Final Exam
How do anti-hypertensive medications alter cardiac output? Increase Heart Rate Increase Stroke Volume Decrease Ejection Fraction Reduce Systemic Vascular Resistance
Reduce Systemic Vascular Resistance
A provider (PHCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the PHCP will write a prescription for? Platelets Packed red blood cells Cryoprecipitate Albumin
Cryoprecipitate
The nurse is assessing a client admitted to the telemetry unit from the Emergency Department with complaints of increasing shortness of breath, and is coughing pink-tinged frothy sputum. During the history assessment, the nurse documents a history of left-sided heart failure. The nurse recognizes the presenting signs and symptoms of which heart failure complication? Acute pulmonary edema Right-sided heart failure Myocardial infarction Bacterial pneumonia
Acute pulmonary edema
Which is the main goal of the treatment plan when providing care to a patient who has just experienced a stroke? Blood pressure management Oral hypoglycemic to maintain blood sugar between 120 and 150 mg/dL Adequate urine output Monitor swallowing function.
Blood pressure management
The nurse is preparing to administer mannitol as ordered for a client with cerebral edema and increased intracranial pressure. The nurse is aware that mannitol should be administered to this client via which route? Intravenously Intramuscular Intraosseously Orally
Intravenously
A patient who was admitted 24 hours ago has become increasingly irritable and now says there are bugs on his bed. Which condition should the nurse suspect? Delirium tremens (DTs) Alcohol-induced psychosis Neurologic injury related to a fall Posttraumatic stress reaction
Delirium tremens (DTs)
You have a patient admitted with an MRSA infection that has improved and will be discharged to home. What teaching items should you EXCLUDE for this patient? Hand hygiene for people who live with the patient is not necessary. If you are prescribed an antibiotic for a MRSA infection, complete the full course of antibiotics. Avoid sharing personal items such as towels or razors. For future care inform health care providers about MRSA status.
Hand hygiene for people who live with the patient is not necessary.
How does a client compensate for metabolic acidosis? Hyperventilation Renal retention of H+ Hypoventilation Renal excretion of HC03
Hyperventilation
A client presents to the walk-in clinic, reporting that he has been vomiting "off and on" for the past 24 hours. The nurse is aware that this client is at risk for which of the following complications? Hypokalemia & metabolic alkalosis Hyperkalemia & metabolic acidosis Hypokalemia & metabolic acidosis Hyperkalemia & metabolic alkalosis
Hypokalemia & metabolic alkalosis
The nurse is caring for a client with increased intracranial pressure. Which respiratory pattern changes will signal increased intracranial pressure? Irregular resps Slow resps Fast & Shallow resps Nasal Flaring
Irregular resps
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis
Metabolic alkalosis
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first? Obtain cultures of the wound. Redress the wound with wet-to-dry dressings Continue to monitor the wound for drainage. Begin antibiotic administration.
Obtain cultures of the wound.
You are caring for a 4 month old infant on day 3 of admission for RSV bronchiolitis. What assessments concerns you the MOST? Respirations 14 breaths per minute Wet diaper 4 hours ago No food intake in 18 hours Mild intercostal retraction noted.
Respirations 14 breaths per minute
Based on review of the literature about violence on inpatient psychiatric units, which characteristic is a predictor of violence? Sarcastic comments Age Race Gender
Sarcastic comments
This pathology is caused by a clot and is usually preceded by stroke-like symptoms that usually resolve in under an hour. TIA Hemmorhagic Thrombotic Embolic
TIA
The nurse understands that RSV usually causes the respiratory infection: bronchiolitis laryngitis pharyngitis No answer text provided.
bronchiolitis
The nurse is assessing a patient using the CAGE Questionnaire. The patient answers yes to all of the questions. The nurse suspects alcoholism and feels the patient is in denial when the patient makes which statement? "I don't have a problem with alcohol. I can quit anytime I want to." "I go to meetings once a day and still drink." "My family and friends have been avoiding me lately." "I know it will be hard to quit, but I am willing to try."
"I don't have a problem with alcohol. I can quit anytime I want to."
Which statement made by a parent indicates an understanding about the management of a child with cellulitis on the arm? "I am supposed to continue the antibiotic until the redness and swelling disappear." "I have been putting ice on my son's arm to relieve the swelling." "I should call the doctor if the redness disappears." "I have been putting a warm soak on my son's arm every 4 hours."
"I have been putting a warm soak on my son's arm every 4 hours."
A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? "I should notify my cardiologist if my feet or legs start to swell." "I am supposed to report to my cardiologist if my pulse rate decreases below 60." "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."
"My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."
The nurse has instructed the family of a client with stroke (brain attack) who has hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? "We need to discourage him from wearing eyeglasses." "We need to remind him to turn his head to scan the lost visual field." "We need to place objects in his impaired field of vision." "We need to approach him from the impaired field of vision."
"We need to remind him to turn his head to scan the lost visual field."
The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? "We need to remind him to turn his head to scan the lost visual field." "We need to place objects in his impaired field of vision." "We need to approach him from the impaired field of vision." "We need to discourage him from wearing eyeglasses."
"We need to remind him to turn his head to scan the lost visual field."
A client comes to the clinic with a neighbor who reports that the client is often seen wandering in the neighborhood and cannot find the way home. Which question should the nurse ask the client to assess short- term memory? "What did you eat for breakfast?" "Can you tell me your name?" "Who is the person who brought you in?" "Where were you were born?"
"What did you eat for breakfast?"
A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? "Do you have any allergies?" "Can you rate the pain on a 0 to 10 scale?" "What time did your pain begin?" "Do you take aspirin daily?"
"What time did your pain begin?"
A client taking an angiotensin-converting enzyme (ACE) inhibitor to treat hypertension calls the clinic nurse and reports that he has a dry, nonproductive cough that is very bothersome. The nurse should respond by making which statement? "The cough must be the start of a respiratory infection." "When this happens typically your PCP will change your medication to an ARB". "The medication needs to be taken with large amounts of water to prevent the cough." "This sometimes happens, and you will need to take a cough medication with each dose of medication."
"When this happens typically your PCP will change your medication to an ARB".
The nurse performs an admission assessment on a client diagnosed with angina pectoris who takes nitroglycerin for chest pain at home. During the assessment, the client complains of chest pain. The nurse should immediately ask the client which of the following question? "Do you have your nitroglycerin with you?" "Are you having any nausea?" "Where is the pain located?" "Are you allergic to any medications?"
"Where is the pain located?"
Disulfiram should not be administered until the client has abstained from alcohol for at least how long? 12 hours 8 hours 16 hours 4 hours
12 hours
A 68-yr-old male patient presents to the emergency department with a BP 210/of 118 and reports a severe headache and vomiting. You know that his BP is dangerously high and must be lowered.
149
After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first? A 56-year-old patient with variant angina who is scheduled to receive nifedipine (Procardia). A 39-year-old patient with pericarditis who is complaining of sharp, stabbing chest pain. A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI).
A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI).
A nurse is aware of the high incidence of intimate partner violence and actively seeks opportunities to screen women for IPV. Which client represents the best opportunity for assessing a woman for IPV? A client who is in the third trimester of pregnancy and who is having biweekly prenatal appointments at a clinic A client who is currently exploring long-term care options for her elderly father A client who expressed interest in joining a grief support group following the death of her husband A client who has brought her young son to the emergency department because he fell at the playground and may have an arm fracture
A client who is in the third trimester of pregnancy and who is having biweekly prenatal appointments at a clinic
A client with heart disease has developed pulmonary edema and is having difficulties breathing. The nurse notes that the client is breathing at a rate of 28/min and has an oxygen saturation of 90% on room air. Which best describes the first response of the nurse? Administer oxygen through a face mask to correct saturation levels Gather supplies to assist with intubation Prepare the client for a thoracentesis Administer pain medication to slow the client's breathing
Administer oxygen through a face mask to correct saturation levels
The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? Age younger than 50 years History of colorectal polyps Family history of colorectal cancer Chronic inflammatory bowel disease
Age younger than 50 years
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? An increased pH and an increased HCO3- A decreased pH and a decreased HCO3- An increased pH and a decreased Paco2 A decreased pH and an increased Paco2
An increased pH and an increased HCO3-
If it is determined that a patient has experienced a simple febrile seizure the next course of action is: Obtain outpatient brain MRI without contrast Lumbar puncture No further imaging Provide educational and emotional support Answer Both C and D
Answer Both C and D
The nurse is caring for a client who is in the chronic phase of stroke and has right-sided hemiparesis. The nurse identifies that the patient is unable to feed themselves. Which is the appropriate nursing intervention? Inform the client that a feeding tube will be placed if progress is not made. Assist the client to eat with the left hand to build strength. Provide a pureed diet that is easy for the client to swallow. Provide a variety of foods on the meal tray to stimulate the client's appetite.
Assist the client to eat with the left hand to build strength.
The nurse is assessing a client newly diagnosed with Stage 1 Hypertension. Which assessment finding should the nurse expect? Visual disturbances Shortness of breath Frequent nosebleeds Asymptomatic
Asymptomatic
A patient with left-sided heart failure is prescribed oxygen at 4 L/min per nasal cannula, furosemide (Lasix), spironolactone (Aldactone), and enalapril (Vasotec). Which assessment should the nurse complete to best evaluate the patient's response to these drugs? Auscultate lung sounds. Observe skin turgor. Measure blood pressure. Review intake and output.
Auscultate lung sounds.
The nurse is caring for a client with a low thrombin level as a result of liver dysfunction. Based on this finding it is most important for the nurse to monitor the client for signs and symptoms of which potential complication? Dehydration Infection Malnutrition Bleeding
Bleeding
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? Chest x-ray via stretcher Blood cultures from two sites Ciprofloxacin (Cipro) 400 mg IV Acetaminophen (Tylenol) suppository
Blood cultures from two sites
The nurse is caring for a 76-year-old male who was admitted for extreme weakness, dizziness, and orthopnea. A diagnosis of heart failure is confirmed by the cardiologist observing JVD and reading is Echo Cardiogram. Which of the following tests was most helpful in determining the diagnosis of heart failure? Brain natriuretic peptide (BNP) Renal Function Panel 12-lead EKG Complete Metabolic Panel (CMP)
Brain natriuretic peptide (BNP)
The nursing student is talking with an client on the medical-surgical floor, who states "I have no family history of cancer, how did this happen?" The nursing student understands that: Family history is the biggest risk factor for cancer. Cancer is most common in younger adults. Cancer can affect all individuals, regardless of age, gender, race, or socioeconomic status. Modifiable risk factors include age and family history.
Cancer can affect all individuals, regardless of age, gender, race, or socioeconomic status.
A client is experiencing severe alcohol withdrawal. Which effects would the nurse most likely assess? Select all that apply. Visible tremors Auditory hallucinations Heart rate around 100 beats/min Marked diaphoresis Increased appetite
Correct Answer Visible tremors Correct! Auditory hallucinations Correct Answer Heart rate around 100 beats/min Correct! Marked diaphoresis
The nurse is caring for a newly admitted older adult in a skilled care facility. Which statement(s) by the client is/ are most concerning? Select all that apply. "I don't remember what I ate for breakfast" "I'm in the emergency room." "I don't think I'll enjoy being here." "My cat 'Mustang' is my baby." "Did my daughter bring my glasses?"
Correct! "I don't remember what I ate for breakfast" Correct! ."I'm in the emergency room."
Usually, there are precursors to aggression and violence. Which behaviors indicate an impending aggressive episode? Select all that apply. Anxiety Raised tone and volume Pacing Lethargy Staring and eye contact
Correct! Anxiety Correct! Raised tone and volume Correct! Pacing Correct! Staring and eye contact
The nurse recognizes a potential health threat to an alcoholic patient who is using the drug disulfiram when the nurse reads in the health record that the patient is also taking which of the following? Select all that apply. Blood thinners Alcohol Diphenhydramine Penicillin Mouthwash
Correct! Blood thinners Correct! Alcohol Correct! Mouthwash
The provider orders an antihypertensive medication for a client whose blood pressure is 205/110 mm Hg. What assessment findings does the student nurse expect for this patient? Select All That Apply. Chest Pain Diminished pulses Pale Cool Skin Blurred Vision Severe Headache
Correct! Chest Pain Correct! Blurred Vision Correct! Severe Headache
The daughter of a 75-year-old woman notices that her mother has mild memory impairment. During a clinic visit, the daughter asks the nurse if her mother is developing Alzheimer's disease (AD). What would be appropriate information to explain the factors to distinguish normal age-related memory impairment from dementia associated with AD? Select all that Apply Dementia has marked progressive deterioration of intellectual functioning and memory. Age-associated memory loss (i.e., slight forgetfulness) is a normal finding in aging. Severe memory loss is a normal part of growing older, especially after age 70. Memory changes are slow in dementia and do not impede social or occupational functioning. Difficulty finding words occurs in dementia but not in normal aging. Dementia is characterized by the inability to solve new problems and learn new skills.
Correct! Dementia has marked progressive deterioration of intellectual functioning and memory. Correct! Age-associated memory loss (i.e., slight forgetfulness) is a normal finding in aging. Correct Answer Difficulty finding words occurs in dementia but not in normal aging. Correct Answer Dementia is characterized by the inability to solve new problems and learn new skills.
The nurse is monitoring a client with heart failure who takes digoxin and whose morning lab level = 2.5. What patient presentation should the nurse assess for? Tremors Diarrhea Irritability Blurred Vision Nausea & Vomiting A controlled heart rate increased urine output
Correct! Diarrhea Correct! Blurred Vision Correct! Nausea & Vomiting
The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply. Multiparity Early menarche Early menopause Family history of breast cancer High-dose radiation exposure to chest Previous cancer of the breast, uterus, or ovaries
Correct! Early menarche Correct! Family history of breast cancer Correct! High-dose radiation exposure to chest Correct! Previous cancer of the breast, uterus, or ovaries
Patients who are psychotic because of underlying psychiatric illness are treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in patients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.) Hallucinations Delusions Anhedonia Disorganized speech and behavior Agitation
Correct! Hallucinations Correct! Delusions Correct Answer Disorganized speech and behavior
Which forms of abuse are examples of psychological abuse? Select all that apply. Humiliating Rape Destroying another's property Incest Insulting
Correct! Humiliating Correct Answer Destroying another's property Correct! Insulting
The nurse is monitoring a client for adverse effects of medications. Which findings are characteristic of adverse effects of hydrochlorothiazide? Select all that apply. Hypokalemia Hypouricemia Hyperglycemia Sulfa allergy Osteoporosis Hypercalcemia
Correct! Hypokalemia Correct! Hyperglycemia Correct! Sulfa allergy Correct! Hypercalcemia
The nurse is providing teaching to a client regarding the prevention of cancer. Which statement by the client indicates teaching has been effective? Select all that apply. I will stop smoking and vaping. I will schedule regular appointments with my doctor. I will exercise daily to help myself lose extra weight. I will limit my alcohol to 3 drinks everyday.
Correct! I will stop smoking and vaping. Correct! I will schedule regular appointments with my doctor. Correct! I will exercise daily to help myself lose extra weight.
An older adult client is hospitalized with a lung infection and has been disoriented and confused since admission. Which cue(s) could be a reason(s) for the cognitive change? Select all that apply. Oxygen saturation level of 90% Use of a bedtime sleeping pill. Temperature of 103.4°F (39.7°C). Unfamiliar environment Administration of nephrotoxic antibiotics
Correct! Oxygen saturation level of 90% Correct! Use of a bedtime sleeping pill. Correct! Temperature of 103.4°F (39.7°C). Correct! Unfamiliar environment
A nurse is caring for client who has been aggressive and violent in the past. Which actions would be appropriate for the nurse to do? Select all that apply. Respect the client's personal space and boundaries. Ensure immediate access to an exit in case leaving is necessary. Approach the client with arms crossed and eyes focused on the client. Ensure that team members know where the nurse is. Wear a scarf to cover up any clothing that could be used to injure.
Correct! Respect the client's personal space and boundaries. Correct! Ensure immediate access to an exit in case leaving is necessary. Correct! Ensure that team members know where the nurse is.
A client is diagnosed with Korsakoff syndrome. Which symptoms would the nurse likely assess? Select all that apply. Vision impairment Hypertension Diaphoresis Confabulation Attention deficit
Correct! Vision impairment Correct! Confabulation Correct! Attention deficit
Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and restlessness. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment FIRST? Crystalloids IV fluid bolus Norepinephrine Low-dose corticosteroids 2 units of Packed Red Blood Cells
Crystalloids IV fluid bolus
Which of the following is the most important assessment to be conducted on the survivor of abuse? Danger assessment Cardiac assessment Mental status exam Social assessment
Danger assessment
The nurse is caring for a hospitalized client with admitting diagnosis of right-sided heart failure (HF). What assessment finding is most consistent with the client's diagnosis? Distended neck veins Pulmonary edema Dry hacking cough Orthopnea
Distended neck veins
As part of a treatment program for alcohol abstinence, a client may benefit from a drug that interferes with the metabolism of the alcohol. Which medication would the nurse anticipate giving? Disulfiram Chlordiazepoxide Diazepam Fluoxetine
Disulfiram
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? Obtain wound cultures. Notify the health care provider. Document the assessment. Start IV antibiotics.
Document the assessment.
The nurse would anticipate the health care provider to order which of the following medications for treatment of mild to moderate dementia associated with Alzheimer's disease (AD)? Donepezil Enalapril Lisinopril Fosinopril
Donepezil
A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed nasal bridge, protruding tongue, and transverse palmar creases. These findings are most suggestive of Microcephaly Cerebral Palsy Down Syndrome Fragile X Syndrome
Down Syndrome
A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? Draw a sample for type and crossmatch and transfuse the client. Prepare to administer an antidote. Draw a sample for prothrombin time (PT) and international normalized ratio (INR). Draw a sample for an activated partial thromboplastin time (aPTT) level.
Draw a sample for prothrombin time (PT) and international normalized ratio (INR).
The nurse is developing a teaching plan for a 64-year-old patient with coronary artery disease (CAD). Which factor should the nurse focus on during the teaching session? Elevated low-density lipoprotein (LDL) level Increased risk of cardiovascular disease with aging Family history of myocardial infarction Greater risk associated with the patient's gender
Elevated low-density lipoprotein (LDL) level
The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? Placing cool compresses on the affected arm Elevating the affected arm on a pillow above heart level Avoiding arm exercises in the immediate postoperative period Maintaining an intravenous site below the antecubital area on the affected side
Elevating the affected arm on a pillow above heart level
The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. She knows this will help break the chain of infection by: Eliminating a portal of entry Increasing the patient's circulation Increasing the patient's protein Eliminating the mode of transmission
Eliminating a portal of entry
The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? Placing a pillow under the knees Encouraging active range-of-motion exercises Restricting fluids Applying a heating pad to the lower extremities
Encouraging active range-of-motion exercises
A client is being admitted to the hospital for treatment of acute cellulitis of the right hand. During the admission assessment, the nurse expects to note which finding? Silver, scaly patch to right hand Xeroderma of the right hand Erythema to the right hand with sharp borders a white color to the hand that is insensitive to touch
Erythema to the right hand with sharp borders
A client has been admitted to the medical unit from the emergency department after experiencing a violent assault. What action should the nurse prioritize when planning this client's care? Establishing rapport with the client Reassuring the client that they are safe on the unit Teaching the client about the risk factors for violence Teaching the client self-protection strategies
Establishing rapport with the client
What is an important nursing action to encourage compliance with taking medications for the client with Alzheimer's disease (AD) who has a new prescription for donepezil? Explain to the spouse/family member the schedule and necessary information about administration of the medication. Arrange to have a home health aide come to the house daily to give the medication. Have the medications set up in a marked medication box. Write a list of times for the client when the medication should be taken and post reminders in brightly colored notes.
Explain to the spouse/family member the schedule and necessary information about administration of the medication.
A patient previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. What is the nurse's best response? Tell the patient there are no spiders and he should stop worrying about it. Ask the patient if he also sees spiders in the day room. Express reasonable doubt that there are spiders on the wall. Ignore his remarks and remain silent when providing care
Express reasonable doubt that there are spiders on the wall.
The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? Turn the head toward the nurse's arm. Extend the tongue. Extend the arms. Focus the eyes on the object held by the nurse.
Extend the tongue.
n discussing disease prevention with a 15-year-old boy and his mother, the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.) Father diagnosed with paranoid schizophrenia Occasional cannabis use Physical abuse by the father Recent immigration from Ecuador Rural residence
Father diagnosed with paranoid schizophrenia Physical abuse by the father Recent immigration from Ecuador Correct
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? Fluid is clear and tests negative for glucose. Fluid is grossly bloody in appearance and has a pH of 6. Fluid clumps together on the dressing and has a pH of 7. Fluid separates into concentric rings and tests positive for glucose.
Fluid separates into concentric rings and tests positive for glucose.
The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific primary health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. Head midline Neck in neutral position Head of bed elevated 30 to 45 degrees Head turned to the side when flat in bed Neck and jaw flexed forward when opening the mouth
Head midline Neck in neutral position Head of bed elevated 30 to 45 degrees
The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should place the patient in which position? Prone Head of the bed elevated 30 degrees with the head in midline position Semi-Fowler's with the hip and the neck flexed Supine and Stroke Appropriate
Head of the bed elevated 30 degrees with the head in midline position
The nurse is triaging a 55-year-old African-American male client with a past history of colon polyps who complains of recent unexplained weight loss, abdominal pain, and change in bowel habits. Which lab study will the nurse want to review based on these symptoms? Hemoglobin UA BUN Bilirubin
Hemoglobin
Clients diagnosed with schizophrenia may experience disordered water balance that may lead to water intoxication. Which effect may occur as a result of water intoxication? Hypernatremia Weight los Oliguria Hyponatremia
Hyponatremia
A new nurse is having difficulty knowing which client should be seen first because they all seem important. The nurse preceptor helps and explains which of the following should be seen first? Hypotension, tachycardia, and lethargy Febrile, tachycardia, and vomiting Abdominal pain, hypertensive and constipated Dizziness with normal vital signs
Hypotension, tachycardia, and lethargy
A client is brought to the emergency department following a car accident. The client's blood alcohol level (BAL) was 0.10%. Which symptom would the client likely exhibit? Impaired coordination Giddiness Emotional lability Lack of muscle control
Impaired coordination
A client in shock develops a central venous pressure (CVP) of 2 mm Hg. Which prescribed intervention should the nurse implement first Increase the rate of intravenous (IV) fluids Insert an indwelling urinary catheter Obtain arterial blood gas results Prepare to hang Heparin IV
Increase the rate of intravenous (IV) fluids
A client with schizophrenia is prescribed clozapine. The nurse would monitor the client closely for specific signs of what condition? Weight loss Infection Nausea Hypotension
Infection
Which approach is important in caring for clients who are aggressive or violent? Knowing where colleagues are and making sure that they know where you are Stating boundaries before the initiation of the conversation Leaving the office door closed while talking to the client Using control as evidenced by verbal and nonverbal behavior
Knowing where colleagues are and making sure that they know where you are
A 68-year-old client is brought to the emergency department after a mental status change in the nursing home. The client is demonstrating signs of septic secondary to Urosepsis. Which of the following types of fluids would be most appropriate to administer initially during the resuscitation period? Lactated Ringer's D10W ½ NS with potassium D5 NS
Lactated Ringer's
A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates which action is needed next? Leaving the rate of the heparin infusion as is Discontinuing the heparin infusion Decreasing the rate of the heparin infusion Increasing the rate of the heparin infusion
Leaving the rate of the heparin infusion as is
A client is admitted to the medical-surgical unit with a 3-day history of vomiting & dehydration due to Covid-19. Arterial blood gases (ABGs) are pH -7.48, PaCO2 -52, & HCO3-35. What acid-base imbalance is this client experiencing? DRAW YOUR MAP TO ANSWER THIS MET ALKALOSIS RESP ALKALOSIS MET ACIDOSIS RESP ACIDOSIS
MET ALKALOSIS
The nurse is receiving a client who will be having chemotherapy and radiation for his tumor. Which of these will the nurse need to implement for this client? Offer foods high in sugar. Limit time with patient by clustering care for 30 minutes only per shift. Keep the head of the bed elevated. Monitor and educate visitors to not visit while ill.
Monitor and educate visitors to not visit while ill.
The nurse is assigned to care for a 68-year-old client who had a right THA 2 days ago. During shift assessment, the nurse documents new onset of symptoms, including chest pain and dyspnea. Computed tomography pulmonary angiography (CTPA) confirmed the diagnosis of a submassive PE. The orthopedic surgeon enters the following orders: Fondaparinux 7.5 mg subcutaneously once daily Warfarin 5 mg orally once daily Supplemental oxygen per NC at 5 L/min Continuous pulse oximetry monitoring Identify which potential nursing interventions are indicated. Monitor the client's hematocrit. Monitor the client's platelet count. Assess the client for bleeding or excessive bruising. Check for availability of phytonadione (vitamin K). Monitor the client's activated partial thromboplastin time (aPTT). Check for availability of protamine sulfate Monitor the client's international normalized ratio (INR).
Monitor the client's hematocrit. Correct! Monitor the client's platelet count. Correct! Assess the client for bleeding or excessive bruising. Correct! Check for availability of phytonadione (vitamin K). Monitor the client's international normalized ratio (INR).
The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? Initiate strict enteric precautions. Move the infant to a private room. Leave the infant in the present room, because RSV is not contagious. Inform the staff that using standard precautions is all that is necessary when caring for the child.
Move the infant to a private room.
The nurse is getting report on a newly admitted 12 month old with a diagnosis of RSV bronchiolitis and poor PO intake, the patient also has a history of frequent upper respiratory infections (URIs). The nurse anticipates which of the following orders: Rocephin IV 25mg/kg/dose x3 days Prednisolone PO 1mg/kg q 24 hours NS 0.9% 20mg/kg over 30 minutes for rehydration Racepinephrine 2.25% (0.5ml ) nebulized
NS 0.9% 20mg/kg over 30 minutes for rehydration
A client with Alzheimer's disease (AD) is started on a cholinesterase inhibitor. The nurse would watch for which side effects associated with this medication? Nausea, vomiting, and diarrhea Elevated cardiac enzymes Headache and confusion Tinnitus and numbness
Nausea, vomiting, and diarrhea
The home care nurse is visiting a male client who is recovering at home after suffering a brain attack (stroke) 2 weeks ago. The client's wife states that the client has difficulty feeding himself and difficulty swallowing food and fluids. Which would be the initial nursing action? Observe the client feeding himself. Make the patient NPO and call the Speech Therapist. Instruct the wife in the use of a feeding syringe to feed the client. Observe the wife feeding the client.
Observe the client feeding himself.
The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next? Give the scheduled IV antibiotic. Give the PRN acetaminophen (Tylenol). Obtain oxygen saturation using pulse oximetry. Notify the health care provider of the patient's vital signs.
Obtain oxygen saturation using pulse oximetry.
Which assessment finding in a patient who has had coronary artery bypass grafting using a right radial artery graft is most important for the nurse to communicate to the health care provider? Redness on both sides of the sternal incision Pallor and weakness of the right hand Fine crackles heard at both lung bases Complaints of incisional chest pain
Pallor and weakness of the right hand
Which condition is an anticholinergic side effect associated with some antipsychotic medications? Photophobia Increased tearing Diarrhea Salivation
Photophobia
The nurse is developing a care plan for a patient newly admitted to a unit that cares for patients with cognitive impairment. What is an important component of care for the patients on this unit? Allow food selections from a menu with several choices. Schedule frequent field trips off the unit for cognitive stimulation. Plan for attendance at activities with several other patients on the unit. Plan for a structured daily routine of events and caregivers.
Plan for a structured daily routine of events and caregivers.
A student nurse is working with an 82-year-old patient diagnosed with dementia. The student is frustrated at times by not knowing how best to care for or communicate with the client. Which of the statements by the student best illustrates best care practice? Positive regard: "Carl, I am glad to be here caring for you today. Let's talk about your plans for the day." Firm direction: "You will take a shower this morning; there is no debating about it so don't try to argue." Limit setting: "Carl, you cannot yell out in your room. You are upsetting other patients." Lighthearted banter: "Carl, you look great today in your new sweater, you handsome devil!"
Positive regard: "Carl, I am glad to be here caring for you today. Let's talk about your plans for the day."
A patient with schizophrenia is admitted to the inpatient unit. Which behavior should the nurse expect to see that is most likely to be associated with this disorder? Monotone speech pattern Presence of hallucinations Wringing of hands Engaged in conversations
Presence of hallucinations
A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? Problem with articulating events from the remote past Difficulty speaking Problem with understanding language Difficulty controlling voluntary motor activity
Problem with understanding language
The nurse is caring for a patient who is experiencing alcohol withdrawal. What is the highest priority for this patient? Promote a safe, calm, and comfortable environment. Describe how the alcohol is causing the withdrawal effects. Leave the patient by him/heherself so as not to cause agitation. Refer the patient to an alcohol-abuse counselor.
Promote a safe, calm, and comfortable environment.
The nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which most appropriate intervention? Restraining the infant to prevent dislodging of tubes Placing small toys in the crib to provide stimulation for the infant Providing a consistent routine with touching, rocking, and cuddling throughout hospitalization Keeping the infant as quiet as possible.
Providing a consistent routine with touching, rocking, and cuddling throughout hospitalization
A pregnant client diagnosed with DVT 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. Which complication should the nurse immediately assess the client for? Pneumonia Pulmonary edema Myocardial Infarction Pulmonary Embolism
Pulmonary Embolism
What should the nurse keep in mind when planning to communicate with a child who has autism? Assume the child has normal verbal communication. Expect the child to use sign language. Realize that the child may exhibit monotone speech and echolalia. Assume the child is not listening if she is not looking at the nurse.
Realize that the child may exhibit monotone speech and echolalia.
The nurse is planning discharge teaching for a patient taking clozapine. Which information is critical to include in the teaching plan? Instructions regarding dietary restrictions Caution about sunlight exposure A chart to record patient weight Reminder to call the clinic if fever, sore throat, or malaise develops
Reminder to call the clinic if fever, sore throat, or malaise develops
The nurse is reviewing the laboratory test results for a client with a diagnosis of DIC who is receiving a transfusion. The nurse notes that the client's platelet count is 20,000 mm3 (200 × 109/L). The nurse should prepare to implement which action based on this finding? Remove the fresh flowers from the client's room. Instruct family members to wear a mask when entering the client's room. Call the dietary department to report that the client will be on a low-bacteria diet. Remove the rectal thermometer from the client's room.
Remove the rectal thermometer from the client's room.
The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mm Hg, PaO2 of 80 mm Hg, and HCO3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance? DRAW YOUR MAP TO ANSWER THIS. Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis
Respiratory acidosis
The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mmol/L), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? USE YOUR MAP TO ANSWER THIS. Respiratory alkalosis, compensated Metabolic acidosis, compensated Metabolic alkalosis, uncompensated Respiratory acidosis, uncompensated
Respiratory alkalosis, compensated
Which side effect is the highest priority for the nurse to assess for when diphenhydramine is administered to a patient also taking antipsychotic medication? Respiratory depression Cognitive impairment Increased psychosis Impaired memory
Respiratory depression
Lisinopril has been recently prescribed for an anemic patient newly diagnosed with hypertension. What should the nurse instruct the client about this medication? Rise slowly from a reclining to a sitting position. Discontinue the medication if nausea occurs. Expect to note a full therapeutic effect immediately. Take the medication with food only.
Rise slowly from a reclining to a sitting position.
When caring for a patient with septic shock, which assessment finding is most important for the nurse to report to the health care provider? Skin cool and clammy BP 92/56 mm Hg Apical pulse 118 beats/min Skin warm and dry
Skin cool and clammy
A nurse plans a community education program related to prevention of the cancer with the highest death rates in both women and men. What should the nurse include in the teaching plan? Screening with colonoscopy Smoking cessation Screening with breast biopsy Regular examination of reproductive organs
Smoking cessation
The student nurse is taking care of a patient with a contusion to the frontal lobe and knows to monitor for what potential changes in the patient? Speech Hearing Sensation Sight
Speech
The nurse is caring for a client who has +3 pitting edema in the legs and a potassium level of 2.3 mEq/L. The nurse expects which of the following diuretics to be ordered? Spironolactone (Aldactone) Furosemide (Lasix) Lisinopril Hydrochorithiazide
Spironolactone (Aldactone)
The nurse at the after hours clinic receives the following orders for a 8 month old patient with suspected RSV and showing signs of mild respiratory distress, what order should he complete FIRST? Obtain a blood sample for a CBC. Suction the patient's nose using saline drops. Perform a PO challenge to see if the patient can tolerate fluids by mouth Educate the family on reasons to follow up.
Suction the patient's nose using saline drops.
A 21-year-old patient diagnosed with a head injury that occurred playing football presents with three tonic-clonic seizures while in the emergency department. The client is talking and awake the following day and asks the nurse what caused him to have a seizure. The nurse provides which explanation as a primary cause of tonic-clonic seizures? TBI congenital abnormality cardiac issue drug overdose
TBI
The client who has been receiving haloperidol on a long-term basis begins to exhibit bizarre facial and tongue movements. Based on these nursing assessment findings, the client is most likely exhibiting signs and symptoms of which disorder? Tardive dyskinesia Oculogyric crisis Pseudoparkinsonism Akathisia
Tardive dyskinesia
The nurse knows that which of the following patients is at the most risk for complications of RSV: The 16 month old with a family history of asthma. The 4 month old with a history of hip dysplasia. The 3 month old who was born at 29 weeks gestation. The 9 month old who attends daycare full-time.
The 3 month old who was born at 29 weeks gestation.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. The client has weakness on the right side of the body. The client has complete bilateral paralysis of the arms and legs. The client is aphasic. The client has weakness on the right side of the face and tongue. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance. The client has lost the ability to move the right arm but is able to walk independently.
The client has weakness on the right side of the body. The client is aphasic. The client has weakness on the right side of the face and tongue.
A client has been receiving memantine for moderate Alzheimer's disease (AD). How would the nurse know that the medication is effective? The client is less agitated and more cooperative. The client is less forgetful. The client has improved short-term memory. The client has normal liver function studies.
The client is less agitated and more cooperative.
A nurse is screening a new client for intimate partner violence. What aspect of this client's current circumstances is the most significant risk factor? The client's family lives on less than $1,000 per month The client has four children The client has no extended family in the area The client immigrated less than 5 years ago
The client's family lives on less than $1,000 per month
The nurse who works with potentially aggressive clients should do so with respect and concern. What are goals of de-escalation? Select all that apply. Work with clients to find solutions Sympathize with the client's perspective. Approach clients calmly. Empathize with the client's perspective. Avoid a power struggle.
The nurse who works with potentially aggressive clients should Correct! Work with clients to find solutions. Correct! Approach clients calmly. Correct! Empathize with the client's perspective. Correct! Avoid a power struggle.
A nurse is giving a parent information about autism. Which statement made by the parent indicates understanding of the teaching? The onset of autism usually occurs before 3 years of age. Autism is characterized by periods of remission and exacerbation. Children with autism have imitation and gesturing skills. Autism can be treated effectively with medication.
The onset of autism usually occurs before 3 years of age.
To prevent Wernicke's encephalopathy from heavy alcohol use, the nurse anticipates an order for which medications? Thiamine and B complex Benzodiazepine Vitamins C and D3 Klonopin
Thiamine and B complex
An ER patient who has had chest pain for several hours is admitted with a rule-out acute myocardial infarction (AMI) diagnosis. Which laboratory test is most appropriate for the nurse to monitor in determining whether the patient has had an AMI? Creatinine Kinase Troponin C-reactive protein Myoglobin
Troponin
Which statement from the parents indicates to the nurse that further teaching is needed in regards to their 14 month old son with RSV: We will give cough medications every 4-6 hours. We will suction his nose at before nap times and meals. We will look for a wet diaper every 6-8 hours. We will make sure to keep him home from daycare.
We will give cough medications every 4-6 hours.
In order to provide the best intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide? What cells are being utilized by the body to attack an infection. Whether a patient has an infection. What specific type of pathogen is causing an infection. Where an infection is located.
What specific type of pathogen is causing an infection.
The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? pH 7.25, Paco2 50 mm Hg pH 7.35, Paco2 40 mm Hg pH 7.50, Paco2 52 mm Hg pH 7.52, Paco2 28 mm Hg
pH 7.25, Paco2 50 mm Hg
The nurse is caring for a client who has a nasogastric (NG) tube ordered to low intermittent suction. When making morning rounds, the nurse finds the NG tube is set to continuous suction. The nurse immediately changes the suction back to low, intermittent suction. Further assessment of the client finds him to be confused, nervous, and with tremors in his hands (all new assessments for this client.) The nurse reports these findings to the client's health care provider, who orders the NG suction to be discontinued for now and also orders a set of arterial blood gases (ABGs.) Which of the following ABGs does the nurse expect to find for this client? DRAW YOUR MAP TO HELP ANSWER THIS pH 7.48, PC02 30, HC03 32 pH 7.32, PC02 50, HC03 28 pH 7.48, PC02 30 HC03 20
pH 7.48, PC02 30, HC03 32
The nurse, who is caring for a client who recently presented to the emergency room, suspects the client is in metabolic alkalosis. Which arterial blood gas values best validate this condition? DRAW YOUR MAP TO ANSWER THIS pH 7.51, PC02 48, HC03 34 pH 7.23, PC02 58, HC03 26 pH 7.58, PC02 22, HC03 23 pH 7.38, PC02 50, Hc03 30
pH 7.51, PC02 48, HC03 34
A 54 year old patient is having a tonic clonic seizure. Which of these interventions by the nurse will ensure safety during the seizure? turn patient on stomach protect from injury stick soft mouth guard on tongue hold patients arm down
protect from injury
Appropriate interventions to facilitate socialization of the cognitively impaired child include: providing age-appropriate toys and play activities. providing safe peer experiences avoiding exposure to strangers who may not understand cognitive development. emphasizing mastery of physical skills because they are the most delayed.
providing safe peer experiences
The most appropriate nursing priority for a child with a cognitive dysfunction is impaired social interaction. deficient knowledge. ineffective coping. risk for injury.
risk for injury.
A parent asks the nurse why a developmental assessment is being conducted for a child during a routine well-child visit. The nurse answers based on the knowledge that routine developmental assessments during well-child visits are: not necessary unless the parents request them. the best method for early detection of cognitive disorders. frightening to parents and children and should be avoided. valuable in measuring intelligence in children.
the best method for early detection of cognitive disorders.
The nurse is providing counseling to the mother of a child diagnosed with fragile X syndrome. She explains to the mother that fragile X syndrome is: most commonly seen in girls. acquired after birth. usually transmitted by the male carrier. usually transmitted by the female carrier.
usually transmitted by the female carrier.