Uworld July 30
Carotid endarterectomy client with drowsy and slurred speech. What for what?
left arm drift during bilateral arm extensions. *risk for stroke FAST
Acute epiglottitis
life-threatening emergency, due to possible airway obstruction from severe swelling of the epiglottitis. Symptoms: fever, sore throat, stridor, drooling, restlessness, tripod positioning
Tracheostomy suctioning
limit 5-10 seconds
Strabismus
misalignment of the eyes *patching the normal eye helps the other eye build stronger build strength
schizophrenia client, who states, "Those blue aliens are trying to kill me." Which of the following nurse actions are appropriate? Select all that apply.
-Acknowledge the client's anxiety about the DELUSIONS -provide single-serve, unopened packages of food (to void suspicion of poisoning hence, do not encourage client to participate in group meetings
A client is transferred from the post-anesthesia recovery unit to the surgical unit following an open cholecystectomy. Which interventions are most important for the nurse to perform to prevent postoperative pneumonia? Select all that apply.
-Ambulate within 8 hours after surgery, if possible -Fowler (45-60 degrees) -Swab mouth with chlorhexidine swabs every 12 hours *hence, pneumatic compression devices is not helpful in preventing pneumonia (helpful for venous return)
A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are appropriate to include in the client's care plan to help prevent a hip fracture? Select all that apply.
-Calcium supplements -Vitamin D supplements -Weight-bearing exercises *do not use bed rest and discourage use of full bed rails as these causes falls. Hence, client trying to jump over rails. wear non-skid footwear
The nurse is caring for a pediatric client who has active varicella with lesions that have not yet crusted. Which of the following actions by the nurse are appropriate? Select all that apply.
-Discontinue isolation precautions after lesions have dried and crusted -Don gown, gloves, and N95 respirator when entering the client's room -ensure pregnant staff members are not assigned to care for this client -place single-use, disposable thermometer and stethoscope in the room -place the client in a private room with negative air pressure AIRBONE: TB, Measles, Varicella *needs N95 particulate respirator (efficient fit for client, negative pressure room
The charge nurse on the cardiac floor is orienting a new graduate nurse. The charge nurse describes various roles of the interdisciplinary team. In which situations would the nurse "case manager" be consulted? Select all that apply
-Facilitating communication between HCPs -Obtaining health information from the client's nursing home -Referral for home health after discharge *case manager does not do reconciliation of meds or visit client daily but may make daily department rounds
DVT risk factors
-age > 60 -being hospitalized and in bed for 3 days
Which instructions should the nurses include when discussing combined estrogen-progestin oral contraceptives? Select all that apply.
-consult the HCP if you experience leg pain or swelling -do not smoke -seek immediate medical treatment if you experience vision loss. *major, side effect of contraceptives is clots *hence, breast tenderness can be normal and not necessarily to notify HCP
Which is a management concern for a male teenage client with cystic fibrosis (CF)? Select all that apply.
-frequent respiratory infections -infertility -vitamin An deficiency *autosomal recessive-thickened mucus that causes plugging of ducts. Major manifestations include recurrent sinus and pulmonary infections, pancreatic malabsorption (vitamin A,D,E,K (all fat-soluble), deficiency of fat-soluble vitamins, and infertility
In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted?
heart rate is 120 *dopamine is part of sympathetic system (so increase everything) This HR indicates dopamine must be reduced
Diabetic ketoacidosis
hyperglycemia which leads to osmotic diuresis, ketosis
An elderly client is prescribed codeine for a severe cough. The home health nurse teaches the client how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? Select all that apply.
-I'll drink at least 8 glasses of water a day -I'll sit on the side of my bed for a few mins before getting up -I'll take my medicine with food *hence, think of adverse effects: constipation, nausea, vomiting, orthostatic hypotension, dizziness. *applying sunscreen is not necessary since photosensitivity is not an adverse effect
urinary catheter delegation to unlicensed assistive personnel
-hold adipose tissue out of the way during catheter insertion -secure the catheter to the client's thigh with an anchor *UAP can hold body's part
The nurse is performing an initial assessment on a client diagnosed with Addison's disease. Which assessment findings should the nurse anticipate? Select all that apply.
-hyperpigmented skin -low blood pressure *hence, acanthosis nigrican is a fat-fold skin for obese people
The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial postprocedure monitoring plan should include what? Select all that apply.
-level of alertness -lung sounds -oxygen saturation -respiratory pattern hence, thoracentesis- to treat pleural effusion temp is not an immediate complication- it is a later complication complication: pneumothorax, when the needle goes into the lungs and cause the lung to slowly deflate, Bleeding is another
Placement of an external fixation device for long-term stabilization of a fractured tibia. Which interventions are appropriate to include in the client's plan of care? Select all that apply.
Perform pin care with 1/2 strength hydration peroxide and normal saline solution or chlorhexidine solution every 4 hours. *nurse should not turn the bolt clockwise. Doc does this.
Abdominal surgery can cause?
pulmonary embolism *SOB, chest pain
A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)?
Hemoglobin and hematocrit level *Pica- abnormal eating during pregnancy- accompanied by iron deficiency
The health care provider is preparing to place a fetal scalp electrode to monitor the fetus of a laboring client. Which of the following assessment findings should the nurse communicate to the health care provider immediately?
Hepatitis B surface antigen test is positive *hence fetal scalp electrode should be avoided in the presence of bloodborne infections (hep B, HIV) because of risk of infection
Symptoms of hypoglycemia
-sweating & pallor -irritability -tremors & weakness -tachycardia -drowsiness
Terazosin to treat benign prostatic hyperplasia (BPH).
Change positions slowly when going from lying to standing *hence, grapefruits are contraindicated with calcium channel blocker & sildenafil take it at bedtime
The charge nurse must assign a room for a client who was transferred from a long-term care facility and is scheduled for extensive surgical debridement to remove infected tissue from an unstageable pressure injury. Which room assignment is the most appropriate for this client?
Cleitn with a GI bleed who has a nasogastric bue droplet precaution- surgical mask, private room,
The nurse is reviewing new laboratory values. Which client would be the priority to report to the health care provider?
Client admitted for cocaine overdose with a creatine kinase of 30,000. creatinine kinase is released when large amounts of muscle tissue break down resulting in rhabdomyolysis *typically anything over 15,000 is related to muscle damage
The nurse is caring for a hospitalized elderly client who is admitted with pneumonia. Which assessment finding is most consistent with the diagnosis of delirium?
Client is inattentive and hallucinating *delirium has sudden onset and involves fluctuating mental status and inattention with disorganized thinking and/or altered LOC
The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG). Which teaching is correct? Select all that apply.
-take a shower daily without soaking chest and leg incisions. -fever >101 -no drive for 4-6 weeks hence, if client is able to walk 1 block or climb 2 flights of stairs without symptoms (chest pain, SOB, fatigue), it is safe to resume sex
A nurse in the gynecology clinic is reviewing client histories. Which report would be most concerning to the nurse?
60 yr old client who reports bloating and pelvic pressure for the past 2 months *hence, these symptoms are for ovarian cancer and OFTEN SUBTLE is another symptom for it -fish-like: overgrowth of vaginal bacterial flor -heavy bleeding is common with intrauterine device
Several clients check into the emergency department at the same time. Which client should be seen first?
7-yr-old who is restless after tonsillectomy surgery 3 days ago *A client who is status post tonsillectomy and adenoidectomy is at risk for hemorrhage up to 14 days after surgery which compromises airway
The nurse assesses 4 children in the clinic. Which assessment finding requires the nurse's priority action?
A 3-mon-old with fever, vomiting, HIGH-PITCHED CRY, and irritability *symptoms relate to increased ICP and potential for bacterial meningitis (droplet precaution)
The clinical coordinator registered nurse (RN) on a surgical unit makes assignments for the staff of RN, licensed practical nurse, and graduate nurse. Which assignment is most appropriate for a new graduate nurse?
A 68-yr-old client with MS, 2 days postop open cholecystectomy with recurrent mucous plugs, who is scheduled for a bronchoscopy this morning *bronchoscopy does not require much prepration *initiating heparin is difficult because it requires aPTT, INR, etc values
A nurse working at a mental health clinic is reviewing four messages from clients requesting a same-day appointment. Which client does the nurse prioritize to call back first?
A client who is experiencing a fever and diarrhea 2 days after the HCP increased the sertraline dose *hence, sertraline increase- at risk for serotonin syndrome (agitation, diaphoresis, tachycardia, autonomic instability & hypertension, diarrhea & hyperactive bowel sounds, hyperreflexia, clonus, tremor St John's wort (herbal) also puts a client at risk for serotonin syndrome
aspirin overdose antidode
Activated charcoal *hence, treatment in early acetylsalicylic acid toxicity
The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom?
Atropine sublingual drops or a transdermal scopolamine patch is used *dries up the excess secretions *morphine is good for terminal dyspnea
What are the meds for osteoporosis?
Bisphosphonate meds (alendronate, risedronate, zoledronic
2 day old infant with Hirschsprung disease. What do you anticipate
Distended abdomen, has not passed stool (meconium), Refusal to feed, green bile *hence, it is not nonbilious vomiting as this is seen with proximal to the pylorus (hypertrophic pyloric stenosis)
Who does consent?
HCP gives consent form. RN only witnesses it.
The nurse in the same-day surgery unit admits a client who will receive general anesthesia. The client has never had surgery before. Which question is most critical for the nurse to ask the client during the preoperative assessment and health history?
Has any family member ever had a bad reaction to general anesthesia *hence, malignant hyperthermia
The nurse assesses a client with benign prostatic hyperplasia. Which client statement requires further assessment?
I have a burning sensation with I urinate *hence, a burning sensation indicates a UTI. cloudy/foul-smelling urine and burning sensation are indicative of UTI when compared with benign prostatic hyperplasia. missed 3 days of finasteride (for BPH) is not harmful.
The nurse is caring for a client who started receiving chemotherapy 10 days ago. Today, the health care provider prescribes FILGRASTIM. Which of the following is an expected outcome of this medication?
Increase in neutrophil count *chemotherapy decreases rapidly growing cells (like bone marrow suppression) for RBCs, WBCs and platelets *cancer chemotherapy causes tumor lysis syndrome, which releases uric acid into kidneys causing kidney injury
The nurse has received report on 4 pediatric clients on a telemetry unit. Which client should the nurse assess first?
Infant client with ventricular septal defect with reported grunting during feeding *client is showing signs of increased respiratory exertion (GRUNTING) and requires further assessment for CHF
client with diabetic ketoacidosis. The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which action should the nurse expect to implement?
Initiate potassium IV when serum potassium is 3.5-5 *hence, hypokalemia often occurs with DKA & administration of IV insulin to prevent arrhythmias
The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is most concerning and requires a nursing response?
Insertion site dressing saturated with clear fluid *indicates leakage
A child with a high level of school absenteeism has been determined to have school phobia. The school nurse should counsel the child's parent/caregiver to take which action?
Insist on school attendance ASAP, starting with a few hours a day *fast adjustment since the child has school phobia
The parents of a hospitalized preschooler are concerned because their toilet-trained child has started wetting the bed. Which response by the nurse is most helpful?
It is normal for your child to regress while hospitalized *REGRESSION during hospitalization is a normal response to the stresss
A diabetic woman has a precipitous delivery in the emergency department. Which initial neonate assessment finding is the priority and requires a nursing response?
Jitteriness *apgar score of 7 at 1 min is okay *circumoral duskiness- bluish around the mouth *diabetic clients at risk for hypocalcemia *hypoglycemia in newborn is <40. Symptoms: JITTERINESS, IRRITABILITY
A 70-year-old client is admitted to the hospital with a lower gastrointestinal bleed. After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode. The client is now pale and diaphoretic and reports dizziness. Which action should the nurse perform first?
Lower the head of the bed *lowering the HOB maintains blood perfusion to the brain. Hence, 500 ml is a lot
A client with a bowel obstruction has been treated with gastric suctioning for 4 days. The nurse notices an increase in nasogastric drainage. Which acid-base imbalance does the nurse correctly identify? Click the exhibit button for more information.
Metabolic alkalosis, uncompensated *to compensate, HCO3 must decrease
A client at 32 weeks gestation goes into cardiac arrest. What is the nurse's best action while performing cardiopulmonary resuscitation for this client?
Perform chest compression slightly higher on the sternum *hence, supine position is not best since vena cava is compressed *if spontaneous circulation does not occur, must deliver within 5 mins of initiating CPR.
The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention?
Perform head tilt and chin lift *hence, open occluded airway hypoxia in obese postop in general anesthesia is due to airway obstruction
A 64-year-old hospitalized client with chronic obstructive pulmonary disease exacerbation has increased lethargy and confusion. The client's pulse oximetry is 88% on 2 liters of oxygen. Arterial blood gas analysis shows a pH of 7.25, PO2 of 60 mm Hg (8.0 kPa), and PCO2 of 80 mm Hg (10.6 kPa). Which of the following should the nurse implement first?
Place client on the bilevel positive airway pressure (BIPAP) machine *BIPAP therapy is an effective treatment to decrease CO2 levels in clients with hypercapnic respiratory failure
The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD). The nurse anticipates which laboratory results for this client?
Polycythemia *this increase in RBC is an anticipated compensatory response to low blood oxygen levels. *anemia is not expected with COPD
A pregnant client comes to the labor and delivery unit stating the water just broke at home. On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate?
Position the client on hands and knees hence, for umblical cord prolapse, knee-chest position or Trendelenburng position Leopold maneuvers- palpating the pregnant abdomen to identify fetal presentation McRoberts maneuver- flexing the thigh onto the maternal abdomen to straighten the sacrum. used for shoulder dystocia
The nurse cares for a 4-year-old who is on long-term, strict bed rest. Which toy is most appropriate to provide diversion and minimize developmental delays?
Puppets *hence, this helps achieve developmental tasks. preschool toys- mimicking adults (dolls, puppets, imaginative toys, dress-up clothing, medical kits, cars, and planes, fingerpaints, crayons, illustrated books, puzzles with large pieces, clay boardgames- school-age soap bubbles- toddlers stacking and nesting toys- toddlers
During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent. What is the best response for the day charge nurse to give?
Suggest that the night nurse discuss concerns with the nurse manager *the situation should be discussed with a person who has 24/7 responsibility
The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room?
Surgical mask *while away from negative-pressure isolation room, all clients on airborne transmission-based precautions must we a surgical mask to contain exhaled respiratory secretions
The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time? Click on the exhibit button for additional information.
The nurse should not document that an incident report was filed or refer to the incident report in the medical record
A home health nurse is visiting a 72-year-old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond?
These symptoms can be common after major surgery. it will take 4-6 weeks to completely heal and start to feel normal again *memory impairment, concentration, language, social integration, emotion lability are common after major surgery
A client with a dislocated shoulder is prescribed a shoulder sling. The nurse applies the sling and evaluates the fit before discharge from the emergency room. Which assessment finding indicates an incorrect fit?
This hand is held slightly below elbow level *hand should be held slightly above the level of the elbow
The nurse observes the rhythm displayed in the exhibit on the cardiac monitor of a client. The client is dizzy and diaphoretic and has a blood pressure of 80/60 mm Hg. What treatment does the nurse anticipate?
Transcutaneous pacing A client in complete heart block is often bradycardic and hemodynamically unstable. Transcutaneous pacing should be used until a permanent pacemaker can be inserted. Atropine, dopamine, or epinephrine may be used to increase heart rate and blood pressure until temporary pacing is started. *adenosine- PSVT *cardioversion-tachydysrhythmias
The nurse reviews the analgesia prescriptions for assigned clients. The nurse should question the health care provider about which prescription?
Transdermal fentanyl patch for a client who is 1 day postop above-the-knee amputation and reports intermittent, throbbing stump pain *hence, transdermal fentanyl patch is for severe chronic pain. *tramadol is a synthetic analgesic prescribed to treat moderate to severe postop pain. Not for acute
simvastatin for a client with hyperlipidemia. The nurse instructs the client to take this medication in which manner?
With the evening meal *hence, most cholesterol in the body is synthesized by the liver during fasting state, at night *NSAIDS (meds that upset stomach) should be taken with food *levothyroxine on empty stomach in the morning *acid suppressing meds (PPI, H2 blockers) taken 30 mins before breakfast
Individuals of American Indian and Asian cultures view direct eye contact
as rude and disrespectful and will likely move the eyes away during conversation in an attempt to prevent it
Tetralogy of Fallot
cyanotic congenital heart defect manifested by signs of irritability and clubbing of fingers due to oxygen saturation of 65-85% until the client can undergo surgical repair.
Poison Ivy
rash develops 12-48 hours after exposure linear in appearance
Ventricular septal defect
septal opening between ventricles causing a left-to-right shunting leading to excess blood flow to the lungs. *places clients at risk for congestive heart failure and pulmonary hypertension
Lateral ankle sprain
wrap the ankle with an elastic compression bandage RICE for first 24-48 hours.
