Q REVIEW #2

Vit. C rich foods? "Can't Cure TB"

"Can't Cure TB" Citrus Fruits Cabbage Tomato Broccoli

A client was prescribed a monoamine oxidase inhibitor (MAOI) for the treatment of depression. Which comment by the client indicates adequate understanding of the dietary restrictions that apply? 1) I cannot eat avocados or bananas. 2) I can eat sausage for breakfast, but not bacon. 3) At least I can still have my beer. 4) I can have blue cheese on my salad but not ranch.

1) I cannot eat avocados or bananas. Clients cannot eat sausage, salami, liver, or bologna. Clients taking these medications cannot consume beer, sherry or chianti wines, or ales. Consuming blue cheese on a salad may result in a hypertensive crisis due to the presence of tyramine.

The nurse has been teaching the parents of a child taking METHylphenidate for the treatment of attention deficit hyperactivity disorder. Which comments by the parents indicate adequate understanding of the important considerations for methylphenidate? SATA 1) I know that I need to monitor weight and growth with the primary healthcare provider. 2) I am supposed to give the medication before meals. 3) This medication may cause increased drowsiness. 4) I need to report any extreme weight loss to the primary healthcare provider. 5) If my child can't sleep, the dosage may need to be increased.

1) I know that I need to monitor weight and growth with the primary healthcare provider. 2) I am supposed to give the medication BEFORE MEALS 4) I need to report any extreme weight loss to the primary healthcare provider. The medication is more likely to cause INSOMNIA if administered late in the day, NOT DROWSINESS. If the client cannot sleep, it is likely that the afternoon dose will be decreased or omitted. Lack of appetite may occur with this medication, resulting in WEIGHT LOSS.

Emphysema (pink puffer) vs. Chronic Bronchitis (blue bloater)

PINK PUFFER = R. side HF dyspnea on exertion barrel chest tachypnea use of accessory muscles with respiration. BLUE BLOATER = R. side HF (edema, JVD) dusky/cyanotic elevated Hgb rhonchi/wheezing productive cough

Polyunsaturated Fats, source?

Plant Oils (corn, sunflower)

What is seen in R. sided HF? L. sided HF?

R. side = anorexia, ascites, hepatomegaly L. side = bibasilar crackles, orthopnea (can't breath laying down)

Cheyne-Stokes

Rhythmic crescendo and decrescendo of rate w/ periods of Apnea (Increased ICP, Brainstem compression)

What OTC med/supplement is contraindicated w/ SSRI? What's contraindicated w/ MAOIs? result?

SSRI + St. Johns Wort = serotonin syndrome MAOI + Tyramind = hypertensive crisis

Vitamin K vs. Potassium (K+)

Vitamin K = clotting factors Potassium (K+) = electrolyte!

Calcitriol

form of Vit. D, increases blood Ca+

Acceptable Rx for Acute Heart Failure (3)

•2 gm Na+ diet •Digoxin (lanoxin) 0.25 mg IV q 4 hours times 3 doses- Increase cardiac contractility and reduce HR •Furosemide (Lasix) 40 mg IVP stat

Vit. D rich foods? "Cute MilkFish Oil"

"Cute MilkFish Oil" Cereal Milk (fortified) Fish Oils

Carbohydrate rich foods? "My Favorite Game is Volleyball"

"My Favorite Game is Volleyball" Milk Fruits Grains Veggies

Tyramine Rich Foods? Contrindicated w/ what drug class? "TYRACS"

"TYRACS" (CI = MAOI's) Tuna Yeast/Yogurt Rum (alcohol) Avocado Cheese/Caffeine Sausuage/Soy Sauce/Sour Cream

Pyridoxine (Vit. B6) rich foods? what med increases B6? what med decreases B6? "You Can Pay Me"

"You Can Pay Me" Yeast Corn Poulty Meat isoniazid (INh) = INcrease levoDopa = Decrease

Kussmaul Respirations

Deep sighing respiration, Metabolic Acidosis (DKA, Renal Fx)

Niacin/Thiamine (B1) & Riboflavin (B2) "Gain Money & Live Forever"

"Gain Money & Live Forever" Grains Meats (pork) Legumes Fish

Saturated Fats, rich food? "Las vegas Bars Beats Hollywood"

"Las vegas Bars Beats Hollywood" Luncheon meat Beef Butter Hard yellow cheese

Magnesium (Mg) Rich Foods? "MAGNET"

"MAGNET" Milk/Meat Avocado/Potato Greens (spinach, broccoli) Nuts/Peas Etc. (raisins,yogurt) Tuna

Cobalamin (Vit. B12) rich foods? "My Liver Can't Detox Brew"

"My Liver Can't Detox Brew" Meat Liver Citrust Fruits Dried Beans Brewer's Yeast

Protein rich foods? "Protein BuilDs Fearless Men"

"Protein BuilDs Fearless Men" Poultry Bread/cereal Dairy Fish Meats

Cholesterol rich foods? "A Sedentary Lifestyle Ends"

"A Sedentary Lifestyle Ends" Animal products Shellfish Liver Egg yolk

Iron (Fe) Rich Foods? what increases Fe absorption? "BeVELed needle"

"BeVELed needle" Breads & Cereals Veggies (dark greens) Egg yolk Liver (Orange Juice increase asborption)

Calcium (Ca) Rich Foods? "CReaMY & Tasty"

"CReaMY & Tasty" Cheese/Collar Greens Rhubarb (pie) Milk Yogurt Tofu

Vit. A rich foods? "Eye Must Feel Very Lively"

"Eye Must Feel Very Lively" Egg Milk (whole) Fruits Veggies (lively-green,orange,yellow) Liver

Phosphorous (PO4) Rich Foods? "FONG"

"FONG" Fish Organ meats-pork,beef,chicken Nuts Grains (whole)

Folic Acid (FA) Rich foods? "FOOL"

"FOOL" Fish Organ meats Oranges Leafy Greens

The nurse is instructing the client on proper use of an inhaler. Which statement indicates that teaching has been successful? SATA I will: 1) "Exhale completely before using my inhaler." 2) "Use my steriod inhaler before the bronchodilator." 3) "Inhale slowly and push down firmly on the inhaler." 4) "Rinse my mouth with water after using my inhaler." 5) "Wait 5 minutes between puffs."

1) "Exhale completely before using my inhaler." 3) "Inhale slowly and push down firmly on the inhaler." 4) "Rinse my mouth with water after using my inhaler." For inhaled quick-relief medication (beta2-agonists), wait about 1 min. between puffs. Wait 5 min. between different inhalers

18) A client is being discharged on lithium carbonate. The nurse knows that teaching about the drug was successful when the cliet makes which statement? SATA I will..... 1) "Notify my primary healthcare provider if I develop severe diarrhea or an excessive urinary output." 2) "Maintain a moderate sodium diet." 3) "Drink between 6-8 glasses of water a day." 4) "Not drink alcohol while on this medication." 5) "Avoid strenuous activity."

1) "Notify my primary healthcare provider if I develop severe diarrhea or an excessive urinary output." 2) "Maintain a moderate sodium diet." 3) "Drink between 6-8 glasses of water a day." 4) "Not drink alcohol while on this medication." 5) "Avoid strenuous activity." All statements are correct and indicate patient understanding of this medication. The client should consume a diet adequate in sodium. Lithium is similar in chemical structure as sodium, behaving in the body much the same way and competing with sodium at various sites in the body. If sodium intake is reduced or the body is depleted of its normal sodium (due to sweating, fever, diuresis), lithium is reabsorbed by the kidneys, increasing the possibility of toxicity. The client should avoid activities that cause excess sodium loss, such as heavy exertion, exerciese in hot weather, saunas.

Which findings would indicate to the nurse that a chronic renal failure client's AV shunt is patent? SATA 1) A bruit is heard with a stethoscope. 2) A thrill is felt on palpation 3) There is a blood return on the venous side of the shunt 4) Urine output greater than 30 ml/hr 5) There is a strong radial pulse in the arm with the AV shunt

1) A bruit is heard with a stethoscope. 2) A thrill is felt on palpation IV sticks should not be performed on the shunt except for dialysis! don't check for blood return! Radial pulse does not determine patency of AV shunt. UO-Not related to patency of AV shunt.

The RN and LDRP is preparing to make her initial rounds. Which of the following clients should she see first? 1) A primipara at term with a board like abdomen and scant dark red bleeding. 2) A multipara at 38 weeks gestation with blood streaked vaginal discharge 3) A primipara at 40 weeks gestation with complaints of urinary frequency 4) A multipara at 36 weeks gestation with pitting pedal edema

1) A primipara at term with a board like abdomen and scant dark red bleeding. This client has symptoms of a placental abruption (abruption placentae). There is an extremely high risk for fetal loss and maternal DIC. 2=This describes loss of the mucous plug, which is a normal occurrence at term. Urinary frequency without dysuria at term indicates descent of the fetus. Edema confined to the feet and ankles is a normal discomfort of pregnancy at term.

Which assignment would be most appropriate for the charge nurse to assign to the LPN in the LDRP unit? SATA 1) A primipara needing assistance with breastfeeding. 2) A multipara complaining of a headache and epigastric discomfort. 3) A primipara who is two days post op cesarean section. 4) A primipara who is preeclamptic in active labor. 5) A multipara post op cesarean section with a PCA pump.

1) A primipara needing assistance with breastfeeding. 3) A primipara who is two days post op cesarean section. PCA pump-Client has an IV narcotic infusing.

A client reports a diminished ability to visually focus on close objects and has also noticed a need for well lit environment to enhance vision. To what would the nurse attribute these changes? 1) Normal changes associated with aging. 2) A cataract is forming. 3) Symptoms of a brain tumor. 4) Precipitated by diabetic retinopathy.

1) Normal changes associated with aging. Aging results in stiffening of the lens, thus lessening the ability to focus. The retina is less sensitive to light making accurate vision low-light situations more difficult. Pupillary response diminishes affecting the ability to adjust to changing light levels. Cataract- blurred, glare w/ lights Brain tumor- increase ICP, blurred Diabetic retinopathy- blurred, impairement in some fields

A client complains of crushing chest pain 3 hours prior to arrival in the emergency department. Initial vital signs show hypotension; a weak, thready pulse; cool, clammy skin; and confusion. Which intervention should the nurse perform first? 1) Airway management 2) Intravenous access 3) Obtaining an EKG 4) Preparing for intra-aortic balloon pump

1) Airway management This client exhibits signs of cardiogenic shock, a complication of myocardial infarction. Hypotension accompanied by clinical signs of increased peripheral resistance (weak, thready pulse and cool, clammy skin) and inadequate organ perfusion (altered mental status and decreased urine output) are found in this client. Airway management is the most important initial intervention. Intravenous access, obtaining an EKG, and possible preparation for an intra-aortic balloon pump are interventions that occur after the initial intervention of airway management.

The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy? Which assessments by the nurse suggests that the client is developing this complication? SATA 1) Asterixis 2) Lethargy 3) Amnesia 4) Behavioral changes 5) Kussmaul respirations

1) Asterixis 2) Lethargy 3) Amnesia 4) Behavioral changes Kussmaul respirations are seen with DKA

While teaching about infection prevention because of a low white count to a client and his family, the home health nurse should inform them to: 1) Avoid people who are ill. 2) Eat raw vegetables. 3) Clean all surfaces with bleach daily. 4) Wash clothes separately from the rest of the family with disinfectant.

1) Avoid people who are ill Raw FOODS carry bacteria. Foods should be well cooked. Cleaning daily with bleach is not necessary.

The nurse plans to teach a client how to manage the use of a behind the ear hearing aid. What teaching strategies should the nurse include? SATA 1) Avoid use of hairspray while wearing hearing aid. 2) A whistling sound when the hearing aid is inserted indicates proper placement. 3) Submerse hearing aid in cool water daily to clean. 4) Show client hearing aid locations where damage commonly occurs. 5) Batteries last 6 months with daily wearing of 10-12 hours.

1) Avoid use of hairspray while wearing hearing aid. 4) Show client hearing aid locations where damage commonly occurs. The residual from the hair spray causes the hearing aid to become oily and greasy. The client should routinely inspect the hearing aid for damage, especially where damage is more likely: ear mold, earphone, dials, cord, and connection plugs. Batteries last 1 wk with daily wearing of 12 hrs.

Which signs and symptoms would indicate to the nurse that the client is having an anaphylactic response after receiving Penicillin? SATA 1) Complaints of a scratchy throat 2) Faint expiratory wheeze on auscultation 3) Client statement, I feel like something is wrong. 4) Bounding radial pulse rate of 100/min 5) BP 100/70

1) Complaints of a scratchy throat 2) Faint expiratory wheeze on auscultation 3) Client statement, I feel like something is wrong. The client would have a WEAK, thready pulse.This blood pressure is not below 90 systolic which could indicate shock. Although on the low side, simply getting this BP reading does not tell you if perfusion is adequate.

A client is complaining of pain rated an 8 out of 10 on the numeric pain scale. The nurse administers an oral pain medication to the client and starts a CD of the client's favorite relaxing music. Fifteen minutes later, the client rates the pain as 2 out of 10 on the numeric pain scale. What type of nonpharmacologic pain relief intervention has the nurse used? 1) Distraction. 2) Biofeedback. 3) Progressive relaxation. 4) Cutaneous stimulation.

1) Distraction. distraction, in the form of music, while the oral analgesic takes effect. •Progressive relaxation- combo of breathing exercises & muscle group contractions and relaxation. •Cutaneous stimulation •Biofeedback- behavioral therapy

Which prescriptions are appropriate for newborn infants? SATA 1) Hepatitis B vaccine 2) Erythromycin Ointment 3) Vitamin K 4) Lanolin 5) PKU Screening

1) Hepatitis B vaccine 2) Erythromycin Ointment (Mandatory prophylactic agent applied in NB's eyes as precaution against ophthalmia neonatorium.) 3) Vitamin K (Aquamephyton) (routine injection to prevent hemorrhagic disease of NB) 5) PKU Screening (Screening for phenylketonuria not reliable until NB has ingested an ample amount of the amino acid phenylalemine, 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.)

What does the nurse know about case management model of client care? 1) Implemented throughout a client's entire hospital stay or episode of illness. 2) Implemented only during a client's acute phase of illness. 3) Implemented if a client is unable to recover from an episode of illness within the expected time frame. 4) Focused on the cost of care delivered to a client.

1) Implemented throughout a client's entire hospital stay or episode of illness. Case management is implemented throughout a client's ENTIRE HOSPITAL STAY or EPISODE OF ILLNESS, and focuses on the collaboration of all HCP involved in the care of the client. Cost-effective care is only one goal of case management.

The nurse is teaching the family of a home bound client about ways to increase the client's independence for bathing while decreasing chance for falls. Which strategies should be included? SATA 1) Install grab bars in the tub or shower. 2) Install hand bars on sides of tub. 3) Use tub/shower seat for bathing. 4) Provide a long handled bath scrubbie for bathing. 5) Schedule bathing routines three times per week.

1) Install grab bars in the tub or shower. 2) Install hand bars on sides of tub. 3) Use tub/shower seat for bathing. 4) Provide a long handled bath scrubbie for bathing. The bathing routine may need to be more often than three times per week depending on the client. Other safety devices should be considered when teaching strategies to improve independence and safety.

Which prescriptions would necessitate the nurse to seek clarification from the primary healthcare provider? SATA 1) Lasix 20.0 mg p.o. daily 2) Librium 50 mg p.o. q 4h p.r.n. for agitation 3) Benadryl 25 mg p.o. hour of sleep for three nights 4) Folic acid 1 mg daily 5) Heparin 1000 IU subcutaneously daily

1) Lasix 20.0 mg p.o. daily (It is inappropriate to have a trailing zero after a decimal point for doses expressed in whole numbers. It can be mistaken as 200 if the decimal point is not seen and read appropriately.) 4) Folic acid 1 mg daily (order lacks a route, thus needs clarification) 5) Heparin 1000 IU subcutaneously daily (This order should be written as Heparin 1,000 units subcutaneously daily. Use commas for dosing units ≥1,000 or use words such as one thousand to improve readability. Use units rather than IU (International units) as it can be mistaken as IV or 10.)

Which assessment is most important for the nurse to perform prior to the administration of diltiazem? 1) Note the rate and character of the apical pulse 2) Ausculate the anterior and posterior breath sounds 3) Check the morning results of serum electrolytes 4) Review the last 24 hour urine output

1) Note the rate and character of the apical pulse Monitor blood pressure and pulse before and frequently during administration of diltiazem. Diltiazem causes systemic vasodilation and suppresses arrythmias. Diltiazem is a calcium channel blocker, but the total serum calcium concentration is not affected by it.

The public health nurse is planning to participate in local forums regarding the placement of a factory that is known to produce pollution through discharge of chemical by-products into the air. What action demonstrates ethical nursing practice in the public health arena? SATA 1) Speaking up for the underrepresented such as the poor and uneducated persons. 2) Encouraging community leaders to accept placement of the factory. 3) Requesting that forums be held throughout the community at various times of the day or evening. 4) Asking for information regarding health status of people in other factory locations. 5) Requesting information from individuals in areas where the factories are currently located.

1) Speaking up for the underrepresented such as the poor and uneducated persons. 3) Requesting that forums be held throughout the community at various times of the day or evening. 4) Asking for information regarding health status of people in other factory locations. 5) Requesting information from individuals in areas where the factories are currently located.

Following a thyroidectomy a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response? 1) Stay with the client, remove the dressing, and elevate the head of bed. 2) Call a code, open the trach set and position the client supine. 3) Have the client say "EEE" to check for laryngeal integrity. 4) Immediately go to the nurse's station and call the primary healthcare provider.

1) Stay with the client, remove the dressing, and elevate the head of bed. Sounds like respiratory distress, looks like respiratory distress, get that dressing off the neck and see if they can breathe any better. Don't call Dr. yet! Not yet! Do something first to see if it gets better.

Which interventions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing? SATA 1) Warm cleansing solutions to body temperature. 2) Clean the wound when there is drainage present. 3) Use cotton balls to clean the suture site. 4) Use sterile gauze squares to dry the wound before applying the dressing. 5) Use sterile forceps when cleaning the wound.

1) Warm cleansing solutions to body temperature. 2) Clean the wound when there is drainage present. 5) Use sterile forceps when cleaning the wound. Don't use sterile gauze squares to dry to wound before applying dressing=Moisture is important for the healing process. Cotton balls may leave small cotton filaments behind that may serve as a site for infection.

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) STAT through a non-tunneled central venous catheter with an open tip in place. In what order should the nrse administer this prescription? •Cleanse access port •Flush saline using push-pause method •Gently aspirate for blood •Administer phenytoin •Flush with normal saline, then with heparin •Connect 10 mL normal saline to access port

1. cleanse the access port. 2. connect 10 mL NS to access port. 3. gently aspirate for blood. 4. flush saline using push-pause method. 5. administer phenytoin. 6. flush with normal saline, then with heparin.

During a conversation with a client on a psychiatric unit the client tells the nurse, everyone here hates me. Which response by the nurse is best? 1) No, they do not hate you. 2) What did you do to make others not like you? 3) Just don't pay attention to what others think of you. 4) I can't speak for the other people, but I don't hate you.

4) I can't speak for the other people, but I don't hate you. Here the nurse is speaking only for the nurse. The nurse cannot legitimately speak for anyone else. The nurse must model the process of not speaking for anyone but themselves.

The following clients arrive to the emergency department at the same time. Which client should the triage nurse give priority to? 1) 24 year old with a possible fracture of the tibia 45 minutes ago. 2) 62 year old had developed left hemiparesis and aphasia beginning 1 hour ago. 3) 42 year old smelling of alcohol and complaining of severe abdominal pain. 4) 50 year old involved in a motor vehicle accident with a possible fractured pelvis.

2) 62 year old had developed left hemiparesis and aphasia beginning 1 hour ago. The client who is 1 hour post hemiparesis and aphasia is likely having a stroke. The window for treatment with fibrolytics is 3 hours, thus taking priority. airway, breathing, circulation, bleeding and shock.

Your client has been taking a loop diuretic while hospitalized. Upon discharge, the nurse must teach the client about the need for adequate potassium intake through foods and/or dietary supplements. Which foods should the nurse suggest to the client? 1) Cereals and breads. 2) Avocados and milk. 3) Table salt and spinach. 4) Lima beans and squash.

2) Avocados and milk. •Cereals and breads are good sources of B vitamins. •Table salt and spinach are good sources of sodium. •Lima beans and squash are good sources of magnesium as are leafy vegetables and potatoes.

A client is diagnosed with emphysema. Which clinical signs should the nurse expect to see? SATA 1) Atelectasis. 2) Barrel chest. 3) Tachypnea. 4) Use of accessory muscles with respiration. 5) Leans backward to breathe.

2) Barrel chest. 3) Tachypnea. 4) Use of accessory muscles with respiration.

Which assessment findings does the nurse expect to find when assessing a client admitted to the emergency department with Left sided CHF? SATA 1) Ascites 2) Bibasilar crackles 3) Orthopnea 4) Hepatomegaly 5) Anorexia

2) Bibasilar crackles 3) Orthopnea

A client is scheduled for plateletpheresis. When taking the client's history, which information is most significant? 1) Allergies to shellfish 2) Date last donated 3) Time of last oral intake 4) Blood type

2) Date last donated Platelet donors can have platelet pheresis as often as every 2 weeks. plateletpheresis = platelet donation

A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor (SSRI) for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation? 1) Are you having trouble sleeping at night? 2) Do you have periods of muscle jerking? 3) Are you having any sexual dysfunction? 4) Is your mood improving?

2) Do you have periods of muscle jerking? Myoclonus, shaking chills, and mental confusion are symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction.

A client being treated for osteoporosis with alendronate complains of slight heartburn after she takes the medicine. What should the nurse suggest to reduce this side-effect? 1) Stop taking the medication and call the primary healthcare provider. 2) Drink plenty of water with the medication. 3) Take the medication before bedtime. 4) Take antacids when taking the medication.

2) Drink plenty of water with the medication. 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.

The nurse is teaching a group of clients about selective serotonin reuptake inhibitors (SSRI). Which comment by the client who is taking one of the medications indicates adequate understanding of the effects/side effects of the medications? 1) I may have decreased weight while taking this drug. 2) I may expect increased sweating while taking this drug. 3) I may actually feel more depressed while taking this medication. 4) I should feel better within a couple of days after beginning the med.

2) I may expect increased sweating while taking this drug. The drug causes temperature dysregulation, with increased sweating in some clients; therefore, the client's comment indicates understanding of the teaching. The medications may cause increased weight in some clients. The client should have a lessening of depressive symptoms within a few weeks The lag time for antidepressants is usually 2-4 wks before the therapeutic effect is reached.

A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before". The nurse's best response should be to tell the client: 1) We need to start the group session now. 2) I will tell the primary healthcare provider about your headaches. For now, let's start our group session. 3) I guess we can discuss your pain now. Group therapy will have to start later. 4) Your headaches are not real, so ignore them. Go on into therapy so we can start.

2) I will tell the primary healthcare provider about your headaches. For now, let's start our group session. Initially, the nurse would fulfill the client's urgent dependency needs, but gradually withdraw attention to physical symptoms. Minimize time given to response to physical complaints. Gradual withdrawal of positive reinforcement will discourage repetition of maladaptive behavior. However, all new symptoms should be reported to ensure physician assessment of the complaint. Do not totally ignore the client's complaint. Do not give the client increased attention: this will give positive reinforcement. The pain is real to the client.

A client presents to the emergency department reporting fever, cough, malaise, and rash appearing as vesicles most prominently on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do? 1) Send the client to the waiting room. 2) Place the client in a negative pressure room. 3) Put a surgical mask on the client. 4) Initiate contact precautions.

2) Place the client in a negative pressure room. Having the client wear a surgical mask is not sufficient in this case. All health care providers should wear a N95 respirator when in contact with the client. After the client is sequestered, the nurse should notify the emergency department primary healthcare provider for further treatment instructions.

A client with hypovolemic shock is receiving Albumin. The nurse evaluates that the Albumin is effective when assessment of the client reveals: 1) Decrease in urine output 2) Reduction in tachycardia 3) Proteinuria 4) Absence of Kussmaul's respirations

2) Reduction in tachycardia Tachycardia is a compensatory mechanism of hypovolemic shock. A reduction in tachycardia in the hypovolemic shock client is indicative of an improved circulating blood volume. Resolution or improvement of hypovolemic shock will result in an increase in urine output.

The nurse has just received a client from the special procedures lab for a liver biopsy. What is the position of choice for this client post procedure? 1) Fowlers 2) Right side 3) Left side 4) Prone

2) Right side Position client on the liver to hold pressure and stop bleeding.

A 15 year old is being admitted with pelvic inflammatory disease secondary to gonorrhea. What would be an appropriate room assignment for the charge nurse to make? 1) Rooming with a 18 year old that sustained a compound fracture when involved in MVC. 2) Rooming with a 15 year old diagnosed with anorexia nervosa that is losing weight. 3) Rooming with a 13 year old with a history of asthma admitted with pneumonia. 4) Rooming with a 14 year old who is immunocompromised.

2) Rooming with a 15 year old diagnosed with anorexia nervosa that is losing weight. Usually adolescents with anorexia nervosa losing weight are put on a behavior modification program and visitors are limited. Therefore, it would probably be best if this client did not have a roommate.Pneumonia could be contagious and should not have a roommate.

Your client presents to the mental health center following an argument with her husband. She describes a verbal argument that began to get physical with shoving of the client. She admits a history of domestic violence. Which phase of the cycle of violence is the client describing? 1) Honeymoon phase 2) Tension-building phase. 3) Acute battering phase 4) Remorse phase

2) TENSION BUILDING PHASE (minor physical violence may occur as well as verbal arguments.) HONEYMOON PHASE: characterized by remorse, promises to never hurt the victim again. ACUTE BATTERING PHASE: includes the release of tension through extreme physical violence. no remorse phase per se, but rather remorse is expressed during the honeymoon phase.

The nurse is caring for a client with a suspected urinary tract infection. Which symptoms are associated with urinary tract infections? SATA 1) Bradycardia. 2) Urgency. 3) Frequency. 4) Hematuria. 5) Nocturia

2) Urgency. 3) Frequency. 4) Hematuria. 5) Nocturia Sx/s of UTI = burning on urination nocturia incontinence suprapubic or pelvic pain hematuria back pain

You are the nurse assigned to care for a woman with the diagnosis of schizophrenia. She complains that she has a hard time "tuning out" the voices. Which suggestion by the nurse indicates appropriate intervention? 1) There is nothing to help with this problem. 2) You might hum when the voices are so troublesome. 3) You should ask your primary healthcare provider to increase your medication. 4) Wear earplugs.

2) You might hum when the voices are so troublesome. Humming or listening to music may help to decrease the intrusive voices. The medication may need to be adjusted, but further assessment is needed.

A client with the diagnosis of mild anxiety asks the nurse why the primary healthcare provider switched medications from lorazepam to buspirone. What should the nurse tell the client? 1) "Lorazepam takes longer to start working than buspirone so the primary healthcare provider decided to switch medications." 2) "Buspirone can be stopped quickly if neccessary." 3) "Buspirone does not depress the central nervous system like lorazepam does so you should not have as much sedation." 4) "You need to ask your primary healthcare provider why the medication was changed from lorazepam to buspirone."

3) "Buspirone does not depress the central nervous system like lorazepam does so you should not have as much sedation."

When planning post procedure care for a client who is having a barium enema, what must the nurse include? 1) Cardiac monitoring for potential arrhythmias 2) Monitoring urinary output 3) Administration of a laxative or enema after the procedure 4) Reordering the client's diet

3) Administration of a laxative or enema after the procedure The client must expel the barium post procedure. If the barium is not eliminated it can harden in the colon and cause an obstruction. This is the reason a post procedure laxative or enema may be given.

After making rounds on clients, a primary healthcare provider hands the nurse a client record and gives the following verbal order: Administer CISPLATIN 1 mg IV over 6 hours. What should be the first action by the nurse following this verbal prescription? 1) Write down the prescription immediately. 2) Repeat the prescription back to the primary healthcare provider. 3) Ask the primary healthcare provider to spell the drug name for clarification. 4) Inform the healthcare provider that this medication requires a written prescription.

4) Inform the healthcare provider that this medication requires a written prescription. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety.

A client was admitted to the hospital with a closed head injury. Three days after admission, his urinary output for 8 hours was 1800 ml. In response to this data, what would be the appropriate nursing action? 1) Hydrate the client with 500 ml of IV fluid in the next hour. 2) Monitor BUN and creatinine. 3) Check urine specific gravity. 4) Recognize this as a side effect of Decadron.

3) Check urine specific gravity. For any client with a head injury and abnormally high urinary output the nurse knows the client is at risk for ADH (anti-diuretic hormone) problems. The pituitary gland is located in the brain. ADH is produced in the pituitary gland. In head injured clients ADH can get messed up. If the client does not have enough ADH large volumes of water will be lost in the urine. The name of this disease is diabetes Insipidus (DI). Large volume losses place the client at risk for shock. The nurse knows to further investigate the problem by checking a urine specific gravity. For clients in DI the urine specific gravity will be very, very low because they are losing so much water. When you see the letters DI think of the "D" for diuresis and think SHOCK first. Administration of 500 ml of fluid over one hour is possible if the client were in shock. The stem of the question, however does not indicate this client is in shock.

The circulating nurse prepares the sterile field in the operating room (OR). Fifteen minutes later, the nurse is informed the surgery will be delayed for 20 minutes because the surgeon is working at another hospital. Which is the best action for the nurse to take? 1) Cover the sterile field with a sterile drape until the surgery is about to begin. 2) Close and tape the OR doors so that no one may enter. 3) Monitor the sterile field while awaiting the surgeon. 4) Tear down the sterile field until the surgeon arrives in the OR.

3) Monitor the sterile field while awaiting the surgeon.

A client at a rehabilitation facility states, "No one asked me which rehabilitation facility I preferred. I feel as if this entire process took place without my involvement. I was not informed of alternative options." Which client right is being violated? 1) The right to considerate and respectful care. 2) The right to self-determination. 3) The right to participate in the plan of care. 4) The right to review medical records related to care and treatment.

3) The right to participate in the plan of care. A client has the right to participate in the plan of care and to refuse a recommended treatment to the extent permitted by law and by hospital policy. In the case of care refusal, the client has the right to alternative care and treatment, and the right to be transferred to another health care facility if that is the client's choice. The right to self-determination relates to resuscitation and advance directive issues.

The primary healthcare provider suspects the client has tuberculosis and orders a Mantoux test. What precautions should the nurse take when administering the Mantoux test? SATA 1) Don sterile gloves. 2) Place the client on reverse isolation. 3) Wear a particulate respirator. 4) Obtain a consent form. 5) Initiate acid-fast bacilli (AFB) precautions.

3) Wear a particulate respirator. 5) Initiate acid-fast bacilli (AFB) precautions. A consent is not necessary. Sterile gloves are not needed. Standard precautions indicate clean gloves. AFB precautions include a private room with negative pressure and a minimum of 6 air exchanges per hour. Ultraviolet lamps and high efficiency particulate air filters are also needed.

The charge nurse is observing the work of a unlicensed assistive personnel (UAP). Which observation will require the nurse to intervene? 1) Placing soiled linen in a hazardous waste linen bag outside of the client's room. 2) Shutting the door completely when exiting the room of a client diagnosed with tuberculosis. 3) Wearing a pair of gloves to collect intake and output reports from each client on the unit. 4) Cleaning a blood pressure cuff with a disinfectant.

3) Wearing a pair of gloves to collect intake and output reports from each client on the unit. Gloves should be removed and hand hygiene performed after leaving each client's room. Gloves quickly become contaminated and then become a potential vehicle for the transfer of organisms between clients. 1-This is a correct action. Do not carry soiled linen down the hall to place in a receptacle.

The nurse prepares to give an injection to a client. When the nurse aspirates prior to injecting, a small amount of blood is noted in the syringe. Which action is most appropriate for the nurse to take? 1) Pull back slightly on the needle and attempt aspiration again. 2) Push the needle into the muscle at least 1 cm and give the injection. 3) Withdraw the needle and restart the process with new medication and equipment. 4) Administer the medication more slowly than normal.

3) Withdraw the needle and restart the process with new medication and equipment. If blood is noted with aspiration after the needle has been inserted, the needle and medication should be discarded. The nurse needs to restart the process with new equipment and medication.

Which client must be assigned to a private room? 1) A primiparous client who delivered twins at 28 weeks gestation two days ago 2) A postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3) A postpartum client who's 2 hour old infant is being worked up for sepsis 4) A postpartum client 32 hours after delivery with a temperature of 101º

4) A postpartum client 32 hours after delivery with a temperature of 101º A temperature of 100.5 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. 3-The infant is suspected of having an infection and will remain in the NICU. The mother is not infected.

A schizophrenic client who is admitted to the hospital for possible bowel obstruction has a nasogastric (NG) tube and reports pain. What should the nurse do at this time? 1) Decrease the stimuli and observe frequently. 2) Administer the prn sedative. 3) Call the primary healthcare provider immediately. 4) Administer the prn pain medication.

4) Administer the prn pain medication. Psychiatric client's have physiologic problems too! Not necessary to call Dr.!

A client with Graves' disease and exophthalmos returns to clinic for evaluation. Which assessment indicates the client is adhering to the teaching plan? 1) Moist, shiny, soft hair 2) Resting heart rate of 120 3) Adheres to the prescribed low sodium diet 4) Demonstrates an absence of corneal irritation

4) Demonstrates an absence of corneal irritation Grave's disease is a hyperthyroidism and can lead to exophthalmos. Exophthalmos is defined as abnormal protrusion of the eyes. These clients tend to have dry, irritated eyes. Absence of corneal irritation indicates the client is following the plan of care which includes eye drops or ointment to protect exposed cornea.

A young woman has been diagnosed with genital herpes. Which comment indicates understanding of the disease and prevention of the spread of the disease? 1) I can be treated and then no one else is at risk. 2) Using condoms will keep my partner from acquiring the disease. 3) If I have no sores, I am not contagious to anyone. 4) My boyfriend should be tested because we have not always used condoms.

4) My boyfriend should be tested because we have not always used condoms. Condoms DECREASE THE RISK, doesn't provide 100% protection. Sex partners may get the disease even if no open sores are present; therefore, they should be tested for the disease.

Because of the possible nervous system side-effects that occur with isoniazid therapy, which supplementary nutritional agent would the nurse teach the client to take as a prophylaxis? 1) Alpha tocopherol 2) Ascorbic acid 3) Calcitriol 4) Pyridoxine

4) Pyridoxine isoniazid- tx TB pyridoxine- prevent peripheral neuropathy

When preparing a client for percutaneous transluminal coronary angioplasty (PTCA), the nurse is aware that the most important client teaching should include: 1) Restricting oral fluids until the gag reflex has returned 2) Encouraging early ambulation and deep breathing exercises 3) Discontinuing medicines following PCI 4) Reporting any chest discomfort following PCI

4) Reporting any chest discomfort following PCI The number one thing you are "worried" about post PTCA is re-occlusion or reinfarction. DO NOT restrict fluids. Fluids are increased to flush the dye used during the procedure from the kidneys. PTCA (same thing as cardiac cath, uses dye)

The nurse is working with a LPN and a nursing assistant. Which client would be inappropriate for the nurse to assign to the LPN? 1) The client in bucks traction requiring frequent pain medication 2) The client 24 hours post appendectomy 3) The client with cholelithiasis scheduled for surgery in the AM 4) The client admitted 6 hours ago in Adrenal insufficiency

4) The client admitted 6 hours ago in Adrenal insufficiency This client has Adrenal insufficiency occurs when at least 90 percent of the adrenal cortex has been destroyed. As a result, often both glucocorticoid (cortisol) and mineralocorticoid (aldostertone) hormones are lacking. This puts the client at risk for fluid volume deficit and shock. 24 hr post app.-Not immediate post-op, more stable client

A client with nausea, vomiting and diarrhea for the past three days has been prescribed one liter of normal saline with 40 mEq (40 mmol/l) of potassium chloride to infuse at 250 mL per hour. Which assessment would the nurse report to the primary healthcare provider prior to initiating the infusion? 1) Blood pressure of 106/54. 2) Apical pulse of 112 per minute. 3) Tenting of the skin over the sternum. 4) Urinary output of 148 mL for the past 6 hours.

4) Urinary output of 148 mL for the past 6 hours. (25 mL/hr) The client's output is below normal. This could indicate a problem with renal perfusion. Potassium is excreted through the kidneys. So if the kidneys are not being perfused the client would retain potassium. The health care provider would need to be aware of the client's low urine output. Expected assess. in pt. w/ FVD = low blood pressure fast pulse rate tenting of skin

First step when pt. wants to leave AMA (against medical advice)

Call the primary healthcare provider

Na+ rich foods?

Fast Foods/Processed/Canned Saltwater fish

Vit. K rich foods?

GREEN LEAFY VEGGIES

Isoniazid treats? what is given in combo?

Isoniazide tx TB Pyridoxine, to prevent neuropathy

The nurse is instructing a client in the use of a cane. Which is the best description of correct cane technique? 1) Place the cane on the weaker side of the body to help support the weaker leg. Using the cane for support, step forward with the good leg, and then move the weaker leg and the cane forward to the good leg. 2) Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client stands with the body weight divided between the two legs. Then the weaker leg is advanced to the cane, with the body weight divided between the good leg and the cane. Finally, the stronger leg is advanced past the cane and the weaker leg, with the body weight divided between the cane and the weaker leg. 3) Place the cane on the weaker side of the body. The cane is placed forward 6 to 10 inches while the client stands with the body weight divided between the two legs. The weaker leg is then advanced to the cane, with the body weight divided between the good leg and the cane. Finally, the stronger leg is advanced past the cane and the weaker leg, with the body weight divided between the cane and the weaker leg. 4) Place the can on the stronger side of the body to help support the weaker leg. Using the cane for support, step forward with the good leg and then move the weaker leg and the cane forward to the good leg.

Place the CANE ON THE STRONG SIDE of the body. 1. THE CANE is placed forward 6-10 inches while the client stands with the body weight divided between the two legs. 2. THEN THE WEAK LEG is advanced to the cane, with the body weight divided between the good leg and the cane. 3. Finally, the STRONG LEG is advanced past the cane and the weaker leg, with the body weight divided between the cane and the weaker leg.

K+ rich foods? RAINBOW COLORS

RAINBOW COLORS RED= strawberry,tomato (not apple!!) ORANGE= orange,CANTALOUPE,carrots YELLOW= banana, POTATO GREEN= avocado, kiwi BLUE= sea = fish PURPLE= raisins •Salt Substitutes•

What are the goals of the case management model of client care?

•COST-EFFECTIVE care to the client. •APPROPRIATE CARE, in a TIMELY manner. •HIGH-QUALITY CARE to the client.