Hurst Practice Exam 2

A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money?

Put itemized cash in envelope and place in hospital safe.

CRIES pain scale

The CRIES scale is used with neonates and infants. Crying- characteristic of pain Requires O2 for SaO2 ,95% Increased Vital signs Expression Sleepless

Which assessment findings would be of concern to the nurse who is caring for a client who has an arterial line to the radial artery?

1. Capillary refill: Left hand-2 seconds; Right hand- 4 seconds. 2. Blue tinged color to finger tips of right hand. 4. Left radial pulse-88/min; Right radial pulse-82/min 5. Blanching to right hand. These are all signs of poor circulation to the right hand. The arterial line could be occluding circulation and needs to be removed.

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client

1. Dinner plate food guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip eating utensils The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The dinner plate food guard will prevent food from being pushed off the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled shoe horn allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip.

A nurse is teaching a group of small farm owners how to prevent pesticide exposure for field workers. What points should the nurse include?

1. Importance of hand washing before eating. 3. Removing clothing and shoes worn in the field before entering the home. 4. Washing fruit and vegetables prior to eating.

The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client?

1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Inform the client that personnel are available to assist with completing an advance directive.

Which prescriptions are appropriate for the nursery nurse to initiate on a newborn prior to discharge home? SATA 1. Hepatitis B vaccine 2. Erythromycin Ointment 3. Vitamin K 4. Lanolin 5. PKU Screening

1. Hepatitis B vaccine 2. Erythromycin Ointment 3. Vitamin K 5. PKU Screening This vaccine is recommended at birth to decrease the incidence of hepatits B virus. Mandatory prophylactic agent is applied in newborn's eyes as precaution against ophthalmia neonatorium. Vitamin K (Aquamephyton) routine injection to prevent hemorrhagic disease of newborn. PKU-Screening for phenylketonuria is not reliable until the newborn has ingested an ample amount of the amino acid, phenylalanine, a constituent of both human and cow's milk. Nurse must document initial ingestion of milk and perform test at least 24 hours after that time. This test is thus done just prior to discharge.

The nurse educator is teaching a group of nursing students about client advocacy. What should the educator tell the students are the consequences of failure to act as a client advocate?

1. Life-threatening complications for the client. 2. Legal action against the nurse and/or healthcare facility. 3. Suspension or loss of license to practice nursing. 5. Loss of client autonomy and right to make decisions.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should the charge nurse assign to the medical-surgical nurse? SATA 1. Total abdominal hysterectomy 2. Breast reduction 3. Vaginal delivery with fetal demise 4. 32 week gestation with lymphoma 5. Post-partal with HELLP syndrome

1. Total abdominal hysterectomy 2. Breast reduction

Following a total hip replacement, the nurse provides discharge teaching to the client. The nurse knows that teaching was effective when the client states which activities are safe to perform? SATA 1. Using an abduction pillow while sleeping 2. Crossing the legs 3. Using a toilet extender 4. Showering rather than taking a bath 5. Tying shoes

1. Using an abduction pillow while sleeping 3. Using a toilet extender 4. Showering rather than taking a bath 1. use an abduction pillow to keep hip in proper alignment and prevent hip dislocation . 2. A toilet extender keeps the hip in proper alignment and prevents hip dislocation. 3. Showering rather than sitting in a tub will prevent flexion of the hip.2. Incorrect: Crossing the leg can pop the hip out of place and prevent total healing and success with the replacement. 5. Incorrect: To tie shoes, the client has to bend over which can pop the hip out of place. The client would need to have shoes that do not require tying or have someone do it for them.

A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. What interventions should the nurse initiate? SATA 1. Wear an N95 respirator when caring for client. 2. Restrict fluid intake to 500 mL per day. 3. Position client in semi-Fowler's position. 4. Place client in a negative pressure airflow room. 5. Do not allow visitors for 48 hours.

1. Wear an N95 respirator when caring for client. 3. Position client in semi-Fowler's position. 4. Place client in a negative pressure airflow room. The nurse should suspect that the client is suffering from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases, nonspecific symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease advances, cough, sputum production, and hemoptysis may appear. This client has the classic symptoms of TB and should be placed on airborne precautions. N95 respirator ensures that the nurse does not inhale the TB organism. Placing in a semi-Fowler's position reduces the work of breathing.

The home health nurse is assessing the home environment for possible irritants that could increase/precipitate symptoms of respiratory problems. Which assessment questions would be important to determine level of risk?

1. What type of heat do you use in the home? 2. Does anyone in the home have hobbies that involve sanding of wood or use of chemicals? 3. Is there anyone in the home who smokes? 4. Do you routinely use aerosol sprays for personal care or cleaning? Presence of wood smoke could increase respiratory problems. Poorly vented gas heaters could increase carbon monoxide in the environment. Use of solvents or other agents that produce irritating fumes could increase risk. The particles from the sanding could irritate the respiratory tract as well. Second-hand smoke is irritating to the respiratory tract. Aerosols could trigger respiratory problems.

In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last.

1. apply clean gloves. Second, remove soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4's. Sixth, clean around Penrose drain using circular pattern inside to outside. Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain. Eighth, apply abdominal dressing pad.

Which assignments would be most appropriate for the RN to delegate to an LPN/VN?

1. child with pneumonia admitted two days ago 2. the child admitted for developmental studies. 3. The twelve year old with post op wound infection taking oral antibiotics is also stable.

What should the nurse do first when caring for a client who is being admitted with a diagnosis of meningococcal meningitis?

Although all the options are appropriate, the priority is to place the client on droplet precaution to prevent the spread of meningococcal meningitis.

A nurse is preparing a lecture about suicide. Which target audience would be most appropriate?

Among those who commit suicide, young men between the ages of 15-24 are more likely to commit suicide than young girls and women. The best line of defense is to teach about the warning signs of suicide to high school teachers, students, and parents of teens and young adults, particularly male.

What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality?

2. Have the screen placed facing away from any visitor or client care area where information could be viewed by unauthorized persons.

A client is diagnosed with new onset grand mal seizures. Which nursing interventions should the nurse implement for this client?

2. Pad the side rails with blankets. 3. Place the bed in low position. 5. Instruct client to call for help when ambulating.

A nurse is caring for a client in an outpatient clinic. The client lost her husband of 51 years three months ago. Which findings support that the client is experiencing normal grief reactions rather than clinical depression? SATA 1. The client is experiencing anhedonia. 2. The client states, "I have good and bad days." 3. The client smiles at the nurse while talking about her grandchild. 4. The client has a persistent state of dysphoria. 5. The client states, "I am having fewer crying spells."

2. The client states, "I have good and bad days." 3. The client smiles at the nurse while talking about her grandchild. 5. The client states, "I am having fewer crying spells."

A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse provide the client prior to discharge? SATA 1. Avoid hot baths and showers. 2. Increase intake of leafy green vegetable products. 3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD. 5. Driving is not recommended for 1 year after placement of an ICD.

3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD.

The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8-12 hours per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler?

3. Spend about 30 minutes with the preschooler prior to bedtime for stories, prayers, etc.

What should a community health nurse include when planning a presentation on prevention and early detection of colon cancer?

A diet high in vegetables, fruits, and whole grains has been linked with a decreased risk of colorectal cancer; exercise regularly The guaiac-based fecal occult blood test detects blood in the stool through a chemical reaction. This test is done yearly.

The charge nurse was notified that a client with 2nd degree burns is being admitted to the floor. Which nurse should be assigned this client? 1. A nurse caring for clients with spina bifida and acute gastroenteritis. 2. The new nurse, out of orientation for 2 months, caring for clients diagnosed with tonsillitis and anorexia nervosa. 3. The pregnant nurse caring for clients with cystic fibrosis and staph infection. 4. A nurse caring for clients with irritable bowel syndrome and post op appendectomy.

A nurse caring for clients with irritable bowel syndrome and post op appendectomy. it would be best to assign the client to this nurse because the clients this nurse is caring for do not have anything contagious, which will decrease the risk of the burn client becoming infected.

A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. Which intervention takes priority?

Activate the community emergency response team.

A hysterical college student arrives in the emergency department in bloody soiled clothing. The nursing assessment reveals facial bruising and multiple contusions consistent with the client's report of being raped. Which initial nursing intervention takes priority at this time? 1. Notify police of the alleged rape. 2. Allow the client privacy to wash self. 3. Remove clothing and bag for evidence. 4. Encourage client to express fears and anxiety.

Allowing the client to first express emotions, such as fear or anxiety, returns a small amount of control to a situation in which the client has little or none. The police will indeed be notified of the situation by the hospital personnel, but the nurse's initial priority is to focus on the client's needs, both physical and emotional.

What should the nurse include when providing education to a client receiving tetracycline?

Antibiotic: for skin infections Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Tetracycline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun. Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective. Tetracycline can make birth control pills less effective. Use a second method of birth control while you are taking this medicine to keep from getting pregnant. Throw away any unused tetracycline when it expires or when it is no longer needed. Do not take this medicine after the expiration date on the label has passed. Expired tetracycline can cause a dangerous syndrome resulting in damage to the kidneys.

Phenytoin

Anticonvulsant

Ranitidine

Antihistamine and Antacid treats: heartburn.,stomach ulcers, gastroesophageal reflux disease (GERD), and conditions that cause too much stomach acid. Ranitidine can cause confusion in the elderly as well as agitation.

A long-term care nurse is planning care for a newly admitted client diagnosed with Alzheimer's disease. What should the nurse include in the plan of care?

Assess the client's ability to perform activities of daily living and allow client to perform alone if capable. Maintain stimuli such as a clock, newspaper, calendar, and/or weather status. Encourage family to visit to maintain socialization. Plan for staff to spend some time talking and listening to the client.

A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last.

Assess the client's orientation. Assist the client to sit on the side of the bed for 1-2 minutes. Apply a gait belt to the client's waist. Have the client stand by the side of the bed for a few seconds. Ambulate in the room

The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the client's admission signature as legible, but, now observes a jerky, illegible signature. What should the nurse suspect is the cause of this handwriting change? 1. Fetor 2. Ataxia 3. Apraxia 4. Asterixis

Asterixis is a tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. Yes, the liver flap, which is an abnormal muscle tremor, is usually found in clients with diseases of the liver. This is an indication that the hepatic failure is worsening and needs to be documented.

Which symptoms would the nurse be likely to observe in the client who overdosed on diazepam?

Benzodiazepines are central nervous system (CNS) depressants. Diazepam is a benzodiazepine. They will slow respirations (bradypnea) and the heart rate (bradycardia). Somnolence (extreme, prolonged drowsiness) would be seen.

The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse?

Call for personnel to escort the client out of the day room.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

Check client's vital signs after ambulating. Obtain a stool specimen.

A primary healthcare provider prescribed KCL 40 mEq in 100 mL NS to infuse over 30 minutes. What action should the nurse take? 1. Administer the KCL through the lowest IV line port. 2. Clarify the prescription with the primary healthcare provider. 3. Mix KCL 40 mEq into the present infusing bag of NS when it reaches 100 mL. 4. Set the infusion pump to 100 mL / hour.

Clarify the prescription with the primary healthcare provider. Potassium chloride should be diluted and administered to infuse no faster than 40 mEq per hour. So this prescription would infuse too quickly and may lead to life threatening arrhythmias.

Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood?

Client needs low sodium and increased proteins. ex.Scrambled eggs, sliced turkey, biscuit, whole milk

A client is scheduled for plateletpheresis. When taking the client's history, which information is most significant?

Date last donated Platelet donors can have plateletpheresis as often as every 14 days.

An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority?

Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds. This client is responding to verbal stimuli by moaning and has an open airway; but any client with an altered level of consciousness is at risk for airway obstruction. The skin assessment indicates a circulation problem.

Two days after a myocardial infarction, a client begins reporting orthopnea and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The urine output has steadily declined over the past 12 hours. What should the nurse do first?

Elevate the head of the bed first. The client is reporting inability to breathe. (Orthopnea means the client needs to sit up to breathe better.) With ANY client having difficulty breathing, the first intervention for the nurse is to sit the client up. This client is showing s/s of heart failure.

A primary healthcare provider informs the nurse to prepare for an amniotomy on a client who's labor has not progressed. What should the nurse assess for prior to the primary healthcare provider performing this procedure?

Fetal engagement is important prior to rupturing the membranes so that the umbilical cord cannot prolapse. Fetal engagement is when the fetus is at station 0 (level of mom's ischial spines).

The charge nurse on the pediatric unit is reviewing the protocol for blood administration with a staff nurse. Which actions by the staff nurse indicate understanding of blood administration?

Filters are used when infusing blood. Two nurses must check the blood product label and blood group. Vital signs are checked frequently during a blood transfusion. For example: A baseline set of vital signs are taken, then again 5 minutes after the initiation of the transfusion, then 15 minutes after transfusion started and every 15 minutes for one hour, then every 30 minutes for one hour, then hourly until infusion is complete.

The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions."

Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration.

A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client?

Flushing, nausea and vomiting, palpitations, tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol (cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole. Antibiotic: take metronidazole on an empty stomach

The nurse is teaching a client who has been prescribed daily glucocorticoids for the treatment of Addison's disease. What teaching points should the nurse emphasize?

Glucocorticoids should not be abruptly discontinued due to the risk of adrenal suppression with prolonged use. Doses should be tapered before being discontinued.

When caring for a client with hepatitis A, the nurse should take what special precaution?

Hepatitis A is transmitted by the fecal/oral route. Use gloves when removing the client's bedpan.

The home health nurse is caring for a client with a neurological urinary tract dysfunction. What information should be included when teaching the client how to perform intermittent self catheterization?

Home intermittent catheterization is a clean, not sterile technique when performed in the home environment. Home intermittent catheterization is preferred over continuous use of an indwelling catheter, as an indwelling catheter increases client risk of urinary tract infection (UTI).

Which electrolyte imbalance would be the nurse's priority concern in the burn client?

Hyperkalemia Good job. When the cells lyse they release potassium, and then the serum potassium goes up. And if the kidneys stop, we are in real trouble.

Which signs and symptoms, if noted by the nurse, would indicate that the client with hyperthyroidism is experiencing thyroid crisis?

Hyperkinesis - muscle spasm Hypertension Restlessness Confusion

A nurse attaches a client to continuous cardiac monitoring due to a potassium level of 2.8 mEq (2.8 mmol). The nurse should monitor for which dysrhythmia?

Hypokalemia is reflected by the EKG. The earliest EKG change is often premature ventricular contractions (PVCs) which can deteriorate into ventricular tachycardia or fibrillation (VT/VF) without appropriate potassium replacement.

What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? SATA 1. Fat distribution greater in abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome.

If the body stores fat primarily in the abdomen, risk of type 2 diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with polycystic ovary syndrome have increased risk of diabetes.

A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect?

Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet.

Family members have been asking triage nurses if loved ones were admitted to the hospital during a national emergency situation with massive casualties. What response should be made by the nurses?

Inform them if their family members have been admitted. The national emergency situation allows waivers for the Health Insurance Portability and Accountability Act (HIPAA) provisions. Due to the emergency situation, the nurse may inform the family members about the status of their loved ones.

The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit?

Jaundiced conjunctiva This is a sign of liver damage, which is caused by an overdose of acetaminophen.

A client with heart failure and pulmonary edema is given furosemide intravenously. Which assessment indicates that the furosemide has achieved the desired effect? 1. Weight has decreased 2 pounds. 2. Systolic blood pressure has decreased. 3. Urinary output has increased. 4. Lungs have fewer rales on auscultation.

Lungs have fewer rales on auscultation. The goal for diuretic therapy in this client is to prevent/relieve fluid accumulation in the lungs. This answer addresses the most life-threatening sequelae with HF. The number one thing to worry about in clients with HF is pulmonary edema, because this is what can kill the client. 1. Incorrect: Weight loss is a good assessment of fluid loss or gain, especially acute weight changes. The stem of the question, however, asks which is the desired effect? The desired effect is to decrease fluid in the lungs and weight loss alone does not ensure that the lungs are clearing. 2. Incorrect: Lowered blood pressure is an expected finding, but treatment of pulmonary edema is the primary goal. 3. Incorrect: Increased urinary output is an expected finding, but treatment of pulmonary edema is the primary goal.

Which nursing intervention should receive priority after a client has returned from having had eye surgery?

Maintain head of bed at 35°. Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures, including the retina and optic nerve, with resulting loss of vision, may result.

Which foods should the nurse teach a client to avoid when prescribed a diet limiting purine rich foods?

Meats: liver, bacon, veal, and venison are high in purine and should be avoided. Seafood: sardines, mussels, codfish, scallops, trout, and haddock are high in purine and should be avoided.

A nurse who has never had varicella has been exposed to a client diagnosed with herpes zoster. What actions should the nurse take?

Notify the person responsible for infection control to get post-exposure treatment initiated within a timely manner. For persons who are susceptible, the varicella-zoster immune globulin should be given within 96 hours of exposure. The infection of herpes zoster is contagious until the crusts have dried and fallen off the skin.

What symptoms would the nurse anticipate in a client being admitted to the hospital with a calcium level of 3.2 mg/dL (0.80 mmol/L)?

Muscle rigidity and cramping. Positive Chvostek's sign. Seizures Laryngospasms Normal serum calcium is 8.7 - 10.3 mg/dL (2.18 - 2.58 mmol/L). The client with a calcium level of 3.2 mg/dL (0.80 mmol/L) is hypocalcemic. With hypocalcemia, the muscle tone is rigid and tight. Therefore, the client may report muscle cramping. A hallmark sign of hypocalcemia is a positive Chvostek's sign, which is a twitching of facial muscles following tapping in the area of the cheekbone, indicative of hyperirritability. The client may be at risk of having seizures due to the neuromuscular irritability. Prolonged contraction of the respiratory and laryngeal muscles causes laryngospasm and stridor and may result in cyanosis

The nurse is caring for a client following spinal surgery. The client is placed on methylprednisolone. What additional drug therapy would the nurse expect to be prescribed with methylprednisolone?

Pantoprazole A potential side effect of methylprednisolone is a peptic ulcer. The primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this side effect.

A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client?

Proper methods of closing eyelids and eye patching. Even though all are educational points that need to be provided to the client, this is the most important educational point to make. Keratitis, or the inflammation of the cornea, is one of the most dangerous complications for a client with Bell's palsy. As a precautionary measure, the nurse must ensure that the cornea is protected even if the eyelids will not close.

A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do?

Protocols on the unit must be followed when someone is requesting to leave AMA. The first step is to call the primary healthcare provider about the client's desire to leave AMA. wrong: 2. Make arrangements for a commitment hearing, as soon as possible. 3. Tell the client the primary healthcare provider must discharge the client prior to leaving. 4. Call the primary healthcare provider and request a discharge order. 2. Incorrect: The client is not suicidal; however, the primary healthcare provider needs input into their decision to leave AMA. It is not appropriate to prepare for a commitment hearing. 3. Incorrect: If the client is not a threat or potential threat to self or others, the client may leave. The nurse may discuss the decision to leave; however, this statement is not accurate. 4. Incorrect: The nurse should call the primary healthcare provider and discuss the situation. The primary healthcare provider should have input into this decision.

The nurse is performing CPR on an adult client with facial and neck trauma. Following the administration of rescue breaths, where is the best location for the nurse to assess for a pulse in this client?

Pulses that are best palpated are large and close to the trunk of the body. The femoral artery is large and at the trunk (proximal) of the body.

A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first?

Remove the source of the panic attack first, then continue to assess the person for symptoms. Removing the cat "fixes" the problem.

A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. What is the first action the nurse should provide to the client?

Research indicates that back massage can enhance client comfort, relaxation, and sleep. This is the least invasive option and should be done first.

A client diagnosed with arachnophobia is prescribed alprazolam 0.5 mg orally three times daily. The nurse knows that teaching about this medication is successful when the client makes what statement?

Sedative It can treat anxiety and panic disorder Suddenly stopping could produce serious withdrawal symptoms, such as depression, insomnia, anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium. Alprazolam works relatively quickly. Drowsiness, confusion, and lethargy are the most common side effects. The client should not drive or operate dangerous machinery while taking the medication. If the client experiences nausea and vomiting, take with food or milk.

Which statement by a student nurse indicates to the nurse educator that teaching regarding witnessing consent signatures has been successful?

Signing as a witness implies that the witness has observed the client personally signing the consent form with no coercion. Only one signature is required as a witness. The witness does not have to be an RN. A witness is required to be over the age of 18.

Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence?

Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence." Beneficence is taking positive action to help others and a desire to do good which is the core principle of client advocacy.

The nurse is caring for a client taking spironolactone. Which dietary change should the nurse teach the client to make when starting treatment with this medication?

Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided.

The nurse is teaching a diabetic client who has been prescribed Lispro insulin about avoiding hypoglycemia. What administration teaching is priority?

Take it with meals. Lispro is a rapid-acting insulin that should only be taken with food or within 15 minutes of a meal.

The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time?

Tell the client it is time to take a shower. Depressed clients often have little energy to do or think. Give short, simple commands during this time.

The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue?

The Cumulative Index for Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing and allied health information.

The nurse is assessing pain after surgery in a 3 year old client with a known developmental delay. Which pain scale should the nurse use to assess this client's pain level?

The FLACC scale can be used for pediatric clients from age 2 months to 7 years and is appropriate when clients cannot communicate their pain.

Which nursing task would be appropriate to delegate to an LPN/VN

The LPN/VN has the knowledge and skill to obtain a wound culture. This is within the scope of practice for the LPN/VN.

The nurse is caring for a client who is to receive an IV infusion of heparin. The client's dose is based on a sliding scale prescription. What is the priority lab value to check before initiating the heparin infusion? 1. PT and/or INR 2. aPTT 3. Platelet count 4. WBC count

The activated partial thromboplastin time (aPTT) is a lab value used to assess pathways in the clotting cascade and is used to monitor Heparin therapy in clients. To maintain a therapeutic level of Heparin, the aPTT should be maintained at 1.5-2.5 times the normal range.

Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take?

The nurse should educate the client about complications that can be prevented with ambulation, such as constipation, pneumonia, or deep vein thrombosis (DVT).

Which task should the nurse perform first? 1. Suctioning the tracheostomy. 2. Changing a colostomy bag that is leaking. 3. Performing an admission assessment on a client. 4. Administering pain medication to a postoperative client.

The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning the tracheostomy should take priority. Remember, airway first.

The clinical specialist is teaching a group of new staff nurses about therapeutic communication. Which statement by one of the staff nurses indicates to the clinical specialist that further teaching is needed?

Therapeutic communication does not include the use of gestures. Gestures are a type of nonverbal communication which can provide assistance in communicating therapeutically with a client. Other forms of nonverbal communication include facial expression, touch, mannerisms, posture, position, and personal space.

When assessing a client, the nurse finds that in response to painful stimuli the upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb, while the lower extremity exhibits extension, internal rotation, and plantar flexion. How would the nurse accurately document this finding?

This describes decorticate posturing because they are moving towards the core of the body.

A client has been prescribed vancomycin 1 gram IV every 12 hours for the treatment of methicillin-resistant staphylococcus aureus (MRSA). Which action by a new nurse when administering this medication would require intervention by the charge nurse?

This dose of medication should be delivered over at least 60 minutes to prevent hypotension and ototoxicity.

What should the nurse document after a client has died?

Time of death Who pronounced the death Disposition of personal articles Destination of body Time body left facility

The six bed Labor and Delivery area is full when the Emergency Department nurse calls for a bed for a woman reporting low back pain, pelvic pressure and increased vaginal discharge at 36 weeks gestation. Which would be the most appropriate action for the charge nurse? 1. Transfer a G4P4 who delivered full-term twins one hour ago to the antepartum/postpartum floor. 2. Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the antepartum/postpartum floor. 3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for eclampsia from the LDR unit to the ante/postpartum unit. 4. Request that the new client be admitted to the antepartum/postpartum floor.

Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the antepartum/postpartum floor. The client and newborn are not in any present distress. Also the delivery occurred 3 hours ago. This client would not be a risk and could be cared for on the antepartum/postpartum floor.

A client is hospitalized because of severe malnutrition related to anorexia nervosa. What is the most important goal for this client?

Until appropriate weight is gained, the client continues to be at risk for major health complications including hypotension, cardiac arrhythmias, poor muscle tone, increased risk for infection, abnormal liver function, and damaged kidneys.

The nurse receives new healthcare provider prescriptions on a client diagnosed with Addison's disease. Which prescriptions should the nurse recognize as being inappropriately written and requiring clarification from the prescriber?

Use "daily" or "every day". QD is an unapproved abbreviation. T.I.W. stands for three times a week; however, it is an unapproved abbreviation. Use "three times a week".

The nurse is preparing to administer iron dextran IM. Which injection site would be best for administration?

Ventrogluteal site This site would be used for Z track IM injections. Iron preparations are administered by the Z track technique, preferably in a large, deep muscle such as the ventrogluteal muscle.

The nurse is caring for a client who has been diagnosed with dissociative identity disorder. What is the most appropriate short term goal?

Verbal recognition of the existence of multiple personalities. This condition is also reffered to as multiple personality disorder. s/s: The existence of two or more distinct identities .The distinct identities are accompanied by changes in behavior, memory and thinking. Ongoing gaps in memory about everyday events, personal information and/or past traumatic events. The symptoms cause significant distress or problems in social, occupational or other areas of functioning.

The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider?

Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention. Angioedema is an adverse effect of ACE inhibitors and can be life threatening. This should be reported immediately to the healthcare provider. The potassium level is too high. Hyperkalemia is an adverse effect of an ACE inhibitor and needs to be reported.

The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurse to place the client in until full consciousness is regained?

When someone is very sedated and not fully conscious, we want them on their side so the airway remains open and the secretions can drain.

Imipramine HCI

antidepressant which is not routinely given with methylprednisolone

A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer? 1. Lorazepam 2. Atropine 3. Benztropine 4. Chlorpromazine

benzotropine These signs and symptoms are reflective of pseudoparkinsonism, a form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic agent maybe used for treatment. This is an anticholinergic agent that may be used for extrapyramidal side effects.

Benzodiazepines

drugs that lower anxiety and reduce stress

Anhedonia

inability to experience pleasure...in clinical depression

Reaction formation

is behaving in a way that is exactly opposite of one's true feelings. (defense mechanism)

The nurse is providing post-operative care to the craniotomy client. Hourly urinary output increases from 100 mL last hour to 500 mL this hour. What action by the nurse takes priority?

we are "worried" this client is going into SHOCK due to diabetes insipidus. So, you better be checking a BP. This is a time where checking the BP is appropriate. If we "assume the worst" I better check a blood pressure. It could have dropped out the bottom.

Decerebrate posturing

when the client is stimulated, and teeth clench and the arms are stiffly extended, adducted, and hyperpronated. The legs are stiffly extended with plantar flexion of the feet. Abnormal extension occurs with lesions in the area of the brain stem.