sata
normal labs
platelets 150,000-400,000 mm3 sodium 135-145 mEq/L potassium 3.5-5.0 mEq/L segmented neutrophils 60%-70% serum creatinine 0.6-1.3 mg/dL white blood cells 5000-10,000 mm3
The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines that which clients would be the most likely candidates for parenteral nutrition (PN)?
1. A client with extensive burns 2. A client with cancer who is septic 3. A client who has had an open cholecystectomy 4. A client with severe exacerbation of Crohn's disease 5. A client with persistent nausea and vomiting from chemotherapy Correct Answer: 1,2,4,5
The nurse is preparing to administer medication using a client's nasogastric tube. Which actions should the nurse take before administering the medication?
1. Check the residual volume. 2.Aspirate the stomach contents. 3.Turn off the suction to the nasogastric tube. 4.Remove the tube and place it in the other nostril. 5.Test the stomach contents for a pH indicating acidity Correct Answer: 1,2,3,5
The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan?
1."The ductus arteriosus allows blood to bypass the fetal lungs." 2."One vein carries oxygenated blood from the placenta to the fetus." 3."The normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy." 4."Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 5."Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta." Correct Answer: 1,2,4
The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid?
1.Allows for fetal movement 2.Surrounds, cushions, and protects the fetus 3.Maintains the body temperature of the fetus 4.Can be used to measure fetal kidney function 5.Prevents large particles such as bacteria from passing to the fetus 6.Provides an exchange of nutrients and waste products between the mother and the fetus Correct Answer: 1,2,3,4
A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications?
1.Ask a family member to donate blood ahead of time. 2.Give an autologous blood donation before the surgery. 3.Take iron supplements before surgery to boost hemoglobin levels. 4.Request that any donated blood be screened twice by the blood bank. 5.Take adequate amounts of vitamin C several days prior to the surgery date. Correct Answer: 1,2
The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment?
1.Auscultating lung sounds 2.Obtaining the client's temperature 3.Assessing the strength of peripheral pulses 4.Obtaining information about the client's respirations 5.Performing a musculoskeletal and neurological examination 6.Asking the client about a family history of any illness or disease Correct Answer: 1,2,4
The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was
1.Bites from ticks or deer flies 2.Inhalation of bacterial spores 3.Through a cut or abrasion in the skin 4.Direct contact with an infected individual 5.Sexual contact with an infected individual 6.Ingestion of contaminated undercooked meat Correct Answer: 2,3,6
A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine?
1.Breast-feeding needs to be stopped for 3 months. 2.Pregnancy needs to be avoided for 1 to 3 months. 3.The vaccine is administered by the subcutaneous route. 4.Exposure to immunosuppressed individuals needs to be avoided. 5.A hypersensitivity reaction can occur if the client has an allergy to eggs. 6.The area of the injection needs to be covered with a sterile gauze for 1 week. Correct Answer: 2,3,4,5
A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet?
1.Broth 2.Coffee 3.Gelatin 4.Pudding 5.Vegetable juice 6.Pureed vegetables Correct Answer: 1,2,3
The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells?
1.Checks the expiration date 2.Inspects for the presence of clots 3.Checks the blood group and type 4.Checks the blood identification number 5.Hangs the blood within the specified time frame per agency policy Correct Answer: 1,5
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take?
1.Contact the surgeon. 2.Instruct the client to remain quiet. 3.Prepare the client for wound closure. 4.Document the findings and actions taken. 5.Place a sterile saline dressing and ice packs over the wound. 6.Place the client in a supine position without a pillow under the head. Correct Answer: 1,2,3,4
The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family?
1.Discourage reminiscing. 2.Make the decisions for the family. 3.Encourage expression of feelings, concerns, and fears. 4.Explain everything that is happening to all family members. 5.Touch and hold the client's or family member's hand if appropriate. 6.Be honest and let the client and family know they will not be abandoned by the nurse. Correct Answer: 3,5,6
The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply.
1.Document a late entry in the client's record. 2.Draw 1 line through the error, initialing and dating it. 3.Try to erase the error for space to write in the correct data. 4.Use whiteout to delete the error to write in the correct data. 5.Write a concise statement to explain why the correction was needed. 6.Document the correct information and end with the nurse's signature and title. Correct Answer: 2,6
A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply.
1.Ensures that a close relative stays with the client 2.Makes a referral for a Catholic priest to visit the client 3.Removes the crucifix from the wall in the client's room 4.Administers the sacrament of the sick to the client if death is imminent 5.Offers to provide a means for praying the rosary if the client wishes 6.Reminds the dietary department that meals served on Fridays during Lent do not contain meat Correct Answer: 1,2,5
The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply.
1.Excessive bubbling in the water seal chamber 2.Vigorous bubbling in the suction control chamber 3.Drainage system maintained below the client's chest 4.50 mL of drainage in the drainage collection chamber 5.Occlusive dressing in place over the chest tube insertion site 6.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation Correct Answer: 3,4,5,6
The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note?
1.Increased heart rate 2.Decline in visual acuity 3.Decreased respiratory rate 4.Decline in long-term memory 5.Increased susceptibility to urinary tract infections 6.Increased incidence of awakening after sleep onset Correct Answer: 2,5,6
The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.
1.ST depression 2.Prominent U wave 3.Tall peaked T waves 4.Prolonged ST segment 5.Widened QRS complexes Correct: 2,5
The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session?
1.Individuals move through all 6 stages in a sequential fashion. 2.Moral development progresses in relationship to cognitive development. 3.A person's ability to make moral judgments develops over a period of time. 4.The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 5.In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society. 6.In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned. Correct Answer: 2,3,4,6
Which purposes of placental functioning should the nurse include in a prenatal class?
1.It cushions and protects the baby. 2.It maintains the temperature of the baby. 3.It is the way the baby gets food and oxygen. 4.It prevents all antibodies and viruses from passing to the baby. 5.It provides an exchange of nutrients and waste products between the mother and developing fetus. Correct Answer: 3,5
Which clients have a high risk of obesity and diabetes mellitus?
1.Latino American man 2.Native American man 3.Asian American woman 4.Hispanic American man 5.African American woman Correct Answer: 1,2,4,5
The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.
1.Nausea 2.Confusion 3.Bradypnea 4.Tachycardia 5.Hyperkalemia 6.Lightheadedness correct:1,2,4,6
The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping?
1.Neglecting personal grooming 2.Looking at old snapshots of family 3.Participating in a senior citizens program 4.Visiting the spouse's grave once a month 5.Decorating a wall with the spouse's pictures and awards received Correct Answer: 2,3,4,5
Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium?
1.Obtain an intravenous (IV) infusion pump. 2.Monitor urine output during administration. 3.Prepare the medication for bolus administration. 4.Monitor the IV site for signs of infiltration or phlebitis. 5.Ensure that the medication is diluted in the appropriate volume of fluid. 6.Ensure that the bag is labeled so that it reads the volume of potassium in the solution. Correct Answer: 1,2,4,5,6
The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. Which findings are consistent with acute rejection of the transplanted kidney?
1.Oliguria 2.Hypotension 3.Fluid retention 4.Temperature of 99.6°F (37.6°C) 5.Serum creatinine of 3.2 mg/dL (282 mcmol/L) Correct Answer: 1,3,5
The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion?
1.Open doors to client rooms. 2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed. 5.Relocate ambulatory clients from the hallways back into their rooms Correct Answer: 2,3,4
The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list?
1.Oranges 2.Broccoli 3.Margarine 4.Cream cheese 5.Luncheon meats 6.Broiled haddock Correct Answer: 3,4,5
The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration?
1.Pain and erythema 2.Pallor and coolness 3.Numbness and pain 4.Edema and blanched skin 5.Formation of a red streak and purulent drainage Correct Answer: 2,3,4
The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply.
1.Peas 2.Nuts 3.Cheese 4.Cauliflower 5.Processed oat cereals Correct Answer: 1,2,4
The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.
1.Peas 2.Raisins 3.Potatoes 4.Cantaloupe 5.Cauliflower 6.Strawberries Correct Answer: 2,3,4,6
Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report?
1.Platelets 35,000 mm3 (35 × 109/L) 2.Sodium 150 mEq/L (150 mmol/L) 3.Potassium 5.0 mEq/L (5.0 mmol/L) 4.Segmented neutrophils 40% (0.40) 5.Serum creatinine, 1 mg/dL (88.3 mmol/L) 6.White blood cells, 3000 mm3 (3.0 × 109/L) Correct Answer: 1,2,4,6
Which interventions are appropriate for the care of an infant? Select all that apply.
1.Provide swaddling. 2.Talk in a loud voice. 3.Provide the infant with a bottle of juice at nap time. 4.Hang mobiles with black and white contrast designs. 5.Caress the infant while bathing or during diaper changes. 6.Allow the infant to cry for at least 10 minutes before responding. Correct Answer: 1,4,5
A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client?
1.Remove the IV catheter at that site. 2.Apply warm moist packs to the site. 3.Notify the health care provider (HCP). 4.Start a new IV line in a proximal portion of the same vein. 5.Document the occurrence, actions taken, and the client's response. Correct Answer: 1,2,3,5
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply.
1.Respirations that are shallow 2.Respirations that are increased in rate 3.Respirations that are abnormally slow 4.Respirations that are abnormally deep 5.Respirations that cease for several seconds correct: 2,4
A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent?
1.Set limits on the child's behavior. 2.Ignore the child when this behavior occurs. 3.Allow the behavior, because this is normal at this age period. 4.Provide a simple explanation of why the behavior is unacceptable. 5.Punish the child every time the child says "no" to change the behavior. Correct Answer: 1,4
The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply
1.The acuity level of the clients 2.Specific requests from the staff 3.The clustering of the rooms on the unit 4.The number of anticipated client discharges 5.Client needs and workers' needs and abilities Correct Answer: 1,5
Which identifies accurate nursing documentation notations? Select all that apply.
1.The client is resting in bed with the eyes closed. 2.Abdominal wound dressing is dry and intact without drainage. 3.The client seemed angry when awakened for vital sign measurement. 4.The client appears to become anxious when it is time for respiratory treatments. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. Correct Answer: 1,2,5
The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.
1.U waves 2.Absent P waves 3.Inverted T waves 4.Depressed ST segment 5.Widened QRS complex Correct Answer: 1,3,4
The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value?
1.U waves 2.Widened T wave 3.Prominent U wave 4.Prolonged QT interval 5.Prolonged ST segment Correct Answer: 4,5
The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications, that are contraindicated for use with ibuprofen?
1.Warfarin 2.Glimepiride 3.Amlodipine 4.Simvastatin 5.Hydrochlorothiazide Correct Answer: 1,2,3
