dont exist)
1. Risk factors of Alzheimer's disease 2. Environmental agents that can cause AD
1. age, gender (more common in women), & fam hx 2. herpes zoster and herpes simplex, exposure to toxic metals (zinc & copper)
1. manifestations of spiritual distress 2. manifestations of disturbed thought processes 3. manifestations of insomnia
1. expresses lack of meaning in life, anger, refusing interactions w family/spiritual leaders, discontinuing routine spiritual practices 2. impaired problem-solving ability, confusion, diff. concentrating, inappropriate thinking, memory deficits 3. difficulty falling asleep, lack of energy, verbal reports of not feeling well rested, diff. concentrating
nurse is providing dietary teaching for a client who is obese and wants to lose 0.91 kg / 2 lb per week. the client currently consumes about 2500 cals per day. to achieve this goal, how many cals should the nurse instruct the client to consume per day
1500 nurse should teach that losing 1 lb of body fat per week requires a reduction of 3,500 calories per week. so multiply 2500 x 7 days then subtract 3500 and divide by 7
nurse is reviewing the recent lab reports for a client who has anorexia nervosa with recurrent purging behavior. which of the following lab values indicates a therapeutic response to the treatment plan? - Hct 55% (no, this is elevated which can be caused by purging behaviors. Normal range is 42-52% for men & 37-47% for women) - BUN 18 mg/dL (YES) - potassium 3.3 mEq/L (no, this is below expected range of 3.5-5.0) - sodium 133 mE1/L (no, this is below the expected range of 136-145 mEq/L)
BUN 18 mg/dL - this is WNL of 10-20, which indicates therapeutic response to tx. If the client still had recurrent purging behavior the BUN would be INCREASED due to dehydration from excessive vomiting or diuretic use.
nurse is preparing to administer phenytoin via intermittent IV bolus to a client who is having a tonic-clonic seizure caused by epilepsy. which of the following factors should the nurse consider when administering IV phenytoin
administer phenytoin at a rate no greater than 50 mg/min also: - mix w/ no more than 50 mL of 0.9% sodium chloride (also want to flush with 0.9% before AND after admin) - normal for phenytoin to develop precipitate when refrigerated (dissolves at room temp) - discard phenytoin if its cloudy or precipitate remains present at room temp - monitor for hypotension and bradycardia when infusing IV bolus, decrease rate of infusion if this occurs
a nurse in an emergency dept. is assessing a newly admitted client. the nurse should identify that which of the following findings is a manifestation of acute cocaine toxicity - hypotension (no, HTN) - pinpoint pupils (no, this occurs w/ barbituates & opioids) - agitation (YES) - hypothermia (no, hyperthermia would occur)
agitation - + dizziness, & tremors. severe toxicity can cause convulsions and myocardial infarction - cocaine toxicity also causes pupil dilation, HTN r/t vasoconstriction, and hyperthermia (remember cocaine is a CNS stimulant)
nurse is reviewing the lab findings of a client who has acute pancreatitis. which of the following findings should the nurse expect? - calcium 10.2 (no this is WNL(9.0-10.5), it would be decreased in acute pancreatitis) - amylase 300 units (YES) - WBC 7,000 (no, this is WNL (5,000-10,000) it would be elevated in acute pancreatitis) - blood glucose 100 mg/dL (no, this is WNL of less than 200, it would be elevated in acute pancreatitis)
amylase 300 units/L
nurse is caring for an infant born at 31 weeks of gestation. for which of the following complications should the nurse anticipate and monitor the newborn? - hyperthermia (no, more likely to have hypo) - apnea (yes) - thrombocytopenia (no, at risk for anemia & polycythemia) - necrotizing enterocolitis (yes) - hypoglycemia (yes)
apnea, necrotizing enterocolitis, hypoglycemia - apnea: delay of breathing for 20 or more seconds - necrotizing enterocolitis: at risk due to intestinal ischemia, immature immune systems, & type of formula - hypoglycemia: fetal glycogen stores develop in last trimester, lack of this and difficulty regulating temps increase risk in preterm newborns
hospice nurse is providing palliative care for a client who is near death and not responding to verbal stimuli. which of the following actions should the nurse take? - admin morphine sulfate PO q 4 HR PRN for pain (no, nurse should admin analgesics sub Q, sublingual, or IV if pt isnt responsive. At end of life, pt can lose ability to swallow) - apply scopolamine transdermal patch for increased oral or respiratory secretions (YES) - use restraints if client is experiencing restlessness (no, provide soothing music, therapeutic touch, and keep the noise level at a minimum when the client is experiencing restlessness. If this is unsuccessful, provide may prescribe med to calm pt) - place heating pad on clients feet to warm cool extremities (no, cool ext are expected. Nurse should not use any type of heating device/equipment to warm client bc they increase risk of injury due to lack of blood flow to affected areas for a client who is unresponsive)
apply a scopolamine transdermal patch for increased oral or resp. secretions - or admin atropine to decrease oral/respiratory secretions that can cause loud, wet respirations referred to as a "death rattle"
hospice nurse is caring for a client who has end stage cancer. the clients partner asked about ways to help reduce the clients pain. which of the following palliative actions should the nurse recommend for tactile distraction
applying warm compresses This is a form of tactile, or touch, distraction that can reduce pain by stimulation of the skin. The nurse should instruct the clients partner to test the temp of the compresses before applying them to clients skin
nurse is admitting a toddler who has wilms tumor. which of the following actions is the nurses priority \
avoid palpation of the abdomen. B/c this can cause tumor to rupture RN should also: -conduct a nutritional assessment (bc they can have anorexia & wt loss) -check toddler's temperature on admission and throughout hospitalization (for fever) -monitor Hgb level (bc they can exhibit anemia) BUT, palpate abdomen is the priority intervention!!
nurse is teaching a client who has a new diagnosis of pelvic inflammatory disease and is starting oral antibiotic therapy. which of the following information should the nurse include in the teaching?
avoid sexual activity until antibiotic therapy is complete. - by both the client and her partner & once manifestations of PID have resolved. Also teach pt to: - check temp BID to monitor for effectiveness of abx tx - use heat therapy to lower abdomen and back to relieve discomforts - restrict ambulation and to recline in a semi-fowlers position
nurse in a pediatric clinic is planning an education program for guardians of school-age children about preventing obesity. which of the following information should the nurse include? - do not allow snacking between meals (no, healthy snacks should be available) - encourage a min of 720 mL (24oz) of juice daily (no, better to give 1-1.5 cups of fruit or milk/water to drink) - avoid using food as a reward for good behavior (YES) - recommend educational television viewing for 3 hr/day (no, limit tv to 2 hr or less per day)
avoid using food as a reward for good behavior
a nurse is teaching a client who has chronic pain about biofeedback. which of the following information should the nurse include about this complementary therapy. - biofeedback provides audio and visual signals to induce a physiological change (YES) - biofeedback involves manipulating soft tissue to increase circulation (no, this is massage therapy) - biofeedback uses a variety of body movements to strengthen muscles (no, this is yoga & pilates) - biofeedback uses digital pressure to reduce pain and improve function (no, this is acupuncture)
biofeedback provides audio and visual signals to induce a physiological change - its a technique that uses audio and visual signals that allow clients to reduce muscle tension by gaining control over autonomic physiological functions
adverse effect of phenytoin (antiepileptic medication)
bleeding gums
nurse is assessing a client who has parkinsons disease which of the following manifestations should the nurse expect
bradykinesia
nurse is assessing a client who has a benign tumor resulting from fibrocystic breast condition. which of the following findings should the nurse expect? - breast pain (YES) - mass in the duct (no this happens in intraductal papilloma breast disorder) - nipple discharge (no this happens in intraductal papilloma breast disorder & ductal ectasia breast disorder) - enlarged axillary nodes (no this is ductal ectasia breast disorder)
breast pain
nurse is teaching a family member of a client who has alzheimers about minimizing behavioral problems at home. which of the following info should the nurse include in the teaching?
briefly leave the room when the client becomes agitated - the family member should return in a short period of time to promote a sense of safety. if the client is still agitated, the fam member should leave the room again and repeat the process until the client displays positive behavior also teach family member: - to use a soft, calm tone of voice - that explaining, arguing, or trying to reason with the client when she is acting out will increase agitation and confusion - to avoid crowds of people when taking client out, & provide a quiet room if available
nurse is caring for a client who is at 13 w of gestation and has positive gonorrhea culture. which of the following medications should the nurse plan to administer? - imiquimod (no, this is a cream to tx condylomata, or warts associated w HPV) - acyclovir (no, this is an antiviral med to tx genital herpes) - ceftriaxone (YES) - metronidazole (no, this an antifungal med used to tx candidiasis/yeast)
ceftriaxone - think xone sounds like sone, abx end in -sone this is an abx that kills neisseria gonorrhoeae
school nurse is planning an educational program for parents about bullying. which of the following information should the nurse include
children who are victims of bullying behavior have an increased risk of suicidal ideation
nurse is providing discharge teaching for the guardian of a newborn who was recently circumcised. which of the following statements should she include
clean the penis with warm water until it is healed
nurse in a mental health clinic is assessing a client who states i dont think my gambling is as big of a problem as my friends think it is. which of the following findings should the nurse identify as meeting the diagnostic criteria of gambling disorder
client asks others for money to compensate for gambling losses - one of the diagnostic criteria for gambling disorder is a reliance on others to provide money to help with negative financial situations that are a direct result of gambling losses. According to the american psychiatric association, a diagnosis of gambling disorder requires that the client's behavior meets four of the defined criteria over the period of the past 12 months.
nurse is assessing a client who is a survivor of intimate partner violence. which of the following findings indicates that the client is in the tension-building phase of battering? - client rationalizes partners battering behavior ( YES) - client purposefully provokes anger from the batterer (no, this is acute-battering phase which is the second phase of the cycle of violence) - the client shows evidence of severe battering injuries (no this is acute-battering phase) - client believes that their partner can control the battering behavior (no, this is a characteristic of the honeymoon phase which is the 3rd phase of the cycle of violence)
client rationalizes the partner's battering behavior
nurse is caring for a client who is experiencing infertility. which of the following meds should the nurse expect the provider to prescribe? -methylergonovine (nothis is a uterine oxytocic medication given to pt w/ uterine atony) - clomiphene (YES) - misoprostol (no, this is a prostaglandin given to ripen cervix and given to pt's for induction of labor) - labetalol (no, this is a beta blocker given to lower BP, used as tx for gestational HTN)
clomiphene
right hemispheric stroke manifestations
constant smiling, impaired sense of humor, disoriented to time & place, inability to recognize familiar faces, poor judgement impulsiveness, denial of illness, lack of awareness, loss of hearing, loss of depth perception
nurse is assessing a client who has MS. which of the following manifestations should the nurse expect - fasciculations of face (no, this/twitching of face or tongue happens w/ amyotrophic lateral sclerosis) - decreased visual acuity (YES) - shuffling gait (no, this occurs in Parkinson's) - muscle rigidity (no, this occurs in Parkinson's)
decreased visual acuity may also have diplopia, changes in peripheral vision, or nystagmus
nurse is assessing an infant who has down syndrome. which of the following manifestations should the nurse expect?
depressed nasal bridge (& small nose) nurse should also expect: -blepharitis -upward/outward slant to eyes - broad, short hands w stubby fingers - protruding abdomen and can have umbilical hernia due to muscular hypotonia
nurse is caring for a client who has a newborn and exhibits manifestations of pospartum depression. which of the following assessment is the nurses priority
determine whether the client plans to harm herself
nurse is counseling a client who has experienced intimate partner violence. which of the following instructions is the priority for the nurse to include in the teaching
develop a safety plan
nurse is assessing a newly admitted client following a stroke. which of the following findings should indicate to the nurse the client has experienced a left hemispheric stroke
difficulty reading other manifestations of left hemispheric stroke: deficits to right visual field, inability to discriminate letters & words, aphasia, and memory deficits
nurse is assessing a client who has acute leukemia and has received an allogeneic bone marrow transplant. the nurse should identify that which of the following findings is a manifestation of graft versus host disease - diffuse rash (yes) - swollen calf (no this is a manifestation of thrombophlebitis) - constipation (no, diarrhea is a manifestation of GVHD) - dry cough (no, this indicates infection rather than GVHD)
diffuse rash which can include blistering and peeling of the skin, is a manifestation of GVHD due to progressive tissue damage. other manifestations include inflammation of the mucosa of the eyes and abdominal pain.
nurse is teaching the parents of a newborn about using a bulb syringe to clear the newborns nose and mouth of excess secretions. which of the following instructions should the nurse include?
discontinue suctioning when the newborns cry sounds clear also teach parent to: - insert syringe into side of newborns mouth - suction mouth first, then nares - compress bulb before inserting syringe
nurse is teaching the guardian of a child who has juvenile idiopathic arthritis about pain management. which of the following statements should the nurse make? - "discourage your child from taking naps during the daytime" (YES) - "place cold packs on affected joints 3x/day to reduce swelling" (no, warm bath/shower can alleviate joint stiffness & decrease pain. Use WARM, moist packs) - "decrease daily intake of high-fiber foods" (no, encourage healthy, well-balanced diet, including high-protein) - "limit childs physical activity to decrease inflammation" (no, ensure child participates in play, such as riding a bike, swimming, throwing/kicking a ball. )
discourage your child from taking naps during the daytime - bc this can make nighttime sleep more difficult. Also, daytime activity can increase joint stiffness & pain, resulting in poor nighttime sleep. The parent should suggest a quiet activity such as reading or playing a video game for 30 to 60 minutes, rather than taking a nap
nurse is providing teaching to a client who has bipolar disorder and a new prescription for lithium. which of the following statements should the nurse make? - "take this med on an empty stomach" (no, take w meals bc it can irritate gastric mucosa) - "restrict intake of salt while taking this med" (no, pt needs to maintain adequate intake while taking lithium. low sodium leads to lithium retention which can cause toxicity) - "drink at least 1.5 liters of fluid per day while taking this med" (YES) - "expect a wt loss of 10-20 lbs w/ this med" (no, wt GAIN is a common adverse effect)
drink at least 1.5 L of fluid per day while taking this med b/c dehydration can lead to lithium toxicity
nurse is assessing a client who had a stroke. nurse should identify that which of the following findings is a manifestation of a right hemisphere stroke? - anxiety (left-hemisphere) - low tolerance for frustration (left hemisphere) - right visual field deficits (left hemisphere) - euphoria (yes)
euphoria (along with impaired visual-spatial perception and left-sided neglect)
nurse is assessing a newly admitted client who has major depressive disorder. which of the following manifestations should the nurse expect in this client?
experiences delusions of persecution
nurse is caring for a newborn who has hyperbillirubinemia. the newborn is prescribed phototherapy to treat this newborn complication. to provide for the safety of the newborn, the nurse should shield which area during phototherapy.
eyes
nurse is assessing a client who is at 24 weeks of gestation during a monthly antepartum visit. which of the following manifestations is a potential prenatal complication and should be reported to the provider
facial swelling
nurse is performing an admission assessment on a client. which of the following findings should the nurse expect? - report of recent wt gain (no a manifestation of chronic pancreatitis is unintentional wt loss) - chest pain that radiates down the left arm (no, a manifestation of chronic pancreatitis is severe, continuous abdominal pain) - foul-smelling bulky stool (yes) - blood glucose level of 65 mg/dL (no, a common complication of chronic pancreatitis is DM resulting in hyperglycemia. This level indicates hypoglycemia.
foul smelling bulky stool - a manifestation of chronic pancreatitis is steatorrhea, which is foul-smelling/fatty stools that are bulky in volume. This worsens as the pancreatitis becomes more advanced and the production of lipase further decreases.
nurse is teaching a client who is at 22w of gestation and has gestational HTN. which of the following information should the nurse include in teaching
gestational HTN usually resolves during the first week postpartum although it can persist for up to 12 weeks after delivery
nurse is providing discharge teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auti-injector. which of the following instructions should the nurse include in the teaching?
give a second injection if the first fails to entirely reverse your child's reaction also teach parent: - to admin intramuscularly into outer thigh at perpendicular angle and hold for 10 seconds, then massage for 10 seconds - a/e = nervousness, palpitations, increased pulse, sweating, dizziness, and HA - to avoid refrigerating bc it can compromise the injection mechanism - store at room temp in a dark place
nurse is caring for a client who has bipolar disorder and is experiencing mania. which of the following actions should the nurse take
give the client short, firm directions when communicating
nurse is reviewing the medical record of a 9 mo. old infant. which of the following findings shoud the nurse report to the provider - WBC count (no, 12,000 is WNL) - HR (no, 110/min is WNL) - Gross motor skills (YES) - RR (no, 28/min is WNL)
gross motor skills (infant requires support at all times when sitting on floor, this indicates a delay. 9 month old should be able to sit unsupported for 10 min at a time)
nurse is teaching about adalimumab with a client who has rheumatoid arthritis. which of the following info should the nurse include? - plan to self admin once a month (no, this is given every other week. can also take weekly if pt isnt also taking methotrexate) - have TB skin test prior to admin (YES) - admin deep into the thigh muscle (NO, give sub-Q in thigh or abdominal area) - roll vial of adalimumab to mix the particulate matter (no, teach pt to check that solution is clear w no particulate matter through the prefilled pen window, if solution is discolored or has particulate matter discard the pen or vial)
have a TB skin test prior to administration of adalimumab - do TB skin test prior to first dose bc if the client has TB a flare-up could occur
nurse is assessing a client who has depression. which of the following manifestations should indicate to the nurse that the client is experiencing low self-esteem? - expresses lack of meaning in life (no, this is a s/s of spiritual distress) - hypersensitivity to criticism (YES) - impaired problem-solving ability (no, this is disturbed thought processes) - difficulty falling asleep (no, this is insomnia)
hypersensitivity to criticism s/s include guilt, shame, expression of helplessness, lack of eye contact or pessimistic outlook on life
nurse is assessing a client who has PTSD after a workplace explosion 3 mo. ago. which of the following findings should the nurse expect? - hypervigilance (YES) - delusions (no, these are false beliefs that reasoning cannot correct - happens w/ schizophrenia) - somnolence (no, insomnia & difficulty concentrating would be a manifestation of PTSD) - amnesia (no, flashbacks of the event/nightmares about the event are manifestations of PTSD)
hypervigilance - or an exaggerated startle response, is a common manifestation of PTSD
nurse is providing discharge teaching to a client who is at 34 weeks of gestation and has placenta previa. which of the following statements by the client indicates an understanding of the instructions?
i need to make arrangements so that i am not by myself at home. also teach pt to: - return to hospital ASAP if ANY bleeding occurs - maintain bed rest with only bathroom privileges - don't place ANYTHING in vagina
nurse is counseling a client who has been undergoing treatment for OCD. which of the following statements should the nurse identify as an indication that the client's therapy has been effective?
i say stop out loud whenever i have a compulsion to wash my hands.
a nurse is evaluating the plan of care for an adolescent who has ADHD. which of the following statements made by the adolescent should indicate to the nurse an improvement in the adolescent's social interaction
i work well in groups of two or three people
nurse at a crisis center is meeting with a client who reports that his adolescent daughter has been increasingly defiant since his divorce 2 years ago. the client states im so stressed that i cant take this anymore. which of the following actions should the nurse take first
identify the client's current coping strategies
nurse is providing discharge teaching to a client who is at 32 weeks of gestation and had an episode of preterm labor. which of the following should the nurse include in the instructions? - increased watery vaginal discharge will occur as pregnancy progresses (no, discharge that is thin & watery can indicate rupture of amniotic membrane, report to provider) - "if contractions recur, drink 2-3 glasses of water" (YES) - "maintain complete bed rest for remainder of pregnancy" (NO, there is no evidence to prove that this is effective. complete bed rest can have A/E on health/well-being of client. Modified bed rest or activity restrictions allow pt to use bathroom, shower & have meals at the table) - "there is no need to report painless contractions to provider" (no, manifestations of preterm labor include painful or painless contractions that occur every 10 minutes or more for 1 hr. report to provider)
if contractions recur, drink two or three glasses of water - dehydration can lead to uterine contractions due to stimulation of the anterior pituitary gland, which secretes antidiuretic hormone & oxytocin. If the pt notices contractions they should first drink 480-720 mL (16-24oz) of fluids to ensure hydration. if contractions persist beyond 1 hour, pt should notify provider.
nurse is assessing a client who has borderline personality disorder. which of the following characteristics should the nurse expect? - arrogance (this would be narcissistic personality disorder) - attention-seeking behavior (this would be histrionic personality disorder) -impulsiveness (YES) - suspicion (this would be paranoid personality disorder)
impulsiveness
nurse is teaching about home safety with parent of a newborn. which of the following info should the nurse include
increase the temperature of the room prior to bathing the newborn (to 79-81 degrees) also: - hot water heater shouldnt be above 120 degrees
nurse is reviewing the lab report of a school age child who has acute poststreptococcal glomerulonephritis. which of the following lab values should the nurse expect - increased specific gravity (YES) - decreased creatinine (no, it would be increased) - decreased BUN (no, it would be increased) - positive urine culture (no, it would be negative)
increased SG This test measures the concentration, therefore the result indicates the childs urine is concentrated
a nurse is admitting a client who is at 36 weeks of gestation and has placenta previa. the client is experiencing moderate vaginal bleeding. which of the following actions should the nurse take? - admin betamethasone to pt (no, this is given if pt is at less than 34 weeks of gestation) - assess dilation of cervix (no this can increase bleeding and lead to hemorrhage) - perform contraction stress test on pt (no, this is used to determine if contractions decrease placental blood flow and produce hypoxia in the fetus) - initiate IV access for the pt (yes)
initiate IV access for the client Nurse should initiate large-bore IV access for a client who has placenta previa and is bleeding. The nurse should also obtain blood specimens for testing and plan to administer a blood transfusion if the pt's bleeding continues
nurse is assessing a 2 year old toddler who has Down syndrome during a well-child visit. the parent reports concerns regarding his child's delayed developmental achievement. which of the following responses should the nurse make?
is your child receiving the physical therapy we recommended?
nurse is admitting a client who is at 36 weeks of gestation and is experiencing eclampsia. which of the following actions is the nurse's priority?
keep the client's head to one side - the first action the nurse should take when using the ABC approach is to turn the client's head to one side and position a pillow under her shoulder. The client is at risk for aspiration during a seizure, so the priority is to keep pt airway patent. Nurse should also: - pad side rails w blankets/pillows to prevent musculoskeletal and integumentary trauma due to uncontrollable limb movements during a seizure - call for help to assist with preventing/managing injuries or with airway clearance from aspiration of secretions during a seizure - admin oxygen w/ nonrebreather mask at 10 L/min once seizure subsides to ensure adequate oxygenation postictally all of the above are correct interventions BUT what is 1st priority?? (ABCs) - KEEP PT HEAD TO ONE SIDE TO ENSURE PATENT AIRWAY
nurse is reviewing the medical record for a client who is in active labor. which of the following findings should the nurse identify as a risk factor for postpartum hemorrhage?
labor induced with oxytocin or a prolonged labor is a risk factor. along with: high parity, uterine inversion, placenta previa, placenta accreta, chorioamnionitis, fetal macrosomia, polyhydramnios, and vacuum-assisted birth.
nurse is caring for a client who is 4 hour postpartum and is experiencing excessive vaginal bleeding. which of the following actions is the nurses priority
massage clients fundus
nurse is caring for a client who is experiencing a postpartum hemorrhage. which of the following medications should the nurse plan to administer? - methylergonovine (YES) - magnesium sulfate (no, this is used to prevent seizures in pts with preeclampsia) - terbutaline (NO, this is a tocolytic med used to tx preterm labor. terbutaline causes relaxation of smooth muscle of uterus) - betamethasone (no this is given to stimulate fetal lung maturity in a client experiencing preterm labor)
methylergonovine - this med causes contractions of the uterine muscle which decreases bleeding
nurse is reviewing the medical record of a client who requests a prescription for an oral contraceptive. which of the following findings should the nurse identify as a contraindication to an oral contraceptive? - hx of gestational diabetes (no a history of diabetes of more than 20 years with vascular disease is contraindicated) - migraine w. aura (YES) - hx of asthma (no) - renal lithiasis (no)
migraine with aura the nurse should identify that migraine with neurologic symptoms is a contraindication to the use of oral contraceptives because this increases a client's risk for stroke. other contraindications of oral contraceptives = liver tumors, HTN, & gallbladder disease
nurse is teaching a client who has a new prescription for sildenafil to treat erectile dysfunction. which of the following information should the nurse include in the teaching?
monitor for dizziness while on this medication (sildenafil can cause hypotension- monitor/report dizziness to HCP) also teach pt: - not to take med more than once per day - med can cause insomnia - that med is effective 30min-4hr before sexual activity
a nurse is planning care for a client who has alcohol use disorder. which of the following medications should the nurse expect the provider to prescribe? - bupropion (no, this is for withdrawal from nicotine) - naltrexone (YES) - buprenorphrine (no, this is for withdrawal from opioids) - methadone (no, this is for pt w/ opioid use disorder and requires detoxification)
naltrexone this is used for alcohol use disorder and can also be used in tx of opioid use disorder
nurse is caring for a client who is at 33 w gestation and has a new diagnosis of preeclampsia. which of the following medications should the nurse expect the provider to prescribe? - nifedipine (yes, this is a calcium channel blocker) - terbutaline (no this is a tocolytic used for tx of preterm labor) - methylergonovine (no, this is a uterotonic med & shouldnt be given due to the adverse effect of HTN) - misoprostol (NO, this is a uterotonic med that causes contractions & is used to tx postpartum hemorrhage)(dont want contractions w pt at 33 weeks)
nifedipine Calcium channel blocker used to relax vascular smooth muscle, which decreases blood pressure.
nurse is educating a group of staff nurses about the difference between non-Hodgkin's lymphoma and hodgkins lymphoma. the nurse should include which of the following statements in the teaching? - "non-hodgkins involves painful lymph nodes" (no, NHL manifest painless, swollen lymph nodes) - "hodgkins is the result of a bacterial infection" (no, HL can be caused by viral infections such as HIV or Epstein-Barr virus) - "non-hodgkins progresses erratically through the lymphatic system" (YES) - "hodgkins rarely responds to treatment" (no, HL responds well to tx. Tx is determined by the stage of the disease)
non-hodgkins lymphoma progresses erratically through the lymphatic system - to other lymph nodes and organ systems. HL spreads systemically from one group of lymph nodes to the next group of nodes.
nurse is planning care for a client who is being admitted for treatment of anorexia nervosa. which of the following actions should the nurse include in the plan? -emphasize nutritional value of foods during meals (no, RN should emphasize social aspect of eating during mealtimes) - limit pt exercise to no more than 30 min/day (no, pt not allowed to exercise until target wt is reached) - observe pt for 60 min after meals (YES) - weigh the pt every other day (no, should weigh pt every day in the morning after pt has voided)
observe the client for 60 min. after meals
nurse is caring for an infant who has a patent ductus arteriosus and HF. which of the following interventions should the nurse perform
offer the infant small, frequent feedings during times of HF, the decreased cardiac output lowers tolerance to activity . The infant might have difficulty meeting caloric needs due to fatigue. Small, frequent feedings can enable overall increased caloric intake. nurse should also: - during episodes of HF the nurse should keep the HOB elevated 30-45 degrees to promote chest expansion and ease WOB - the nurse should assess the infants APICAL pulse every 2-4 hours as needed. When cardiac output is low there might be a discrepancy b/w the apical and radial pulse.
nurse is updating the meal plan for a client who has resolving diverticulitis and is being advanced to a high fiber diet. the nurse should recognize that which of the following food is the best source of fiber? - 1 cup green grapes (1.4g fiber) - 1 cup lettuce (1 g of fiber) - one medium banana (3.1 g of fiber) - one medium cucumber (1.4g of fiber)
one medium banana
a nurse caring for a client who has gastroenteritis and reports diarrhea and vomiting for 3 days. which of the following findings should the nurse recognize as a manifestation of this inflammatory bowel disease? -hiccups (no this would be peritonitis, hiccups are caused by inflammation of the diaphragm) - rebound tenderness of the abdomen (no this would be peritonitis) - orthostatic hypotension (YES) - shoulder pain (no, this would be peritonitis, can also have chest pain)
orthostatic hypotension (caused by dehydration from fluid loss and electrolyte imbalance)
nurse is assessing an adolescent client who has ewing sarcoma. which of the following manifestations should the nurse expect? -pain in upper thigh (YES) - client reports increased urination (no) - client reports swelling of fingers (no) - client reports blood in stool (no)
pain in the upper thigh nurse should expect a pt with Ewing sarcoma to report (localized) pain. Along with a palpable mass, fever, and swelling.
nurse is caring for a client following a stroke. which of the following actions should the nurse take to increase the clients cerebral perfusion? - elevate HOB to 90. degrees (no, lower bed to increase cerebral perfusion, less than 25 degrees) - position pt's head in midline position (YES) - place pt in sims' position (no, nurse should place pt in supine position, avoid flexing pt's hips bc this can increase intrathoracic pressure) - encourage pt to cough deeply (no, this cn increase ICP and reduce cerebral perfusion)
position the client's head in a midline position (to increase cerebral perfusion. the nurse should avoid flexing the pt's neck, bc this can decrease cerebral venous drainage and decrease cerebral perfusion)
nurse is planning care for a newborn who was born at 33 weeks gestation and is 2 days old. which of the following interventions should the nurse include?
position the newborn side-lying or prone while in the nursery. also: - only bathe newborn with plain water - dim lights in nursery during night & at intervals during day (this helps to establish diurnal/noctural rhythms & promotes sleep/wake cycles - promote skin to skin (there is no wt requirement, helps to reduce stress, regulate temp and O2 sats in newborn, and promotes bonding b/w parent & newborn)
nurse is obtaining a history from a client who has major depressive disorder. which of the following findings should the nurse identify as a risk factor for suicide
recent move across the country to look for work - loss of employment + isolation from one's usual social networks, family, and friends can increase a client's risk for suicide.
nurse is assessing a 2 year old toddler at a well visit. for which of the following findings shuld the nurse refer the toddler for an evaluation for autism spectrum disorder
reluctance to make eye contact
a nurse is caring for a client who is receiving IV oxytocin for induction of labor. the fetal heart rate tracing reveals multiple variable decelerations. which of the following actions should the nurse take? - resposition client (YES) - admin methylergonovine (no, this should not be given while client is pregnant bc it is used to tx uterine hypotonia) - admin oxygen 2 L/min via nasal cannula (no, admin O2 at 10 l/min via nonrebreather mask bc O2 at this rate improves uteroplacental perfusion) - prepare client for a biophysical profile (no, this is used during antepartum period to discern fetal wellbeing)
reposition the client - to relieve compression of the umbilical cord
nurse is teaching about managing fatigue with a client who has end-stage COPD. which of the following statements should the nurse include in the teaching? - "eat dry foods to minimize coughing" (no, dry foods can stimulate coughing which causes fatigue) - "rest elbows on table when doing an activity" (yes, and raise height of table to prevent back strain) - "walk daily for 60 min followed w/ rest period" (no, walk at self-paced rate & stop when s/s of fatigue occur. pt should rest, walk again, then rest again, until 20 min of walking is completed) - "raise HOB to 15 degrees when sleeping" (no, pt should sit upright w/ HOB elevated to decreased dyspnea)
rest your elbows on a table when doing an activity
nurse is teaching about acute glomerulonephritis. which of the following info should the nurse include? -expect urine to remain clear or straw colored (no, it will be smoky/reddish brown/rust colored) -restrict fluid intake based on previous day's UOP (YES, restrict to 500-600 mL above the 24 hr UOP to prevent fluid volume overload, increased BP, and edema) - include foods high in sodium in the diet (NO, pt should DECREASE sodium to prevent fluid volume overload, increased BP, and edema) - measure wt twice/wk (no, measure wt and BP DAILY, increase indicates fluid retention)
restrict fluid intake based on previous day's urine output - restrict to 500-600 mL above the 24 hr UOP to prevent fluid volume overload, increased BP, and edema
nurse assessing opioid withdrawal should expect what manifestation? - rhinorrhea (YES) - pinpoint pupils (no, they would have enlarged pupils, hyperreflexia and diaphoresis) - bradypnea (no, they would have tachypnea) - increased appetite (no, they would have N, V, and abdominal cramping)
rhinorrhea (along with yawning, tearing, and hyperthermia)
nurse is reviewing the lab results for a client who has HELLP syndrome. which of the following laboratory results should the nurse expect? - Hct 37% (no, over 33% is normal for a pregnant pt - HELLP will have a decreased Hct) - BUN 15 mg/dL (no, b/w 10-20 is WNL for pregnant pt) - Plt count 150,000/mm (no, b/w 150,000-400,000 is WNL for pregnant pt) - serum uric acid 11 mg/dL (YES, 11 is ABOVE normal range of 2.7-7.3. Pts with HELLP have elevated serum uric acid)
serum uric acid 11 mg/dL Normal range = 2.7 to 7.3, this is elevated
nurse is providing dietary management to a client who is at 10 w of gestation and has hyperemesis gravidarum. what statement should the nurse make
should eat at least every 2 hours to avoid an empty stomach also teach: - cold foods may be better tolerated - consume sweet foods then proteins - dairy may be better tolerated than other foods
nurse in a providers office is reviewing the lab report of a client who take lithium for bipolar disorder. which of the following lab results should the nurse report to the provider - WBC count 7,000 (no, if it was over 10,000 it would indicate leukocytosis (lithium can cause this) and would need to be reported) - BUN 15 (no, dehydration can cause lithium toxicity (indicated by plasma lvls over 1.4, but this level does not indicate dehydration) - Potassium 4.2 (no, this is WNL) - sodium 128 (yes)
sodium 128 this is below expected range (136-145) and places client at risk for lithium toxicity. Report this to provider
community health nurse is assessing an older adult client. nurse should identify that which of the following findings is a manifestation of elder neglect? - peripheral edema (no, this indicates fluid overload) - difficulty sleeping (NO, this is expected due to difficulty falling asleep and staying asleep in an older adult client) - sunken eyes (YES) - decreased bowel sounds (no, this is expected in older clients)
sunken eyes This is a manifestation of dehydration and can indicated elder neglect/abuse. Other s/s include malnutrition, contractures, and excessive body odor.
nurse is teaching about disease management with a client who has parkinsons disease. which of the following statements should the nurse include in the teaching?
take medications at the same time each day (to maintain therapeutic medication levels) also teach pt to: - schedule appts later in the day to provide adequate time for tasks & to decrease likelihood of hurrying which can increase fatigue/stress - plan high calorie/high protein meals - stand up straight and look forward when walking to steady the gait & prevent falls
nurse is reviewing the medical history of a client. the nurse should identify that which of the following findings indicates the client is at risk for a stroke? - hx of hypopituitarism (no, hx of this puts pt at risk for developing osteoporosis) - takes combination of oral contraceptive (YES) - drinks 150 mL (5 oz)(1 glass) of wine each day (no, 3 more more drinks per day places pt at risk for stroke) - avoids saturated fats in cooking (no, pt who eats saturated fats are at risk, avoiding them decreases the risk)
takes a combination oral contraceptive
nurse is teaching a client who has melanoma about nonsurgical treatment options. the nurse should include which of the following options in the teaching? - brachytherapy (no, this is tx of prostate cancer and ineffective in tx of melanoma) - topical chemotherapy (no, this is used for tx of multiple actinic keratoses or for widespread superficial basal cell carcinoma) - targeted therapy (YES) - radiation therapy (no, this is used to tx large, deeply invasive basal cell tumors in clients who might have a poor surgical outcome. radiation is ineffective in tx melanoma due to its relative resistance)
targeted therapy - the medication vemurafenib is an oral medication administered for the tx of melanoma that can target specific molecules and interfere with cell division and the growth and progression of the disease.
nurse is teaching a client who is scheduled for the placement of a penile implant for the treatment of erectile dysfunction. which of the following statements by the client indicates an understanding of the teaching? - "this implant has a suction device that will draw blood into my penis" (no, this would be a vacuum device) - "this implant can be deflated by pushing a button in my scrotum" (YES) - "this implant uses a rubber ring to help maintain my erection" (no, this is a vacuum constriction device) - "this implant will protect me from STIs" (no, only using condoms can do this)
this implant can be deflated by pushing a button in my scrotum instruct pt that the implant causes tumescence through the use of saline that fills a prosthesis in the penis. The prosthesis is deflated by pushing a button in the scrotum
nurse in a mental health facility is assessing a client who has a history of alcohol use disorder. the client states their last drink was 24 hour ago. for which of the following manifestations of alcohol withdrawal should the nurse monitor? - hypotension (no, it would be increased within 12-72 hr of the last drink) - somnolence (no the pt would have disturbed sleep w/in 12-72 hours of last drink) - tremors (YES) - bradycardia (no, pt would have tachycardia w/in 12-72 hours of last drink)
tremors (if physical dependence is high, the tremors can be intense)
nurse is providing teaching to a cleint who has preeclampsia without severe features. which of the following instructions should the nurse include? - monitor temp twice per day (no, teach to monitor BP twice each week, elevated temp is not expected w/ preeclampsia) - restrict fluid intake to four 245-mL (8oz) glasses a day (no, clients w/ severe features should limit fluid intake to prevent pulmonary edema) - maintain a dark, quiet environment as much as possible (no, this is for clients w. severe features to avoid stimuli that may cause seizure activity) - use a side-lying position when resting in bed or on the couch (YES)
use a side-lying position when resting in bed or on the couch (this increases blood flow to uterus & placenta, this position optimizes delivery of nutrients and oxygen to fetus) also teach pt to: - monitor BP twice each week
nurse is teaching about approaches to care with the family of a client who has a new diagnosis of dementia with confusion. which of the following info should the nurse include in the teaching? - use large calendars that are easy for the pt to read (yes) - keep the pt's room completely dark at night (no, it should be dimly lit to prevent falls & wandering) - provide thorough explanations when speaking with the client (NO, the nurse should provide simple explanations/directions to prevent confusion) - speak loudly when communicating w/ client (no, speak slowly to normal volume, too loud might upset or anger the pt)
use pictures and gestures when giving instructions
nurse is teaching about pancreatic enzyme replacement therapy with a client who has chronic pancreatitis and is starting to take pancrelipase capsules. which of the following info should the nurse include when teaching about pancrelipase? - admin the capsules after each meal (no, teach to take before or with each meal and to drink a glass of water) - vary the amount of medication taken based on the amount of food consumed (YES) - sprinkle med on a protein-rich food (NO, it can be mixed with applesauce or another acidic type food if pt has difficulty swallowing, never CHEW OR CRUSH) - take the med with calcium carbonate antacids when needed (no, take pancrelipase after antacid or H2 blocker bc they decrease gastric pH and cause the enzymes to become inactivated)
vary the amount of medication taken based on the amount of food consumed take half the dose prescribed for meals when having a snack, total daily dose should equal the amt for 3 meals and 2-3 snacks perday
nurse is assessing a client following stroke. nurse should identify that which of the following findings is a manifestation of increased ICP? - sudden onset of eye pain (NO, this a manifestations of acute glaucoma & is a medical emergency) - kussmaul respirations (no, cheyne-stokes are a manifestation of IICP) - vomiting (YES) - hypotension (no, HTN is a manifestation of IICP)
vomiting (other manifestations include decreased LOC, slurred speech, change in pupil size, and widened pulse pressure)
nurse is teaching about self management of STIs with a client who has genital herpes. which of the following instructions should the nurse include in the teaching
wear gloves when applying anesthetic ointments to avoid spreading infection to other areas. also teach pt to: - begin oral antiviral med w/in 1 day of outbreak - use latex or polyurethane condoms during sexual activity - take a sitz bath 3-4/day
nurse is teaching a client who has epilepsy and a prescription for valproic acid. the nurse should instruct the client to report which of the following as an adverse effect of the medication? - yellow sclera (YES) - elevated temperatures (no, adverse effect would be hypothermia, teach client to dress warmly in cold weather to reduce risk of injury) - bleeding gums (no, adverse effect is indigestion & anorexia, teach pt to report changes in appetite.
yellow sclera (hepatotoxicity is a potentially life-threatening adverse effect, teach pt to report yellow sclera or yellowing of the mucous membranes, abdominal pain, and loss of appetite to provider ASAP)
nurse in an emergency dept. is counseling a client who experienced sexual violence. after addressing the client's physical needs, which of the following statements is the priority for the nurse to make
you are safe here
a nurse is caring for a client who has alzheimers. the client's daughter asks the nurse if she will have AD as well. which of the responses should the nurse make regarding the genetic predisposition of this disease.
you can be tested for the presence of apolipoprotein, an indication of an increased risk of developing AD. The nurse should inform the daughter that genetic testing can be done prior to the occurrence of any S/S. The test notes the presence of the apolipoprotein E-4 gene, which can indicate an increased risk of developing AD.
a nurse is teaching a client who is preop for an abd. hysterectomy with a bilateral salpingo-oopherectomy. which of the following statements should the nurse make
you might develop menopausal symptoms after this procedure such as; hot flashes, night sweats, and vaginal dryness, because the ovaries, which produce sex hormones, will be removed teach pt that: - even though she cannot get pregnant, she can still get STI's - she may have some vaginal drainage for a few days post-op but since the uterus is removed she will no longer have a period - she should avoid intercourse for 4-6 weeks to reduce the risk of bleeding
nurse is providing teaching to a client who has a new prescription for a diaphragm. which of the following statements should the nurse make?
you should be refitted for a new diaphragm if your weight changes by 20 percent or more also teach pt: - to insert diaphragm no more than 6 hr prior to sex and apply 10 mL (2tsp) of spermicide inside diaphragm prior to insertion - diaphragm should remain in place for at least 6 hr after intercourse, pt should remove diaphragm no more than 24 hr after sex to reduce risk of toxic shock syndrome - replace diaphragm every 2 years - pt should be refitted for a new diaphragm after abdominal surgery, pelvic surgery, and each pregnancy
