second study
After three weeks of antibiotic therapy, a child who weighs 55 pounds develops painful oral lesions, so the heal care provider prescribes acyclovir (Zovirax) 20 mg/kg daily. How many mg should the PN administer to this child?
500
After report, the PN receives the laboratory values for four clients. Which client requires the PNs immediate intervention? A. client who is trembling and has a glucose level of 50 mg/dl B. a client who has hemoglobin of 8 grams and is short of breath after a shower C. a client who is febrile and has a WBC count of 14,000/mm3 D. a client whose prothrombin time is 30 seconds and finger stick site is bleeding
A. client who is trembling and has a glucose level of 50 mg/dl
Immediately after birth, which nursing intervention has the highest priority for the newborn infant? A. preventing heat loss and neonatal cold stress B. placing the neonate to the breast C. administering ophthalmic antibiotic ointment D. evaluating the neonate's 1 and 5 minute Apgar scores
A. preventing heat loss and neonatal cold stress
An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the the PN, who is taking the client the clients vital signs. What action should the PN implement ? A. reinforce the needs for extra rest periods and plenty of sleep B. offer to reschedule for treatment for the following week C. plan to monitor the client's vital signs every thirty minutes D. notify the healthcare provider or charge nurse immediately
A. reinforce the needs for extra rest periods and plenty of sleep
A resident of a long-term care facility who has a drainage stage 2 pressure ulcer receives a prescription for sterile, warm, moist compress q12 hours for 20 minutes to the site. What precautions should the PN take when performing this procedure? select all that apply. A. remove soiled dressings with procedure gloved and don sterile gloves for moist dressing application B. place 4x4 gauze sponges on the pressure ulcer and pour warmed water on the dressed site C. apply moisture resistant cover over the saturated dressing during the 20 minute application D. pour warmed sterile solution to an open sterile dressing tray that contained sterile gauze pads E. after the procedure, place all supplies and dressings into the trash can for removal from the bedside.
A. remove soiled dressings with procedure gloved and don sterile gloves for moist dressing application B. place 4x4 gauze sponges on the pressure ulcer and pour warmed water on the dressed site D. pour warmed sterile solution to an open sterile dressing tray that contained sterile gauze pads
which product should the PN provide to ensure effective oral care for a client undergoing chemotherapy? A. soft-bristled toothbrush B. mint-flavored dental floss C. alcohol-based antibacterial mouthwash D. water pressure gum cleaner
A. soft-bristled toothbrush
A client with a fractured left hip fracture is in Bucks's traction. The PN should expect the client to exhibit which outcome? A. the left foot is warm to touch with a palpable dorsalis pedis pulse B. decreased peripheral pulses and capillary refill >3 seconds in the left foot C. a positive Homan's sign in the left calf D. a burning, tingling sensation under the left foam boot
A. the left foot is warm to touch with a palpable dorsalis pedis pulse
an adolescent male with severe acne recently started treatment with isotretinoin, a form of vitamin A. During a follow-up clinic appointment, which assessment is most important for the PN to complete? A.ask about occurrence and frequency of nosebleeds B.measure the number and size of acne cysts C. assess for dry mouth and chapping of the lips D. discuss the client's feelings and emotions
A.ask about occurrence and frequency of nosebleeds
Based on the principle of asepsis the PN should consider which situation to be sterile?
An open Foley catheter kit set up on a table at the PN waist level
when the PN plans daily care for a group pf clients, which client should the PN see first due to the risk of complication? A. young adult reporting pain following gall bladder surgery B. an older client with a stroke who is febrile and confused c. a middle aged client with blood pressure of 140/88 D. an adult client with a peptic ulcer who is feeling nauseated
B. an older client with a stroke who is febrile and confused
A client with Alzheimers disease (AD) is receiving trazadone (Desyrel) a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the clients mood and sleep patterns are improved but there is no change in cognitive ability. How should the nurse respond to this information? A. explain that it may take several weeks for the medication to be effective B. confirm that the desired effect of medication has been achieved c. notify the healthcare provider that a change in dosage may be needed D. evaluate when and how the medication is being administered to the client
B. confirm that the desired effect of medication has been achieved
The spouse of a hospitalized client asks the PN for acetaminophen for a tension headache. Which action should the PN take? A. give the spouse acetaminophen from the nurse's personal supply B. explain that medication can only be provided to clients C determine if the spouse has any medication allergies D. request the pharmacy to send acetaminophen to the unit
B. explain that medication can only be provided to clients
While the PN and UAP are turning a client with an abdominal incision, the clients incision eviscerate. Which task is best for the PN to assign to the UAP? A. cover the wound B. gather supplies C. keep the client calm D. reposition the client
B. gather supplies
The PN is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. what is most important to reinforce in this clients plan of care? A. precaution about avoiding sunlight B. interventions to decrease emotional stress C. instructions about applying an anti-fungal ointment D. strategies to increase omega 3 fatty acids in the diet
B. interventions to decrease emotional stress
To obtain an estimate of a clients systolic blood pressure, what action should the PN take first? A. release the blood pressure cuff valve B. palpate the client's brachial pulse C. pump up the blood pressure cuff D. position the stethoscope diaphragm
B. palpate the client's brachial pulse
The PN obtains a finger stick glucose for a client with type 1 diabetes mellitus who is conscious and demonstrating hand tremors and shaking. The PN reports the clients result of 55 mg/dL to the nurse. What action should the PN implement next? A. assist the RN with initiating an IV access and saline lock B. provide the client of glass of milk and crackers C. give a prescribed dose of glucagon IM D. administer a dose of regular insulin per sliding scale
B. provide the client of glass of milk and crackers
which foot care instructions is most important for the PN to reinforce that minimizes a Long term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)? A. make sure shoe size fits to minimize rubbing and blisters B. report any foot injury or sore that does not readily heal C. monitor finger stick glucose daily for tight control D. after washing feet, dry thoroughly between toes
B. report any foot injury or sore that does not readily heal
The PN administers an antibiotic to a client with a respiratory tract infection...evaluate the medications effectiveness, which laboratory values should the PN monitor? select all that apply A. prothrombin time B. sputum culture and sensitivity C. capillary glucose D. white blood cell count E. serum potassium F. urinalysis
B. sputum culture and sensitivity D. white blood cell count
During recovery after the delivery of a normal infant a client is receiving...ringers 1000 mL with oxytocin 20 units. The PN should evaluate the client for which therapeutic response? A. delivery of the placenta B. stimulation of uterine contractions C. promotion of the let down reflex D. return uterus to a pre-pregnancy size
B. stimulation of uterine contractions
In administering nystatin suspension to the gums of an infant with a candida infection, which approach should the PN take? A. draw up the medication in a needle less syringe which the infant can suck B. use a gloved finger to rub the suspension over the infected area C irritate the infected area with medicated solution after applying sterile gloves D. measure the prescribed amount of solution into the infant's bottle
B. use a gloved finger to rub the suspension over the infected area
A client with hypertension complains of a persistent dry cough. The PN should tell the client that this is a common side effect of which daily medication? A. Clonidine (Catapres) B. Spironolactone ( Aldactone) C. Quinapril (Accupril) D. Losartan (Cozaar)
C. Quinapril (Accupril)
The PN is planning care for a client who has generalized tonic clonic seizures and is vomiting and having frequent diarrhea stools to reduce the risk of injury to this client which nursing measurements should the PN implement? A. tympanic temperatures and oral tongue blades B. rectal temperatures and perineal skin barrier creams C. axillary temperatures and padded side rails D. oral temperature and oral suction equipment
C. axillary temperatures and padded side rails
A new mother asks the pn about an area of swelling on her baby head that lies across the suture line near the posterior fontanel. How should the PN respond? A. cephalhematoma causes no problems B. caput succedaneum may need to be drained C. caput succedaneum will be absorbed and cause no problems D. cephalhematoma may cause jaundice as it is absorbed
C. caput succedaneum will be absorbed and cause no problems
A 0800 a clients apical pulse rate is 98 beats/minute> Four hours later the apical pulse rate is 54 beats/minute. What action should the PN take next? A. obtain blood glucose measurement B. measure the apical radial deficit C. determine the level of consciousness D. auscultate for adventitious breath sounds
C. determine the level of consciousness
A male client who is diagnosed with schizophrenia is taking an antipsychotic medication and calls the psychiatric clinic. The client tell the PN that he is achy and stiff, has a temperature of 103.4 F and is sweating. How should the PN respond to this client? A. recommend that the client arrive at the clinic within the next 2 hours B. tell the client a prescription will be called into the pharmacy by the psychiatrist C. direct the client to obtain immediate transportation to the emergency center D. suggest the client treat the flu-like symptoms with over the counter medication
C. direct the client to obtain immediate transportation to the emergency center
A male client who was admitted with gangrene of the right lower extremity is confused ad his wife refuses to sign the operative permit for an above the knee amputation. What action should the PN take first? A. explain the consequences of sepsis if the amputation is delayed B. notify the RN that the client's wife needs further explanation about the procedure C. encourage the client's wife to express concerns about making the decision D. document on the client record the refusal for surgical treatment
C. encourage the client's wife to express concerns about making the decision
Prior to giving digoxin, the PN assesses that a 2-month old infants heart rate is 120 beats/min. Based on this finding what action should the PN take? A. request the charge nurse to administer the medication B. withhold the medication until the next scheduled dose C. give the medication and document the heart rate D. withhold the medication and notify the charge nurse
C. give the medication and document the heart rate
During a clinic visit for a sore throat a clients basal metabolic panel reveals a serum potassium of 3.0 mEq/L. Which action should the PN recommend to the client based on this finding? A. force liquid intake to 1,500 ml daily B. encourage use of a soft toothbrush C. increase intake of dried peached and apricots D. reduce intake of red meats
C. increase intake of dried peached and apricots
The Glasgow coma scale is being used to monitor a client in the critical care unit. The scale is used to evaluate what client status? A. mental status B. cranial nerve status C. level of consiousness D. ability to communicate
C. level of consiousness
The PN overhears a female client with Cushings syndrome tell her family in a...very loud and angry voice to leave her room and not come back. The response by the PN is baed on recognizing which common manifestation of the syndrome? A. memory loss B. impaired cognition C. mood alterations D. hearing loss
C. mood alterations
A client is diagnosed with with hyperthyroidism. Which symptoms should the PN expect this client to exhibit? A. bradycardia and constipation B. lethargy and lack of appetite C. muscle cramping and dry, flushed skin D. palpitations and shortness of breath
C. muscle cramping and dry, flushed skin
A client develops generalized edema associated with chronic kidney disease (CKD). The PN understands the formation of the edema is the result of which physiological process? A. inflammation of the vessel intima resulting in an aggregation of immune complexes B. decreased capillary hydrostatic pressure releasing atrial natriuretic hormone (ANH) C. plasma protein resulting in decreased oncotic pressure within the vessels D. increase in the serum osmolality influencing a decreased release of vasopressin
C. plasma protein resulting in decreased oncotic pressure within the vessels
When entering the room of an older female resident of a long term care facility, the PN finds one of the male residents in bed with her. What action should the PN take? A. tell the couple to dress and that you'll be back in 10 minutes B. explain to the couple that they are violating the rules of the residence C. quietly escort the male client back to his room D. close the door and report the finding to the charge nurse.
C. quietly escort the male client back to his room
when assessing an adult male who present at the community health clinic with a history of hypertension the nurse notes that he has 2+ pitting edema in both ankles. he also has a history of gastroesophogeal reflux disease and depression. which interventions is most important for the PN to implement? A. arrange to transport the client to the hospital B. instruct the cleint to keep a food journal, including portion size C. review the client' use of over the counter (OTC) medications D. reinforce the importance if keeping feet elevated
C. review the client' use of over the counter (OTC) medications
A client who is primigravida at term comes to the prenatal clinic and tells the PN that she is having contractions every 5 minutes. The PN monitors the client for 1 hour using a external fetal monitor and determines that the clients contractions are 7 to 15 minutes apart lasting 20-30 seconds with mild intensity by palpation. What action should the PN take? A. direct the client to check into the hospital within the next hour for evaluation of possible urinary tract infection B. send the client home and tell her to drink at least 1,000 ml of fluid each day to flush her bladder C. send the client home and instruct her to call the clinic when her contractions occur every 5 minutes apart for one hour D. tell the client to go directly to the hospital for admission to labor and delivery for active labor
C. send the client home and instruct her to call the clinic when her contractions occur every 5 minutes apart for one hour
which client information is most important for the PN to consider when providing instructions to the UAP about providing morning care to a postoperative client? A. oriented to person only B. blood pressure of 144/84 C. urinary output of 50 ml/hour D. oxygen saturation measurement of 95-96%
C. urinary output of 50 ml/hour
The PN enters the room of a client who is disoriented and has a wrist restraint secured as seen in the picture what action should the PN take? photo is of hospital bed and restraint Is on the bed frame in a bow tie A. raise the upper side rail B. release the restraint tie C. use a full knot to secure the restraint tied D. secure the tie to the bathroom side rail
C. use a full knot to secure the restraint tied
The PN is assisting a client to the bathroom after right cataract extraction. The client has an eye shield over the right eye. How should the PN asset the client during ambulation? A. support the client on the right side while walking to the bathroom B. walk on the client's left side while assisting the client to the bathroom C. place the client in front of the nurse while both walk to the bathroom D stand in front of the client and lead the client forward to the bathroom
D stand in front of the client and lead the client forward to the bathroom
when the PN attempts to assist an 18-year old female client with mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and yells at the PN "get out of here! Ill get up when I'm ready!" which response is best for the PN to make? A. you must ambulate to avoid complications which could cause more discomfort when ambulating B. your healthcare provider has left specific instruction to ambulate on the first postoperative day C. i will be back in 30 minutes to help you get out of bed and walk around the room today D. I know you feel angry about the pain of ambulation, but this is a necessary part of getting well
D. I know you feel angry about the pain of ambulation, but this is a necessary part of getting well
The PN is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue. How should the PN respond? A. describe how liver damage may result in lifelong fatigue B. encourage frequent activity to restore sleep awake cycles C. obtain a prescription for PRN sedative to promote rest D. affirm the importance of rest to promote liver healing
D. affirm the importance of rest to promote liver healing
An older adult female is admitted with syncope and laboratory findings indicate that her hemoglobin is 8.0 grams /dL . She has a recent history of headaches and frequent falls. Admission prescription orders include continuation of all home medications. Which medication should the PN withhold until consulting with the charge nurse? A. docusate sodium B. levothyroxine C. calcium citrate D. aspirin
D. aspirin
The PN and UAP are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement? A. ask the UAP to leave the room and assess the client's body for bruising B. carefully observe the interaction between the client and family members C. instruct the UAP to protect the client's left side when transferring to a chair D. demonstrate to the UAP how to approach the client from the client's left side
D. demonstrate to the UAP how to approach the client from the client's left side
The PN is caring for a client who was recently diagnosed with hepatitis B virus (HBV). The PN observes that the clients urine is the color of dark tea. What action should the PN take? A. document the appearance of the urine B. check the client's white blood cell count C. obtain a urine sample to test for bleeding D. encourage increased oral fluid intake
D. encourage increased oral fluid intake
Based on the nursing diagnosis of "risk for infection" which intervention should the PN implement when providing care for an elderly client with urinary incontinence? A. insert an indwelling urinary catheter B. initiate contact isolation precautions C. utilize and antibacterial perineal wash D. maintain standard precautions
D. maintain standard precautions
The PN views the mid-line episiotomy of a client who reports pain in her stitches. What action should the PN take first? A. initiate daily warm sitz baths during onset of pain B. check medication administration record for last PRN analgesic C. apply an ice pack for 20 minutes to the episiotomy D. observe suture line for separation and hematoma formation
D. observe suture line for separation and hematoma formation
The PN plans to evaluate an adults response to a prescription for colchicine. Last week the client was seen in the clinic for pain in the great left toe, which was the result of an acute attack of gout. which data should the PN obtain to evaluate the therapeutic effectiveness of this medication? A. appearance of the great toe on the affected foot B. range of motion of lower extremities C. fatigue level since staring to drug treatment D. pain scale level during walking
D. pain scale level during walking
A client reports feeling numbness and tingling in extremities. What action should the PN implement? A. provide a high protein snack to the client B. encourage increased oral fluid intake C. assess the client's temperature D review the client's serum electrolyte levels
D. review the client's serum electrolyte levels
A 5-year old child is admitted with full thickness burns over 30% of the total body surface areas (TBSA). After fluid replacement therapy is initiated, which finding should the PN use to evaluate the effectiveness of the therapy? A. skin turgor B. mucous membranes C. heart rated D. urine output
D. urine output
The hearing of ringing in the ears what medication should be reported to the Health provider ?
Gentamicin
After applying alcohol based hand rub to the palms of the hand and rubbing paps together what action should the PN take next? a place hands on top of each other and interlace fingers b I am uncomfortable performing a skill which I am not certified c on the stronger side of the body d measure appropriate vital signs
a place hands on top of each other and interlace fingers
A client with schizophrenia is withdrawn isolates himself in the day room and answers questions with one or two word responses which intervention is most important ? a measure appropriate vital signs b take him to his room c ignore it d take blood pressure
a. measure appropriate vital signs
A client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug? a provide oral care b give water c do nothing d mouthwash
a. provide oral care
Because of staffing shortages the charge nurse assigns a PN to perform a skill which the PN is not yet certified to perform what is the best response by the PN? a do the task anyway b I am uncomfortable performing a skill which I am not certified c I am not going to do it d No
b I am uncomfortable performing a skill which I am not certified
A new mother is breastfeeding her newborn for the first time and complains of nipple pain when the baby sucks. What should the nurse tell the mom? a she needs to deal with it b ensure that all the areolar tissue of the nipple is in the infants mouth c apply ointment d stop breastfeeding
b ensure that all the areolar tissue of the nipple is in the infants mouth
A client recovering from a stroke is learning how to use a cane. How should it be placed? a weak side b on the stronger side of body c 2 inches to the left sided 2 inches to right side
b on the stronger side of body
While performing the apical pulse of an adult male client the PN notes that the point of maximal impulse is located at the 4th intercostals space medial to the midclavicular line what is the assessment for? a abnormal b expected finding c needs to notify RN d do it again
b. expected finding
Client with Hungtingtons disease starts jerking around while the family is there what should the PN do? a tell him to stop b offer emotional support to family c ignore it d report to charge nurse
b. offer emotional support to family
what site should the PN use when administering RHO D? a gluteus maximus b stomach c deltoid d gluteus media
c deltoid
A client on bed rest refuses to wear the prescribed pneumatic compression device after surgery, what action should the PN implement in response to the clients refusal ? a place hands on top of each other and interlace fingers b wear a supportive bra at all times c emphasize the importance of active foot flexion d I am uncomfortable performing a skill which I am not certified
c emphasize the importance of active foot flexion
A client with type 2 diabetes becomes unresponsive and says I'm not feeling right which action should the PN take? a give him water b expected side effects c give 4 ounces of apple juice d give him milk
c give 4 ounces of apple juice
A new mother is bottle feeding instead of breastfeeding the PN should instruct the to most effective way to deal with breast engorgement and discomfort is to? a stop breastfeeding b apply a cream c wear supportive bra at all times d let breast air dry
c wear supportive bra at all times
When preparing to administer medications to an older resident the PN notices that several medications that were supposed to be administered during the previous shift have not been entered as given In the computer. What action should the PN take?
contact the medication nurse to clarify the findings
The PN is caring for a client in bucks tract what is the priority goal for the client in traction? a patient's head is lower than their fee b visualization of the lower abdomen and pelvis c for patients who develop hypovolemic shock d maintain straight body alignment
d. maintain straight body alignment
on admission to the medical unit a client who is homeless and has a history of HIV with persistent cough?
erythema and indurations of 5mm at site
28 year old client is in active labor and complains of a cramp in her leg. what intervention should the PN implement ?
extend the leg and flex the fooT
A client is admitted for observation after experiencing a TIA
high risk for injury
A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the PN to provide to the UAP who is completing morning care for this client?
measure all emeisies accurately
Client who has four gold seed implants on a chest wall tumor is on radiation precautions what basic precautions should the PN nurse observe when administering direct client care?
minimal time maximum distance and protective shielding
Client voiding small amounts every 24 hours
the catheterized volume determines the need to reinsert the indwelling catheter
Single mother of a child with head injury comes crying to the clinic what should the PN tell her?
this must seem overwhelming to you right now
when should a person use additional birth control precautions?
when taking antibiotics for an infection
