Self-Assessment

The nurse is teaching a client about newly prescribed cyclosporine. Which client statement indicates a need for further teaching?

"I am going to a concert with my friends this weekend" *Cyclosporine is an immunosuppressant. Clients are at increased risk for infection and secondary cancers. Consuming grapefruit increases the risk for drug toxicity. Gingival hyperplasia, hirsutism, uncontrolled HTN, and kidney toxicity are other common adverse effects.

The nurse reinforces teaching to the parents of a 12 month old who has began weaning from breastfeeding. Which statement by the parents indicates that teaching has been effective?

"I can start substituting breastfeeding sessions with whole cow's milk" *Weaning is best achieved gradually to avoid breast engorgement and infant distress. Gradual weaning from breastfeeding may begin with the introduction of solid foods at age 6 months. Whole cow's milk may be given to children after age 12 months.

The home health nurse visits a client with inflammatory bowel disease who recently underwent a total colectomy with ileostomy creation. Which statement by the client indicates that the client understands ileostomy care?

"I cut the appliance opening slightly larger than my stoma" *When caring for a client with an ileostomy, the nurse encourages the client to cleanse peristomal skin with mild soap and water, ensure that the ostomy appliance fits well, change appliances every 5-10 days, and increase fluid intake.

The student nurse plans postmortem care for an orthodox jewish client hospitalized for the last week with heart failure who did not sign consents for any postmortem actions. Which statement by the student would require further education by the supervising nurse?

"I will prepare the client for transfer to the morgue for autopsy" *Orthodox Jews do not permit autopsies unless certain conditions are met. Often, the client's family preforms postmortem care, covers the face with a sheet, and remains with the body until burial. Families should always be consulted for specific beliefs prior to providing postmortem care.

The nurse is caring for a client taking escitalopram who reports no improvement of depressive feelings since starting the medication 2 months ago. What is the best response by the nurse?

"Let's talk more about how you have been taking this medication" *SSRI (escitalopram, sertraline, fluoxetine) take about 1-4 weeks from the first dose to improve depression symptoms. If the medication is ineffective, the nurse should determine client compliance prior to notifying HCP.

A female client is visiting the clinic for an annual well-woman examination. The client reports having sex with women. Which question will help the nurse determine the client's risk for sexually transmitted infections?

"What barrier methods do you and you partner(s) use?" *All women who engage in sexual activities are at risk for sexually transmitted infections, regardless of sexual orientation or history. Health-promotion activities and education should be aimed at safe sexual practices (barrier methods, hygienic use of sex toys)

When the nurse recommends a hospital bed for the client in the last stage of Huntington disease with the family, the client's spouse becomes visibly upset and says, "no hospital bed. I'm just not ready for it yet." What is best response by the nurse?

"What upsets you about having a hospital bed?" *Family members of a client with a degenerative disease may be resistant to care recommendations during periods of grief (denial). The nurse should use therapeutic communication that focuses on exploring family members' concerns and validating their feelings.

A 76 yo who has heart failure is taking digoxin, furosemide, and sucralfate is experiencing sudden weight gain and orthopnea. Which question would be the most beneficial for the nurse to ask at this time?

"When are you taking each of your medications?" *Cardiac glycosides (digoxin) improve cardiac output and efficiency in clients with heart failure. Sucralfate (Carafate) taken at the same time as digoxin can decrease absorption of the latter, thereby increasing symptoms of heart failure. Clients should take sucralfate at least 2 hours after digoxin.

The client admitted to the psych unit with severe anxiety is pacing rapidly in the room, crying, and hyperventilating. The client yells, "I can't believe you took my belongings! Where are you keeping them? This is so frustrating!" What is appropriate response by the nurse?

"Your belongings are locked in a safe place to ensure that they are protected while you are here." *When caring for a client experiencing severe anxiety, nurses should provide a calm presence, reassure clients of safety, use simple statements, and answer questions directly. Nurses should not leave the client alone, interfere with coping behaviors, or transfer their own frustrations to the client.

A nurse is caring for a client with a long leg cast applied to treat a tibial fracture. What interventions can be delegated to UAP?

1.) Alert the nurse of client reports of a tingling sensation 2.) Assist client in performing range of motion exercises 3.) Elevate the casted limb above heart level *A client with a cast requires frequent neurovascular assessment to monitor for compartment syndrome. Appropriate tasks for UAP for a client with a cast include elevating the casted extremity, assisting with ROM exercises, and alerting the nurse of client reports of tingling, pain, or decreased sensation.

Which following incidents does the nurse recognize as a violation of client confidentiality?

1.) An oncology nurse reviews EHR of a client in the ER who was the victim of a recent mass shooting event. 2.) The LPN leaves the client's report sheet in the cafeteria after lunch. 3.) The UAP tells a client that the hospital roommate will return to the room after receiving hemodialysis. *Clients' health information should be discussed and viewed only by the team members directly involved in those clients' care. Nurses must also ensure that documents containing client's information remain with staff at all times and are disposed of securely.

The nurse determines that a client with incontinence and limited mobility is at increased risk for skin breakdown and pressure injury. While caring for this client, which of the interventions are appropriate?

1.) Applying moisture barrier cream to the skin after performing perineal care. 2.) Providing a diet that is high in protein and contains adequate calories. 3.) Repositioning the client using a turn sheet q2h 4.) Using foam padding placed under the client's legs to elevate the heels *Frequent assessment, proper skin care, repositioning every 2 hours, a high-protein diet with adequate calories, and use of support surfaces can help prevents pressure injuries. Fluid restriction can cause hemoconcentration and worsen circulation, thereby increasing the risk pressure injury

The L&D nurse is caring for a client whose unborn child has been diagnosed with anencephaly. Which of the following nursing actions are appropriate for supporting the client in preparation for birth?

1.) Discuss the newborn's expected appearance with the client. 2.) Explore the client's preferences for social and spiritual support *Anencephaly is the absence of a major portion of the fetal brain and skull and is incompatible with life. The nurse supports a client experiencing antenatal grief and loss by acknowledging the client's situation, exploring preferences for social and spiritual support, and helping the client anticipate the unique aspects of their situation (appearance, grieving process)

A client diagnosed with septic arthritis of the knee. What manifestations does the nurse expect to find?

1.) Fever 2.) Joint swelling with effusion 3.) Limited range of motion 4.) Moderate to severe pain *Septic arthritis can lead to irreversible joint damage if not treated promptly. Characteristic manifestations include severe pain of sudden onset, erythema, warmth, swelling, limited range of motion, and fever.

The clinic nurse evaluates the ongoing treatment plan for a client with major depressive disorder. Which of the following client statements indicate a positive response to treatment?

1.) I joined a book club with some of the parents from my kids' school 2.) The haircut and color are very different, but I think I like the new look *Positive outcomes associated with an effective treatment regimen for major depressive disorder include improved self-esteem, a renewed interest in self-care, increased social interaction, and a return to normal daily activities. Clients also demonstrate hope for a purposeful life and the ability to plan for the future.

The nurse is preparing to change the dressing of a client's subclavian central venous catheter using a chlorhexidine gluconate impregnated patch and transparent adhesive dressing. Place steps in correct order.

1.) Perform hand hygiene, don face mask, place a mask on the client, and apply clean gloves 2.) Remove old dressing and CHG-impregnated patch, assess insertion site 3.) Discard the clean gloves, perform hand hygiene, and apply sterile gloves 4.) Cleanse the site with CHG for at least 30 seconds using friction, allow to air dry completely 5.) Apply CHG patch over catheter insertion site and cover with a sterile transparent dressing

Four clients enter the pediatric ER. Which client should the nurse see first?

12 month old who was wheezing at home and is now lethargic with no wheezing *A client who suddenly stops wheezing may be experiencing impending respiratory failure and should be assessed immediately

After assessing 4 clients in the pediatric ER, the nurse should alert the HCP to see which client first?

4 month old who is lethargic with fever and vomiting *Bacterial meningitis is inflammation of the meninges, which causes cerebral edema and may be fatal. Clients with fever and signs of increased ICP needs close monitoring, isolation, spinal fluid cultures, and antibiotics

The nurse is caring for a client with chronic pancreatitis. Which meal should the nurse recommend when assisting the client in selecting food items from a menu?

Baked tilapia with lemon wedge, sweet potatoes, and green peas *Clients with pancreatitis often cannot secrete lipase in sufficient quantities to digest consumed fats, requiring the client to follow a low-fat diet. Low-fat food choices include lean meats, non-fat dairy products, vegetables/fruits prepared without added fat, and low-fat carbs

The nurse in a psych unit is approached by an aggressive client who grabs the nurse's stethoscope and attempts to strangle the nurse with it. The nurse is able to escape the client's grasp unharmed. Which action should the nurse take first?

Begin escorting other clients out of the room *When dealing with a violent client, nurses should use crisis-management techniques to ensure the safety of all clients. Interventions include assembling a crisis team to create a specific plan, removing other clients from the area, communicating calmly, and implementing restrictive interventions

4 clients are assigned to the ER nurse. Which client should the nurse see first?

Client in a motor vehicle collision whose head hit the steering wheel *A blow to the head may cause serious brain injury. Regular neuro assessments should be performed, and the client should be evaluated from concussion, contusion, skull fracture, and epidural or subdural hematoma.

Which client should the nurse see first?

Client receiving normal saline IV at 250 mL/hr who is reporting puffy legs and a new cough *Fluid overload can occur with increased infusion rates and should be addressed promptly to prevent respiratory or cardiovascular compromise.

The clinic nurse is listening to voicemail messages in the office. Which client should the nurse call back first?

Client started on phenytoin a week ago reports blistered lesions on the face and trunk *Stevens-Johnson syndrome is an immune-medicated reaction triggered by certain classes of drugs (Sulfonamide antibiotics, allopurinol, anticonvulsants). It is characterized by blistered lesions on the face, trunk, and palms and may be fatal if left untreated.

A nurse is set to triage victims at a mass casualty incident site following a disaster and correctly identifies which client as the priority for transport to a hospital?

Client who is cool and clammy with a glass shard penetrating the chest wall *During mass casualty incidents, nurses triage to do the greatest amount of good for the greatest number of clients. Clients are triaged rapidly using a color coded system to categorize them from the highest medical priority (red) to lowest (black)

Which client presenting to the women's health clinic should the nurse assess first?

Client whose last menstrual period was 7 weeks ago and reports severe pelvic pain *Ectopic pregnancy can result in rupture and life-threatening hemorrhage if not promptly identified. Any woman with amenorrhea, pelvic or abdominal pain, and/or subsequent vaginal bleeding/spotting should be evaluated promptly for the possibility of ectopic pregnancy.

A nurse is screening clients for skin cancer. Which assessment would be most concerning?

Client with a blue and black, irregular papule on the hand. *Nurses should use the ABCDE to identify lesions with melanoma-like characteristics: (A-Asymmetry, B-Border irregularity, C-Color changes, D-Diameter, E-Evolving). Findings with melanoma-like characteristics are more concerning than finding indicating basal cell cancer, psoriasis, or actinic keratoses.

The nurse conducts telephone screenings with several clients who are scheduled for CT scan of the abdomen with oral contrast. The nurse should notify the HCP about which client before the CT scan is performed?

Client with a hx of stroke who has dysphagia and is drooling *Oral contrast enhances the visibility and definition of GI structures on CT scan. When caring for clients prescribed oral contrast, the nurse should check for iodine allergy because some types of oral contrast contain iodine. The nurse should also assess for any condition that significantly impairs swallowing or airway protection, which could result in aspiration.

The monitor teach on the telemetry unit notifies the charge nurse that there are no more client telemetry boxes available for new admissions. Which client should the charge nurse consider for discontinuation of telemetry monitoring?

Client with chronic atrial fibrillation prescribed warfarin with an INR of 3.0 *When discontinuing telemetry monitoring on a client, the RN must consider hemodynamic status, cardiac rhythm, and risk for complications. A client with chronic atrial fibrillation and a therapeutic INR has a low risk for developing a lethal arrhythmia and can safely be removed from continuous telemetry monitoring.

UAP reports being splashed in the eye while emptying urine from the catheter bag or client with AIDS. UAP is afraid of becoming infected with HIV and requests immediate testing. What is nurses priority?

Direct the UAP to immediately flush the eye with water at the unit's eyewash station *Following accidental eye exposure to body fluids or chemicals, the worker should immediately flush the eye with water or saline. After reporting the incident to appropriate personnel, the worker may be sent to the ER or occupational health department to receive post-exposure care

The nurse is caring for a client 1 hour after receiving the first electroconvulsive therapy treatment for severe major depressive disorder. The client reports a headache, is disoriented to place, and cannot recall the spouse's name. What is the appropriate nursing action?

Document the findings in the client's medical record *Electroconvulsive therapy is used to treat client with severe depression or bipolar disorder that has not responded to other therapies. Temporary confusion, disorientation, and memory loss are common side effects.

The nurse is teaching a seminar about atypical presentation of myocardial infarction. The nurse teaches about which factor that increases a client's risk or experiencing atypical symptoms?

Female gender *Atypical presentation of myocardial infarction involves associated symptoms (sweating, nauseam dyspnea) with no chest pain. Women, older adults, and clients with diabetes or neuropathy are more likely to have an atypical presentation

What prescription is priority for the nurse to administer to the patient with sickle cell crisis who just received a blood transfusion?

Furosemide 20mg IV once, now *Circulatory overload is a life-threatening complication of blood transfusion characterized by pulmonary edema, headache, HTN, and tachycardia. If a client displays symptoms of pulmonary edema, the nurse should prioritize administering diuretics and preparing additional respiratory support.

A nurse is administering a rituximab infusion to a client with lymphoma in an oncology clinic. Which client symptom would be a priority to report to HCP?

New-onset tachypnea and dyspnea *Rituximab can produce a powerful immune response (bronchospasm, dyspnea, tachypnea, hypotension, angioedema). Clients should be closely monitored during and after the infusion.

The nurse is caring for a client who is 2 days postop craniotomy with bone flap removal. The nurse notes clear wound drainage saturating the dressing over the incision. Which action by the nurse is most appropriate at this time?

Notify HCP of the color and amount of drainage. *Clients post-craniotomy are at risk for developing a cerebrospinal fluid leak. Incisional edema or clear drainage from the incision, nose, or ear is reported immediately to the HCP for evaluation and intervention to decrease the risk of meningitis.

A nurse caring for a client following a right femoral angiogram is unable to palpate the right pedal pulse. What should the nurse do next?

Obtain a doppler ultrasound *After a peripheral angiogram, frequent neurovascular checks are required to assess peripheral circulation. Signs of decreased perfusion must be investigated prior to further interventions.

The nurse responds to a neighbor's calls for help and finds the neighbor's infant is choking but still responsive. Which intervention is most appropriate?

Perform 5 back slaps followed by 5 downward chest thrusts *To relieve choking in a responsive infant, perform cycles of 5 back slaps and 5 chest thrusts to expel the obstructions. If the infant becomes unresponsive initiate CPR

The new nurse caring for a 3 month old client who is sedated in the ICU following surgery, needs to prevent skin breakdown. Which action performed by the new nurse would cause the charge nurse to intervene?

Placing a donut pillow under the head *Sedated infants are at increased risk of pressure injuries due to limited mobility, sensory deficits, and incontience. The nurse should elevate HOD 30 degrees to reduce pressure, apply a moisture barrier to any vulnerable tissue areas, reposition the pulse oximeter q4h, and avoid the use of baby powder and donut pillows.

On inspection, while preparing to administer a unit of packed red blood cells, the nurse notices a large air bubble at the top of the bag. What is the appropriate action by the nurse at this time?

Return the blood to the blood bank, notify them that the air is present, and obtain a new bag *Blood products that are found to have impaired packaging, are expired, or show signs of contamination (discoloration, gas formation, clots/inclusions, malodor) must not be transfused and should immediately be returned to the blood bank for investigation.

A client comes to the ER after being bitten by a bat. The nurse observes 2 small, nondraining puncture wounds resembling pinpricks on the fingertip. Which action should the nurse implement first?

Scrub the wound with povidone-iodine solution or soap and water *The rabies virus affects the central nervous system and is transmitted by the saliva of infected animals usually via a bite or scratch. Postexposure prophylaxis includes immediate wound care with povidine-iodine or soap and water; vaccines for tetanus and rabies, or rabies immunoglobulin, may be given afterward

The nurse checks a BP with an automatic, noninvasive machine that inflates for a long amount of time, suddenly stops inflation, and displays error message. Which action by the nurse is appropriate?

Send the machine for maintenance and repeat the measurement manually *The nurse should verify the correct cuff size and take a manual BP

An elderly client with diabetes comes to the clinic in winter reporting numbness of the feet. After removing the client's shoes and socks, the nurse notes that the feet are ice cold to the touch and appear waxy and pale. What is the appropriate nursing action?

Soak the client's lower legs in a warm water bath *Tissue damaged by frostbite may appear pale, waxy, blue, or mottled due to frozen intracellular fluid. Affected extremities are thawed in warm water bath and analgesics are administered. Manual friction (massage, ambulation) is contraindicated as it may further damage the tissue

The nurse is reviewing health history information for a client who is being seen for a routine physical examination. Which of the following clinical findings indicate that the client is at risk for latex allergy?

Sought care 1 year ago for vaginitis after using a condom *Latex allergy is an exaggerated, immune-mediated reaction triggered by exposure to latex-containing products. Findings that may indicate latex allergy include swelling, hives, pain/burning, and itching after exposure to latex; certain food allergies (banana, avocado) and repeated latex exposures (hx multiple surgeries, health care workers)

What should the nurse do if concerned that a coworker may be under the influence of an impairing substance?

Speak with the nursing supervisor about the concern. *Nurses have an ethical and professional obligation to protect and promote client safety. A nurse who suspects that a coworker may be impaired at work, regardless of cause, should immediately report the concern to a supervisor to prevents possible harm to clients.

What nursing intervention is most appropriate when caring for a client with impairment to cranial nerve II?

Verbally explain nursing interventions in detail. *Clients with impairment of cranial nerve II have altered visual acuity or visual fields. To ensure that the client understands interventions, the nurse should verbally explain all procedures in detail.

The nurse assess s3 extra heart sound of a 77 yo client with chronic heart failure

s3, the third heart sound, is a 'dub' sound the immediately follows S2. It is a normal finding in children and young adults. S3, an abnormal finding in older adults, often indicates heart failure.