remediation 2

A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client

"Do not eat or drink anything but water for 12 hours before the blood test."

The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate

"In some instances the result is a retarded bone growth."

The parents of a 4 year-old hospitalized child tell the nurse, "We are leaving now and will be back at 6 PM." A few hours later the child asks the nurse when the parents will come again. What is the best response by the nurse?

"They will be back right after supper."

A client has received 2 units of whole blood today following an episode of GI bleeding, which of the following laboratory reports would the nurse monitor closely?

- H &H

Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the HCP

- I went to the bathroom an dmy urine looked very red and it didnt hurt when I went

The nurse is discussing with a group of students the disease Kawasaki, What statement made by a student is incorrect?

- Kawasaki disease occurs most often in boys, children younger than 5 age 5 and children of Hispanic descent

The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the mother supports the presence of this problem?

- When I put the baby in a back lying position that's how I find the baby. The correct answer is D: Unable to roll from

A nurse is assessing several clients in a long term health care facility, which client is at highest risk for development of decubitus ulcers

- a 79 year old malnourished client on bed rest

which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of a PCA with a pump?

- a preschooler with intermittent episodes of alertness

A client who had a percutaneous transluminal coronary angioplasty two weeks ago returns to the clinic for a follow-up visit, the client has a postop ejection fraction of 30%. today the client has lungs which are clear, +1 pedal edema, and a 5 pound weight gain, which interventions the nurse implement

- assess compliance with routine prescription - fluid retention may be a sign that the client is not taking the medication as prescribed

A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest, when repositioning the client, the nurse notices 200 cc of dark, red, fluid flows into the collection chamber of the chest drain. what is the most appropriate nursing action

- continue to monitor the rate of drainage

A preeclampsic client who delivered 24 hours ago remains in the labor and delivery recovery room, she continues to receive mag, sulfate at 2 grams per hour, her total input is limited to 125 ml per hour, and urinary output for the last hour was 850 ml. what interventions should the nurse implement?

- continue with the plan of care for this client - continue with the plan, diuresis in 24 to 48 hours after birth is a sign of improvement in the preeclamptic client, as relaxation of arteriolar spasms occur, kidney perfusion increases

the nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant, which action should the nurse include

- divide the medication into two injection with volumes under 1 ml - IM injection for children under 3 of age should not exceed 1 ml. divide the dose into smaller volumes for injection in two different sites

Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? a. Ensure that the knot can be quickly released. b. Tie the knot with a double turn or square knot. c. Move the ties so the restraints are secured to the side rails. d. Ensure that the restraints are snug against the client's wrist.

- ensure that the knot can be quickly released

In monitoring tissue perfusion in a client following an above knee amputation which action should the nurse include in the P.O.C

- evaluate closest proximal pulse - a primary focus of care for a client with an AKA is monitoring signs of adequate tissue perfusion, which include evaluating skin color and ongoing assessment

A client with Type 2 DM is admitted for frequent hyperglycemic episodes and a HBA1c if 10%, insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6hr are prescribed, what action should the nurse include in this clients plan of care

- fingerstick glucose assessment q6hr with meals - review with the client proper foot care and prevention of injury - coordinate carbohydrate controlled meals and consistent times and intervals - teach subcutaneous injection technique sit rotation and insulin management

The HCP order reads aspirate NGT every 4 hours and check pH of aspirate, the pH of the aspirate is 10, which action should the nurse take

- hold the tube feeding and notify the HCP

when assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement

- increase intravenous infusion - a fundus that is dextroverted up to the right and elevated above the umbilicus is indicative of bladder distention/urine retention

A client has been dx with Zollinger Ellison syndrome what information is important to reinforce

- it is critical to report promptly to your HCP any findings of peptic ulcers

A nurse is providing care to a 63 year old with pneumonia, which intervention promotes the clients comfort

- keep conversations short

A client has a history of COPD as the nurse enters the room his oxygen is running at 6 l/min, his color os flushed and his respirations are 8 per minute, what should the nurse do first

- lower the oxygen rate

Which information is a priority for the RN to reinforce to an older client after IV pyelography

- measure urine output for the next day and immediately notify HCP if it should decrease

A client has an indwelling catheter with continuous bladder irrigation after undergoing TURP 12 hours ago, which finding at this time should be reported to the HCP?

- minimal drainage into the urinary collection bag

Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse? a. Diarrhea and flatulence b. Abdominal cramps c. Muscle pain d. Altered taste

- muscle pain - statins can cause rhabdomyolysis, a potentially fatal disease of skeletal muscle characterized by myoglobinuria and manifested with muscle pain

A client is recovering from a hip replacement and is taking Tylenol every 3 hours for pain, in checking the client, which findings suggest a side effect of the analgesic?

- no bm for three days

A 4 yr old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur, the nurse finds that the child is now crying and the right foot os pale with absence of a pulse, what should the nurse do first?

- notify the health care provider

A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors, he reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurse to include in the clients plan of care?

- observe for changes in level of consciousness - based on the clients history he may be exhibiting signs of hepatic involvement and encephalopathy

Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs

- orthostatic hypotension is a common side effect

An older male client arrives at the clinic complaining that his bladder always feels full, he complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream, which action should the nurse implement?

- palpate the client's suprapubic area for distention - the client is exhibiting classic signs of an enlarged prostate gland, which restricts urine flow and cause bothersome lower UTI

A nurse is performing CPR on an adult who went into cardio. arrest, another nurse enters the room in response to the call. After checking the clients pulse and respirations, what should be the function of the second nurse

- participate with compressions or breathing

A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client? a. Chew food slowly and thoroughly before attempting to swallow b. Plan volume-controlled evenly-space meal thorough the day c. Sip fluid slowly with each meal and between meals d. Eliminate or reduce intake fatty and gas forming food

- plan volume controlled evenly space meal thorough the day - it is important for the client to learn how to eat without damaging the surgical site and to keep the digestive system from dumping the food instead of digesting it

The nurse receives an order to give a client iron by deep injection. The nurse knows that the reason for this route is to

- prevent the drug from tissue irritation

while assessing a clients chest tube, the nurse discovers bubbling i the water seal chamber of the chest tube collection device, the clients vital signs are bp 80/40, hr 120, RR 32, O2 88%, what interventions should the nurse implement

- provide supplemental oxygen - auscultate bilateral lung fields - reinforce occlusive CT dressing - air bubble indicate an air leak from the lungs, the chest tube site, or the chest tube collection system, providing oxygen and auscultating the lungs

The nurse is assessing a client 2 hours postop after a femoral-popliteal bypass, the upper leg dressing becomes saturated with blood, the nurse's first action should be to

- reinforce the dressing and elevate the leg

The nurse is preparing a 4 day old infant with serum bilirubin level of 19 for discharge from the hospital, when teaching the parent about home phototherapy, which instruction should the nurse include in the discharge teaching plan?

- reposition the infant every 2 hours - an infant receiving phototherapy for hyperlipidemia should be repositioned every 2 hours

A client who had a below the knee amputation is experiencing severe limb pain and ask the nurse is mirror therapy will make the pain stop, what should the RN respond

- research indicates that mirror therapy is effective in reducing phantom limb pain

Following an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take? a. Review the immunization records of all children in the elementary school b. Report the measles outbreak to all community health organizations c. Schedule a mobile public health vehicle to offer measles inoculations to unvaccinated children. d. Restrict unvaccinated children from attending school until measles outbreak is resolved.

- restrict unvaccinated children from attending school until measles outbreak is resolved

Discharge instructions for a client taking alprazolam should include which of the following

- sudden cessation of alprazolam

Which of these observations made by the nurse during excretory urogram indicates a complication

- the clients entire body turns a bright red color

The RN is assigned to care for four clients, after receiving the report which client should the nurse see first?

- three days postop, colon resection receiving transfusions of packed RBCs

A client who had a vasectomy is in post recovery unit at an outpatient clinic, which of these point is most important to reinforce by the nurse

- unitl the HCP has determined that your ejaculation doesn't contain sperm, continue to use another form of contraception

A 2 year-old child is brought to the emergency department at 2:00 in the afternoon. The mother states: "My child has not had a wet diaper all day." The nurse finds the child is pale with a heart rate of 132. What assessment data should the nurse obtain next?

A: Status of skin turgor

A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on this data, what is the first nursing action?

Administer oxygen

While interviewing a client, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to

Ask the client what she is feeling

The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to

Assess for abdominal distention

The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?

Assess movement and sensation of extremities

Therapeutic nurse-client interaction occurs when the nurse

Assists the client to clarify the meaning of what the client has said

The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?

Continue to monitor the client to see if the bubbling increases

The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client?

Begin treatment with acyclovir at the onset of symptoms of recurrence

The nurse is caring for a 4 year-old admitted after receiving burns to more than 50% of his body. Which laboratory data should be reviewed by the nurse as a priority in the first 24 hours?

Blood urea nitrogen

A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are

Brittle hair, lanugo, amenorrhea

Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis?

Chest physiotherapy twice a day

An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice?

Chicken strips, corn on the cob, milk

Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose?

Rash, blood dyscrasias, severe depression

The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?

Repeatedly checking that the door is locked

The nurse is teaching a client newly diagnosed with asthma how to use the metereddose inhaler (MDI). The client asks when they will know the canister is empty. The best response is

Drop the canister in water to observe floating

The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized?

Empty the child''s mouth in any case of possible poisoning

A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child?

Epistaxis

The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

Extreme fatigue

The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include

Formula or breast milk

A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority?

Frequent neurovascular assessments of the affected leg

The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately?

Increased restlessness

A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?

Increasing pulse rate

A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?

Inspiratory crackles

A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse's contribution and begins to find objections to the suggestion. The nurse manager's best response is to

Let's move to the 'what if...' as related to these objections for an exploration of spin off ideas.

A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse?

Listen quietly without comment

The nurse's primary intervention for a client who is experiencing a panic attack is to

Maintain safety for the client

What finding signifies that children have attained the stage of concrete operations (Piaget)?

Makes the moral judgment that "stealing is wrong"

Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills?

Offer the client frequent opportunities to interact with 1 person

A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?

Parental anxiety related to knowledge deficit

The nurse is planning discharge for a 90 year-old client with musculoskeletal weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls?

Place nightlight in the bedroom

A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?

Playing with cars on the pavement near burning leaves

When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic reponse to the drug?

Prothrombin time

An important goal in the development of a therapeutic inpatient milieu is to

Provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions

The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The first assessment the nurse should perform is

Pulse oximetry

A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy?

Retinopathy of prematurity

A middle ages woman talks to the nurse in the HCP about uterine fibroids also called leiomyomas and myomas, what statement by the woman indicates more education is needed?

fibroids that cause no problems still need to be taken out

The nurse is caring for an acutely ill 10 year-old client. Which of the following assessments would require the nurses immediate attention?

Slow, irregular respirations

The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. What is the physiological basis for this instruction?

Stimulates hydrochloric acid production

A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what?

Tardive dyskinesia

During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?

Telangiectatic nevi are normal and will disappear as the baby grows

A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report?

The client's urine output was 1500 cc in 5 hours

The nurse is caring for a client with uncontrolled hypertension. Which findings require priority nursing action?

Weakness in left arm

A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time?

What does the skin on the testicles look and feel like?

The nurse is caring for a client in a. fib, the heart rate is 250 and the ventricular rate at 75, which finding is the most concern?

a cold pale, lower leg

While caring for a client who was admitted with MI 2 days ago, the nurse notes today temperature is 101, what is the appropriate intervention

administer acetaminophen as ordered as this normal at this time

A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? A) Cut the child's hair short to remove the nits B) Apply warm soaks to the head twice daily C) Wash the child's linen and clothing in a bleach solution D) Application of pediculicides

application of pediculicides

A nurse is to collect a sputum specimen for acid-fast bacillus from a client, which action should the nurse take first?

assist with oral hygeine

The nurse is preparing a discharge teaching plan for a client who had a liver transplant, which instruction is most important to include in this plan

avoid crowds for first two months for surgery

The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity, which choice indicates the client understands dietary needs?

baked potato

An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the following allergies. Of these allergies which one should all health care personnel be aware of?

balloons

Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media, and an antipyrine and benzocaine otic are also prescribed for pain and inflammation, what instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution?

have the child lie with the ear up for one to two minutes after installation

Which statements best describe the effects of immobility in children

immobility has similar physical effects to those found in adults

A client has returned from a cardiac catheterization that was two hours ago. Which finding would indicate that the client has a potential complication from the procedure? a. No pulse in the affected extremity b. Increased blood pressure c. Increased heart rate d. Decreased urine output

no pulse in the affected extremity

A client with diarrhea should avoid

orange juice

A client with CAD who is experiencing syncopal episodes is admitted for an EPS and possible cardiac ablation therapy, which intervention should the nurse delegate to the UAP?

prepare the skin for procedure

A nurse assess a young adult in the ER a MVC, which of the following neurological sign is most concern?

pupils fixed and dilated

the leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the UAP place a heating pad on the mottled area, what action should the nurse take?

remove the heating pads and place a soft blanket over the clients leg and feet

A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right with the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees

side lying on the left with the head elevated 10 degrees

A client diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube, what is the best explanation for the nurse to provide this client?

the tube will remove excess air from your chest