Missed questions

The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider?

"I had rheumatic fever when I was 10 years old." Rationale: After having rheumatic fever, a client would need to be pre-medicated with antibiotics prior to any surgical or dental procedure to prevent a recurrence.

buspirone

"I should not drink alcohol while taking this medication." "I will rise slowly from lying to sitting or standing." "I will notify my primary healthcare provider of any unusal facial movements."

The charge nurse is evaluating knowledge of tracheostomy suctioning of a new nurse prior to that procedure being performed. Which statement by the new nurse would indicate to the charge nurse that additional education is needed?

"I will instill normal saline bullets to liquefy secretions." Rationale: The best ways to liquefy secretions are to humidify secretions and hydrate the patient. Do not use normal saline solution or normal saline bullets routinely to loosen tracheal secretions because this practice may reach only limited areas, may flush particles into the lower respiratory tract, may lead to decreased post-suctioning oxygen saturation, increases bacterial colonization, and damages bronchial surfactant.

A woman, diagnosed with an ectopic pregnancy, asks the nurse the purpose of receiving methotrexate. What is the best reply for the nurse to make?

"This medication will stop the growth of the embryo to save your fallopian tube." Rationale: The medical management of an ectopic pregnancy is to prescribe methotrexate. The action of methotrexate is to stop the growth of the embryo in the fallopian tube. The embryo is reabsorbed and the fallopian tube can be saved.

A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take.

1- O2 2-insert another IV 3-BG level 4-NG tube 5-Repeat VS Rationale: -Needs O2 first bc they are showing signs of hypoxia (tachycardia and anxious) -needs IV second bc it improves the BP -needs BG level third bc you have already addressed air and circulation -needs recheck of VS last bc it can assess the effectiveness of your actions

normal INR

2-3 if on warfarin

The unit charge nurse is responsible for reporting all healthcare associated infections. Which client condition needs to be reported?

A client diagnosed with Clostridium Difficile while receiving intravenous (IV) antibiotics. Rationale: Clostridium Difficile is a spore forming bacterium that has significant healthcare associated infections (HAI) potential. Clients with intravenous catheters are at a higher risk for HAI.

how much folic acid per day in order to reduce neural tube defects?

400 mcg/day

A new mother brings her infant to the clinic for a well-baby checkup. While at the clinic, the mother asks the nurse if there are any reasons why her infant should not have the measles, mumps, rubella (MMR) vaccine. The nurse's response is based on evidence that the MMR vaccine is contraindicated under which condition?

A known allergy to gelatin.

The nurse is caring for a client with myasthenia gravis. What is essential for the nurse to teach this client regarding treatment?

Setting the alarm clock for medication times. Rationale: Yes! Medication must be taken on time. Too early can cause weakness and too late can cause extreme weakness to point of paralysis.

The nurse is administering the prescribed Mantoux tuberculin skin test to a client. The nurse does not observe the tense blister-like formation at the injection site. Which action should the nurse take?

Administer another Mantoux tuberculin skin test at a different site. Rationale: If there is not a wheal of at least 6 mm in diameter after the solution is injected , the test should be administered again. The nurse would need to administer another Mantoux tuberculin skin test in another area about 5-6 cm from the original injection site.

Which intervention can the nurse safely delegate to an unlicensed assistive personnel (UAP)?

Apply a condom catheter to an incontinent client. Rationale: With proper instruction a UAP may be delegated to apply a condom catheter. This is not an invasive procedure.

A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client?

Ask the primary healthcare provider to prescribe a diabetes educator consult. Rationale: Referrals to appropriate agencies or departments are often made by the home care nurse. Client needs must be met in the most efficient way while utilizing appropriate expertise. This client has poorly controlled diabetes resulting in a wound. A diabetes educator can help develop a plan to prevent further complications of diabetes.

The nurse is caring for a client with renal failure. The client has a 24 hour intake of 2500 mL and a 24 hour urinary output of 200 mL. What is the priority nursing assessment?

Auscultate breath sounds. Rationale: The nurse is "worried" about fluid volume excess. In fluid volume excess (FVE), the number one concern is heart failure with resultant pulmonary edema. In FVE, you can stress the heart so much that the heart begins to fail. With heart failure, the cardiac output decreases. With decreased cardiac output, there is decreased forward flow out of the heart. With decreased forward flow there is back flow. Back flow from the left ventricle results in fluid accumulation in the lungs. The best assessment for heart failure is to auscultate lung sounds.

A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse?

BP reading *the BP given is 90/40* Rationale: The low blood pressure indicates that systemic tissue perfusion will not be adequate. The blood pressure needs to be improved rapidly.

The primary healthcare provider prescribes a combination of pyrazinamide and isoniazid to treat a client with tuberculosis. The client asks the nurse, "Why am I taking two drugs?" Which explanation should the nurse give the client?

Bacterial resistance is decreased. Rationale: The CDC says that the initial phase of treatment for newly diagnosed cases of pulmonary TB should consist of a multiple-medication regimen because many cases of TB are caused by strains of the bacteria that are resistant to isoniazid or rifampin. This client has been prescribed the multiple medication regimen of pyrazinamide and isoniazid.

A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take?

Begin treatment by inserting two large bore IVs of Normal Saline. Rationale: In emergencies, if it is impossible to obtain consent from the client or an authorized person, a health care provider may perform a procedure required to benefit the client or save a life without liability for failure to obtain consent. In such cases the law assumes that the client would wish to be treated. Begin treatment for diabetic ketoacidosis (DKA).

While performing a vaginal examination on a client in labor, the nurse feels soft, squishy tissue instead of a head. What conclusion should the nurse make based on this assessment finding?

Breech Rationale: The nurse is palpating the buttocks of the fetus. The buttocks would be assessed as soft, squishy tissue. This is evidence of a breech presentation.

The nurse is performing the admission assessment on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery?

Client's last menstrual period was 8 weeks ago. Rationale: The client may be pregnant, so a pregnancy test will need to be completed prior to administering anesthetic agents. As you look at these options they are all possible but only one is a priority and in this case life threatening.

A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse do?

Consult with the pharmacy for a different medication concentration. Rationale: The nurse must consult with the pharmacy to receive further instructions. The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy.

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. Rationale: The first priority is to notify the designated organ procurement team. These personnel are trained to determine if the client would be an appropriate donor, how to approach the grieving family and discuss options, and to make any necessary arrangements in such a situation. Time is of the essence in the case of organ donation. Even if the family refuses to donate organs, it is the Procurement Team that will deal with the situation.

A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action?

Decrease stimuli in the room. Rationale: The nurse should remain calm and quiet by the client. A stimulating environment may increase the client's level of anxiety.

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure?

Elevate head of bed to fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches of distal NG tube. Insert NG tube into unobstructed naris. Advance NG tube upward and backward until resistance is met. Rotate catheter and advance into nasopharynx. Have client swallow ice as NG tube advances into stomach. Secure NG tube.

A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected?

Ensure a do-not-resuscitate prescription has been provided. Rationale: The nurse should check the medical record for a DNR order. By law, a person who does not have a do-not-resuscitate (DNR) prescription, must be provided CPR in the event of a cardiac/respiratory arrest. This action will ensure the client's end-of-life wishes have been communicated and will honor the client's wishes.

A client with Crohn's disease develops a fever and symptoms of an infection. The nurse recognizes this complication may occur as a result of which finding?

Fistula formation with an abscess Rationale: Clients who suffer from Crohn's disease are at risk for developing fistulas, and an abscess can result from the fistula.

The nurse is teaching the client about benzodiazepines. Which comments by the client indicate adequate understanding of the drug effects/side effects?

I should not drive my car until I see how the medication affects me. I can expect my reaction time to be slowed in the beginning. I must be careful to take the medication for a limited time. There is a risk for dependence on this medication.

The nurse is caring for a newly diagnosed diabetic in diabetic hyperosmolar hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate the immediate treatment plan for this client will include?

Intravenous administration of isotonic saline. Rationale: Clients who present with HHNK are severely dehydrated. This is because high glucose levels in the vascular space lead to particle induced diuresis (PID) or osmotic diuresis. The clients lose large amounts of volume out of vascular space. The client may even be "shocky". Isotonic saline is the treatment of choice for clients who are in HHNK. Isotonic saline will go into the vascular space and stay there thus improving the fluid volume deficit that has developed.

When assessing a client's testes, which finding would indicate to the nurse the need for further investigation?

Lump the size of a piece of rice. Rationale: most common symptoms of testicular cancer are a painless enlargement of one testis and the appearance of a palpable small hard lump on the front or side of testicle

An elderly client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action?

Lung assessments every 2-4 hours. Rationale: The IV is infusing at 200 mL/hr which is a rapid infusion rate for an elderly client. The lungs should be assessed every 2-4 hours to evaluate for potential fluid volume excess (FVE).

paranoid personality

NO group therapy

do you need a consent to perform a Mantoux test?

NO!!

is chorioamnionitis contagious?

NO!!

Which client must the nurse assign to a private room?

Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C) Rationale: A temperature of 100.5° F (38.05° C) or greater in a client more than 24 hours postpartum is likely an indication of infection. This client should be kept separate from other mothers and babies.

A client was prescribed thioridazine hcl five days ago and presents to the emergency department with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication does the nurse suspect?

Pseudoparkinsonism Rationale: Pseudoparkinsonism may appear 1 to 5 days following initiation of antipsychotic medications: occurs most often in women, the elderly, and dehydrated clients. Symptoms include tremor, shuffling gait, drooling, and rigidity.

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. Rationale: The interaction with the nurse can keep the conversation reality based and provide interaction with someone. Clients with schizophrenia may be very withdrawn and need the presence of the nurse.

A client with a history of increasing dyspnea over the past week comes to the emergency department. After arterial blood gases (ABGs) are drawn, which information would be important for the nurse to document?

The client was on 2 L of oxygen by nasal canula.

A parent tells the clinic nurse, "My child has just been diagnosed with attention-deficit/hyperactivity disorder (ADHD). What will be done to help my child?" How should the nurse best respond to the parent?

The standard of care for children with ADHD includes central nervous system stimulants along with behavior and family therapy. Rationale: Multimodal treatment of ADHD is the standard of care for children. There is a lot to be gained by supporting medication treatment with appropriate educational, psychosocial, and family interventions.

A client with chronic alcoholism has been admitted to the intensive care unit after overdosing on alcohol. Which medication should the nurse prepare to administer?

Thiamine 100 mg IV twice a day Rationale: Prescribing of thiamine action is to alleviate dehydration, prevent delirium and precaution treatment for vitamin B complex deficiency. Thiamine 50-100 mg IV or IM is indicated twice a day for clients with chronic alcoholism. It is usually given for several days, followed by 10-20 mg once a day until a therapeutic response is obtained.

Which pediatric client should the nurse see first?

Three year old with wheezes in right lower lobe. Rationale: The child having respiratory difficulty should be seen first. This is an example of using Maslow to set priorities. Airway will always be first followed by breathing and circulation. This client is not stable.

A nurse is planning to provide an education class on preconception health care to a group of young women wishing to become pregnant. What points should the nurse include in this class?

attain a healthy weight, make sure vaccines are up to date, avoid alcohol, and learn family history all of these promote the birth of a healthy baby

genital herpes 2

can be transmitted to newborn during child birth through birth canal

UAPs

cannot remove indwelling catheters

A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B12 intramuscularly. What should the nurse include in discharge instructions?

continued for life

bacterial meningitis

droplet

what PPE do you need for draining of a large abdominal mass if you are holding the patient during the procedure?

face shield gown mask regular exam gloves

The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client?

increase fiber Rationale: A symptom of hypothyroidism is constipation due to the decreased mobility of the intestinal tract. Client's with hypothyroidism should increase their dietary fiber to prevent constipation.

albumin

know its working if you see an increase in UO

A hospice nurse is assessing a client reporting chronic pain (5/10 on the pain scale). In addition to the primary healthcare provider and the nurse, what member of the care team will assist in providing comfort therapies for this client?

massage therapist Rationale: The massage therapist provides alternative therapies that complement the medical pain control therapies being provided by the primary healthcare provider and the nurse.

presbyopia

near point of focus gets further away usually begins in the 40s expected finding in a 60 yo

ages 45-54

need mammogram and flu shot yearly

inserting orogastric tube

need suction!! bc of gagging and vomiting and it reduces risk of aspiration

booster seats

needed until 4'9" and are between 8 and 12 yo

The nurse will be admitting a client from the operating room following a left total pneumonectomy for adenocarcinoma. Which type of chest drainage should the nurse anticipate that the client will have?

no chest drainage necessary

Which findings would indicate to the nurse that a client with Addison's disease has received too much glucocorticoid replacement?

rapid weight gain increased cholesterol Rationale: Excessive drug therapy with glucocorticoids will cause rapid weight gain, round face, and fluid retention. Cholesterol and triglycerides in the blood are also increased by glucocorticoids. Long term use of high steroid doses can lead to symptoms such as thinning skin, easy bruising, changes in the shape or location of body fat (especially in your face, neck, back, and waist), increased acne or facial hair, menstrual problems, impotence, or loss of interest in sex.

what should you not do to needles

recap them!!

propranolol

report if feel short of breath when walking could be the result of the adverse reactions of bronchospasm or heart failure

post op liver biopsy

right lateral decubitus "lying on right side"

The nurse is providing care to a client who has a large abdominal dressing. Which intervention is most likely to reduce the risk of skin irritation due to frequent dressing changes?

secure with Montgomery straps Rationale: allows the dressing to be held in place without the use of tape

laxatives during pregnancy

should NOT be taken unless doctor prescribes them usually prescribes a stool softener over a laxative

slidenafil

should only be taken once/day MC side effects- flushing, headache, dyspepsia notify if on alpha adrenergic blocker

The nurse is preparing to provide oral care to an unconscious client. What is the most important step for the nurse to provide?

side lying position Rationale: Positioning the client in a side-lying position allows secretions to drain from the mouth and prevents aspiration. The most important aspect of care is the protection of the airway of this unconscious client. This is accomplished through proper positioning of the client in a side-lying position.

bedrest client

skin should be assessed every 2 hours!!

hepatitis A

symptoms include: fever, malaise, loss of appetite, diarrhea, nausea, abdominal discomfort, dark color urine, jaundice spread through ingestion of food or water contaminated with feces

TB

weight loss