ATI remediation

During an emergency, a physician has asked for I.V. calcium to treat a client with hypocalcemia. The nurse should:

Check with the physician for his complete order.

A client develops decreased renal function and requires a change in antibiotic dosage. On which factor should the physician base the dosage change?

creatinine clearance

A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving

A-positive blood to an A-negative client.

What is Naegele's rule?

Add 7 days to the first day of the LMP and subtract 3 months to estimate a woman's EDC

Which action should be the priority when caring for a school-age child admitted to the pediatric unit with the diagnosis of Guillain-Barré syndrome?

Evaluate the child's bilateral muscle strength.

The nurse is caring for a client that has undergone a colon resection. While turning the client, wound dehiscence with evisceration occurs. What is the nurse's first response?

Place saline-soaked sterile dressings on the wound

true/false; Sleep disturbances are common for children with ADHD?

True

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?

"Before you do the exercise, I'll give you pain medication if you need it.

A client has been taking furosemide for 2 days. The nurse should review the laboratory record for changes in which blood level?

decreased potassium

What does preoccupational death mean?

fear of dying

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

keeping the client in one position to decrease bleeding

What is renal calculi ?

kidney stones

When is the placenta detached?

lengthening of cord

What is thrombocytopenia?

low platelet count

The nurse is preparing a client with an indwelling urinary (Foley) catheter for a catheter irrigation. The client states, "I don't understand why I need this procedure." What is the nurse's best response?

"Flushing your catheter is needed to unblock your flow of urine."

Which client statement should the nurse evaluate as indicating the client's correct understanding of the causes of coronary artery disease (CAD)?

"The leading cause of CAD is atherosclerosis."

What is the average FHR?

110-160 bpm

A nurse is preparing to administer a unit of blood to a client with anemia. After removal of the blood from the refrigerator, the transfusion of the blood must be completed within:

4 hours

What is PKU referring to a neonate?

A birth defect that causes an amino acid called phenylalanine to build up in the body.

What is hemophilia A?

A disorder in which blood doesn't clot normally.

What is diabetes insipidus?

A disorder of salt and water metabolism marked by intense thirst and heavy urination.

A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown. At 1030, the client has sharp mid-chest pain after having a bowel movement. What should the nurse do first?

Assess the client's vital signs.

The nurse is providing discharge teaching to a client diagnosed with a peptic ulcer. Which instruction should the nurse provide?

Avoid taking any over-the-counter nonsteroidal anti-inflammatory medications."

What is intussusception?

Intussusception is a medical emergency involving obstruction of the intestine.

A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which action should the nurse take?

Note that the nurse caring for the client cannot be a witness.

Which intervention should the nurse employ to reduce trauma caused during vaccine administration to a 6-month-old infant?

Simultaneously administer vaccines at separate sites with a second nurse.

A nurse explains to a client with thyroid disease that the thyroid gland normally produces

T3, thyroxine (T4), and calcitonin.

The nurse administers a tap water enema to a client. While the solution is being infused, the client has abdominal cramping. What should the nurse do first?

Temporarily stop the infusion, and have the client take deep breaths.

For a 3-year-old child with tracheobronchitis, the nurse formulates a nursing diagnosis of ineffective airway clearance related to stasis of secretions. After implementing interventions, what does the nurse indicate as the most desired outcome?

The child exhibits clear breath sounds.

A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy?

The client demonstrates ability to tolerate more activity without chest pain.

Which consideration is the most important when performing tracheotomy suctioning?

The client should be hyperoxygenated, then suctioned for 10 to 15 seconds

A pediatric client has just had a plaster cast placed on his lower left leg. Which action should the nurse take to provide safe cast care?

Use only the palms of the hand when handling the cast.

A nurse is caring for a pediatric client with scoliosis who has to wear a brace. The nurse should develop a teaching plan with the client to include which instruction?

Wear a form-fitting t-shirt under the brace.

The nurse is performing a digital rectal examination. Which finding is a key sign for prostate cancer?

a hard prostate, localized or diffuse

What is anthrax?

a rare/serious bacterial infection

How can you treat a pt with dystonic reaction?

benztropine

A nurse uses Nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes have ruptured, the paper will turn which color?

blue

After suctioning a client, a nurse should expect to find

clear breath sounds

What therapeutic outcome does the nurse expect for a client who has received a premedication of glycopyrrolate?

decreased secretions

The nurse assesses a child with suspected juvenile hypothyroidism. Which signs or symptoms should the nurse expect this child to manifest?

dry skin and constipation

While the nurse is performing a complete assessment of a term neonate, which finding would alert the nurse to notify the health care provider (HCP)?

expiratory grunt

What is agoraphobia?

fear of public places

A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called?

flight of ideas (abrupt change in topic)

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

high protein

A child with cystic fibrosis has been admitted to the pediatric unit. What type of diet should the nurse request for the client?

high-calorie, high-protein

A client with cancer is being evaluated for possible metastasis. What is one of the most common metastasis sites for cancer cells?

liver

What does gluccosteriods do to pts BS?

raises it

A client received magnesium sulfate during labor. Which condition should the nurse anticipate as a potential problem in the neonate?

respiratory depression

After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective if the client does not develop which complication?

seizures

A nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should include information about

tamoxifen

Describe the scoring of a Glosgow coma scale?

the lower the number, the worse the pt is

True/False. Ethical standards are higher than law standards?

true

A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by

turning the client's head suddenly while holding the eyelids open.

A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?

use smallest needle possible

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when the nurse notes tidal movements or fluctuations in which compartment of the system as the client breathes?

water-seal chamber

A client begins clozapine therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The client is instructed to return to the office laboratory weekly for 6 months to have blood drawn. Which laboratory results would be of concern to the nurse after the third test?

white blood count (WBC) of 3000

Which finding is normal for a client during the icteric phase of hepatitis A?

yellowed sclera

What should the nurse include in the client's teaching about the side effects of hydrochlorothiazide? Select all that apply.

"Hydrochlorothiazide can cause your eyes to be sensitive to light." "Hydrochlorothiazide can cause the sodium in your blood to be too low." "Hydrochlorothiazide can cause high blood sugar."

A client with a history of painful, continuous muscle spasms is prescribed diazepam, 2 mg P.O. twice daily. The client states the medication is effective and requests to use it long term. Which response by the nurse is most appropriate?

"Long-term use of this medication may result in addiction.

A 2-year-old child is prescribed cyclosporine. The parent says the child doesn't like taking the liquid medication. Which statement by the nurse is most appropriate?

"Offer the medication diluted with chocolate milk or orange juice to make it more palatable."

A community nurse is assessing a young child who has had a colostomy stoma for several years. The nurse notices that the stoma is dark pink and moist. What is the best response to the child's parents about the appearance of the stoma?

"The stoma looks healthy; continue your present care."

A client with new-onset seizures of unknown cause is started on phenytoin. The healthcare provider has ordered a loading dose of 15 mg/kg I.V. to be given at a rate of 40 mg/min. What is the loading dose in milligrams if the client weighs 176 lb (80 kg)? Record your answer using a whole number

1200

What is ulcerative colitis?

Chronic inflammatory disease that causes ulceration of the colonic mucosa

A client with hyperthyroidism is to have a thyroidectomy. The health care provider (HCP) has prescribed propranolol. In reviewing the client's history, the nurse notes that the client has asthma. What should the nurse do next?

Contact the HCP and discuss the prescription for propranolol because of the client's history of having asthma.

A client with heart failure will take oral furosemide at home. To help the client evaluate the effectiveness of furosemide therapy, the nurse should teach the client to:

Daily weight

A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus?

Gently aspirate the I.V. catheter to check for a blood return

A client is typed and cross-matched for three units of packed cells. What are important precautions for the nurse to take before initiating the transfusion? Select all that apply.

Have two nurses check the blood type and identity. Initiate an IV with normal saline. Take baseline vital signs.

A client at 27 weeks gestation experiences uterine cramping and also secretes a small amount of bright red bleeding and mucus. The client calls her prenatal clinic nurse. Which of the following recommendations is most appropriate from the nurse?

Instruct the client to go to an emergency room for an urgent assessment. ** remember pick the answer that is best in regards to safety

Which action has the highest priority in the care of a client with chronic renal failure?

Maintain a low-sodium diet.

What is the most important goal of nursing care for a client who is in shock?

Manage inadequate tissue perfusion.

Which action would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched?

Notify the primary care provider because this may indicate a neurologic problem.

A nurse explains the process of cane usage to a hospitalized client with left-sided weakness. Place the steps of teaching proper cane usage in the correct order. All options must be used.

Perform hand hygiene. Secure a gait belt around client's waist. Place the cane in the right hand. Have client advance the cane and the left leg. Have client advance the right leg.

Which nursing intervention should be included in the care of an unconscious child with Reye's syndrome?

Place the child on a sheepskin.

An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain prior to surgery?

Place the client in semi-Fowler's position with the knees to the chest.

S1 is loudest at ? And S2 is loudest at the ?

S1 is loudest at the apex, and S2 is loudest at the base.

A primiparous client is on a regular diet 24 hours postpartum. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle?

The mother can bring the daughter any foods that she desires.

To protect a client who has received tissue plasminogen activator (t-PA) or alteplase recombinant therapy, what should the nurse do?

Use the radial artery to obtain blood gas samples.

A child is diagnosed with Wilms' tumor. During assessment, the nurse expects to detect

abdominal mass

Which factor best indicates that a client is complying with digoxin therapy?

ability to correctly count the radial pulse

A mother states that a health care provider (HCP) described her daughter as having 20/60 vision, and she asks the nurse what this means. The nurse responds based on the interpretation that the child is experiencing which condition?

ability to see at 20 feet what she should see at 60 feet

Describe what abstract thinking is?

able to understand things that are real but arent directly tied to concrete objects

A nurse is palpating the uterine fundus of a client who gave birth to a neonate 8 hours ago. Identify the area where the nurse should expect to feel the fundus.

at the belly button

A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client?

broth, gelatin cubes, and tea

The nurse notes serous discharge when an abdominal dressing is changed. How would the nurse would document this drainage?

clear, watery, yellow-tinged drainage

What is neuroleptic malignant syndrome?

consists of muscle rigidity, fever, autonomic instability, and cognitive changes such as delirium. is due to antipsychotic agents

A client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which signs or symptoms indicates a toxic response to the chemotherapy?

cough and shortness of breath

A client returns from a left heart catheterization. The right groin was used for catheter access. In which location should the nurse palpate the distal pulse on this client?

dorsal surface of the right foot

What are tactile hallucinations?

feeling bodily sensations (can occur in alcohol withdrawal)

What is third spacing?

he movement of bodily fluid from the blood, into the spaces between the cells.

What is addisons disease?

hormone deficiency caused by damage to the outer layer of the adrenal gland they need diet high in salt, carbs, and protein low in potassium

Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream?

hypertonic

A client's serum ammonia level is elevated, and the health care provider (HCP) prescribes 30 mL of lactulose. Which effect is common for this drug?

increased bowel movements

After teaching the mother of a toddler with iron deficiency anemia about diet modifications, the nurse determines that the teaching was initially effective when the mother verbalizes she will make which dietary change?

increased intake of iron-rich solids and decreased milk intake

What is diverticulitis?

inflammation of the diverticula(digestive tract)

What is peritonitis?

inflammation of the peritoneum (lining of the abdomen)

What is a dystonic reaction?

involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures

Describe PTCA (percutaneous transluminal coronary angioplasty)?

involves opening a blocked artery with an inflatable balloon located on the end of a catheter

What is the normal range for PKU levels?

less than 2 milligrams per deciliter (mg/dL)

The nurse is caring for a client with diabetes insipidus (DI). What is the nurse's priority intervention?

maintain adequate hydration

The nurse should instruct the client with vitamin B12 deficiency to eat which foods to obtain the best supply of vitamin B12?

meats and dairy products

What is an appropriate nursing action to detect early signs of metabolic complications in a client receiving total parental nutrition (TPN)?

monitor output

The client with chronic obstructive pulmonary disease is taking theophylline. The nurse should instruct the client to report which signs of theophylline toxicity? Select all that apply.

nausea vomiting seizures insomnia

What is cultural habitutation?

no response to over stimulation

The nurse is teaching an adolescent with celiac disease about dietary changes that will help maintain a healthy lifestyle. Which of the following foods can the nurse safely recommend as part of the adolescent's diet? Select all that apply.

potatoes apples corn

A positive tuberculin skin test indicates that a client

produced an immune response

When assessing a child with bronchiolitis, which finding does the nurse expect?

productive cough

What is Wilms tumor?

rare type of kidney cancer; a nephroblastoma

What should you expect to find on assessment of diverticulitis and peritonitis?

rigid abdomen wall

Describe the Rule of Nines?

separates body in 11 portions, 9% each -- estimates degree of burns

A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease?

serum potassium level of 5.8 mEq/L (5.8 mmol/L)

An elderly client admitted with new-onset confusion, headache, and bounding pulse has been drinking copious amounts of water and voiding frequently. The nurse reviews the laboratory results (see accompanying chart). Which of the abnormal lab values is consistent with the client's symptoms?

serum sodium

What is SARS?

severe acute respiratory syndrome. A contagious and sometimes fatal respiratory illness caused by a coronavirus.

A male neonate with a 3 X 5-cm sac in the lumbar region of his back is diagnosed with myelomeningocele. What should the nurse expect to find when inspecting this sac?

spinal fluid, nerve tissue, and spinal bony defect

The nurse is caring for a toddler who has been diagnosed with pernicious anemia. Which of the following should the nurse include in the health teaching about pernicious anemia for the parents?

the need to comply with lifelong injections of vitamin B12

A client recently gave birth. Two minutes before breast-feeding the baby, she administers one nasal spray (40 units/ml) of oxytocin into each nostril. Why is the client using this drug?

to stimulate lactation

A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the health care provider (HCP) before having which procedure?

tooth extraction

A nurse is caring for a toddler in respiratory distress requiring endotracheal intubation. When gathering supplies, which item should the nurse obtain that is most important for this child?

uncuffed endotracheal tube

A child, age 5, is brought to the pediatrician's office for a routine visit. When inspecting the child's mouth, the nurse expects to find how many teeth?

up to 20

When caring for a client with diabetes insipidus, the nurse expects to administer

vasopressin

A nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will order daily supplements of calcium and

vitamin D

The nurse is assessing a client recovering from a hemorrhagic cerebral vascular accident (CVA) that occurred 7 days ago. Which assessment finding should be reported to the healthcare provider?

worsening headache

The nurse is giving preoperative instructions to a client who will be undergoing rhinoplasty. What should the nurse tell the client?

"Do not take aspirin-containing medications for 2 weeks before surgery."

The client is to receive theophylline 500 mg IV in 500 mL of normal saline solution to run over 4 hours. The tubing delivers 60 gtt/mL. The nurse should set the infusion pump to administer the solution at how many milliliters per hour? Record your answer using a whole number.

125

At what gestational age should a primigravida expect to start feeling quickening?

18-20 weeks

Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 0200, 0530, 0800, 1100, 1400, 1630, 2000, and 2230. What is the total amount of calories the infant received today? Record your answer using a whole number.

240

What is risperidone

atypical antipsychotic

A parent asks, "How should I bathe my baby now that he has had surgery for his inguinal hernia?" Which instruction should the nurse give the mother?

"Give him a sponge bath daily for 1 week."

Which of the following indicates that the client with Addison's disease is receiving too much glucocorticoid replacement?

rapid weight gain

A client is diagnosed with diabetes mellitus. The physician orders 15 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. The nurse checks the medication order, assembles equipment, washes their hands, rotates the NPH insulin vial, puts on disposable gloves, and cleans the stoppers. To draw the two insulin doses into the single U-100 insulin syringe, which sequence should the nurse use?

Inject 35 units air into NPH vial; inject 15 units air into regular insulin vial, withdraw 15 units regular insulin; withdraw 35 units NPH.

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?

"You must avoid coughing, sneezing, and blowing your nose."

A client who is recovering from gastric surgery is receiving IV fluids to be infused at 100 mL/hour. The IV tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour? Record your answer using a whole number.

25

A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?

Administration of Rho(D) immune globulin I.M. to the mother within 72 hours

A first-time mother is concerned that her 6-month-old infant is not gaining enough weight. What should the nurse tell the mother?

Birth weight doubles by 6 months

"How does bethanechol act on the bladder?" How should the nurse respond?

stimulates smooth muscle of bladder

What is biofeedback?

It is a way to concentrate on the body's response during a stressful situation.

What is risperidone?

It is an antipsychotic drug mainly used to treat schizophrenia

A client is receiving parenteral nutrition through a central venous catheter. As the nurse is changing the dressing at the catheter site, the client asks why this type of catheter is being used instead of a regular peripheral I.V. Which is the best response by the nurse to explain the use of the central venous catheter?

The nutrients that are being administered are too concentrated for a peripheral I.V."

A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. Which factor is most important for the nurse to assess next?

temp

What is hypospadias?

is a birth defect in which the opening of the urethra is on the underside of the penis instead of at the tip.

Describe the relation between spirituality and religion?

organized system of beliefs

What is heparin used for? What is an adverse reaction of heparin?

prevents blood clots. slow pulse

A 10-year-old child has blood glucose readings during a 24-hour period. Which reading requires the most immediate intervention?

50(low)

After gathering all necessary equipment and setting up the supplies, what should be the first step in performing endotracheal (ET) or tracheal suctioning in an infant?

Provide extra oxygen by using a ventilator or through manual bagging.

Before corrective surgery, a nurse places a neonate with tracheoesophageal fistula (TEF) on his back in a crib with his head and shoulders elevated. Which finding indicates the positioning has been effective?

enhanced pooling of secretions in the bottom of the upper esophageal pouch

The nurse is monitoring an infant with meningitis for signs of increased intracranial pressure (ICP). The nurse should assess the infant for which signs and symptoms? Select all that apply. mood swings irritability emesis bulging fontanel headache

irritability bulging fontanel emesis

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

light-headedness or paresthesia

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances?

metabolic acidosis

After gastric resection surgery, which signs alert the nurse to the development of a leaking anastomosis?

pain, fever, and abdominal rigidity

The nurse should ensure that which item is placed when the client is to receive intravascular therapy for more than 6 days?

peripherally inserted central catheter (PICC)

A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. The assessments during this visit include: blood pressure 140/90 mm Hg; pulse 80 beats/min; respiratory rate 16 breaths/min. What further information should the nurse obtain to determine if this client is becoming preeclamptic?

proteinuria

A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of

sodium and potassium abnormalities

The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for:

sudden, severe hypertension

The health care provider (HCP) prescribes a urinalysis for a child who has undergone surgical repair of a hypospadias. Which results should the nurse report to the HCP?

twenty-five white blood cells per high-powered field