Hurst Q Review

The nurse is observing a new nurse explain phototherapy to the mother of a newborn with a bilirubin of 12 mg/dL one day after birth. The nurse determines the new nurse understands the phototherapy process when what statements are made to the mother?

"The infant's eyes must be covered throughout the light session." "Body temperature must be checked frequently to monitor for fever." "We check bilirubin levels several times daily to be sure it's decreasing."

The nurse has been caring for a client who is confused. Upon entering the room, the nurse finds the client on the floor. The side rails are up, there is urine on the floor, and an abrasion is noted on the client's forehead. Which information should the nurse include in the incident report?

Abrasion on the clients forehead Clients confused state Presence of urine on the floor Side rails were up

The previous shift nurse reported to the oncoming nurse a suspicion that a client's central line has developed a fibrin sheath. Which prescription does the nurse anticipate the healthcare provider will prescribe?

Alteplase

A 65 year old client is admitted for management of dehydration with an IV infusion of LR @ 125 mL/hr. What assessment findings would be of concern to the nurse?

Anxiety Crackles noted right posterior lung field S3 heart sound

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?

Asterixis

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?

Capillary refill: Left hand-2 seconds; Right hand- 4 seconds. Blue tinged color to finger tips of the right hand Left radial pulse-88/min; Right radial pulse-82/min Blanching to right hand

A client, post laparoscopic cholecystectomy, develops pain in their right shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain?

Carbon dioxide used intraperitoneally is irritating the phrenic nerve.

Which information obtained during a well-baby checkup of a 3 month old infant would the nurse need to report to the primary healthcare provider?

Caregiver states infant tastes salty. Frequent coughing with thick, blood-streaked sputum. Foul-smelling, greasy stools. No weight gain since last check-up.

The charge nurse is planning the staff assignments for the clients on a neurological unit. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit?

Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam.

The charge nurse on the Labor and Delivery unit is making morning assignments. What client would be most appropriate for a newly hired licensed practical nurse (LPN)?

Completing perineal care for post-delivery clients.

A client has been admitted to the ICU following an extensive anterior-wall myocardial infarction. What change in vital signs would alert the nurse the client may be experiencing cardiogenic shock?

Decreased urinary output. Blood pressure of 80/40. Cold and clammy skin.

A nurse working in a locked psychiatric unit is caring for a client diagnosed with paranoia. The client becomes very agitated and shouts, "I am not going to my session today!" What action by the nurse would be most appropriate?

Escort the client to an easel and canvas in order for the client to paint. 4

The nurse is teaching a community health class for cancer prevention and screening. Which individual does the nurse recognize as having the highest risk for colon cancer?

Has a family history of colon polyps

A client arrives at the emergency department (ED) in obvious emotional distress, reporting perioral numbness and tingling of the fingers and toes. The nurse notes a respiratory rate is 56/min. What should be the initial intervention performed by the nurse?

Have the client breathe into a paper bag.

An alert client presents to the emergency department with vomiting for 3 days and has been unable to keep food or fluids down for the last 24 hours. Which imbalances does the nurse suspect this client has?

Hypokalemia Metabolic alkalosis

Parents of school-aged children are working toward a goal of healthy family TV viewing. Which parental statement indicates adequate understanding of appropriate use of TV in the family?

I don't allow my kids to watch violent TV shows.

A client with a history of cardiac disease has safely delivered a full-term infant. When discussing discharge instructions, the nurse knows the teaching was successful when the client makes what statement?

I must include lots of fiber to prevent constipation

A client with a history of cardiac disease has safely delivered a full-term infant. When discussing discharge instructions, the nurse knows the teaching was successful when the client makes what statement?

I should return to my previous dose of cardiac medication

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

Jaundiced conjunctiva

Which prescription should the nurse question for a client diagnosed with heart failure who has a Swan-Ganz mean pulmonary artery pressure of 20 mm Hg?

Normal saline infusion at 100 mL/hr

The nurse is performing morning care on a client on the medical unit. What should the nurse do after changing a client's bed linen?

Place the linen into a leak proof container sitting outside the room.

A client comes into the clinic reporting muscle pain and tenderness but denies previous injury. Based on data gathered by the nurse, what client medication does the nurse suspect is causing this problem?

Rosuvastatin

The nurse initiates cardiac monitoring on a 6 year old immediately after the child has a seizure. How should the nurse document the rhythm?

Sinus arrhythmia

Which client could the telemetry charge nurse safely transfer in order to admit a new client?

Twenty-four hour post operative carotid endarterectomy.

What should the nurse include when providing teaching to a female client prescribed doxycycline for the treatment of acne?

Use a non-hormone method of birth control while taking this medication. Wear protective clothing when outside. Drink plenty of fluids while taking this medication.

Which action by a nurse would require the charge nurse to intervene?

Walking in the hallway outside the operating room without a hair covering.

The nurse is working on a health promotion plan for a young family whose child has severe allergies and asthma symptoms. Which interventions would be important to include in the health promotion plan?

Wash stuffed animals/toys frequently in hot water. Make sure that bathrooms and high humidity areas are properly vented. Limit carpet in the bedrooms. Vacuum floors and upholstered furniture regularly.

What is most important for the nurse to have at the client's bedside when inserting a large orogastric tube for rapid gastric lavage?

Suction equipment

The client with bleeding esophageal varices has a Blakemore tube in place. What piece of equipment should be present at the bedside?

Surgical scissors

A client who has chronic renal failure has been prescribed synthetic erythropoietin for the prevention of anemia. Which assessment finding should be reported to the primary healthcare provider?

Swelling of feet and ankles

A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual?

Attend an activity with the client who is reluctant to go alone. Consider client preferences when possible in decisions concerning care. Provide a blanket when the client is cold. Provide food when the client is hungry.

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?

"Are you using any products that contain alcohol?"

A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response?

"The pain you feel is real."

The emergency department nurse is assigned to care for four pediatric clients with varying symptoms. Which client should the nurse examine first?

6 month old with respiratory rate of 68/min while sleeping

A medical surgical nurse has been floated to the pediatric unit to assist during a staffing shortage. Which clients would be most appropriate for the float nurse?

A 10 year old in sickle cell crisis. A 8 year old with Crohn's disease. A 4 year old with acute asthma.

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?

A filter was used when administering the blood. A second nurse checked the blood compatibility. A set of vital signs was taken 5 minutes after the blood infusion started.

A client with Graves' disease and exophthalmos returns to the clinic for evaluation. Which assessment indicates to the nurse that the client is adhering to the teaching plan?

An absence of corneal irritation

What action should the nurse take first for the 5 year old client brought to the urgent care clinic with a blistering sunburn?

Apply cool water soaks.

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 client's ability to perform activities of daily living. Place a clock and calendar in client's room. Encourage family to visit client often. Have nursing staff spend time talking and listening to client.

Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection?

Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change.

Which client would be appropriate for the RN to assign to the LPN?

Client requiring enemas and antibiotics. Client with frequent reports of nausea and vomiting following chemotherapy. Client requiring frequent sterile dressing changes.

Which client will the charge nurse intervene on behalf when making rounds?

Client who has been sitting in a chair for 2 ½ hours.

While a nurse was in shift report, four clients called the nurses' station. Which client should the nurse see first?

Client who needs a peak blood level drawn because the antibiotic just finished infusing.

A teenage client is placed on life-support as a result of a motor vehicle accident (MVA). Following an electroencephalogram (EEG), the client has been declared brain dead. Which action by the nurse would take priority?

Contact the regional organ procurement team.

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?

Decorticate posturing

The nurse receives the morning lab results of four clients during the change of shift report. Which client should the nurse assess first?

Diabetes with a Fasting Blood Sugar (FBS) of 40 mg/dL (2.2 mmol/L).

The emergency department called the labor and delivery unit to give report on a 24 year old primigravida at term, having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate?

Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse.

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?

FLACC scale

The primary healthcare provider is preparing to drain a large abdominal abscess. The client has dementia and moves about on the bed frequently. Which personal protective equipment (PPE) should the nurse wear while holding the client for the procedure?

Face shield Gown Mask Regular exam gloves

What impaired functions does the nurse expect to observe in the client admitted with an injury to the frontal lobe of the brain?

Impaired speech. Decreased concentration.

What information should be included in the health promotion plan for parents regarding the promotion of adequate bowel elimination in their toddler?

Include adequate fiber in the diet through whole grains and fruits. Increase intake of water daily. Provide toileting opportunities that are free from distractions.

During evening rounds, the nurse discovers that a violent client with a history of threats against a former girlfriend cannot be located. The client's window is open and personal belongings missing. Based on recent threats of violence against the girlfriend, what is the nurse's initial action?

Initiate the missing client protocol.

A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients from a culture other than the nurse's culture. Which points should the nurse include in the presentation?

Lack of knowledge about a client's culture is a major barrier to therapeutic communication. Do not touch the client until you know what the cultural belief is about touching. Adapt care to client's cultural needs and preferences.

A nurse is planning a health education seminar for a group of females who are age 45-54. What should the nurse recommend be done annually?

Mammography Influenza vaccine

The nurse is caring for a client while fluorouracil is being infused. The client reports burning at the intravenous (IV) site. What should the nurse do first?

Stop the infusion.

A client is hospitalized for recurrent angina with hypertension and has been started on new medications. When reviewing the admission forms, the nurse should immediately question which prescription?

Potassium 10 meq. P.O. once daily.

What should the nurse who is educating about the most common initial visual changes associated with glaucoma inform the client?

Progressive tunnel vision occurs.

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.

While making evening rounds, the nurse discovers an elderly, confused client standing next to the bed with the IV pulled out, gown wet with urine and the side rails still in the up position. The client's arm band is on the floor. To ensure client safety, what is the most important intervention for the nurse to include in the plan of care?

Provide for scheduled toileting intervals.

A client asks the nurse, "What causes hypermagnesemia?" The nurse should explain to the client that hypermagnesemia can occur secondary to what health problem?

Renal insufficiency

The charge nurse is delegating assignments on the Alzheimer's unit of a long-term care facility. What task could be assigned to the unlicensed assistive personnel (UAP)?

Replace soiled heel protectors on bedfast client. Escort dementia client on an outdoor walk. Assist client to complete the daily menu list.

The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client?

Spending time in brief one on one interactions with the nurse

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 Angioedema Serum potassium of 5.8