trends exit

The parents bring their one-yr old child with a VSD to the clinic to a well child visit. Whichassessment should the nurse report immediately?

2+ pitting edema in extremities

Which self care measure is most important to the nurse to include in the plan of care of a client recently diagnosed with type2 diabetes mellitus?

A realistic exercise plan

Audio sound of wheezing and question states just took a dose of fast acting inhaler, what to do next?

Administer a second dose of the patients meds

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

Altered consciousness within the first 24 hours after injury.

A client who does not appear to be pregnant is constantly antepartal clinic and tells the nurse that she thinks she may be " about 2 months pregnant". If the client is pregnant, which sign can the nurse expect her to exhibit?

Amenorrhea.

A group of nurses implement a pilot study to eval a proposed evidence based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which actions should be taken (SATA)

Arrange in-service training thru the Education Dept - Propose clinical prac guidelines to the nursing committee - Invite data review by the QI Dep

After administering a proton pump inhibitor (PP1), which action should the nurse take to evaluate the effectiveness of this medication?

Ask the client about GI pain

When administering brompheniramine maleate, an extended release antihistamine tablet, the nurse is told by the male client that he cannot swallow tablets. Which intervention should the nurse implement?

Ask the pharmacist to send it in liquid form.

While removing staples from a client's postoperative wound site, the nurse observes that the client's eyes are closed and the client's face and hands are clenched. The client states," I just hate having staples removed." After acknowledging the clients anxiety, which action should the nurse implement?

Attempt to distract the client was general conversation.

A client with postpartum depression, who is admitted to the behavioral health unit,refuses to leave her room or eat meals. In addition to maintaining physical safety, which short-term goal should the nurse include in the plan of care?

Attends one group activity per day

An older client with a 3 day history of abdominal distention is admitted with a small bowel obstruction. The nurse inserts a nasogastric tube and attaches it to low intermittent suction. Which ongoing client assessment takes priority when providing care?

Auscultate bowel sounds

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)?

BMI

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first?

Begin manual ventilation immediately.

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts?

Begin to show signs of improvement in affect.

The nurse supplies a blood pressure cuff around a client's left thigh. To measure the client's pressure, where should the diaphragm of the stethoscope be placed? (Mark location on image)

Behind left popliteal)

How do you check for an infant's pulse?

Brachial pulse fingers on inside of elbow

The nurse is caring for a client who is receiving continuous ambulatory dialysis (CAPD) and notes that the output flow is 100ml less than the input actions should the nurse implement first?

Change the client's position

While the nurse is providing morning care for a client with chronic obstructive pulmonary disease (COPD), the client becomes very dyspneic and starts to panic. Which action should the nurse implement first?

Convoy to tell the client to breathe slowly

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Culture for sensitive organism

A female client is admitted for diabetic crisis resulting from inadequate dietary practices.After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most important for successful adherence to the diabetic diet?

Demonstrate a willingness to adhere to diet consistently

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

Destruction of joint cartilage

A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first?

Determine type of chemical exposure.

The nurse is providing discharge instruction to a client who is receiving sertraline 50 mg by mouth daily for depression. Which symptom should the nurse tell the client to report to the healthcare provider?

Dry mucous membrane

During the administration of albuterol per nebulizer, the client complains of shakiness. The client's vital signs are heart rate 120 beats/minutes, respirations 20 breaths/minute, blood pressure 140/88. What action should the nurse take?

Educate client about the side effects of albuterol.

Something about distracting a 4 year old while at an appointment, what are you going to distract the child with?

Either let them play with a needleless syringe or pen light on and off.

The nurse is caring for a client with human immunodeficiency virus (HIV) who has developed oral thrush and is experiencing burning and soreness in the mouth. Which intervention should the nurse implement first?

Encourage frequent mouth care

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for them to explore further prior to the start of the procedure?

Experience facial swelling after eating crab

An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse?

Explain that the client will start to lose consciousness and his body system will slow down

The nurse identifies several nursing problems for a client with a hip fracture who is experiencing fecal incontinence and diarrhea as result of drinking contaminated water. The client has a communication barrier and a sibling is the caregiver. In planning care, which identified nursing problem has the highest priority?

Fluid volume deficit

Which client problem has the higher priority for child with sickle cell anemia who has a temperature of 101 degrees Fahrenheit (38.3C)?

Fluid volume deficit related to temperature elevation.

When conducting diet teaching for a client who was diagnosed with a MI, which snack foods should the nurse encourage the client to eat? (SATA)

Fresh turkey slices and berries - Raw unsalted almonds and apples

A nurse puts on a gait belt to ambulate the client, client is falling, what are you going to do?

Gently bring the client down to the floor

A child needs multiple shots to be done, child is crying, what are you going to lessen the pain?

Give the child multiple shots at once

In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?

Glucose.

An adolescent who was diagnosed with diabetes mellitus type 1 at the age of nine, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis?

Had a cold and ear infection for the past two days.

When taking health hx, which information collected by the nurse correlates most directly with a diagnosis of chronic peripheral arterial insufficiency?

History of intermittent claudication.

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

Hypokalemia

The nurse is preparing an adult with Addison's disease for self-management. Which Information should the nurse include in the client's instruction?

Importance of recording daily weights

Which nursing intervention should the nurse implement for client safety?

Instruct the client to keep hands under the sterile field.

The mother of a 7 month old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Instruct the mother to change a child's diaper more often

An adolescent male client is admitted to the hospital. Based on Erikson's theory of psychosocial development, which nursing intervention best assists this adolescent's adjustment to his hospital stay?

Invite him to participate in the evening group activity

When should the nurse conduct an Allen's test

Just before arterial blood gasses are drawn peripherally.

Which technique should the nurse include when applying an elastic bandage to a client's extremity?

Leave the end of the limb exposed for circulation checks.

To reduce the risk of symptom exacerbation for a client with multiple sclerosis, which instruction should the nurse include in the client's discharge plan? (SATA)

Limit fluids to avoid bladder distention. - Take warm baths before starting exercise. - Space activities to allow for rest periods.

A nurse assesses client whose hand begins to spasm when the BP cuff is inflated. Theclient complains of paresthesias in fingers and toes. Which lab finding should the nurse expect?

Low serum calcium

A male client who had a small bowel resection acquired methicillin-resistant staphylococcus aureus (MRSA) while hospitalized. He was treated and released but was readmitted today because of diarrhea and dehydration. It is important for the nurse to implement which intervention?

Maintain contact transmission precautions

A pregnant client who is four hours post-total abdominal hysterectomy.The previous nurse reports that it was necessary to change the clients perineal pad hourly, and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first

Measure the urinary output

The nurse implements a secondary prevention program for sexually transmitted infections in a local Health Center. Which outcome indicates that the program was effective?

More than 50% of address clients were diagnosed early in their disease process.

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Muscle pain

A patient with Constipation needs to increase fiber intake. Which snack suggestions should the nurse provide?

Oatmeal cookies Raisin Bran Muffins Raspberries

A client taking Clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?

Observe the appearance of the stool.

A client with possible acute kidney injury (AKI) is admitted to the hospital and ammitol is prescribed as a fluid challenge. Prior to carrying our the rx what intervention should the nurse implement?

Obtain VS and breath sounds

A client who is 32 weeks gestation is seen in the emergency department reporting vision changes. The nurse observes the client has also experienced a rapid weight gain over six weeks. Which action should the nurse implement next?

Obtain a blood pressure

An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?

Obtain a clean catch mid-stream specimen

A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client?

Obtain a list of medications taken for cardiac history.

Something about an elderly client's eyes, what's concerning?

Opacity of the eyes

Following an open reduction of the tibia, the nurse notes bleeding on the clients cast. What action should the nurse implement?

Outline the area with ink and check it every 15min to see if the area has increased

When washing soiled hands, the nurse first what's the hands and apply soap. The nurse should complete additional actions in which sequence? (arrange from first action on top to Last Action on bottom)

Palms, interlace fingers, dry hands, turn off faucet

Chest tube drainage system asks about blood drawn out.

Place X on 850ml in 2nd drainage tube measurement

A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room?

Place the ID bands on the infant and the mother

During a Women's Health Fair, which assignment is best for the practical nurse (PN) who is working with a registered nurse (RN)?

Prepare a woman for a bone density screening.

A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive?

Prepare skin for procedure

The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize?

Protect joint function.

A client is hospitalized after experiencing a myocardial infarction. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

Provide a bedside commode for toileting.

While taking vitals, a critically ill male client grabs a nurse's hand and ask the nurse to not leave. What action is best for the nurse to take?

Pull up a chair and sit beside the clients bed.

A nurse is planning to implement a tuberculosis screening program at a community health clinic. What technique should the nurse use to screen clients who are non compromised?

Purified protein derivative (PPD)

A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

Red edematous stomal appearance.

An older client with a long history of coronary artery disease (CAD), hypertension (HTN),and heart failure (HF) arrives in the emergency department in respiratory distress. The healthcare prescribed furosemide IV. Which therapeutic response to furosemide should the nurse expected in the client with acute HF?

Reduced preload

After receiving IV fluids in the emergency department, an elderly client is admitted to the acute care unit with a medical diagnosis of dehydration. The client is receiving 0.9% normal saline at 125 ml/hour via saline lock and has a bounding pulse, tachycardia, and pedal edema. When contacting the healthcare provider, the nurse anticipates a prescription: what intervention?

Remove the saline lock from the client's arm.

A client with a 6 cm thoracic aneurysm is being prepared for surgery. The nurse reports to the healthcare provider that the client's blood pressure is 220/112 mmHg, so an antihypertensive agent is added to the client's IV infusion. Which finding warrants immediate intervention by the nurse?

Reports a tearing, sharp pain between shoulder blades

The nurse determines that a client with acute renal failure has a 24-hour urinary output of 400 ml. Which prescription should the nurse question?

Restrict fluid intake to 400 ml per 24 hours.

The nurse is educating a client with chronic kidney disease about dietary changes. Which finding indicates to the nurse that the client needs additional teaching?

Restricts iron rich foods and iron supplements.

A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement?

Review the client's current list of medications

A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider?

Serum calcium

The nurse is caring for a client who is in renal failure. In reviewing the client's laboratory data, which result must be reported immediately to the healthcare provider?

Serum potassium 7mEq/L (7mmol/L)

The nurse is completing the admission assessm. Of a 3 y/o who is admitted w/ bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased ICP?

Sluggish and unequal pupillary responses

An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?

Start an intravenous (IV) infusion of normal saline

After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism(PE). Which intervention is most important for the nurse to include in the clients plan of care?

Teach how to use incentive spirometry

An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as the result of cerebrovascular accident (CVA). Which action should the nurse include in the plan of care?

Teach the client to turn his head from side to side for visual scanning.

A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?

Teach tracheal suctioning techniques

A client is on droplet precautions, everyone was fitted for respiratory mask, the UAP was asked to go in clean the patient (cant remember), the UAP refused to do it because she wasn't fitted for a respiratory mask?

The UAP doesn't need to be fitted for a respiratory mask.

A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (SATA)

Topical alcohol rub. - Topical corticosteroid. - Oral antihistamine.

A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply)

Topical corticosteroid Oral antihistamine

The nurse is preparing discharge instructions for an older client with heart failure who will be starting a new prescription medication. Which action should the nurse take when reviewing the instructions with the client?

Turn on the overhead light when giving instructions

When conduction diet teaching for a client who is on a post op full liquid diet. Which foods should the nurse encourage the client to eat (SATA)

Vegetable juice - Frozen vanilla yogurt - Clear beef broth

A child w/ heart failure (HF) is taking digitalis. Which sign indicates to the RN that the child may be experiencing digitalis toxicity?

Vomiting

A client with MS is receiving beta-1B interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum lab values should the nurse monitor? (SATA)

WBC - RB - Platelet count

Something about a patient with a wound who has radiation, how are you going to clean the wound?

We the answer that has Q-tip in it.

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

Withhold food and fluid intake.

Video - Nurse is performing straight catheterization on a plastic dummy. What should nurse do next ? Remove it and insert it in the correct area.

belongs in the urethral opening, hole above!