Question Trainer 2

The nursing assistive personnel (NAP) reports to the RN that the client with anemia reports weakness. Which nursing response is best?

"Set up the clients lunch tray" Standard, unchanging procedure; decreases cardiac workload

The nurse supervises care given to a group of clients on the unit. The nurse observes a staff member entering a client's room wearing gown and gloves. The nurse knows the staff member is caring for which client? 1. An 18-month-old with respiratory syncytial virus 2. A 4-year-old with Kawasaki disease 3. A 10-year-old with Lyme disease 4. A 16-year-old with infectious mononucleosis

1. An 18-month-old with respiratory syncytial virus - acute viral infection; requires contact precautions All rest are standard precautions

The client develops a low intestinal obstruction. The nurse anticipates which findings? 1. Nausea 2. Vomiting 3. Explosive diarrhea 4. Tarry stool 5. Abdominal distension 6. Rectal bleeding

1. Nausea 2. Vomiting 5. Abdominal distention

The nurse prepares discharge teaching for the parents of the newborn. Which info does the nurse provide regarding the accuracy of a PKU test? 1. The initial specimen should be collected as close to discharge as possible but not later than 7 days 2. The infant can have water but should not have formula for 6 hrs before the test 3. The test will need to be repeated at 6 weeks and at the 3 month check-up 4. Blood will be drawn at three 1-hour intervals; there is no specific prep

1. The initial specimen should be collected as close to discharge as possible but not later than 7 days If the initial specimen is collected before it is 24 hrs old, a repeat test should be performed by 2 weeks of age

The health care provider prescribes lithium carbonate 300 mg PO QID for the adult client. The nurse in the outpatient clinic instructs the client about the med. The nurse encourages the client to maintain an adequate intake of which substance? 1. Sodium 2. Protein 3. Potassium 4, Iron

1. Sodium Akali metal salt acts like sodium ions in the body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity

Normal BUN

10-20

The nurse plans discharge teaching for the client after a lumbar laminectomy. Which muscle or muscles does the nurse instruct the client to exercise regularly?

2. Abdominal - strengthening the abdominal muscles adds support for the muscles supporting the lumbar sine

Which symptoms would you observe in someone with diabetes insipidus ? 1. Glucosuria 2. Cracked lips 3. Weight gain of 5 lb 4. BP 160/100, pulse 56 5. Urinary output of 4 L/24 hrs 6. Urine specific gravity of 1.004

2. Cracked lips 5. Urinary output of 4 L/hr 6. Urine specific gravity of 1.004

Which behaviors are most characteristic of of mania ? 1. Paranoia 2. Grandiose delusions 3. Somatic difficulties 4. Difficulty concentrating 5. Agitation 6. Distorted perceptions

2. Grandiose delusions 4. Difficulty concentrating 5. Agitation - clients are constantly in motion

Which nursing goal is most appropriate to pneumonia secondary to chronic pulmonary disease? 1. Maintain and improve the quality of oxygenation. 2. Improve the status of ventilation

2. Improve the status of ventilation. To improve the quality of ventilation refers to levels of carbon dioxide and oxygen

Which change in the pattern of urinary elimination occurs normally with aging ? 1. Decreased frequency 2. Nocturia 3. Incontinence 4. Hematuria

2. Nocturia

The nurse recognizes which symptoms as characteristic of a panic attack? 1. Decreased blood pressure 2. Palpitations 3. Decreased perceptual field 4. Bradycardia 5. Diaphoresis 6. Fear of going crazy

2. Palpitations 3. Decreased perceptual field 5. Diaphoresis 6. Fear of going crazy

Which nursing action has the HIGHEST priority for a client with hypoparathyroidism ? 1. Develop a teaching plan 2. Plan measures to deal with cardiac dysrhythmias 3. Take measures to prevent a respiratory infection 4. Assess lab results

2. Plan measures to deal with cardiac dysrhythmias - related to low serum calcium would be the highest priority

The 4-year-old child is admitted with drooling and an inflamed epiglottis. The nurse identifies which symptom as indicative of an increase in respiratory distress? 1. Bradycardia 2. Tachycardia 3. General pallor 4. Irritability

2. Tachycardia - increase in the respiratory rate is an ealry sign of hypoxia

Circulatory overload

An excess of blood or body fluids in the circulation or extracellular tissues. SS - Wet breath sounds, Urticaria, SOB

Menieres syndrome

An inner ear disorder that causes episodes of vertigo

What is the best method for the nurse to use when evaluating the effectiveness of tracheal suctioning?

Auscultates the chest for change or clearing of adventitious breath sounds To ensure the airway is clear of secretions

Major adverse effects of haloperidol

Blood dyscrasia and extrapyramidal symptoms

The nurse observes the student nurse auscultate the right middle lobe lung of the client. The nurse knows the student is auscultating correctly id the stethoscope is placed in which position?

Right anterior chest between the fourth and sixth intercostal spaces Cannot auscultate the rmL from the posterior

If PN is abruptly discontinued, the nurse expects the client to exhibit which S/S ?

Diaphoresis, confusion, tachycardia Insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination

The nurse assesses the client immediately after an exploratory laparotomy. Which nursing observation indicates the complication of intestinal obstruction?

Distended abdomen with reports of pain

A client with depressed mood has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities at which time ?

During the morning hours

Nausea during a woman's first trimester is related to ?

Elevation in the hormones

CBI (urinary bladder irrigation)

Enables urine to keep flowing - continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postop TURP client

The adolescent is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse includes which information in the preop teaching session?

Encourage the client to share feelings and fears about the surgery

The nurse notes that an adolescent female attending camp consumes 3 meals day, averaging 900 cals and 3 mg of iron for each meal. The client menstruates monthly and is of appropriate weight for height. Which statement best describes the adolescent's intake?

High in calories and low in iron The client is consuming 900 x 3 =2,700 kcals/day. Females 12-18 years old need 2000 kcal/day. The client is consuming 3 mg x 3 = 9 mg/day of iron. Females 12-13 years old need 8 mg/day, and females 14-18 years old need 15 mg/day of iron

Hemolytic reaction to a blood transfusion

Hypotension, Low back pain, fever

Normal Hemoglobin (Hgb)

Male 13-18 Female 12-16

Normal hematocrit (HCT)

Male 42-52% Female 35-47%

Bacterial meningitis

Meningitis is an inflammation of the membranes (meninges) surrounding your brain and spinal cord. Bacteria that enter the bloodstream and travel to the brain and spinal cord cause acute bacterial meningitis.

The nurse cares for the client diagnosed with a recurrent UTI. The health care provider prescribes ciprofloxacin. The nurse instructs the client to limit intake of which fluid? 1. Milke 2. Cranberry juice 3. Water 4. Tea

Milk

What is a Miller-Abbott tube used for ?

Miller-Abbott tube removes fluid and gas from the small intestine. It provides for intestinal decompression; intestinal tube is often used for treatment of paralytic ileus

Adverse affect of estrogen

Nausea

The newborn is diagnosed with fetal alcohol syndrome. The nurse knows which action action is an important consideration for this newborn? 1. Prevent iron deficiency anemia 2. Decrease touch to prevent over stimulation 3. Provide feedings via gavage to decrease energy expenditure 4. Replace vitamins depleted as a result of poor maternal diet

4. Replace vitamins depleted as a result of poor maternal diet Frequently, maternal diet is poor and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function

Normal Calcium

8.5-10.5

Normal PT

9.5-12 secs

The nurse reviews procedures with the health care team. The nurse intervenes if the RN staff member makes which statement? 1."It is my responnsibility to ensure the consent form has been signed and is attached to the client's record." 2. "It is my responsibility to witness the signature of the client before surgery is performed" 3. "It is my responsibility to explain the surgery and ask the client to sign the consent form" 4. "It is my responsibility to answer questions the client may have before surgery"

3. "It is my responsibility to explain the surgery and ask the client to sign the consent form" Health care providers should provide explanation and obtain client's signature

The nurse cares for the client with a radium implant. During the removal of the implant, it is most important for the nurse to take which action? 1. Clean the radium implant carefully with a disinfectant using long forceps. 2. Handle the radium carefully using forceps and rubber latex gloves. 3. Document the date and time of removal together with the total time of implant treatment. 4. Double-bag the radium implant before the person from radiology removes it from the room.

3. Document the date and time of removal together with the total time of implant treatment. At no time should the nurse or client handle the radium; radiology department is responsible for handling implant

The client at 16 weeks gestation has an amniocentesis. The client asks what will be learned from this procedure. Which condition can be detected? 1. Tetralogy of fallot 2. Talipes equinovarus 3. Hemolytic disease of the newborn 4. Cleft lip and palate

3. Hemolytic disease of the newborn Maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis

Normal creatinine

0.7-1.4

The client was just placed in physical restraints. Which nursing intervention is most important for the client's care? 1. Prepare PRN dose of psychotropic medication. 2. Check that the restraints have been applied correctly. 3. Review hospital policy regarding duration of restraints 4. Monitor the client's needs for hydration and nutrition while restrained

2. Check that the restraints have been applied correctly

The nurse assesses the client diagnosed with a spinal cord injury. Which findings suggests the complication of autonomic dysreflexia ? 1. Urinary bladder spasm pain 2. Severe pounding headache 3. Profuse sweating 4. Tachycardia 5. Severe hypotension 6. Nasal congestion

2. Severe pounding headache 3. Profuse sweating 6. Nasal congestion 4. Tachycardia - no because pulse will slow

The nurse obtains a specimen from the client for sputum culture and sensitivity (C and S). Which instruction is best? 1. After pursed lip breathing, cough into a container. 2. Upon awakening, cough deeply and expectorate into a container. 3. Save all sputum for three days in a covered container. 4. After respiratory treatment, expectorate into a container.

2. Upon awakening, cough deeply and expectorate into a container - specimens should be obtained in the early morning because secretions develop during the night

What is the best age to toilet train a child ?

20 months - by 24 months may be able to achieve daytime bladder control

The client returns from surgery. There is a fine, reddened rash around the area where providone iodine prep was applied prior to surgery. The nursing notation in the client's record includes which observation? 1. Time and circumstances under which the rash was noted 3. Notation on an allergy list and notification of the health care provider

3. Notation on an allergy list and notification of the health care provider Suspected reaction to substances should be reported to the health care provider and noted on list of possible allergies

The client returns from surgery after a right mastectomy. There is an IV of 0.9% NaCl infusing at 100 mL/h into the left forearm. The IV infiltrates several hrs later. The nurse supervises the student nurse preparing to insert a new peripheral IV cath. The nurse intervenes in which situation? 1. The student nurse selects a site where the veins are soft and elastic. 2. The student nurse selects a site on the distal portion of the left arm. 3. The student nurse selects a site close to the wrist joint 4. The student nurse holds the skin taut prior to the insertion of the cath

3. The student nurse selects a site close to the wrist joint Inappropriate; movement in area could cause displacement 2. Acceptable site selection, right extremity avoided with mastectomy

Normal potassium (K)

3.5-5.0

The client is newly diagnosed with Buerger's disease. The clinic nurse obtains a health history. The nurse expects the client's history to include which symptom? 1. Heart palpitations 2. Dizziness when walking 3. Blurred vision 4. Digital sensitivity to cold

4. Digital sensitivity to cold Vasculitis of blood vessels in upper and lower extremities

What is the most common reaction of the significant other to a rape victim? 1. Supportive and helpful to the victim 2. Disconnected from and apathetic toward the victim 3. Frustrated and feeling vulnerable, but denying the need for help 4. Emotionally distressed and needing assistance

4. Emotionally distressed and needing assistance 1. they may not have the immediate coping strategies to do so

Which assessment info indicates to the nurse the client has hypocalcemia ? 1. Constipation 2. Depressed reflexes 3. Decreased muscle strength 4. Positive Trousseau's sign

4. Positive Trousseau's sign All the rest of the symptoms are associated with hypercalcemia

Promethazine hydrochloride 25 mg IV push is ordered for the client. Prior to administering this medication, the nurse makes which assessment? 1. The color of the medication soiltion 2. The client's pulse and temperature 3. The time of the last analgesic dose the client recieved 4. The patency of the client's vein

4. The patency of the client's vein Extravasation will cause necrosis

Normal WBC count

5,000-10,000

Miller-Abbott tube

A double-channel intestinal tube with an inflatable balloon at its distal end, used for diagnosing and treating obstructive lesions of the small intestine.

Hep A

A highly contagious liver infection

Magnetic resonance imaging (MRI) usually takes how long

About 90 minutes and is not painful

Respiratory syncytial virus

Acute viral infection

Desired response to morphine sulfate

Administered to minimize anxiety associated with respiratory distress from pulmonary edema

Antipsychotics are contraindicated with ?

Alcohol

Grave's disease

An immune system disorder of the butterfly-shaped gland in the throat (thyroid)

Chlorpromazine

Antipsychotic

The client diagnosed with myasthenia gravis. it is most important for the nurse to consider which action?

Assess muscle groups toward the end of the day

What is a sign of an obstructed Urinary cath?

Bladder distention

Naloxone

Can treat narcotic overdose in an emergency situation

PKU (phenylketonuria) test

Checks whether a newborn baby has the enzyme needed to use phenylalanine in his or her body. Phenylalanine is an amino acid that is needed for normal growth and development. Blood sample taken from the babies heel

Addison's disease typical skin assessment would reveal ?

Darker skin that is more pigmented

Urticaria

Hives

Pneumonia

Infection that inflames air sacs in one or both lungs, which may fill with fluid

Buerger's disease

Inflammation and thrombosis in small and medium-sized blood vessels, typically in the legs and leading to gangrene

Airborne precautions mnemonic

MTV - Measles Tuberculosis Varicella

The nurse evaluates the desired client response to diuretic therapy. Which action is the most reliable client measure for the nurse to use?

Obtain daily weights - effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights

The client with gastric ulcers will experience pain at which time ?

One-half to 1 hr after a meal

Promethazine hydrochloride

Phenothiazine used to treat N/V caused by anesthesia or surgery, certain types of allergic

For any "protective environment" question, you would need ...?

Positive pressure !

Droplet precautions

Requires a mask

Airborne precautions

Requires a mask (respirator/N-95 for TB/SARS) also requires a private room

What precautions should be in place for respiratory syncytial virus ?

Requires contact precautions; assign to private room or with other RSV-infected children

Contact precautions

Requires gown and gloves

What precautions are required for Hep A ?

Standard precautions - sources for this virus are saliva, feces, and blood

Amniocentesis

The sampling of amniotic fluid using a hollow needle inserted into the uterus, to screen for developmental abnormalities in the fetus

Which finding does the nurse recognize as pertinent to Cushing syndrome?

Thin extremities with easy bruising

Hemoglobin A1C

This tests indicates how well the blood sugar has been controlled the past 2-3 months

Transurethral prostatectomy (TURP)

Used to treat benign prostatic hyperplasia

Symptoms expected in Grave's disease

Weight loss of 10 lbs in 3 weeks, restless, reflexes will be hyperactive, will have heat intolerance due to increased metabolic rate Increased metabolic rate causes weight loss even with increased appetite

Laparotomy

A surgical incision into the abdominal cavity, for diagnosis or in preparation for surgery

Autonomic dysreflexia

A syndrome in which there is a sudden onset of excessively high blood pressure.

Myasthenia gravis

A weakness and rapid fatigue of muscles under voluntary control

Typical CBC results of someone with bacterial meningitis

Cloudy CSF - indicating inflammation/infection. Hgb and HCT within the normal ranges; WBC elevated

Cerebral spinal fluid is normally which color ?

Clear

Low WBC count

Clients will be susceptible to infection

Positive Trousseau's sign

In the absence of blood flow, the patient's hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm

Which psychosocial stage does the nurse identify as the priority in a care plan for a 20 year old client ?

Intimacy versus isolation