Fundamental Hesi Review YG
A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate?
"Nontraditional approaches to health care can be beneficial.
1. Oxygen saturation in 91 %. What is de cause?
+2 edema in the finger (donde se puso el aparato).
1. Potassium 2.5?
-La nurse check rate and frequency. -other answer inform the doctor to administer K.
1. Patient budista dead, patient's family want to see body for two hours for spiritual?
-Nurse put the shut and return to room after 2 hours -The nurse leaves them locked in the room and returns to the room after 2 hours.
37 mgrs. at 50 mgrs./ ml.
0.7 ml.
Two medications that were given together?
0.9
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices.
A
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion? The infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150
150 ml/hr
The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering.
B
When is the log-rolling technique used?
In column operations to keep it aligned when the patient is mobilized.
Who is using the role-playing technique?
In the adolescents.
Patient that you drop the System for entering data
Inform the department to fixed it
Therapeutic dose of heparin?
1.5 to 2.5 times normal of PT
Patient with terminal cancer feels good and recommends hospice?
Recommend the patient to receive indications about hospice.
Man with sensory overload?
Reduce environmental stimulus.
The plan of care for the client was to lose 7 pounds by the end of the month. The client only lost 3 pounds. The nurse should:
Reevaluate the plan of care for appropriateness
Nursing actions for the older adult should include health education and promotion of self-care. Which is most important when working with the older adult client?
Reinforcing the client's strengths and promoting reminiscing
A medication that was given twice a day x 10 days, how many pills were taken at the end of the treatment (ten days)?
20 tablets because the tablets had the same mg as the indicated dose (taken 2 tabs daily).
Normal amylase level?
25 to 151
Lasix Hand 20 mgrs. DO 40 mgrs. BID. How many tablets give all day.
4 Tablets.
The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin.
A
The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.
A
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse.
A
1. A question about the priorization?
78 years old patient with Alzheimer disease who have SUNDOWING.
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities.
A
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CRF.
A
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe.
A
After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.
A
An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension.
A
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. It is important that you continue your medication while learning to meditate. B. Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C. Obtain your healthcare provider's permission before starting meditation. D. Complementary therapy and western medicine can be effective for you.
A
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
A
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A. Avoid any types of sprays, powders, and perfumes. B. Wearing a mask while cleaning will not help to avoid allergens. C. Purchase any type of clothing, but be sure it is washed before wearing it. D. Pollen count is related to hay fever, not to allergens.
A
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion.
A
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.
A Is the correct calculation: 20,000 units/500 ml = 40 units (the amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour amount of 1,000 to reach the same conclusion = 11,000 units.
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? A. 0.5 ml. B. 1 ml. C. 1.5 ml. D. 2 ml.
A Using ratio and proportion: 8mg: 1ml :: 4mg:Xml 8X=4 X=0.5
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure.
B
Patient that can not sleep?
Avoid caffeine, establish sleep patterns
The nurse who wants to change a nursing Act rule?
Write to the state legislator.
Video of a nurse caring for a patient who does range of motion, what movement was missing?
Abduction.
Pte transfer from another unit and you receive the pte. What is the first thing to do?
Ability to see if pte can CHEW ( masticar)and Swallow( tragar).
Which of the following legal defenses is the most important for a nurse to develop?
Accountability
The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water. The NGT should be flushed before, after and in between each medication administered
B
See video of nurse holding ear of patient. What is next?
Administer med in the ear canal
Patient complains about unable to sleep. He reported that he likes to have a glass of wine before going to bed:
Advice to get wine 3 hours before going to bed.
Ear irrigation position:
Affected ear upright
Nurse who is taking care of a patient, they call her for an emergency, what action shows before that patient?
After resolving the other case back to the room of the patient to continue caring.
Informed consent where the friend of a nurse wanted to find out something from your daughter's electronic record (select all that applied)?
All were marked except the one that said to ask the daughter if she gave her consent to do this.
Indian man who brought grass for ritual and wants to put it under his pillow?
Allow the herbs to get under the pillow.
Outcome in a pte after surgery in pain:
Ambulate without discomfort
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer.
B
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation
B
Injection site IM 3ml?
ventrogluteal site
Patient with pneumonia has red tongue?
Apply oxygen.
¿Nurse who is called by two patients with pain?
Ask both patients the degree of pain in the scale of 1 to 10.
Patient with restless grimacing going from bed to wheelchair. The nurse asks if he has pain. The patient says no?
Ask the patient why is he doing so.
Flash oximetry pulse alarm:
Assess lung sound and refill capillary
1. Patient interview for aspects related to sexuality?
Assess patient in a less sensitive way.
1. Pt has fecal incontinence unable to get up and worried to soil the bed lines?
Assist patient to a bed side commode.
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A. In 8 weeks you will be able to bend at the waist to reach items on the floor. B. Place a pillow between your knees while lying in bed to prevent hip dislocation. C. It is safe to use a walker to get out of bed, but you need assistance when walking. D. Take pain medication 30 minutes after your physical therapy sessions.
B
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses.
B
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A. What is your daily calorie consumption? B. What vitamin and mineral supplements do you take? C. Do you feel that you are overweight? D. Will a clear liquid diet be okay after surgery?
B
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed. Blood transfusions are forbidden
B
A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area.
B
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use.
B
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner.
B
A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors.
B
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.
B
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A. prone. B. Fowler's. C. Sims'. D. supine.
B
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.
B
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep. Relocation
B
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A. 0.5 tablet. B. 1 tablet. C. 1.5 tablets. D. 2 tablets.
B
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min.
B
Impact fecal; first?
vital signs
Patient with hepatitis C and encephalitis, what does the nurse tell the helper should use to bath the patient?
wear gloves
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.
B
What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.
B
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet.
B
When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.
B
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A. 1 ml. B. 1.5 ml. C. 1.75 ml. D. 2 ml.
B Is the correct calculation: Dosage on hand/amount on hand = Dosage desired/x amount. 20 mg : 2 ml = 15 mg : x . 20x = 30. x = 30/20; = 1½ or 1.5 ml.
Patient who arrives the consultation and has a rash of unknown cause for the first time, that you do??
wear goggle and gloves.
Patient with mastectomy crying?
work with the arm quiet.
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A. 13 ml/hour. B. 63 ml/hour. C. 80 ml/hour. D. 125 ml/hour.
B is the correct calculation: To calculate this problem correctly, remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour.
Elderly who doesn't sleep:
Back Rubs
When you are ordered to collect a urine sample?
Be sure the patient can urinate (void)
In a patient with a catheter who is going to take a urine sample, when are the gloves put on?
Before taking the syringe to puncture the Port.
Best way to evaluate pressure cuff usage:
Body mass (BMI)
Ear drop what to do?
Bring the medication closer to the ear
1. Nurse report fire in bathroom close all patient door? The nurse's first action after discovering an electrical fire in a patient's room is to: A) Activate the fire alarm. B) Confine the fire by closing all doors and windows. C) Remove all patients in immediate danger. D) Extinguish the fire by using the nearest fire extinguisher.
C
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
C
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A. asks relevant questions regarding the dressing change. B. states he will be able to complete the wound care regimen. C. demonstrates the wound care procedure correctly. D. has all the necessary supplies for wound care.
C
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred.
C
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.
C
At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.
C
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A. Request another nurse to complete the physical assessment. B. Ask the client to stop crying and tell the nurse what is wrong. C. Acknowledge the client's distress and tell her it is all right to cry. D. Leave the room so that the client can be alone to cry in private.
C
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters.
C
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A. Remain calm with the client and record abnormal results in the chart. B. Notify the medication nurse immediately if the pulse or blood pressure is low. C. Report the results of the vital signs to the nurse. D. Reassure the client that the vital signs are normal.
C
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.
C
The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus. B. Hypothalamus. C. Frontal lobe. D. Parietal lobe.
C
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, and vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie.
C
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase.
C
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25
C
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices.
C
Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.
C
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.
C
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position. To avoid shearing forces when repositioning, the client should be lifted gently across a surface
D
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets.
C is the correct calculation: D/H × Q = 7.5/5 × 1 tablet = 1½ tablets.
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.
D
During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.
D
Elevate the head of the bed:
CNA put the head of the bed down and pulled the patient up.
1. Living will patient family power of attorney?
Call the doctor
Dr ordered medication and the pharmacy sent a higher dose:
Call the pharmacy to clarify
Pte comes from surgery and RN decides to ambulate pte and the family is upset: What to do:
Check blood pressure
Patient who is in a hospice, is dying and unconscious, how do you evaluate that he is dying?
Check cornea , to see if it is dry (dry cornea)
1. Patient with low potassium level?
Check epical pulse.
In the nasopharyngeal intubation that is evaluated?
Check membranes and skin.
Patient with COPD and patient is clamy (humid, sticky cold). What to do?
Check respiration of patient
Patient says she is in pain:
Check the last time the med was giving
Patient lying for more the three days. What does the nurse do before lifting him out of bed?
Check the pupils.
Nurse performing ear wash:
Check the water's temperature
Picture pouring something in a bottle:
Close the bottle
Patient for which stool specimen should be collected for occult blood and patient gave a normal brown stool:
Collect specimen from current stool
Photo of an oxygen equipment, what to do?
Connect the hose to the oxygen equipment.
Patient O2 remains the same 94% in Patient with feeding tube receiving suctioning procedure
Continue suctioning
When the patient has ulcer and around it is red, what is done?
Cotton dressing is used.
A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as:
Crackles
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300
D
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs q15 minutes for the first hour. D. Ensure the accuracy of the blood type match.
D
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator.
D
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. demonstrates loss of remote memory. B. exhibits expressive dysphasia. C. has a diminished attention span. D. is disoriented to place and time.
D
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot
D
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again.
D
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. Hot remedies restore balance after surgery, which is considered a "cold" condition.
D
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat.
D
Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.
D
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference.
D
Male without circumscription, what do you do when you are given a urinary catheter
Enter more the catheter in the penis and then inflate the balloon.
Patient who is being treated for monilial
Evaluate of the patient if using tampon.
What do you want to know about advanced policies?
Family attorney.
Muslin patient agitated at dialysis scheduled time speaks very little English
Find translator to determine reason for agitation
An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180
D is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30 mcg/min × 60 min/hr.
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.
D is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min
Ways to identify a patient?
Identify the name of the patient.
Order to restrain a patient and the CNA (Certified Nurse Assistant) tight (narrow, hermetico) the patient on the side of the bed.
Demonstrate the CNA how to do it
Patient with sodium 123:
Did you drink a lot of water with ice?
Patient with extensive burns on the legs?
Diet rich in protein (egg) and orange juice.
Low Na patient?
Drink water
In the discharge, patient who is anxious and speaks little English?
Give a clear explanation of medications by writing.
Alternative pain medication patient medicate after 4 hours pain not resolve?
Guided imagery and slow breathing.
Patient who is going to get up and looks (busca) for help:
Help lie back down in bed
Patient with lung surgery with pain that the bedclothes are changing?
Help with the sheets from top to the bottom (buttocks).
Tube insertion in place and RN is going to feed pte and the residual is 150.
Hold the feeding
Patient not cooperate with this treatment diagnosis?
Hopeless.
How to transfer patient from bed to wheelchair. First thing to know:
How Pte BEAR (soporta)... LOW EXTREMITIES..
1. Patient has a pressure ulcer with granulation tissue what kind of dressing you will apply?
Hydrogel (duoderm) dressing.
135. To prevent infection due to catheter .
Irrigate with syringe 20 ml of normal saline.
How to evaluate a patient with rheumatoid arthritis?
It evaluates how you can perform daily activities with pain.
Nurse with nails with acrylic?
It is a source of nosocomial infection.
Assessment to patient who said he is an agnostic spiritual:
Just document AGNOSTIC
When the urinary catheter is removed?
Knowing that urine after removal of the catheter.
The nurse comes to take vital signs of the patient, the patient is altered( is Upset) and does not want to be touched?
Leave him alone to rest calm and then take vital signs.
Patient with analgesic in patch and no relief?
Leave the patch on and apply PRN analgesic indicated
Patient with enema who does not retain it?
Make an evaluation or assessment of bowel movements.
135. Patient checks input and output. What are you goin to measure as fluid?
Milk only.
During the beginning phase of a therapeutic relationship, a clear understanding of participants' roles is important because the client:
Needs to know what to expect from the relationship
Patient with pertussis?
Normal mask without filter.
Employees at risk of infection.
Nosocomial Rate.
UAP goes out with a plant from a room where a patient has clostridium diff:
Nurse needs to says to UAP to take the gown and gloves off
135. To see video of patient restraint attached to bed wheel side bed rail.
Nurse readjusts at proper pole
Patient after mastectomy stays in bedroom and crying , nurse therapeutic behavior.?
Nurse stays in room with patient in silent and place hand on forearm
The patient with the nasogastric tube coughed a few minutes ago, but no longer:
Nursing control tube for placement
Patient is made assessment that follows after in the process of nursing
Nursing diagnostic.
Do you have chronic pain that you do not want a surgery ?
Only use acupuncture.
The grandmother of a young adult who entered the psychiatric clinic requests information about patient
Patient needs to sign a consent/release of information including to his grandmother
1. Pt with Right side hemiplegia for left CVA?
Patient transfer from bed to chair in a left side.
Four Patients, Rn needs to prioritize one:
Patient who needs antibiotic at 0900
Patient with healthy wound that closes for second intention and is suppurating?
Perform sampling for crops. Take a sample for crops.
1. NAP taking blood pressure for ORTH Blood pressure?
Place the patient in supine position.
Pacient is being DISCHARGE with a bladder catheter, the patient complain of suprapubic pain and in the physical examination he has a distended bladder?
Prepare to insert the catheter again.
A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to:
Promote cell growth and bone union
Skin lesion picture, select all apply?
Promote the administration of liquids changes of position in the bed.
Patient that the UAP is doing a bath in the bed and what the nurse says?
Promote the drying of the feet correctly.
Pte with inflammation of legs after surgery went home. What tell to pte?
Pte needs to MOVE legs while lying on bed, Flexion(exercise)
With fecal incontinence, what is it that is Training when a vacuum goes?
Put bed side commode next to bed 30 minutes after meals.
1. Patient Fr 28/min and SO2 at 94%?
Put it in semi fowler position.
Video of the handling of an ampulla?
Put the gauze around before opening it.
Patient with dropper precaution that moves from the room and do not want to wear the mask for the eyeglasses?
Put the surgical mask down and the noise bridges glasses , with a mask tape and above can put the glasses.
What to do when we explore the pedis pulse and we do not feel it?
Re-evaluate again but pressing softer. O reassess pressing again but smoother.
Patient the family during the visit remove the restriction (restrain), when they leave the nurse?
Re-evaluate the patient to find out if he needs the restrain.
1. Patient complaint of pain after one hour of given medication?
Reassess patient pain.
Out care for pain medication for patient?
Request pain 5 on a scale 0 to 10 after 1 hour.
Cyanosis in foot and fingertips:
Respiration
Planning a patient's goal?
Review the main nursing diagnosis.
1. Nurse empty urine 150 ml/h. What is the patient at risk for?
Risk for infection.
Older adult with diarrhea Diagnosis
Risk of fluid volume deficit.
Patient with SO2 in 89% and then in 87%?
Secure nasal cannula.
Patient end of life and do not want life support:
Something about COMMITTE
Patient in hospice end of life to husband wandering
Spouse spent time with the patient and listen to fulfil patient expectation.
Image of stage pressure ulcer:
Stage 2 pressure ulcer
1. Nurse question patient ratio include action taken by the state board of nursing?
State legislature licensure.
The nurse is assessing a group of older adults. Which should the nurse consider to be least likely to be affected by aging?
Strategies to handle stress
Nurse VIDEO cleaning hands with alcohol?
Teach you the correct hand washing technique.
Patient operated knee fracture, two hours ago, He had knee replacement, refers to intense pain?
Teaching of pain infusion pump.
Patient with final cancer the doctor says that he is going to die and he asks the nurse?
Tell her that it is very bad.
The woman sticks with the boss and gets very angry and annoyed and comes to give the complaints to the doctor.
Tell me more about how you feel when .......
Patient with insomnia?
Tell me more about insomnia.
64. Girl who is admitted, the boyfriend leaves after the visit and she is sad?
Tell me more about your boyfriend's visit.
Patient with sequelae of an AVE (stroke) with motor deficit?
Tennis with Velcro (small).
In the planning care of the patient leaving discharge with an ostomy?
That the patient shows that he can of ostomy care.
Pte overweight and wants to lose weight because he is obese. What to do?
The fat between(20-30 about that)
A nurse applies a heating pad to a client's buttocks. Upon removal of the heating pad, the nurse discovers that the client has received burns due to incorrect settings when the heating pad was initiated. Which principle would legally apply?
The nurse could be held liable for the injury that occurred
Pte politician who burns and a journalist comes to interview him?
To sent to of the communication department
During a newborn assessment the nurse identifies that the temperature, pulse, respirations, and other physical characteristics are within the expected range. The nurse records these findings on the clinical record. Legally, how should the nurse's action be interpreted?
The nurse met the requirements set forth in the Nurse Practice Act
The nursing is teaching a NRP about the use of the gloves
The nurse must wear gloves before taking assessment.
Patient with diabetes ketoacidosis, Potassium level is high 6.3
The only med available to treat hyperkalemia KAGEXALATE.
DVT(Deep vein thrombosis) in leg:
To Keep patient on bed rest
What is the primary purpose of evidence-based nursing (EBP)?
Using results from research to improve the outcome of nursing care
Before applying ointment to the skin?
Wash the area with soap and water.
Patient with liquid diet and want to drink coffee?
You can take plain coffee, but without cream or milk.
Patient with contact precaution. What does the nurse tell the UAP?
You must wear the gown and gloves when performing the care.
An adult child of a dying client says to the nurse in the nursing home, "I am so upset because my parent is always angry at me." The nurse's best initial response is
Your parent is: Working through acceptance of the situation."
Patient complains of chronic pain: All that Apply,
a) Administer ANALGESIC around the clock b) Massages and WARM compress c) Pain Scale
Select all that apply elderly wandering:
a) Call light/bell on mattress b) Escort to room c) Orienting / surroundings
Pte blood pressure was normal, suddenly become high. Select all that apply:
a) Retake B/P in the opposite arm b) Find out activity patient was involved at
Patient with pain after 1h?
apply rock back technique.
Patient that is vegetarian; What is given to reinforce?
beans.
Video where I put a person wearing sterile gloves and then I touch and opened a box of gauze, then they told me what to do?
change gloves.
1. Patient with hypernatremia?
check food label.
Patient with drainage of abdomen?
clean from the inside to outside.
drainage in cholecystectomy
compression drainage
Woman with bleeding from vaginal tear?
contact safe method.
All that applied Insomnia?
do correct schedule take out the coffee.
How you administer eye drops?
do not touch the eye with dropper.
1. Picture of Hemovac picture (all that apply)?
do the dressing down Hemovac close the valve off look hemoglobin of patient.
To prevent infection urinary:
encourage fluid.
Give treatment in 4 patients?
first antibiotic.
Patient with soft diet complain of constipation, physical examination bowel sounds diminished, warn prune juice?
give warn prune juice
Bedridden patient who sits asking?
how do you feel.
The nurse evaluates the systolic blood pressure of the patient, he does not feel palpitations at 90, how far does he have to take the clock?
inflate Blood pressure cuff to 120.
Navajo patient who does not look in the face?
keep talking.
Image to mark the pulse closest to the popliteus?
mark the femoral pulse (look closely at which foot).
1. Patient with heart disease with one list of low fat diet (avocado, cherries, peas, etc)?
need to check fat content.
Doctor who indicates placebo?
nurse discuss with patient.
1. Patient with dysphagia what breakfast (all apply)?
oatmeal whit honey apple sauce pear nectar
Medication orientation?
observer as it gives.
1. Patient using 3 point walking (crutches)?
patient need to check palm of the hands.
Lesion red in the sacrum?
patient replacement.
1. Patient with risk of break down skin is applied at Braden Scale, That patient to choose ?
patient with urine incontinent
1. Patient with MRSA?
put gloves, gown.
Patient with erythema on abdomen and pain
put the PPI to carry out the assessment
Patient who is going to be given an enema, the patient says she does not know if she will retain the enema before reaching the bathroom?
put the commode side next to the bed (bed side).
Temperature technique?
say that is okay to auxiliary.
Urine 24h that a void was accidentally lost?
start again.
Patient with urinary catheter? All that apply
take it to the shower Put on gloves to collect the urine sample
When a patient is in a hospice, the family asked the nurse when she will be given medicine for the pain medication?
the medication (drugs) are give around the clock.
135. Family advice nurse to administer high dose of medication to shorten patient hospice life.
the nurse committed murder.
23. Patient with tetralogy of Fallot?
time must be difficult for you.
Patient who wants to sit on the bed?
to lower the bed or get off the bed.