STUDY FOR EXIT HESI
An infant is receiving Penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units//mL. How many mL should she give?
0.4
A patient with MS is receiving interferon beta 0.1875 mg subQ QOD. The nurse reconstitutes the vial by slowly injecting 1.2 mL of diluent into the interferon vial for a reconstituted solution of 0.25 mg/1 mL. How many mL should nurse administer?
0.75
The RN is using a straight catheter kit to collect a sterile urine specimen from a female patient. After positioning and prepping the patient, rank the actions in the last sequences they should be implemented.
1. Open sterile kit close to the patient's peri area 2. Don sterile gloves and prepare sterile field 3. Cleanse urinary meatus using solution, swab, and forceps provided 4. Place distal end of the catheter in sterile specimen cup and insert catheter in meatus
A patient with multiple sclerosis is receiving baclofen 15 mg PO three times daily. The drug is available in 10 mg tabs. How many should the nurse administer in a 24 hour period?
4.5
The healthcare provider prescribes fluid of 0.9 sodium chloride 1,000 mL to be infused over 4 hours. The IV administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion? (round to nearest whole number) gtt/min = volume (mL) / time (min) x drop factor (gtt/mL) Flow rate = 1000 mL/240 min x 10 gtt/mL = 41.667 gtt/min
42
After administrating a 12 ounce can of nutritional supplement, 3 teaspoons of medication, and 120mL of water, the nurse should document the patient's fluid intake as how many mLs? 12x30 + 5x3 + 120
495
The nurse supplies a blood pressure cuff around a patient's left thigh. To measure client's pressure, where should the diaphragm of the stethoscope be placed?
Behind knee
Following a cardiac catheterization, an adult patient is sent to the cardiovascular unit. The nurse instructs the patient to keep the affected leg immobile. Which intervention should the nurse plan to include in the plan of care? a. Apply sequential compression device b. Ambulate once v/s stable c. Monitor telemetry of dysthythmias d. Maintain NPO until bowel sounds return
Monitor telemetry of dysthythmias
A adult patient experiences a gas tank fire when riding a motorcycle and is admitted to the ER with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the EMR? a. 36% b. 9% c. 45% d. 15%
a. 36%
The RN has completed diet teaching for a patient being d/c for a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice indicates that teaching was effective? a. A tuna fish sandwich with chips and ice cream b. A salad with three kinds of lettuce and fruit c. A peanut butter sandwich with soda and cookies d. Vegetable soup, crackers, milk
a. A tuna fish sandwich with chips and ice cream
A nurse who usually works on a step down unit is moved to work in the ICU. Which patient is best for the charge nurse to assign to this nurse? a. A ventilator dependent patient with COPD b. A patient with a new onset of diabetic ketoacidosis and on an insulin drip c. A patient admitted for a narcotic OD who is ventilated with respiratory alkalosis d. A ventilated patient admitted today w respiratory failure and respiratory acidosis
a. A ventilator dependent patient with COPD
The nurse completed a dressing change for a patient with partial thickness burns to both legs. After completing the dressing change, what intervention should the nurse implement? a. Administer a PRN dose of pain meds b. Raise the head of bed to 90 degrees c. Perform passive range of motion d. Position ankles in a dorsiflexed position
a. Administer a PRN dose of pain meds
The nurse is caring for a group of patients with the help on an LPN. Which nursing actions should the nurse assign to the LPN. (SATA) a. Administer a dose of insulin per sliding scale for a patient with type 2 diabetes b. Obtain post-op v/s for a patient one day following unilateral knee arthroplasty c. Perform daily surgical dressing change for a patient who had abdominal hysterectomy d. Initiate patient controlled analgesic pump for two patients immediately post-op e. Start the second blood transfusion for a patient 12 hours following BKA surgery
a. Administer a dose of insulin per sliding scale for a patient with type 2 diabetes b. Obtain post-op v/s for a patient one day following unilateral knee arthroplasty c. Perform daily surgical dressing change for a patient who had abdominal hysterectomy
An adult patient tells the nurse her grandmother was diagnosed with colorectal cancer at age 75 and the patient is implementing measures to reduce her own risk. Which of the patient's plans indicates the need for further information? a. Annual sigmoidoscopy screening b. Increased intake of fruits, veggies, and whole grains c. Reduced dietary intake of animal fat and protein d. Yearly fecal occult blood testing
a. Annual sigmoidoscopy screening
The nurse assesses the patient who has new onset diarrhea. It is most important for the RN to question the patient about recent use of what meds? a. Antibiotics b. Anticoagulants c. Antihypertensives d. Anticholinergics
a. Antibiotics
An adult patient's apical pulse is 110 bpm. What intervention should the nurse implement first? a. Assess the patient's radial pulse and apical at same time b. Assess the patient to determine the reason why the pulse is elevated c. Notify the charge nurse that the pulse is elevated d. Attempt to calm the patient and take the pulse again in one hour
a. Assess the patient's radial pulse and apical at same time
A middle aged female patient tells the nurse that she lost an inch of height in the last year. What is the priority nursing intervention? a. Assist patient to schedule a bone density exam b. Observe presence of hump c. Advice patient to begin stretching exercises d. Encourage patient to eat calcium rich foods
a. Assist patient to schedule a bone density exam
An unconscious patient is admitted to the ICU and is placed on a ventilator. The ventilator alarms continuously and the patient's oxygen is 62%. What should the nurse do first? a. Begin manual ventilation immediately b. Silence alarm and call tech c. Monitor manual ventilation immediately d. Call RT
a. Begin manual ventilation immediately
The nurse is planning care for a patient who admits having suicidal thoughts. Which patient behavior indicates the highest risk for the patient acting on these suicidal thoughts? a. Begin to show signs of improvement in affect b. Lacks interest in the activity of family and friends c. Express feelings of sadness and loneliness d. Neglects personal hygiene
a. Begin to show signs of improvement in affect
A female patient with chronic kidney disease and renal failure has an indwelling peritoneal catheter in used for dialysis. While bathing, her dressing becomes wet. What action should the nurse take? a. Change dressing b. Reinforce dressing c. Flush peritoneal dialysis catheter d. Scrub catheter with iodine
a. Change dressing
A family member reports that the patient who is bedridden has not been turned or repositioned all night and is sleeping on a special air mattress with no sheets. What information should the nurse provide to the family? a. Clarify that an aerated support surface doesn't use sheets that often because of skin breakdown b. Describe the night staff's plan of care to ensure the patient's sleep isn't disturbed c. Explain that turning is only necessary to reposition the patient only during waking hours d. Suggest that a family member turn the patient during the night when someone is there
a. Clarify that an aerated support surface doesn't use sheets that often because of skin breakdown
A male patient is admitted for the removal of an internal fixation that was inserted for the ankle fracture. During the admission hx, he tells the nurse he recently received vancomycin for a methicillin resistant staphylococcus aureus wound infection. Which action should the RN take? (SATA) a. Collect multiple site screening culture for MRSA b. Call doctor for a linezolid prescription c. Place patient on contact precaution d. Obtain sputum specimen for culture and sensitivity e. Monitor for sign of infection
a. Collect multiple site screening culture for MRSA c. Place patient on contact precaution e. Monitor for sign of infection
The nurse assesses a patient one hour after starting a transfusion and determines there are no indications of a reaction. What instructions should the RN provide the CNA? a. Continue to measure the patient's v/s every 30 mins until the transfusion is over b. Since a reaction didn't occur, the priority is to maintain comfort c. Monitor patient carefully for the next 3 hrs and report onset of reaction immediately d. Notify the RN when transfusion is over so further patient assessment can be done
a. Continue to measure the patient's v/s every 30 mins until the transfusion is over
A patient with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which patient's serum lab values requires intervention? a. Creatinine 4 mg/dL b. Total calcium 9 mg/dL c. Phosphate 4mg/dL d. Fasting glucose 95 mg/dL
a. Creatinine 4 mg/dL
The nurse is assessing a patient with a closed head injury sustained in a MVA. Which finding indicates the lowest neurological functioning? a. Decerebrate posturing during position changes b. Withdrawal from painful stimuli c. Decorticate posturing during tracheal suctioning d. Localization of a tactile stimulus
a. Decerebrate posturing during position changes
The RN assesses a patient who had bilateral total knee replacement four hours ago. The RN notes that the dressing on the patient's right knee is saturated with serosanguineous drainage. What does the RN do? a. Determine if the wound drainage device is suctioning correctly b. Withhold next dose of heparin c. Monitor WBC count Confirm the motion device intact
a. Determine if the wound drainage device is suctioning correctly
A patient with renal disease seems anxious and presents with onset of SOB, lethargy, edema, and weight gain. What action should the RN implement? a. Determine serum potassium b. Calculate daily fluid intake c. Assess signs of vertigo d. Review pulse oximeter
a. Determine serum potassium
A patient with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend? a. Dry roasted almonds b. Cheddar cheese and crackers c. Carrot and celery sticks d. Beef bologna sausage slices
a. Dry roasted almonds
During a postpartum assessment of a patient who is 5 hrs post vag delivery, the nurse assesses the fundus is 3 finger breadths above the umbilicus and positioned to the side. Which action is implemented first? a. Encourage void b. Massage until firm c. Catheterize for residual urinary volume d. Provide PO replacement fluids
a. Encourage void
A patient who is hypotensive is receiving dopamine an adrenergic agonist, IV at 8mcg/kg/min. Which intervention should the RN implement while administering this med? a. Measure urinary output every hr b. Monitor potassium c. Seizure precautions d. Pupillary response to light hourly
a. Measure urinary output every hr
The RN identifies an electrolyte imbalance, elevated pulse, weight gain of 4.4 lbs in 24 hrs of a patient with chronic kidney disease, what intervention is taken? a. Monitor serum electrolytes daily b. Provide distilled water only c. Document girth d. Perform ROM exercises
a. Monitor serum electrolytes daily
A patient with DVT is receiving a continuous IV heparin infusion. The patient has tarry, black diarrhea and reports abdominal pain. Which action should the nurse implement? (SATA) a. Monitor stools for presence of blood b. Auscultate bowel sounds in all quadrants c. Assess characteristic of pain d. Review last partial thromboplastin time results e. Prepare to administer warfarin
a. Monitor stools for presence of blood c. Assess characteristic of pain e. Prepare to administer warfarin
A male patient with an antisocial personality disorder is admitted to an inpatient mental health unit for multiple substance dependency. When providing a history, the patient justifies to the nurse his use of drugs. Based on this pattern of behavior, this patient's history if most likely to include which finding? a. Multiple convictions for misdemeanors and Class B felonies b. Delusions of grandiosity and persecution c. Suicidal ideations and multiple attempts d. Photos and panic attacks when confronted by authority
a. Multiple convictions for misdemeanors and Class B felonies
A patient is admitted reporting an acute onset of right flank pain and urinary urgency. Which assessment is most important for the nurse to obtain? a. Numerical rated pain intensity b. Amount of caffeine intake c. Body temp d. Fluid intake for past 24 hrs
a. Numerical rated pain intensity
A patient taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first? a. Observe appearance of stool b. Review lab values c. Auscultate the bowel sounds d. Assess elasticity of patient's skin
a. Observe appearance of stool
A 16 y/o patient who has been treated in the past for seizure disorder is admitted to the hospital immediately after admission he begins to have a grand mal seizure. Which action should the RN implement? a. Observe patient carefully b. Place a padded tongue blade between patient's teeth c. Obtain assistance in holding him to prevent injury d. Call rapid response team
a. Observe patient carefully
A young female college student visits the health clinic early winter to get birth control pills. The RN asks if the student received an influenza vaccination. The student stated she didn't receive it because she has asthma. How should the RN respond? a. Offer to provide the influenza vaccine to the student while she is at the clinic b. Encourage the student to obtain a vaccination prior to the next influenza season c. Confirm that a history of asthma can increase risks associated with the vaccine d. Advise the student that the nasal spray vaccine reduces side effects for people with asthma
a. Offer to provide the influenza vaccine to the student while she is at the clinic
A patient who was splashed with a chemical has both eyes covered with bandages. When assisting the patient with eating, which intervention should the nurse instruct the CNA to implement? a. Orient the patient to the location of the food on the plate b. Ask the family to visit during mealtimes to assist with feeding c. Provide with only finger foods d. Feed the patient the entire meal
a. Orient the patient to the location of the food on the plate
An older woman who lives alone is admitted after falling and fracturing her left hip. With no immediate family in the area, she is concerned about her pets. Which intervention should the RN implement? (SATA) a. Palpate and mark pedal pulses b. Alert social work of patient's concerns c. Assess ability to bear weight when standing d. Evaluate pain using pain scale e. Support left leg with two pillows
a. Palpate and mark pedal pulses b. Alert social work of patient's concerns d. Evaluate pain using pain scale
The RN is caring for a group of pt with the help of a LPN. Which nursing actions should the nurse assign to the LPN? (SATA) a. Perform surgical dressing change for a patient who had abdominal hysterectomy b. Obtain post-op V/S for a patient following unilateral knee arthroplasty c. Initiate PCA pumps for 2 clients immediately post-op d. Administer insulin per sliding scale for pt with type 2 diabetes
a. Perform surgical dressing change for a patient who had abdominal hysterectomy b. Obtain post-op V/S for a patient following unilateral knee arthroplasty d. Administer insulin per sliding scale for pt with type 2 diabetes
A patient who underwent an uncomplicated gastric bypass is having difficulty with diet management. Which dietary instruction is most important for the RN to explain? a. Plan volume controlled evenly space meal throughout the day b. Sip fluid slowly with each meals and between meals c. Eliminate or reduce fatty intake and gas forming foods d. Chew few slowly and thoughroughly before swallowing
a. Plan volume controlled evenly space meal throughout the day
The nurse finds a patient 33 weeks gestation in cardiac arrest. What adaptation to CPR should the nurse implement? a. Position a firm wedge to support pelvis and thorax at 30 degree tilt b. Apply oxygen by mask after opening the airway c. Apply less compression force to reduce aspiration d. Give continuous compression with ventilation ratio
a. Position a firm wedge to support pelvis and thorax at 30 degree tilt
The RN is teaching a group of patients with rheumatoid arthritis about the need to modify daily activities. What goal should the RN emphasize? a. Protect joint function b. Improve circulation c. Control tremors d. Increase weight bearing
a. Protect joint function
An older patient with a history of pernicious anemia has developed ataxia and paresthesia. In planning care, which nursing intervention has the highest priority? a. Provide assistance with ambulation b. Keep HOB elevated c. Offer PRN sleep aid nighttime d. Instruct healthy food choise
a. Provide assistance with ambulation
After receiving IV fluids in the ER, an elderly patient is admitted to the acute care unit with a medical diagnosis of dehydration. The patient is receiving 0.9% normal saline 125 mL/hr via saline lock and has a bounding pulse, tachycardia, and pedal edema. When contacting the dr, the nurse anticipates a prescription with what intervention? a. Remove the saline lock from the arm b. Increase rate of normal saline c. Decrease rate of normal saline infusion d. Change IV solution to 0.45% saline solution
a. Remove the saline lock from the arm
A nurse stops at the site of a motorcycle accident and finds a young male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the care about 50 feet away. What action should she take first? a. Stabilize the victim's neck and roll over to evaluate his status b. Return to the car to call 911 c. Open the airway and initiate resuscitative measures d. Examine the victim's body surfaces for arterial bleeding
a. Stabilize the victim's neck and roll over to evaluate his status
A male patient reports to the on-call clinic nurse that he took Tadalafil 10 mg PO two hours ago and now his skin feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. What action should the nurse take? a. Tell the patient have someone bring him to the ER immediately b. Advise the patient to place one nitroglycerin tab under his tongue c. Reassure that the skin flushing is a common side effect of the medication d. Instruct the patient to increase his intake of oral medication until the skin flushing is relieved
a. Tell the patient have someone bring him to the ER immediately
A patient with eczema is experiencing severe pruritus. Which PRN prescriptions should the RN administer? (SATA) a. Topical corticosteroid b. Topical scabicide c. Topical alcohol rub d. Transdermal analgesic e. Oral antihistamine
a. Topical corticosteroid e. Oral antihistamine
A patient is admitted to the mental health unit with relationship distress with spouse and depressed mood. Finding of which diagnostic tests provide the most information for developing the plan of care? a. Urine drug screen b. Complete blood count c. Basic metabolic panel d. Electrocardiogram
a. Urine drug screen
The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge home. Which recommendations should the nurse provide this patient? (SATA) a. Wash stump with soap and water b. Avoid range of motion exercise c. Apply alcohol to the stump after bathing d. Inspect skin for redness e. Use a residual limb shrinker
a. Wash stump with soap and water d. Inspect skin for redness e. Use a residual limb shrinker
Four patient arrive on the L&D unit at the same time. Which patient should nurse assess first? a. A 3 week multigravida with a prescription for blood pressures b. A 39 week primigravida with biophysical profile score 5/8 c. A 38 week primigravida who reports contractions every 10 mins d. A 41 week multigravida who is scheduled induction of labor today
b. A 39 week primigravida with biophysical profile score 5/8
The RN administers the osmotic diuretic mannitol to a patient who has a closed head injury. Which assessment finding indicates immediate response to administration of mannitol? a. A decrease in skin turgor b. A decrease in intracranial pressure c. An increase in sodium d. An increase in serum osmolality
b. A decrease in intracranial pressure
An older resident of a long term facility has a 5 yr history of hypertension. The patient has a headache and rates the pain as a 5 on a scale of 0-10. The patient BP is 142/89. Which intervention does the RN implement? (SATA) a. Notify the provider b. Administer lisinopril c. Withhold warfarin d. Provide PRN dose of acetaminophen for headache e. Assess for postural hypotension
b. Administer lisinopril d. Provide PRN dose of acetaminophen for headache
The nurse enters room of a patient with Parkinson's who is taking carbidopa-levodopa. The patient is arising slowly from the chair while the CNA stands next to the chair. What action should the nurse take? a. Demonstrate how to help the patient move efficiently b. Affirm that the patient should arise slowly from the chair c. Tell the CNA to assist the patient in moving more quickly d. Offer PRN to reduce painful movement
b. Affirm that the patient should arise slowly from the chair
While receiving a male post-op patient's staples, the nurse observes that the patient's eyes are closer and his face and hands are clenched. The patient says "I just hate having staples removed." What does the nurse do? a. Reassure the patient that this is a simple procedure b. Attempt to distract him with general conversation c. Encourage the patient to continue to verbalize his anxiety d. Explain the procedure in detail while removing the staples
b. Attempt to distract him with general conversation
The nurse is measuring output of an infant admitted for vomiting and diarrhea. During the 12 hour shift, the infant drinks 4 ounces of pedialyte, vomits 25 mL, and voids twice. The dry diaper is 50 grams and one wet diaper is 75 grams, and the other is 105 grams. Which computer documentation should the nurse enter in the record? a. Document in the flow sheet that the infant voided times 2 and vomited 25 mL b. Calculate differences in wet and dry diapers and document 80 mL urine output c. Compare the differences between the infant's body weight and admission weight d. Subtract vomits from 120 mL pedialyte then document 95 L oral intake
b. Calculate differences in wet and dry diapers and document 80 mL urine output
A RN who is working the ER triage is presented with 4 patients at once. The patient presenting with which symptoms requires the most immediate by the RN? a. Unable to bear weight on the left foot with swelling and bruising b. Chest discomfort one hour after consuming a large, spicy meal c. One inch bleeding laceration on the chin of a crying 5 y/o d. Low grade fever, headache, and malaise for the past 72 hrs
b. Chest discomfort one hour after consuming a large, spicy meal
A patient with bleeding esophageal varices receives vasopressin IV. What should the nurse monitor for during the IV infusion of this medication? a. Vasodilation of the extremities b. Chest pain and dysrhythmia c. Hypotension and tachycardia d. Decreasing GI cramping and nausea
b. Chest pain and dysrhythmia
A mother runs into the ER with a toddler in her arms and tells the nurse that she got into some cleaning products. The child smells of chemicals on hands, face, and clothing. After ensuring airway is patent, what action should the nurse implement first? a. Obtain equipment for gastric lavage b. Determine type of chemical exposure c. Assess child for altered sensorium d. Call poison control
b. Determine type of chemical exposure
The nurse is preparing to administer an oral antibiotic to a patient with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication? a. Ask the patient about soft food preferences b. Determine which side of the body is weak c. Obtain and record vital signs d. Auscultate client's breath sounds
b. Determine which side of the body is weak
A male patient with cirrhosis has jaundice and pruritis. He tells the nurse that he was soaking in hot baths at night with no relief or discomfort. What action should the nurse take? a. Explain that the symptoms are caused by liver damage and can't be relieved b. Encourage the patient to use cooler water and apply calamine lotion after soaking c. Obtain a PRN prescription for an analgesic that the client can use for symptom relief d. Suggest that the patient take brief showers and apply oil-based lotion after showering
b. Encourage the patient use cooler water and apply calamine lotion after soaking
A patient who is admitted to the care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? a. Patch one eye b. Evaluate swallow c. Reorient often d. Range of motion
b. Evaluate swallow
The nurse is caring for a young adult patient with acromegaly. It is most important for the nurse to monitor which of the patient's laboratory test results? a. WBC count b. Glucose c. Hemoglobin d. Partial thromboplastin Time
b. Glucose
When caring for a pt with Cushing syndrome, which serum lab value is most important for the RN to monitor? a. Lactate b. Glucose c. Hemoglobin d. Creatinine
b. Glucose
A patient with diabetes tells the nurse that her healthy "chubby" baby is irritable and not active. After obtaining a dietary history, the RN determines that the infant refuses to eat any infant cereal. Which is important to report? a. Breast feeds 10 mins at night b. Has porcelain skin and tripled birth weight c. Doesn't take infant vitamin supplement d. Ingests 6 ten ounce bottles of cow's milk daily
b. Has porcelain skin and tripled birth weight
A patient with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The patient's lab values include sodium 129, glucose 54, and potassium 5.3. When reporting these findings to the healthcare provider, the RN anticipates a prescription for which meds? a. Insulin b. Hydrocortisone c. Broad spectrum antibiotic d. Potassium chloride
b. Hydrocortisone
When implementing a disaster intervention plan, which intervention should the RN implement first? a. Initiate the d/c of stable patients from hospital units b. Identify a command center where activities are coordinated c. Assess community safety needs impacted by the disaster d. Instruct all essential off-duty personnel to report to the facility
b. Identify a command center where activities are coordinated
A child newly diagnosed with sickle cell anemia is being d/c from the hospital. Which information is most important for the nurse to provide the parents prior to d/c? a. Referral for social services b. Instruction about how much fluid the child should drink daily c. Signs of addiction to opioid medications d. Information about non-pharmaceutical pain relief measures
b. Instruction about how much fluid the child should drink daily
When should the nurse conduct an Allen's test a. When pulmonary artery pressures are obtained b. Just before arterial blood gasses are drawn c. Prior to attempting a cardiac output calculation d. To assess for presence of DVT in leg
b. Just before arterial blood gasses are drawn
Following the evacuation of a subdural hematoma, an older adult man develops an infection. He is transferred to the neuro intensive care with a temperature of 102.8° F (39.3° C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60. What is the priority intervention to include for this client's plan of care? A. Check neuro vital signs q4 hours. B. Maintain intravenous access. C. Keep the suture line clean and dry. D. Measure hourly urinary output.
b. Maintain intravenous access
The charge nurse is making assignments on the psych unit for a LPN and a RN. Which patient should be given to the RN? a. An older male who tells the staff that he's superman and can fly b. Male with schizophrenia who says voices are telling him to kill his psychiatrist c. Patient in the depressive phase of bipolar disorder and is getting lithium d. A patient depressed for the past several months and denies social ideation
b. Male with schizophrenia who says voices are telling him to kill his psychiatrist
While assisting a patient who recently had a hip replacement onto the bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing. the patient's skin is warm to touch and there is a strong odor from the urine. What does the nurse do? a. Remove dressing and assess wound b. Measure patient's temp c. Insert urinary catheter d. Obtain urine sample from bedpan
b. Measure patient's temp
A patient is brought to the ER by ambulance following a motorcycle accident. He wasn't wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention? a. Rebound abdominal tenderness b. Nausea and projectile vomit c. Rib pain w deep inspiration d. Diminished bilateral breath sounds
b. Nausea and projectile vomit
A small round area appears under the patient's skin as the RN administers an intradermal medication. What action should the RN take? a. Elevate the area and apply light pressure b. Notify the healthcare provider of the allergic response c. Document the site where medication was given d. Apply a cold pack for 20 mins
b. Notify the healthcare provider of the allergic response
A 17 year old adolescent is brought to the ER by his parents because the adolescent has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first? a. Assess the patient's temperature b. Place a mask on the patient c. Determine the patient's BP d. Obtain a chest x-ray per protocol
b. Place a mask on the patient
At 40 week gestation, a laboring patient who is lying in a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? a. Place pillow under the patient's head and knees b. Place a wedge under the patient's right hip c. Encourage patient to turn on her left side d. Explain that her position isn't safe
b. Place a wedge under the patient's right hip
The nurse is preparing a 50 mL dose of 50% dextrose IV for a patient with insulin shock. How should the nurse administer the medication? a. Dilute dextrose in 1 liter of 0.9% normal saline solution b. Push undiluted slowly through the currently infusing IV c. Mix dextrose in a 50 mL piggyback for a total volume of 100 mL d. Ask the pharmacist to add the dextrose to a TPN solution
b. Push undiluted slowly through the currently infusing IV
A patient recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease and peripheral vascular disease is being d/c from a SNF. Which action is most important for the nurse to implement? a. Provide typed instructions for healthy diet b. Reinforce need for adequate hydration c. Explain exercises daily regimen d. Demonstrate specific strengthening exercises
b. Reinforce need for adequate hydration
Following morning care, a patient with a c-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which interventions should the nurse implement first? a. Assess the patient's BP every 15 mins b. Relieve any kinks or obstruction in the patient's foley c. Teach patient to response symptoms of dyreflexia d. Administer PRN dose of hydrazine
b. Relieve any kinks or obstruction in the patient's foley
The nurse enters the room of a patient who is awaiting surgery for appendicitis. The CNA has helped the patient to a position of comfort with the right leg flexed and has applied a heating pad to the patient's abdomen to relieve the pain. Which action should the nurse implement first? a. Determine if the consent form has been signed b. Remove the heating pad from the abdomen c. Confirm that the CNA has assisted the patient to a position of comfort d. Evaluate the effectiveness of the heating pad in relieving pain
b. Remove the heating pad from the abdomen
The nurse is supervising a CNA who will be providing personal care for a patient with watery diarrhea caused by cdiff. Which action by the nurse takes priority? a. Remind the CNA to keep the patients water filled b. Review use of PPE with CNA c. Provide barrier cream for application of the perineal area d. Instruct the CNA to record the number of bowel movements
b. Review use of PPE with CNA
An older patient is admitted for repair of a broken hip. To reduce the risk of infection postoperative period, which nursing care intervention should the nurse include in the patient's plan of care? (SATA) a. Administer low molecular weight heparin b. Teach patient to use incentive spirometer every 2 hours while awake c. Remove urinary catheter as soon as possible and encourage voiding d. Maintain sequential compression devices while in bed e. Assess pain level and medicate PRN as prescribed
b. Teach patient to use incentive spirometer every 2 hours while awake c. Remove urinary catheter as soon possible and encourage voiding
A mother brings her 4 month old son to the clinic with a quarter taped over his umbilicus and tells the nurse this is supposed to fix her child's hernia. Which explanations should the RN provide? a. An abdominal binder can be worn daily to reduce protrusion b. This hernia is a normal variation that resolves without treatment c. The quarter should be secured with an elastic bandage wrap d. Restrictive clothing will help the hernia go away
b. This hernia is a normal variation that resolves without treatment
When caring for a patient who has acute respiratory distress syndrome, the nurse elevates the HOB 30 degrees. What is the reason for this intervention? a. To promote retraction of the intercostal accessory muscles b. To reduce abdominal pressure on the diaphragm c. To decrease pressure on the medullary center which stimulates breathing d. To promote bronchodilation and effective airway clearance
b. To reduce abdominal pressure on the diaphragm
What information should the nurse include in the d/c teaching plan of a patient with low back pain who is taking cyclobenzaprine to control muscle spasms? a. Avoid using heat or ice to injured muscles while taking this medication b. Use cold and allergy medications only as directed by a doctor c. Take the medication on an empty stomach d. Discontinue all non steroidal anti inflammatory meds
b. Use cold and allergy medications only as directed by a doctor
On admission to the ER, a patient who was diagnosed with bipolar disorder 3 yrs ago reports that this morning she took a handful of meds and left a suicide note for her family. Which info is important for the RN to obtain? a. Which fam member has the note b. What drug the patient used in the suicide attempt c. When the pt last took drugs for bipolar disorder d. Whether pt attempted suicide in pass
b. What drug the patient used in the suicide attempt
A patient presents to the clinic with concerns regarding her left breast. Which assessment findings are most important for the nurse to report to the doctor? a. Multiple, firm, round, freely moveable masses b. A slight asymmetry of the breasts c. A fixed nodular mass with skin dimpling d. Bloody discharge from the nipple
c. A fixed nodular mass with skin dimpling
A patient with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse that the client is experiencing a therapeutic response to the phenytoin? a. Increased time of ambulation between periods of rest b. Decrease in intracranial pressure and cerebral edema c. Absence of seizure activity for the duration of treatment d. Normal electroencephalogram after drug administration
c. Absence of seizure activity for the duration of treatment
A patient with a TBI becomes less responsive to stimuli. The patient has a DNR and the nurse observes that the CNA has stopped turning the patient from side to side as previously scheduled. What should the RN do? a. Encourage CNA to provide comfort care measures only b. Assume total care of the patient to monitor neuralgic function c. Advise CNA to resume positioning the patient d. Assign a LPN to assist the CNA in turning the patient
c. Advise CNA to resume positioning the patient
A male patient in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The patient states that he is tired of fighting his illness and is only continuing treatments because his family wants him to live. Which action should the nurse take? a. Notify the family that treatments have been discontinued b. Arrange a meeting with the family, physician, and patient c. Ask the chaplain to discuss death issues with patient d. Request consult with the hospital social worker
c. Ask the chaplain to discuss death issues with patient
While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the patient stares into the distance and appears to be concentrating on something else other than the lesson. What action should the nurse take? a. Remind patient that the rescue inhaler might save his life b. Gently touch the patient then continue with the teaching c. Ask the patient what he is thinking d. Leave patient alone so he can grieve his illness
c. Ask the patient what he is thinking
A patient who had a percutaneous coronary intervention two weeks ago returns to the clinic for a f/u. The patient has a post-op ejection fraction of 30%. Today the patient has lungs that are clear, +1 pedal edema, and a 5 lb weight gain. Which intervention should the nurse implement? a. Insert saline lock for iv diuretic therapy b. Arrange transport for admission to hospital c. Assess compliance with routine prescriptions d. Instruct patient to monitor daily caloric intake
c. Assess compliance with routine prescriptions
The mother of a child with cerebral palsy asks the nurse if the child's impaired movements will worsen as the child grows. Which response provides the best explanation. a. Continued development of the brain lesion determines the child's outcome b. Severe motor dysfunction determines the extent of the successful habilitation c. Brain damage with CP is not progressive but does have a variable course d. CP is one of the most common permanent physical disability in children
c. Brain damage with CP is not progressive but does have a variable course
The healthcare provider prescribed furosemide for a 4 year old child who has a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective? a. Urinary output decrease of 5 mL/hr b. Urine specific gravity change from 1.021 to 1.031 c. Daily weight decreases 2 lbs d. Blood urea nitrogen (BUN) increase from 8 to 12 mg/dL
c. Daily weight decreases 2 lbs
The nurse is completing an admission assessment for a male patient with paranoid schizophrenia. The patient tells the nurse that the staff dislikes him. What action should the nurse take? a. Assess the clien't speech patter for a flight of class b. Observe the patient for activities such as repeated hand washing c. Determine if the patient has formulated any plans regarding the staff d. Ask the patient if he has a plan to harm himself
c. Determine if the patient has formulated any plans regarding the staff
An s3 heart sound is auscultated in a patient in her third trimester of pregnancy. what intervention should the nurse take? a. Prepare the patient for an echocardiogram b. Limit patient's fluids c. Document in the patient's record d. Notify provider
c. Document in patient's record
During the administration of albuterol via nebulizer, the patient complains of shakiness. The patient's v/s are 120 bpm HR, 20 RR, 140/88. What action does the RN take? a. Administer anxiolytic b. Obtain 12 lead electrocardiogram c. Educate patient about side effects of albuterol d. Stop albuterol administration and restart in 30 mins
c. Educate patient about side effects of albuterol
The nurse observes a LPN pouring warm water over the peri area of a female patient who is frequently urinary incontinent while the patient is on a bedpan. What action should the RN take? a. Recommend a complete bed bath to cleanse the peri area more fully b. Instruct the PN that this technique promotes infection in elderly females c. Evaluate the effectiveness of this measure to stimulate patient voiding d. Suggest contacting the provider for a catheter insertion prescription
c. Evaluate the effectiveness of this measure to stimulate patient voiding
The RN is assessing a patient who recently had an upper respiratory infection and presents to the ER with lower extremity numbness and difficulty swallowing. Based on these findings, this patient is at risk for which pathophysiology condition? a. Epstein Barr b. Cytomegalovirus c. Guillen Barre d. Mycoplasma Pneumonia
c. Guillen Barre
A patient is admitted to the ICU with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? a. Ketonuria b. Peripheral edema c. Hypokalemia d. Elevated BP
c. Hypokalemia
A young female presents at the ER with acute lower abdominal pain. Which assessment is most important for the nurse to report to the healthcare provider? a. History of IBS b. Pain scale of 9 on a 0-10 scale c. Last menstrual period 7 weeks ago d. Reports white, curdy vaginal discharge
c. Last menstrual period 7 weeks ago
A male patient is returning to the surgical unit following a left nephrectomy and is medicated with morphine sulfate 4 mg IV. His dressing has a small amount of bloody drainage and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this patient's plan of care? a. Assess for back muscle aches b. Obtain body weight daily c. Monitor urinary output hourly d. Record drainage from drain
c. Monitor urinary output hourly
When caring for a patient with a traumatic brain injury who had a craniotomy for increased intracranial pressure, the nurse assesses the patient using the Glasgow coma scale every two hours. For the past 8 hours, the patient's GCS score has been 14. What does this GCS finding indicate? a. Rehabilitative prognosis is an expected full recovery b. Insertion of an ICP monitoring device is necessary c. Neurologically stable without indications of an increased ICP d. Risk for irreversible cerebral damage related to increased ICP
c. Neurologically stable without indications of an increased ICP
An adult patient with a broken femur is transferred to the med surg unit to await surgical internal fixation after the application of an external traction device to stabilize the leg. An hour after an opioid analgesic was administered, the patient reports muscle spasm and pain at the fracture site. While waiting for the patient to be transported to surgery, which action should the nurse implement? a. Reduce weight on traction b. Administer PRN dose of muscle relaxant c. Observe for signs of DVT d. Check patient's most recent electrolyte values
c. Observe for signs of DVT
A patient in early septic shock states what is the primary cause of hypotension? a. Vagal response b. Cardiac failure c. Peripheral vasodilation d. Peripheral vasoconstriction
c. Peripheral vasodilation
A male patient approaches the RN with an angry expression on his face and raises his voice saying "my roommate is the most selfish-self centered person. If he loses his temper one more time, I am going to punch him. " The RN recognizes the patient is using which defense mechanism? a. Denial b. Splitting c. Projection d. Rationalization
c. Projection
A patient w bladder cancer had surgical placement of a ureteroileostomy yesterday. Which post-op assessment finding should the nurse report? a. Stomal output of 40 mL in last hr b. Liquid brown drainage c. Red edematous stoma appearance d. Mucous strings in drainage
c. Red edematous stoma appearance
The nurse auscultates a patient's abdomen and hears a loud bruit near the umbilicus. What is the RNs best action based on this finding? a. Document assessment finding b. Palpate abdomen lightly in all four quadrants c. Report finding to dr d. Place patient in semi-fowler's
c. Report finding to dr
While caring for a patient's post-op dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender, but without draining. Which is the most important action to take? a. Determines the drainage has an unpleasant smell b. Cleanse the wound with a sterile saline solution c. Request a culture and sensitivity of the wound d. Monitor the patient's WBC count
c. Request a culture and sensitivity of the wound
The RN is caring for a 3 y/o child who is 2 hrs post-op from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction? a. BP trend is downward and pulse is rapid and irregular b. The pressure dressing at right femoral area is moist and oozing blood c. Right foot is cool to the touch and appears pale and blanched d. Pulse distal to the femoral artery is weaker on left foot than right
c. Right foot is cool to the touch and appears pale and blanched d. Pulse distal to the femoral
The nurse is planning d/c teaching for a patient who had an evacuation of gestational trophoblastic disease two days ago. Which info is most important for the nurse to include in the patient's teaching plan? a. Location and times for support group b. Rho(D) immune globulin to prevent isoimmunization c. Schedule f/u visit with healthcare provider d. Oral contraceptive use for at least one year
c. Schedule f/u visit with healthcare provider
When administering ceftriaxone sodium IV to a patient prior to surgery, which assessment finding requires immediate intervention by the nurse? a. Headache b. Pruritus c. Stridor d. Nausea
c. Stridor
When attempting to establish risk reduction strategies in a community, the RN notes that studies indicate a high number of people with growth stunting and mental deficiencies caused by hypothyroidism. The RN should seek funding to implement which screening? a. TSH levels in woman over 45 b. T3 levels in school-aged kids c. T4 in newborns d. Iodine in 60 year olds
c. T4 in newborns
The nurse is developing a plan of care for an older male patient with type 2 diabetes who reports blurred vision. Which outcome shows a plan of care for this patient? a. The patient will express acceptance of his changing health status b. The patient's family will state signs and symptoms about the disease c. The nurse will demonstrate the procedure for accurate eye care d. The patient's blood pressure will be less than 140/80 this month
c. The nurse will demonstrate the procedure for accurate eye care
Several patients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the patient's signature on the consent form? a. The patient is illiterate but verbalizes understanding and consent b. A 15 y/o primigravida has been self-supporting for the past 6 months c. The obstetrician explained a procedure that a neurologist will perform d. The patient was medicated for pain with a narcotic IM 6 hours ago
c. The obstetrician explained a procedure that a neurologist will perform
A patient is admitted to a medical unit with a diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome? a. Atenolol b. Famotidine c. Thiamine d. Lorazapam
c. Thiamine
Following a gunshot wound, an adult patient has a hemoglobin level of 4 grams/dL. The nurse prepares to administer a unit of blood for an emergency transfusion. The patient has AB negative blood and the blood bank sends a unit of Type A Rh negative blood, reporting that there isn't Type AB negative blood currently available. Which intervention should be made by the nurse? a. Administer normal saline solution until type AB negative is available b. Obtain additional consent for administration of Type A negative blood c. Transfuse Type A negative blood until Type AB is available d. Recheck the patient's hemoglobin, blood type, and Rh factor
c. Transfuse Type A negative blood until Type AB is available
A nurse working on an endocrine unit should see which patient first? a. Adolescent w diabetes arguing about insulin dose b. Geriatric with Addison's disease with blood sugar of 62 mg/dL c. Adult with blood sugar of 384 and urine output of 350 mL in last hr d. A patient taking corticosteroids who has become disoriented in the last 2 hours
d. A patient taking corticosteroids who has become disoriented in the last 2 hours
A patient presents to the ER reporting a raspy voice, cold intolerance, and fatigue. Lab tests indicates an elevated thyroid stimulating hormone and low T3 and T4 levels. After the patient is admitted to the telemetry unit, which interventions is most important for the nurse to implement? a. Offer blankets and a warm drink b. Assess for presence of non pitting edema c. Note the patient's most recent hemoglobin level d. Administer dose of levothyroxine
d. Administer dose of levothyroxine
When administering brompheniramine maleate, an extended release antihistamine tablet, the nurse is told by the male patient that he cannot swallow tablets. Which intervention should the nurse implement? a. Document the patient's refusal to take the medication b. Crush and mix with pudding c. Document that the patient cannot take the prescription d. Ask the pharmacist to send a liquid form
d. Ask the pharmacist to send a liquid form
An older patient is admitted with a possible cerebral vascular accident. He has facial paralysis and can't move his left side. When entering the room the RN finds his wife tearful and trying unsuccessfully to give him a drink of water. What action should teh RN take? a. Give the wife a straw to help facilitate the patient's drinking b. Assist the wife and give the patient sips of water c. Obtain a thickening powder before providing fluids d. Ask the wife to stop and assess the patient's swallowing
d. Ask the wife to stop and assess the patient's swallowing
A patient with chronic kidney disease has an AV fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent a. Distended veins in the left hand b. Left radial pulse is 2+ bounding c. Auscultation of a thrill in left forearm d. Assessment of a bruit on the left forearm
d. Assessment of a bruit on the left forearm
A 15 y/o boy was diagnosed with type 1 diabetes. He tells the nurse that he's having difficulty adhering to his meal plans when he is with his friends. What nursing intervention is best for the nurse to implement? a. Recommend he avoid fast food restaurants until he is familiar with his prescribed diet b. Advise him to take his own food with him when going to restaurants with his friends c. Encourage him to find activities with his friends that don't involve eating d. Assist him in identifying popular fast foods that are within his meal plan for diabetes
d. Assist him in identifying popular fast foods that are within his meal plan for diabetes
The nurse is evaluating the diet teaching of a patient with hypertension. What dinner selection indicates that the patient understands the dietary recommendations for hypertension? a. Grilled steak, baked potato with sour cream, green beans, coffee b. Beef stir fry, fried rice, egg drop soup, diet coke, and pumpkin pie c. Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon merengue pie d. Baked pork chop, applesauce, corn on the cob, 1% milk and key lime pie
d. Baked pork chop, applesauce, corn on the cob, 1% milk and key lime pie
A 6 y/o child who had surgery yesterday refuses to use the incentive spirometer. Which intervention should the nurse take? a. Ask mother to assist b. Allow child to choose when to perform I.S. c. Contract child to use I.S. only after meals d. Blow out lights, blow bubbles, and encourage child's laughter
d. Blow out lights, blow bubbles, and encourage child's laughter
The nurse is caring for a patient who is receiving continuous ambulatory peritoneal dialysis and notes that the output flow is 100mL less than the input flow. Which actions does she implement first? a. Continue to monitor I&O with next exchange b. Check BP and serum bicarbonate c. Irrigate dialysis catheter d. Change patient's position
d. Change patient's position
The patient with PP depression who is admitted to the behavioral health unit refuses to leave her room and eat. In addition to patient safety, which short-term goal should the nurse include? a. Attends 1 group activity daily b. Sleeps 6 hrs a night c. Engages in 1 client to client interaction daily d. Consumes 3 meals and 1500 mL fluid daily
d. Consumes 3 meals and 1500 mL fluid daily
A female patient is admitted for diabetic crisis resulting from inadequate dietary practice. After stabilization, the RN talks to the patient about her diet. What patient characteristic is most important for successful adherence to the diabetic diet? a. Knows that insulin must be given 30 min before eating b. Frequently eats fruits and vegetables at meals and between meals c. Has someone available who can prepare and oversee the diet d. Demonstrates willingness to adhere to the diet consistently
d. Demonstrates willingness to adhere to the diet consistently
A patient with persistent lower back pain has received a prescription for electronic stimulator. After the nurse applies the electrodes and turns the power on, the patient reports a tingling sensation, how does the nurse respond? a. Remove electrodes and observe skin redness b. Decrease strength of electrical signals c. Check amount of gel coating on electrodes d. Determine if the sensation is uncomfortable
d. Determine if the sensation is uncomfortable
A resident of a long term facility with dementia is having difficulty eating in the dining room. The patient becomes frustrated when dropping utensils on the floor and refuses to eat. What actions should the RN implement? a. Allow patient to choose items from a menu b. Assign staff to feed the patient c. Have meals brought to the patient's room d. Encourage the patient to eat finger foods
d. Encourage the patient to eat finger foods
The RN is preparing to send a patient to the cardiac cath lab for an angioplasty. Which patient report is most important for them to explore further prior to the start of the procedure? a. Drank a glass of water in the past 2 hrs b. Reports left chest pain c. Verbalize fear of being in confined space d. Experience facial swelling after eating crab
d. Experience facial swelling after eating crab
A young woman visits the clinic and learns she is positive for BRCA 1 gene mutation and asks the nurse what to expect next. How should the nurse respond? a. Provide information about survival rates woman who have this genetic mutation b. Gather additional information about the patient's family history for all types of cancer c. Offer assurance that there will be a variety of effective treatments for breast cancer d. Explain that counseling will be provided to give her information about her cancer risk
d. Explain that counseling will be provided to give her information about her cancer risk
A male patient is admitted to the hospital due to multiple fractures following a motor vehicle collision that occurred when he ran his car into his ex-spouse's home. When the patient becomes angry and starts throwing objects at the staff, which PRN prescription should the nurse implement? a. Apply soft wrist restraints if needed for patient safety b. Consultation with chaplain for emotional support c. Hydromorphone d. Haloperidol
d. Haloperidol
A patient with arthritis has been receiving treatment with naproxen and now reports stomach pain, increasing weakness, and fatigue. Which lab test should the nurse monitor? a. Calcium b. Erythrocyte sedimentation rate c. Osmolaltiy d. Hemoglobin
d. Hemoglobin
The nurse is teaching a mother of a newborn with cleft lip how to bottle feed her baby using a Medela Haberman feeder, which has a valve to control the release of mil and slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. Which instructions should the nurse provide? a. Alternate milk with water during the feedings b. Squeeze the nipple base to introduce milk into the mouth c. Position baby in left lateral position after feeding d. Hold newborn in an upright position
d. Hold newborn in an upright position
A patient with history of adrenal insufficiency is admitted to the ICU with an acute adrenal crisis. The patient is complaining of nausea and joint pain. Vital signs are 102 temperature, 138 HR, 80/60 BP. Which intervention should the nurse implement first? a. Obtain analgesic prescription b. Cover patient with cooling blanket c. Administer PRN oral antipyretic d. Infuse intravenous fluid bolus
d. Infuse IV fluid bolus
A patient with peptic ulcer disease receives a prescription for intermittent suction via a salem sump nasogastric tube. After inserting the NGT and obtaining coffee ground gastric contents, the nurse clamps the NGT because the patient must leave the room for diagnostic studies. Upon return to the unit, the patient complains of nausea. What action should the nurse implement first? a. Administering a prescribed antiemetic agent b. Provide oral suction using a Yankauer tip c. Connect the NGT to low intermittent suction d. Irrigate the NGT with normal saline
d. Irrigate the NGT with normal saline
The nurse is preparing a teaching plan for an older female patient diagnosed with osteoporosis. What outcome has the highest priority? a. Lists 5 calcium rich foods to be added to her diet b. Identify 2 treatments for constipation due to immobility c. State 4 risk factors of the development for osteoporosis d. Names 3 home safety hazards to be resolved immediately
d. Names 3 home safety hazards to be resolved immediately
While changing the dressing of a patient who is immobile, the RN notices the boundary of the wound has increased. Before reporting this finding to the dr, the RN should evaluate which of the lab values? a. Potassium and sodium b. C Reactive Protein c. Platelets d. Neutrophil
d. Neutrophil
The school nurse is preparing a teaching pamphlet in response to requests from parents regarding a pinworm outbreak at the local preschool. Which info about the most common prescribed medication, mebendazole, should be given? a. Insert as a rectal suppository b. A second dose of medication should be given in 2 weeks c. It is safe for all children to take this med d. Only children with perianal itching should take the med
d. Only children with perianal itching should take the med
After 2 days treatment of dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing and the child's urine output is 50 mL/hr. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which should the nurse implement? a. Increase IV fluid flow rate b. Review 24 hr intake and output c. Obtain ABGs d. Perform a finger stick glucose test
d. Perform a finger stick glucose test
The nurse is demonstrating correct transfer procedures to the CNA working on a rehab unit. The CNA asks the nurse how to safely move a physically disabled patient from the wheelchair to the bed. What action should the nurse recommend? a. Apply a gait belt around the client's waist once a standing position has been assumed b. Pull the patient into position by reaching from the opposite side of the bed c. Hold the patient at arm's length while transferring to better distribute the body weight d. Place the patient's locked wheelchair on the patient's strong side next to the bed
d. Place the patient's locked wheelchair on the patient's strong side next to the bed
During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN) a. Encourage woman at risk for cancer to obtain colonoscopy b. PResent class on self breast examination c. Explain f/u needed for a patient with prehypertension d. Prepare a woman for bone density screening
d. Prepare a woman for bone density screening
Following laser trabeculoplasty surgery for open-angle glaucoma, the patient reports acute pain deep within the eye. What action should the nurse take? a. Apply bilateral eye shields to reduce photosensitivity b. Begin postoperative prophylactic antibiotics c. Administer an antiemetic to prevent vomiting d. Report the eye pain to the surgeon
d. Report the eye pain to the surgeon
An older adult male is admitted with complication r/t chronic obstructive pulmonary disease. He reports progressive dyspnea that worsens on exertion and his weakness has increased over the pass month. The nurse notes that he has dependent edema in both lower legs. Based on these findings, which dietary instruction should the nurse provide? a.Limit intake of high caloric foods b. Maintain low protein diet c. Eat meals at the same time daily d. Restrict daily fluid intake
d. Restrict daily fluid intake
The nurse is preparing to administer an IV dose of ciprofloxacin to a patient with a UTI. Which patient data requires the most immediate intervention by the nurse? a. WBC count of 12,000 mm^3 b. Serum sodium of 145 c. Urine culture positive for MRSA d. Serum creatinine of 4.5 mg/dL
d. Serum creatinine of 4.5 mg/dL
The nurse is performing a peritoneal dialysis on a patient with chronic kidney disease. Which assessment finding should the nurse report to the provider? a. The patient complains of abdominal fullness and cramping during installation b. The patient complains of a slight shortness of breath during instillation c. The amount of the returning dialysis fluid is greater than the amount instilled d. The appearance of the returning dialysate fluid is cloudy
d. The appearance of the returning dialysate fluid is cloudy
A pt admitted to the ICU with a right chest tube attached to a THORA-SEAL chest drainage becomes anxious and complains of difficulty breathing. The nurse determines the patient is tachypneic with absent breath sounds in the right lung fields. Which additional findings indicates the patient has developed a tension pneumothorax? a. Continuous bubbling in the water seal chamber b. Decrease bright red blood drainage c. Tachypnea and difficulty breathing d. Tracheal deviation toward the left lung
d. Tracheal deviation toward the left lung
Prior to obtaining a trapeze bar for a patient with limited mobility, which patient assessment is most important for the nurse to obtain? a. Balance and posture b. Pressure sore risk c. Risk for disuse syndrome d. Upper body muscle strength
d. Upper body muscle strength
When planning care for a patient with acute pancreatitis, which nursing intervention has the highest priority? a. Administer antiemetic b. Initiate IV fluid replacement c. Evaluate intake and output d. Withhold food and fluid intake
d. Withhold food and fluid intake
