Module 1

The nurse is caring for four clients. Which does the nurse anticipate may have a latex sensitivity?

21-year-old who cannot eat bananas The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes

A nurse is administering a piggyback infusion to a client with partial thickness or second-degree burns. Which describes the most important feature of a piggyback infusion?

A parenteral drug is given in tandem with an IV solution

Which type of hematopoietic stem cell transplantation is characterized by cells from a donor other than the patient?

Allogenic Autologous donor cells come from the patient. Synergetic donor cells are from an identical twin.

5-fluorouracil (5-FU) is classified as which type of anti-neoplastic plastic agent?

Antimetabolite

A nurse has administered an injection to a client. Which intervention should the nurse performed to reduce discomfort and provide quick relief?

Apply pressure to the site during needle withdrawal

A nurse is working with a 15-year-old client with sickle cell anemia. The client was started on a new pain management plan today, and the nurse is evaluating the effectiveness of the plan. Which is not appropriate to include in the nursing care?

Asking only the clients parents to be present at the education session

The nurse is discussing car safety with the mother of a six-year-old child. The child some other questions the need for the use of special car seats for her child. What information can be provided to her?

At the age of six your child should be using a booster seat

The nurse should teach the patient who is being radiated about protecting his skin and oral mucosa. And important teaching point would be to tell the patient to

Cleanse the skin with a mild soap, using his fingertips, not a rough washcloth

A client diagnosed with acute myelocytic leukemia has been receiving chemotherapy. During the last two cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia?

Closely observe the client skin for petechiae and bruising

A nurse is administering a scheduled medication to a client using the institutions barcode system. The nurse has scanned the clients armband as well as the scheduled medication. The system has signaled a discrepancy between the dose prescribed and the dose scanned. What is the nurses most appropriate response?

Consult with a colleague and identify the source of the error signal before proceeding

A client shares with the nurse how much the client appreciates understanding the physiology of breast-feeding. The client states, I felt very comfortable with what you explained to me, and I feel I will be successful at breast-feeding. In effective learning, this represents the nurse

Creating an atmosphere for discussion of feelings

The nurse is getting accustomed to the role of nurse manager. What are the requirements for this nursing roll? SATA

Creating schedules for the unit Managing the units operational budget Introducing methods to improve staff efficiency Evaluating the success of the unit policies

You are a nurse working on a bone marrow transplant unit. Your patient is scheduled to receive a bone marrow transplant. What information will you provide to the patients visitors?

Do not visit if they've had a recent infection

The nurse is providing an educational presentation on dietary recommendations for reducing the risk of cancer. Which of the following food selections were demonstrated good understanding of the information provided in the presentation? SATA

Egg white omelette with spinach and mushrooms Steamed broccoli and carrots Turkey breast on whole wheat bread

A nurse can improve one's skill with time management by taking which action?

Evaluating success with accomplishment of goals in client care

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short term restraints should the nurse use to control the adults movement during the procedure?

Extremity restraint

A nurse is caring for a 45 year old male client who lost function in both of his legs due to an automobile accident. Which of the following should the nurse do first to personalize learning?

Gather pertinent information from the client

Which statement made by a client who was recently admitted to the medical unit with a diagnosis of pneumonia indicates a physical in ability to learn?

I am having difficulty breathing

The client has finished the first round of chemotherapy. Which statement made by the client indicates a need for further teaching by the nurse?

I can continue taking my vitamins and herbs because they make me feel better

The nurses discussing the use of patient controlled analgesia pump with the postoperative patient. Which statement by the patient indicates a need for additional education?

I should not press the button more often than every 3 to 4 hours

The spouse of a client who has recently been diagnosed with early stage Alzheimer's disease ask the nurse to recommend website that may supplement the spouse is learning about this diagnosis. How should the nurse respond to the spouses request

Identify and recommend some credible websites appropriate to the spouses learning needs

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

Identifying systemic factors on the unit that may have contributed to the event

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client safety and could be used as an alternative to restraints?

Investigate the possibility of discontinuing his or her catheter

Nurse A receives an urgent phone call and hands several medication's to nurse B stating, please give these to my client. I will be right back. What is the rationale behind nurse B's response not to administer the medication to the client?

It violates the rights of medication administration

A nurse is forming an education plan for a client who is being discharged from the nursing unit after cardiac catheterization. Which diagnosis and intervention are most appropriate for this client?

Knowledge Deficient: Risk for altered perfusion secondary to re-occlusion

A nurse works for a facility that does not utilize modified safety injection equipment after use, how will the nurse prevent needle sticks? SATA

Leave the needle uncapped and dispose of it in a puncture resistant container Scoop the cap back onto a used needle with one hand without touching the cap

The nurse performs a breast exam on a client and find a firm, non-movable lump in the upper outer quadrant of the right breast that the client reports was not there three weeks ago. What does this binding suggest?

Malignant tumor

The nurse manager notices a trend in nurses routinely arriving to work late. How can the nurse use the transactional leadership style to get nurses to arrive to work on time?

Monitor time clock reports on a monthly basis and enter all nurses who have not been tardy into a raffle for a paid day vacation

The nurse and unlicensed assistive personnel are working together to admit a client newly diagnosed with diabetes to a nursing unit. Which task would be inappropriate to delegate to the UAP?

Monitoring insulin requirements

When a client says, I don't care if I get better, I have nothing to live for anyway. Which type of counseling would be appropriate?

Motivational counseling

The nurse is caring for a client that is disoriented. The nurse place is the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing actions are appropriate? SATA

Obtain order from a licensed provider within minutes of restraint application. Check circulation and skin condition every two hours. Offer regular, frequent opportunities for toileting.

A nurse arranges all the resources available to teach a teenage client how to manage asthma. Which role is this nurse performing?

Organizing

The nurse is caring for a client who has normal sailing in fusing through a peripheral intervenous catheter with a prescription for a secondary infusion of antibiotic. Which technique would be most appropriate for the nurse to administer the secondary infusion by gravity?

Placing the secondary infusion higher than the primary solution

An older client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurses best action for reducing the clients risk of falls?

Provide a bedside commode and ensure adequate lighting

A serum sodium concentration lower than 115 mEq/L is associated with

Seizure It is also associated with abnormal reflexes, papilledema, coma, and death.

Client reports pain at his IV insertion site. The nurse assesses the site and suspects phlebitis based on which assessment findings? SATA

The IV solution is infusing sluggishly The vein feels cord like on palpation

A client, eager to go home from an acute care facility, calls out to have discharge education completed. The nurse is not able to get to the clients room until an hour later, and find the client asleep. The clients significant other states, she will be out for a couple hours after that pain medication. Which of the following best describes what must happen with the education session?

The client is not demonstrating readiness to learn due to the effects of medication

A client is newly prescribed a medication that must be taken on an empty stomach. Which statement by the nurse best describes why some medication should be taken before meals?

This is because food and some drinks can affect the way your medicine works

A client with an infection is receiving intravenous antibiotic therapy. The client has an intermittent infusion device in place. The nurse flushes the device with normal saline solution before administering the antibiotic based on which rational?

To prevent blood clot formation

Which factor is related to the highest proportion of falls in long-term care settings?

Toileting More than 42% of falls in an acute care agency were toileting related

A pediatric nurse is discussing injury prevention with a group of new parents. What are the leading causes of mortality and morbidity and in children? SATA

Unintentional gunshot wound's Drowning Accidental poisoning Suffocation

A nurse is administering medication to a client via a gastric tube and finds that the medicine enters the tube and then the two becomes clogged. What is the appropriate intervention in this situation?

Use a syringe to plunge the tube to try to dislodge the medication

The nurse is preparing to administer a medication to a client when the client states, last time I took that medication, I broke out in hives. What is the priority action by the nurse?

Withhold the medication and notify the healthcare provider that ordered the medication

A client with cancer is being evaluated for possible metastasis. What is one of the most common metastasis sites for cancer cells?

liver The five most common cancer metastasis sites are lymph nodes, lung, bone, brain, and liver