EXAM 4 4TH SEMESTER

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further nursing assessment?

Snoring sounds when inhaling

Which laboratory value in a client being managed for hypothyroidism will the nurse report to the primary healthcare provider immediately?

Sodium 125

which serum laboratory value in a client receiving conivaptin therapy for SIADH will the nurse report immediately to the primary healthcare provider to prevent harm?

Sodium 148

What would the nurse do first when the provider has written a discharge order for an older adult client who cannot walk independently and has no family

Speak with a provider about the client self-care abilities

which diarrhetic will the nurse expect to be prescribed by the primary healthcare provider to manage a client who has hyperaldosteronism

Spiralactone

A 21-year-old client slipped and fell into the community swimming pool, and does not resurface. What does the lifeguard, who is a nurse, do after the rescue when the client is unconscious?

Stabilize the spine

What is the nurses best response when a preoperative client speaks about fear of a reaction if blood is given during his or her surgery?

" You could donate some of your own blood, which is an autologous donation, a few weeks before your surgery?"

A client admitted to the hospital states, "Someone asked me to fill out an advance directive when I was admitted, but I was too stressed. What is that for?" How will the nurse respond?

"Advance directives allow a client to convey health care wishes."

Which precaution will the nurse include when providing instructions to the female client with hypothyroidism who is prescribed to take thyroid hormone replacement therapy (HRT)?

"Avoid over-the-counter medications unless prescribed by your primary health care provider."

What is the nurse's best first response when a client with a suspected endocrine disorder says, "I can't, you know, satisfy my wife anymore."?

"Can you please tell me more?"

Which question asked by a 48-year-old client with sleep apnea whose blood glucose level is elevated suggests to the nurse the possibility of a growth hormone excess?

"Does everyone's feet get bigger during menopause?"

The elementary school nurse is teaching children how to prevent injuries from cold exposure in the winter. Which student statement demonstrates that the teaching has been effective?

"Dressing in layers is important."

Which question is most relevant to ask a male client suspected to have a gonadotropin deficiency?

"How often do you need to shave your face?"

Which statement made by the client alerts the nurse to the possibility of hypothyroidism?

"I am always tired, even when I get 10 or 12 hours of sleep."

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks?

"I had a heart attack 4 months ago."

The nurse reviews a routine discharge teaching plan on postoperative care with a client. Which client statement indicates that teaching about wound care has been effective?

"I may need to restrict my activities for several months."

Which statement made by the client who is going home after a transsphenoidal hypophysectomy indicates to the nurse correct understanding of actions to prevent complications from this treatment?

"I will keep the cat food bowl on my counter so that I do not have to bend over."

After instructing a client about the correct procedure for a 24-hour urine test, which client statement indicates to the nurse a need for further teaching?

"I will not eat any fatty foods when I am collecting urine for this test."

Which statement made by a client about thyroid hormone replacement therapy (HRT) indicates to the nurse that further teaching is needed?

"If I continue to lose weight, I may need an increased dose."

The nurse is instructing a client about the postoperative use of antiembolism stockings. Which statement by the client indicates the need for further teaching? (Select all that apply.)

"It is up to me to determine how long I wear the stockings at each interval." "My stockings are loose so they do not hurt my legs."

Which statement made by a client who is undergoing therapy with radioactive iodine (RAI) for Graves disease indicates a lack of understanding about the disorder and its treatment?

"It will be great to lose my "bug-eyed" appearance.

What is the nurse's best response when family members of a client with hyperthyroidism express concern about the client's frequent mood swings?

"Mood swings are common should diminish with treatment."

The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction from the nurse?

"Pain medication will take away all of my pain."

A high school athlete recently suffered heat exhaustion. The school nurse is instructing the student on how to prevent a recurrence of this situation. Which student statement demonstrates that the nurse's teaching has been effective?

"Taking frequent rests is important when in a hot environment."

What is the nurse's best response when a client, who has been taking high-dose corticosteroid therapy for a month for a problem that has now resolved, asks you why she needs to continue taking the corticosteroid?

"The drug suppressed your own adrenal gland secretion of corticosteroids. Slowly decreasing the dose over time allows your adrenal glands to start adequate secretion again."

A blind client is to have a surgical procedure. What is the nurses best response when a client asks if he or she will be permitted to sign the consent form?

"Yes, but your signature will need to be witnessed by two people"

The family of a client who is unconscious and dying realizes that their mother will die soon. The client's children are having a difficult time letting go. How will the nurse respond to the needs of this family?

"This must be difficult for you."

The nurse is performing a spiritual assessment on a dying client. Which question provides the most accurate data on this aspect of the client's life?

"What gives you purpose in life?"

A client who lost a home to a hurricane several years ago tells the nurse, "I get very nervous during a thunderstorm and want to hide under the bed." What is the appropriate nursing response?

"What helps you when you begin feeling this way?"

What is the nurse's best response when a client with Cushing syndrome screams at her husband, bursts into tears, throws her water pitcher against the wall, and then says "I feel like I am going crazy"?

"You feel this way because of your high hormone levels. Your health care provider can prescribe an antianxiety drug for you."

The nurse is teaching a class of park ranger trainees about prioritizing care for clients who have received snakebites. Which ranger's statement demonstrates a need for further teaching?

"You should place a tourniquet above the site of the bite."

The daughter of a client who is dying states, "I don't want my father to be uncomfortable." How will the nurse respond?

"Your father will be closely monitored and cared for."

The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the assistive personnel to visit?

Aggressive brain tumor and needs daily assistance with ambulation and bathing

The nurse is teaching a class on advance directives. What will the nurse include? (Select all that apply.)

-A living will identifies health care wishes regarding end of life treatment. -A health care proxy can only make decisions once a person no longer has their own ability to make decisions.

Which assessment finding in a client who had a parathyroidectomy yesterday indicates to the nurse that immediate action is needed?

Bilateral leg muscle twitching

The nurse is caring for a client who reports being bitten by a brown recluse spider. What assessment finding does the nurse anticipate? (Select all that apply.)

Central bite mark with edema and erythema Center of the bite turning bluish-purple

For which change reported by a client taking bromocriptine therapy to manage hyperpituitarism will the nurse notify the primary health care provider immediately to prevent harm?

Chest pain

when caring for a client of the Jewish faith, who is dying which cultural concert must the nurse keep in mind

A client who is extremely ill and dying, should not be left alone

which is the best example of the greatest good for the greatest number of people?

30 people with possible exposure to a bioterrorism agent or quarantine, including five children, who are asymptomatic

Which client will the nurse consider to be at highest risk for development of Graves' disease

35-year-old has type one diabetes

with which clients will the nurse remain especially vigilant for respiratory complications during the first 24 hours after surgery? Select all that apply.

39-year-old with a 55 pack year smoking history 62 year old with COPD 80-year-old, whose last influenza vaccination was two years ago

Clients who have been admitted to the emergency department (ED) are assessed by the ED triage nurse for an oncoming shift. Which client is most appropriate for the nurse to assign to an LPN/LVN?

A client with heat exhaustion, receiving an IV of normal saline, with a temperature of 98.6° C (37° C)

What is the nurses best response when a client with hypothyroidism asks how long woman replacement therapy will be needed

HRT will be needed for the rest of your life, because hypothyroidism has no cure

With which client is the nurse most alert for postoperative nausea and vomiting

42 year old with a history of motion sickness

which client with the triage nurse categorize as urgent?

44-year-old with a dislocated elbow

which client will the nurse recognize as having high risk for developing secondary adrenal insufficiency?

45-year-old is suddenly stops, taking high dose corticosteroid therapy

with which client will the nurse be aware of an increased risk for Hyperparathyroidism?

45-year-old man receiving dialysis for end stage kidney disease

which action is most likely to be implemented first when a client near dying tells the nurse about an uncomfortable feeling of breathlessness?

5 mg morphine sulfate IV

which client will the nurse recognize as being at increased risk for development of SIADH?

58 year old with small cell lung cancer

Which client does the nurse consider to be at highest risk for a change in thyroid function from thyroiditis

61-year-old man who had influenza three weeks ago

what is the nurses best first action for a client who is six hours postoperative from abdominal surgery and now has profuse bleeding from the incision?

Apply pressure to the wound dressing

The nurse working on an inpatient hospice unit has received the change-of-shift report. Which client does the nurse assess first?

A 26-year-old with metastatic breast cancer who is experiencing pain rated at 10 (0-to-10 scale) and anxiety

The nurse has just received report on a group of clients. Which client is the nurse's first priority?

A 28 year old with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L).

With which client will the nurse be aware of an increased risk for hypoparathyroidism?

A 35-year-old woman who had radiation therapy for Graves disease

Which client does the nurse identify at greatest risk for slow wound healing?

A 47-year-old man with obesity and diabetes

For which client will the nurse question the prescription for long-term androgen therapy?

A 52 year old with a history of prostate cancer treatment.

The nurse routinely screens all clients in the ED for depression. Which client does the nurse identify at the highest risk for depression?

A 59-year-old Caucasian male

Which client does the nurse identify at greatest risk for heat exhaustion?

A 78-year-old gardener

which key points would the nurse include when presenting information about lightning injuries in a community setting? Select all that apply.

A lightning strike is eminent if your hair stands on end you see a blue halo around objects and hear high-pitched or cracking noises Do not stand under an isolated, tall tree, or structure in an open area, such as a field, Ridge or hilltop lightning to strike high points If inside a building, stay away from open doors, windows, fireplaces, metal fixtures, and plumbing If inside a tent, stay away from the metal tent, poles and wet fabric of the tent walls Avoid metal objects, such as chairs or bleachers, put down tools, fishing rods, garden equipment, golf clubs, and umbrellas

For which situation with the ED nurse who is working alone in triage activate the panic button

A person walks in and starts threatening the registration staff with a weapon

what important information does the disability portion of the primary survey provide for the emergency department staff?

A rapid baseline assessment of the neurological status of the client

Which client assessment finding indicates to the nurse the need to assess further for possible endocrine problem

A weight loss of 15 lbs in the past 6 weeks without dieting.

Which action is most important for the nurse to take first after finding a client who has severe hypothyroidism to be unresponsive to attempts to waken her and have a heart rate of 46 beats/min?

Applying oxygen by mask

A client comes to the emergency department (ED), reporting being bitten by a scorpion. Which action will the nurse perform first?

Assess vital signs.

Which factor or condition does the nurse expect to result in an increase in a client's production of thyroid hormones (TH)?

Cold environmental temperatures

which classification with a client having surgery who also had a myocardial infarction six weeks ago, fit best bass on the American society of anesthesiologist system

ASA class IV

Which disorder has clinical signs and symptoms that may cause a black widow spider bite to be misdiagnosed

Acute abdomen

On a hot summer day, an older adult is found by a neighbor lying on the floor, agitated and confused. After calling 911, the neighbor places ice bags on the client's groin area and armpits. Upon arrival at the hospital, which action does the emergency department (ED) nurse perform first?

Administer high-flow oxygen therapy.

A client with terminal lung cancer is receiving hospice care at home. Which nursing action will the RN manager ask the LPN/LVN to do?

Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea.

The nurse is coordinating care for a client who was bitten by a black widow spider. Which nursing action can be delegated to the LPN/LVN?

Administering tetanus toxoid vaccine intramuscularly

which action is most appropriate for the nurse to take in the preoperative holding area when a client who is scheduled to have an adrenalectomy for hypercortisolism is prescribed to receive cortisol by intravenous infusion?

Administering the drug as prescribed

The triage nurse has a suggestion for improving response in the next mass casualty event. Which option does the nurse use to introduce this idea?

Administrative review

Clients who have deficiencies of which hormones will the nurse assess for increased risk of life-threatening consequences?

Adrenocorticotrophicn hormone (ACTH) and thyroid-stimulating hormone (TSH)

What is the most significant risk for any snakebite victim?

Airway compromise and respiratory failure

what is the nurses best response when a client calls the ED to ask what would be done immediately for a brown recluse spider bite on the hand?

Apply cold, compresses and rest as much as possible

A client who is dying is having difficulty swallowing oral medications. Which intervention will the nurse implement for this client?

Ask the provider if the medications can be discontinued or substituted.

A client has died after a long hospital stay. The family was present at the time of the client's death. Which postmortem nursing action is appropriate?

Asking the family if they wish to help wash the client

What is the appropriate initial action after a school nurse has treated injuries related to a school shooting?

Assess own individual feelings.

The nurse reviews the vital signs of a client diagnosed with Graves disease and notes that the client's temperature is 99.6° F (37.6° C). After notifying the primary health care provider, what is the nurse's best next action?

Assessing cardiac status

After a client is prepared for surgery in before preoperative drugs are given in the client is transferred to surgery which intervention can the nurse delegate to the assistive personnel

Assist the client to the bathroom to empty his or her bladder

Which action will the nurse instruct assistive personnel to perform to prevent harm for a client who has adrenal insufficiency?

Assisting a client to change positions slowly

what situation describes the most appropriate reassignment of nursing staff?

Medical staff nurses are reassigned to provide care for stable emergency room clients

After receiving a change-of-shift report, the client with which condition would be assessed by the emergency department (ED) nurse first?

Bee sting on the jawline with difficulty swallowing

Which trends in serum electrolyte values will the nurse expect to find in a client who has untreated hypoparathyroidism?

Below normal calcium levels; above normal phosphorus levels

Which action immediately after a hypophysectomy will the nurse instruct a client to avoid to prevent harm? (Select all that apply.)

Bending at the waist Coughing

which signs and symptoms with the nurse recognize and a client with the most severe frostbite?

Blisters over the carpool or tarsal, and the body part is numb, cold and bloodless

A client with a gunshot wound is brought to the emergency department (ED). Which nursing intervention is appropriate?

Blood and body fluid precautions

what situation constitutes an internal disaster?

Broken water pipe in the service level of a nursing home causing a total loss of electricity for two days

For which laboratory value and the nurse immediately assess the reflexes of a client who has hypoparathyroidism

Calcium 7.8.

Which items are most important for the nurse to ensure are in the room when a client returns from having a thyroidectomy? (Select all that apply.)

Calcium gluconate Oxygen Suction Emergency tracheotomy kit

what is a nurses first action when a client develops an abdominal wound evisceration after a hard sneeze?

Call for help and stay with the client

which is the most important assessment tool for a nurse to use when assessing a client struck by lightning who was brought to the emergency department who is alert that is confused and reports pain in his right hand, and foot with fern, like marks

Cardiac monitor

Which first section with the triage nurse take for a client who comes to the ED with blurred vision, difficulty speaking, left extremity weakness and difficulty walking

Categorize the client as emergent

Which is the priority action for the nurse when providing care for an older adult with weakness, nausea, vomiting, and dizziness, who was outside during a period when the temperature was 110°, but forgot to drink water

Check the client for orthostatic, hypotension and tachycardia

what guidance with the nurse be sure to give the assistive personnel when caring for a client with a heat injury, who started shivering in receiving an IV dose of propofol?

Check the clients blood pressure before allowing them out of bed

What's additional assessment as a priority for the nurse to perform on a client who develops a fever of 102°F the day after a transsphenoidal hypophysectomy

Checking neck range of motion

Which action in the plan of care for a client who is hospitalized for pituitary function testing would be most appropriate for the nurse to delegate to an experienced assistive personnel (AP)?

Checking the client's blood glucose levels every 4 hours

what is the nurses best action win crusting on about half of the suture line and oozing of a small amount of serosanguinous drainage is president during the dressing change of a clients abdominal dressing on the second postoperative day?

Clean the suture line with sterile saline in apply new dressings

which change in a clients condition indicates to the nurse that corticosteroid therapy for the client in acute adrenal crisis is effective

Client is alert and oriented

Which assessment finding of a client at 10 hours after a subtotal thyroidectomy indicates to the nurse possible airway obstruction

Client is drooling

For which assessment finding in a client who had a transsphenoidal hypophysectomy yesterday will the nurse notify the primary health care provider immediately?

Client report of a headache and stiff neck

Which assessment finding in a client with hyperaldosteronism indicates to the nurse that the condition is becoming more severe?

Client reports numbness and tingling around the mouth.

which is the most important priority for nurses when caring for a client preoperatively?

Client safety

For which client will the nurse choose to perform SBIRT?

Client who continues to use alcohol

The emergency department charge nurse is making client assignments and delegating care immediately following a mass casualty event. Which client will be delegated to an assistive personnel (AP)?

Client who is unconscious with massive aortic bleeding

for which client is the forensic nurse examiner most likely to be consulted?

Client who was gang raped by a group of fraternity students

what is the nurse expect will be the appearance of a client win the handoff report states that the client has a GCS of three?

Client will be completely unresponsive

Which client will the nurse responding to a mass casualty event provide with a yellow tag? (Select all that apply.)

Client with a foot injury who cannot walk Client with an open leg fracture and normal vital signs

which symptoms will the nurse expect to find an assessment of a client with hypothyroidism? Select all that apply.

Cold intolerance Constipation Hypotension Weight gain

The nurse is providing reminders to a community group about safety procedures to prevent drowning. Which situation does the nurse identify that poses the greatest risk for drowning?

College students going to a swimming party at a boat house

What is the nurses priority action when interviewing a preoperative client who had a right hip replacement?

Communicate this to the operative personnel

What is the most essential component of the emergency nurses skill base?

Communication

The nurse is caring for a client who may be the victim of domestic violence. When the health care provider discharges the client to home, what is the appropriate nursing action?

Consult with Social Services.

The nurse is caring for a client in the ED who reports speaking English as a second language. Which nursing intervention is appropriate?

Contact an interpreter contracted through the hospital.

As the nurse gives a client the informed consent form to sign, the client asks, "Now what exactly are they going to do to me?" What is the appropriate nursing action?

Contact the surgeon.

which client signs and symptoms does the nurse consider postoperative complications rather than expected responses to the experience? Select all that apply.

Core body temperature of 95.2 Fahrenheit. Pulmonary embolism Paralytic ileus

what is the nurses best response when a client who must continue to take a corticosteroid asks why an H2 histamine blocker has been prescribed?

Corticosteroids are associated with an increase risk for gastric ulcers

decreases of which hormone level does the nurse suspect may be responsible for a client reduced catecholamine levels and decreased cardiac muscle excitability

Cortisol

Resuscitation for a client who sustained cardiac arrest in the emergency department (ED) was unsuccessful. Which nursing intervention is appropriate when the family members ask to view the body? (Select all that apply.)

Cover the client with a sheet, leaving the face exposed. Remove lines and indwelling tubes unless a forensic investigation is anticipated.

Which action would the nurse take when assessing a dying client with findings, including coldness of extremities that are also mottled and cyanotic

Cover the client with a warm blanket

Which action does the nurse implement for a client with wound evisceration?

Cover the wound with a sterile, warm, moist dressing.

which action would the nurse include in his or her personnel emergency preparedness plan?

Create a disaster, supply kit with clothing and basic survival supplies

Which electrolyte laboratory result for a presurgical client will the nurse report to the anesthesiologist?

Creatinine, 1.9 mg/dL (168 mcmol/L)

which new onset problem is most important for the nurse to instruct a client starting on propylthiouracil as therapy for hyperthyroidism to notify the primary healthcare provider immediately

Dark colored urine

For which symptoms will the nurse instruct the family and client who is being treated for diabetes insipidus (DI) to call 911 or go to the nearest emergency department? (Select all that apply.)

Decreased urine output Weigh gain of more than 2.2 lb (1 kg) in 24 hours Persistent headache Acute confusion

The client who has been taking synthetic thyroid hormone replacement therapy for three months, reports, all of the following conditions. Which condition indicates to the nurse that the drug dosage may need to be adjusted?

Difficulty sleeping

The nurse is caring for a client who is actively dying. What nursing action is appropriate? (Select all that apply.)

Do not encourage the client to stay awake. Offer to insert a Foley catheter for comfort. Use moist swabs to keep the mouth and lips moist.

Which precaution is most important for the nurse to teach to prevent harm, and a client prescribed oral corticosteroids for hormone replacement therapy after a bilateral adrenalectomy

Do not stop taking this drug without consulting your primary healthcare provider

What is the nurses best action win assessment of a client's nasogastric tube drainage shows the presence of 140 mL of greenish yellow drainage?

Document for finding as the only action

Which client and family have the most accurate understanding of hospice care

Dying client and family believe it is important to focus on facilitating quality of life

an older adult is having a cataract removal surgery. what is the best category for this surgery?

Elective

Which signs and symptoms in a client who has hyperthyroidism indicate to the nurse possible progression to a thyroid storm? (Select all that apply.)

Elevated temperature Tachycardia Elevated systolic blood pressure Abdominal pain and nausea

Which action is most important for the nurse to perform when caring for an older client decreased antidiuretic hormone (ADH) production?

Encouraging fluids every 2 hours

What is the nurse's best action when noticing that the phlebotomist, who plans to draw blood from the client with severe hypercortisolism, displays symptoms of a cold?

Ensuring the phlebotomist wears a facemask while in the client's room

A client comes to the emergency department covered with an unknown substance. What action will the nurse take first?

Escort to a decontamination room.

The medical command physician has appointed the nurse as the triage officer. Which duty does the nurse anticipate performing in this role? (Select all that apply.)

Evaluate clients who are brought to the hospital with a tag. Evaluate clients who come to the hospital without a tag.

which report from a client who has hypothyroidism and is taking synthetic thyroid hormone replacement therapy indicates to the nurse that more teaching is necessary

Even though the pill is small and mix it with planning to make it easier to swallow

What is the nurses best response win the spouse of a dying client expressed concern that the client has no appetite and eat very little?

Explain to the spouse that loss of appetite is normal when a client near's death, and teach about the risk for aspiration

What was the ED nurse do when a family arrives and wants to see the client after death due to multiple injuries from a aggravated assault

Explain with the family will see dim the lights, leave the clients face exposed and cover the rest of the body with a blanket

which treatment does the nurse most likely expect for a client admitted with severe hypothermia?

Extracorporeal rewarming methods, such as cardiopulmonary bypass

The nurse is coordinating interprofessional palliative care interventions for the client who is dying. Which goal is the nurse seeking to meet?

Facilitating a peaceful death for the client

What is the primary focus for client care at a level 3 Trauma Center?

Focus on the initial injury stabilization and emergent client transfer

A client is admitted to the emergency department after reporting being raped. Who is the best team member for the admitting nurse to contact to provide care for this client?

Forensic nurse examiner

Which type of drug therapy will the nurse prepare to teach about to a client who has mild hyperparathyroidism?

Furosemide diuretics

which assessment technique with the nurse used to confirm a scorpion sting on the right hand of a client

Gentle tapping, at the site of the Sting usually causes increased pain

While on the school playground, a teacher is stung on the hand by a bee, resulting in redness and swelling. The school nurse is nearby when it happens. What is the appropriate nursing action?

Gently scrape stinger out with a credit card.

Which laboratory findings will the nurse use to validate the statement of a client with diabetes that therapy instructions for glucose control "have been followed to the letter" for the past 2 months?

Glycosylated hemoglobin (HbA1c)

What a mass casualty event occurs which group of victims is most likely to require the largest amount of physical space

Green tagged victims

For which new-onset symptom or behavior will the nurse teach a client taking thyroid hormone replacement therapy (HRT) to report immediately to the primary health care provider?

Hand tremors

Which action will the nurse perform when the assistive personnel reports that the client now has a death rattle?

Have the assistive personnel assistant nurse in turning the client on the side to reduce gargling

The nurse is caring for a client who was admitted after a diving accident in a lake. Which task is appropriate to delegate to an experienced assistive personnel (AP)?

Helping to maintain cervical spine stability during transfer to a stretcher

What condition does the nurse suspect when a client admitted with high altitude sickness, develops apathy, and refuses to perform ADLs the next morning then later, in the day, is unable to move in bed, or to set up independently

High altitude, cerebral edema

which manifestations with the nurse expect for a client with a history of malignant hyperthermia? Select all that apply.

High body temperature Tachypnea Skin mottling Muscle rigidity of jaw and upper chest Increased serum, potassium level

Which changes in laboratory values will the nurse expect to see in a client who has tumor causing excess secretion of aldosterone? (Select all that apply.)

Hypokalemia Hypernatremia

What is the ED nurses best response when the surgical nurse answered the phone and says you people always jump admissions on us during shift change

I apologize for the timing. How much time do you need for shift change?

for which statement by a client who experienced a bee sting with the nurse, recommend the client go to the emergency department?

I was stung by at least 40 to 50 bees all over my belly

Which statement by client undergoing radioactive iodine therapy, demonstrates to the nurse that the client has correct understanding of post procedure precautions

I will be sure to only use one toilet and not let others use it for two weeks

which statement made by a female client receiving hormone replacement therapy with estrogen and progesterone for anterior pituitary hypofunction indicates to the nurse correct understanding of the drug therapy?

I will report any leg pain or swelling immediately to my primary health care provider

Which client statement represents the symptoms, most feared and perceived as distressing by dying clients

I'm hoping that my healthcare provider prescribes a lot of pain medication

Which first aid measure will the nurse apply to a client who was bitten by a pit viper on the lower left leg while waiting for transportation to the hospital

Immobilize the leg with a splint in the functional position

What is the main role of the incident commander in a disaster?

Implements and oversees the emergency plan.

Which client assessment finding indicates to the nurse the need to assess further for a possible endocrine problem?

Increased facial hair and absent menses in a 28-year-old nonpregnant woman

What effect on circulating levels of sodium and glucose does the nurse expect in a client who has been taking an oral cortisol preparation for 2 years because of a respiratory problem?

Increased sodium; increased glucose

what is the expected first outcome of a hormone binding correctly to the receptor of its target tissue?

Increased specific function of the target tissue

why is a deficiency in the production of the anterior pituitary hormone ACTH life-threatening?

Inhibits adrenal production of cortisol, which is necessary for life

Which primary health care provider order will the nurse perform first for a client with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 105 mEq/L (105 mmol/L)?

Inserting an indwelling catheter and monitoring urine output

Which statements regarding hyperthyroidism are accurate? (Select all that apply.)

Is much more common among women than among men. Produces symptoms of a hypermetabolic state. Most common form is Graves disease.

which complication does the nurse suspect when a client who had a thyroidectomy one day I go now has a weak voice, and hoarseness?

Laryngeal nerve damage

An air medical helicopter arrives on the scene of a high-speed motorcycle collision with a train. The client was not wearing a helmet and is very confused, with a Glasgow Coma Scale score of 13. There is an apparent partial amputation of both hands. Vital signs are stable and the airway is secure. Which level of trauma center would be the most appropriate destination for this client?

Level I

A client presents to the emergency department (ED) stating, "I got bit by something when I was cleaning out the basement." On assessment, the nurse notices a bite mark with a bluish-purple center on the client's posterior calf. What treatment would the nurse anticipate delivering?

Localized wound care

Which type of drug does the nurse identify that is contraindicated for a client who was stung by a scorpion? (Select all that apply.)

Lorazepam Secobarbitol Hydrocodone

In collaboration with the registered dietitian nutritionist, which dietary alterations will the nurse instruct a client with Cushing disease to make?

Low carbohydrate, high calorie, and low sodium

A hiker begins to feel ill within 48 hours of climbing a mountain. Symptoms include poor activity tolerance, tachycardia, tachypnea, and a dry cough. Which treatment will the telehealth nurse recommend?

Lower altitude

what is an appropriate project for nurses serving on a committee that is to develop tools and aids for the medical command physician to use during a disaster event?

Make a list that includes contact information for all trauma and orthopedic surgeons

Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy?

Monitoring oxygen saturation

which physical assessment findings with the nurse expect in a client with long-term Cushing disease? Select all that apply.

Moon face Truncal obesity thin easily damage skin Extremity muscle wasting

A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order will the nurse implement first?

Morphine sulfate sublingually as needed

Which statements are true about the nature of death in the United States? Select all that apply.

Most people die after a long period of chronic illness The most common cause of death is heart disease Medicare covers the cost of death for most people

what is the first priority for the nurse when walking in the woods with a friend who has bitten by a snake?

Move the person to a safe area

While at a soccer match, a player drops to the ground with heat exhaustion and a diminished level of consciousness. After ensuring the client's airway is clean, what is the team nurse's next action?

Move the player to the shade.

The nurse's hospital was affected by a hurricane. When explaining the disaster response, how does the nurse identify this type of disaster? (Select all that apply.)

Natural External

Which client symptom appearing after a head injury suffered in a car crash is most relevant for the nurse to consider the possibility of diabetes insipidus (DI)?

No change in urine output with minimal fluid intake.

Which signs, symptoms, or behaviors will the nurse expect to find when assessing a client who has just been diagnosed with hypothyroidism? (Select all that apply.)

Nonpitting edema of hands and feet Decreased deep tendon reflexes Pulse rate below 60 beats/min

during a disaster drill, which action would be most appropriate to assigned to an assistive personnel, who usually works in labor and delivery?

Obtain and record vital signs for the yellow tag clients

There has been an explosion at a local refinery with numerous reported injuries. Which client does the nurse identify as the priority for treatment?

Older adult with heavy bleeding

Which client will the nurse consider to have the most predisposing factors that increase the risk for a heat related injury?

Overweight, older, adult male who drinks beer during an afternoon baseball game

when a rescue teams descent is delayed by weather from taking a client to the hospital for symptoms of high altitude, pulmonary edema. What is the most important immediate treatment for this client during the delay?

Oxygen administration

which hormone levels will the nurse expect to be deficient in a client who has undergone removal of the posterior pituitary gland?

Oxytocin and vasopressin

A client is scheduled to have an ileostomy placed. How does the nurse document this type of surgery?

Palliative

What is the best classification for surgery when a client with Crohn's disease has a colostomy

Palliative

A golfer who is caught in a thunderstorm is struck by lightning. A fellow golfer, who is a nurse, runs to the victim's aid. What action will the nurse take first?

Palpate to check for the presence of a pulse.

which assessment finding indicates to the nurse that a clients peristaltic activity has resumed after surgery?

Passing of flatus or stool

The nurse is caring for a client with a knife wound. How will the nurse document this type of injury?

Penetrating

The nurse is caring for a client after a motor vehicle crash whose vital signs are BP 110/70, HR 98, R 18, SaO2 98% on room air. After assessing the Glasgow Coma Scale score as 15, and noting no apparent injuries other than a seat belt abrasion, what will the nurse do next?

Perform ongoing monitoring

which phase of the client care in PACU requires the nurse to perform the most intensive observations and assessments

Phase 1

What is the function of the hospital incident commander?

Physician or administrator who assumes overall leadership for implementing the emergency plan

A client who is dying cannot swallow and is accumulating audible mucus in the upper airway (death rattles). These noises are upsetting to family members. What nursing action is appropriate?

Place the client in a side-lying position so secretions can drain.

Which priority would be included in the emergency management plan for a small community Hospital in a suburban area of a large city?

Plan for transporting patients to other hospitals

what is the nurses best response when a local new station called the hospital ED to verify the number of victims in details of a local disaster?

Please hold and I will connect you with the community relations officer

what would the nurse expect when assessing an odor preoperative client and finding brittle nails, dry flaky, skin, muscle wasting, and dry sparse hair?

Poor fluid and nutrition status

What must a nurse based in Texas who is a member of a disaster, medical assistance team and has been asked to serve in Colorado do when he or she does not hold an active Colorado nursing license

Prepare for deployment because he or she will be considered a federal employee with valid licensure

Which history information provided by client with hypothyroidism will the nurse consider as possible cause of the disorder

Previous thyroid radiation

which postoperative interventions would the preoperative nurse typically teach a client to prevent complications following surgery? Select all that apply.

Range of motion exercises Incision splinting Deep breathing exercises Use of incentive spirometry

What is the nurses best action/response when the family of an 89-year-old who had surgery yesterday states that they are concerned because although the client name who everyone was, he was unable to tell them what day it is, or the name of the vice president

Reassure the family that the drugs and anesthesia used in surgery often make the older adult need a little longer to return to his pre-surgical baseline

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse to contact the surgeon?

Redness and swelling around the incision

what is the best action for the nurse to take after using the impact of events, scale, revised with an assistive personnel, who works in a long-term care facility that was devastated by fire when the IES-R scores are high on all subscales?

Refer the AP to a psychiatrist or clinical psychologist for additional evaluation

The nurse is preparing a personal readiness "go bag". Which essential item will the nurse include for personal preparedness? (Select all that apply.)

Regional map Potable water Personal identification materials Cell phone Radio

what was the initial action of first responders in a community based disaster?

Remove people from danger

The nurse suspects that a client in the ED may be a victim of human trafficking. Which signs and symptoms support this assumption? (Select all that apply.)

Reports having had three abortions in the past 2 years. Missing patches of hair. Allows the accompanying person to answer all nursing questions. Notes various ED visits for sexually transmitted infections (STIs) recorded in the electronic health record. Burns in various places on the body.

which nonverbal manifestations in an older adult client indicate to the nurse that the client is likely having acute pain? Select all that apply.

Restlessness. Profuse sweating. Confusion. Increased blood pressure.

Which action will the nurse instruct assistive personnel to avoid when caring for a client with diabetes insipidus to prevent harm?

Restricting fluids

In which activity does the nurse anticipate participating in during a disaster event debriefing? (Select all that apply.)

Review of staff performance during the disaster Collaboration regarding system effectiveness for improvement

What would the nurse suspect when caring for a client who had a cardiac and respiratory arrest after being struck by lightning when the client is now alert and appears to be recovering but you're an in the drainage bag is now decrease in volume. And it's dark and tea coloured?

Rhabdomyolosis

Which changing trends in a client's serum laboratory values indicate to the nurse that thyroid hormone replacement therapy for hypothyroidism is effective?

Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels

What is the nurse do for a client who has white waxy skin of the nose, cheeks and ears?

Seek shelter immediately and warm the body parts using body heat

Which laboratory finding in a client with a possible pituitary disorder will the nurse report to the health care provider immediately?

Serum sodium 110 mEq/L (110 mmol/L)

Which change in serum electrolyte values in the past 12 hours for a client with syndrome of inappropriate antidiuretic hormone (SIADH) being treated with tolvaptan will the nurse report immediately to the health care provider?

Serum sodium increases from 122 mEq/L to 140 mEq/L.

Which client report of changes in appearance indicates to the nurse that a client's adrenal insufficiency is related to direct malfunction of the adrenal glands?

Skin darkening

which change in appearance with the nurse expect to find in a client who has excessive production of melanocyte stimulating hormone

Skin darkening

When assessing the hydration status of an older postoperative client, where will the nurse assessed for skin dryness and tenting

Sternum

During a mass casualty, which client condition does the nurse prioritize for care?

Sucking chest wound

A client with opioid depression has received naloxone. Vitals signs are currently recorded as BP 110/70, P 70, R 16, and T 98.9° F. Which additional treatment does the nurse anticipate will be needed?

Supplemental pain medication

After successful treatment of clients involved in a mass casualty incident, the incident commander deactivates the emergency response plan. Which activity is most important for the emergency department (ED) charge nurse to initiate at this time?

Take inventory and restock the ED with supplies and equipment.

Which precaution has the highest priority for the nurse to teach a client starting thyroid hormone replacement therapy to prevent harm

Take the drug exactly as prescribed

The nurse completes the preoperative checklist for a client scheduled for general surgery. Which factor does the nurse identify that places the client at high risk for the planned procedure? (Select all that apply.)

Takes saw palmetto for benign prostatic hyperplasia (BPH) Currently prescribed methylprednisolone therapy History of diabetes mellitus

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first?

Talk to the client to be sure of their wishes.

which action for care of a client after major abdominal surgery will the nurse perform to prevent harm?

Teach the client to splint the wound for support and comfort when getting out of bed.

A hospice client becomes too weak to swallow. What does the nurse do initially to increase the client's comfort?

Teaches the family how to provide oral care.

The nurse is about to give the prescribe pain medication to a client 30 minutes before a schedule dressing change. The client states the drug makes him feel sick and he would rather tough it out. What is the nurses best first response

Tell me more about the sick feeling

which element of a long-term care facilities, emergency, preparedness plan must be resolved to meet the guidelines of the life, safety code, published by the national fire protection association?

The building has one main front door, and the side doors are sealed shut

which statement with the nurse use first when giving a handoff report to the next shift nurse using the S bar method?

The client is a 65 year old who came to the ED for a severe headache

what is the best procedure for a client identification when caring for an unconscious admission with no known identification or family and the ED nurse must administer a medication to the client?

The client is designated as John/Jane Doe, and the nurse uses two unique identifiers

what is the nurses interpretation of a postoperative clients laboratory results that show an increase in band cells?

The client is developing an infection

The client has a durable power of attorney for healthcare, also called a healthcare proxy. When would the nurse contact the designated person?

The client is discovered at 3 AM in a comatose state

which statement about the joint commission mandates for emergency preparedness plans for maintenance of ongoing disaster preparedness is true.

The emergency preparedness plan must be tested through drills or actual participation in a real event at least twice a year

Why is a goiter often present in clients who have Graves disease?

The excessive autoantibodies bind to the thyroid-stimulating hormone receptor sites, which increases the number and size of glandular cells in the thyroid gland.

What is the nurses best response to a male client with a prolactinoma tumor of the anterior pituitary gland when he asked why he has not been able to achieve an erection?

The high levels of prolactin suppress release of your normal sex hormones

Informed consent implies to the nurse that a client understands which of the following? Select all that apply.

The nature and reason for the surgery Who will be performing the surgery The risks associated with the surgical procedure, and its potential outcomes The risks associated with the use of anesthesia

During a mass casualty, staff roles are defined. If the triage officer is incapacitated, who is the best choice for replacement?

Triage nurse

Which statement best describes the interprofessional collaborative rolls of the nurse and surgeon when obtaining informed consent?

The nurse may serve as witness to the client signature after the surgeon has the consent form signed, but before preoperative sedation is given, and surgery is performed

Which laboratory value indicates to the nurse that a client who had a subtotal thyroidectomy for thyroid cancer several months ago may now have a recurrence of the disorder

Thyroglobulin level of 120

what is the one exception to the ABCDE primary survey?

Uncontrolled external bleeding

which precaution or action is most important for the nurse to teach the client who is to collect a 24 hour urine specimen for endocrine testing?

Urinate at the end of 24 hours and add that sample to the collection container

Which assessment finding in a client with diagnosis of diabetes insipidus (DI) indicates to the nurse that desmopressin therapy is effective?

Urine output of 30 to 50 mL/hr

which urine characteristics indicate to the nurse that a client being managed for diabetes insipidus requires another dose of desmopressin

Urine output, volume increased; urine, specific, gravity, decreased

what is the next priority for the nurse in the ED caring for a client with a heat injury after airway, breathing and circulation are insured?

Use methods of rapid cooling

Which action will the nurse take to prevent Harmon related to SIADH when a client with a disorder is receiving feedings through a NG tube

Using normal sailing instead of water as the irrigation fluid

The nurse in the ED is preparing to discharge a client with a visual defect who needs to take an antibiotic at home. Which method will the nurse use to teach about drug therapy? (Select all that apply.)

Verbal teaching to the client Distribution of large-print reading material

which are essential teaching points with a nurse instructs a community group about prevention of drowning? Select all that apply.

Watch people who can't swim and who are in or around the water Never dive in shallow water Make sure the water rescue equipment is available Test water depth before diving in headfirst

What is the best way for the emergency healthcare provider and Nurse to inform a client that their family member has died of extensive injuries despite resuscitation efforts

We're sorry to inform you that your loved one died due to extensive injuries

What information would be most important for the nurse to get in order to determine the potential for a multi casualty event versus a mass casualty event at a local high school?

What are the number and the severity of injuries

when will the nurse working in a large urban hospital Most likely referred to the ED is automated electronic tracking system.

When desiring to know if the client CT scan has been completed

The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of The Joint Commission National Patient Safety Goals (NPSG), what will the nurse do as the priority?

Witness marking of the left knee site with the client awake and the surgeon present.

which ED clients who are currently on stretchers, and waiting for discharge or transfer to an inpatient bed are at greatest risk for falls? Select all that apply.

Young client, with heavy, vaginal bleeding, secondary to a miscarriage Middle aged at all with severe nausea and vomiting in frequent watery stool over three days Opioid naïve teenager with a fracture he received morphine sulfate 3 mg IV for pain Old adult client with acute dementia secondary to an infection

What is the nurses best response when the spouse of an older adult asks why it is important to avoid situations why the client would be at risk for a heat related illness?

Your spouse has less body fluid and can become easily dehydrated

which are appropriate actions for the nurse to take when a client with a heat stroke has been admitted to the ED? Select all that apply.

administer cooled normal saline solution Place client on oxygen by nasal cannula as prescribed Insert an indwelling urinary catheter Obtain baseline labs

A client with appendicitis is to have an uncomplicated appendectomy performed. What is the best classification for this surgery?

curative

which action does the nurse perform first for a postoperative client arriving on the medical surgical unit after discharge from the PACU?

access respiratory status for adequate gas exchange

which actions will the nurse use when rewarming a client who has a deep frostbite of the right lower leg? Select all that apply.

administer a tetanus immunization for prophylaxis Elevate extremity above the heart for rewarming Administer an opioid analgesic for pain associated with rewarming Use rapid rewarding in a 104 to 106°F warm bath

what is the nurses best action to prevent hard for a client who arrives at the PACU with a respiratory rate of Timbers for a minute and an SPO2 of 94% after receiving fentanyl during surgery?

administer oxygen, maintain an open airway, monitor, pulse oximetry

Which priority HCP prescribed action would the nurse expect for a dying client with dyspnea crackles on auscultation, peripheral edema, and other signs of heart failure

administration of the diuretics furosemide

when the nurse is screening a pre-operative, client, which factors increase the risk for complications during the perioperative period? Select all that apply.

age 72 35 pounds overweight Smokes, half a pack of cigarettes a day Type two diabetes

which are the key elements when the nurse performs a primary survey on a client brought to the emergency department? Select all that apply.

airway/cervical spine Breathing Circulation Disability Exposure

which statements regarding endocrine function and hormones are correct? Select all that apply.

all tissues and organs are affected by the endocrine system Every hormonal car is a receptor to modify the activities of its target tissue A tropic hormone from one endocrine gland has another endocrine gland as its target tissue The body system that works most closely with the endocrine system to maintain homeostasis is the nervous system

which client is correctly triage and marked with the appropriate collar tag?

an older adult male with shortness of breath and a pneumothorax: red tag

which drugs usually taken daily by client with the surgeon instruct the nurse to be sure to administer prior to surgery? Select all that apply

anticonvulsant Beta blocker

which hormone deficiency does the nurse associate with a client who has diabetes insipidus?

antidiuretic hormone

A client in hospice is deteriorating, and the family is concerned about restlessness. Which are the best actions for the nurse to perform?

assess for pain, provide analgesics, and make the client as comfortable as possible

what would the nurse do first when gunshots are heard in the waiting room?

assess the level of threat to self and others then call for help

which perimeter is most important for the nurse to access for a client admitted to the PACU after surgery under epidural anesthesia

assessing the response to pinprick stimulation from the feet to the mid chest level

which strategies would the ED nurse used to conduct an interview with a client who has been verbally aggressive for the past couple hours? Select all that apply.

attempt de escalating strategies before harm is done Notify security and supervisory staff of the situation Conduct the interview near the door in a quiet room

Which actions would the ED nurse expect to perform as a member of the ED bereavement committee?

attend funerals, send sympathy cards and make follow up calls to the family

what is the first priority concern for nurse is providing care for homeless clients in the ED setting?

attending to their needs for personal safety

which common sense actions to avoid being bitten by a poisonous snake would the nurse teach to a group of clients in the community setting? Select all that apply.

be extremely careful and locations were snakes may hide Wear protective, close, such as boots, heavy pants and leather gloves Inspect suspicious areas before placing hands and feet in them Striking distance can be up to 2/3 the length of the snake Newly dead or decapitated, snakes can inflict a bite for up to an hour after death Do you not transport the snake take a digital photo of the snake at a safe distance

which response is caused by the diving reflex may help save the life of a drowning victim? Select all that apply.

bradycardia Decreased cardiac output Vasoconstriction of vessels in the intestines and kidneys

which are among the most common reasons that client seek care in the ED? Select all that apply.

breathing problems Injury such as falls in older adults Headache

for which signs and symptoms does the nurse monitor when a client comes to the emergency department with an anaphylactic reaction to a bee sting? Select all that apply.

bronchospasm Laryngeal edema Respiratory distress Cardiac dysrhythmias

which change in laboratory values indicate to the nurse that the fluid restriction ordered for a client with SIADH is having the desired effect?

increase to serum sodium

which food selections will the nurse and collaboration with a registered dietitian nutritionist, TJ client who has a lower than normal level of thyroid hormones to increase in the diet? Select all that apply.

cheese Protein Seafood Iodized salt

what is serum electrolyte will the nurse need to monitor most closely after a client has surgery for total removal of the thyroid gland?

calcium

which substances does the nurse expect to be prescribed for a client who has hyperparathyroidism to manage the symptoms? Select all that apply.

calcium supplement Vitamin D

which responsibility is appropriate for the nurse assigned to assist the hospital incident commander during a disaster drill?

call all nursing units to determine the number of patients who could potentially be discharged

hey, preoperative clients vital signs before transport to surgery holding area are: BP, 90/60 heart rate 110 R R 24 T 100.9. What is the nurses priority action?

call and notify the surgeon immediately

Which laboratory test would predict severity of organ damage for a homeless client found confused with several sunburn on expose skin, and with a core body temperature of 106°

cardiac troponin I

which basic supplies with the nurse include in his or her personal disaster kit? Select all that apply.

cell phone and charger Towels washcloths the soap, hand sanitizer Battery powered radio Sturdy footwear Toiletry articles 1 gallon water per day for at least three days Sleeping bag and pillow Duct tape, and plastic sheeting

which assessment have the highest priority for the nurse to perform on a 76-year-old client who began thyroid hormone replacement therapy two weeks ago? Select all that apply.

checking for tumors Determining the presence or absence of chest pain

Emergency Medical Services arrives at the scene of an automobile crash. On primary assessment, the driver is found to be unresponsive, not breathing, and has a grossly deformed left leg with no pulse. What is the first resuscitation intervention to be performed?

clear airway

which information with the ED nurse be sure to include in a situation background assessment recommendation report to be given to the medical nurse regarding a client admitted for bacterial meningitis? Select all that apply.

client is currently alert and oriented times two speech is clear but rambling IV normal saline is infusing into the left anterior forearm Client has received the first dose of IV ceftriaxone at 7 AM Client reports severe headache with high fever, which started four days ago Lumbar puncture results are pending, but meningococcal meningitis is suspected Client has Mel characteristics, but prefers to be called Miss Jenny Jones Cardiac monitor shows normal sinus rhythm with occasional PAC

which clients with the triage nurse classify as emergent, needing to be seen immediately? Select all that apply.

client with crushing substernal, chest pain and shortness of breath Client was active hemorrhage after a motor vehicle car crash

which clients with the triage nurse designate as black tagged? Select all that apply.

client with massive head trauma Client with extensive full thickness burns

which are vulnerable populations that often seek care in the ED? Select all that apply.

clientswith substance abuse problems Clients with mental health needs Clients who are older adults Clients who are poor

which action will the nurse take next after emptying 80 mL of sanguinous drainage from the Jackson-Pratt drain in the clients hip after hip surgery?

compress and close the drain to assure suction

what are the advantages for clients whose surgery is accomplished in a same-day surgery center? select all that apply.

cost-effective care high degree of client satisfaction Service oriented process Case manager to coordinate post discharge care

which problems does the nurse expect in an older adult as a result of age related changes in the endocrine system? Select all that apply.

decreased core body temperature Dehydration Hyperglycemia Polyuria

which client conditions will the nurse expect to stimulate the renin angiotensin aldosterone system? Select all that apply.

dehydration Hypoxemia

which disorders will the nurse expect that a client with an abnormal functioning posterior pituitary gland could possibly have? Select all that apply

diabetes insipidus SIADH

What is the best classification for the surgery when a female client has a biopsy of a nodule found in the right breast

diagnostic

A hypertensive client with a large, abdominal aortic aneurysm is having a surgical repair. What is the best category for this surgery?

emergent

which actions will the nurse take to prevent hypoxemia in the postoperative client? Select all that apply.

encourage the client to cough in deep breathe Ambulate the client as early as the surgeon permits Remind the client to use incentives perimeter every hour while awake

which actions would be useful when the nurse is helping people after a mass casualty event? Select all that apply.

establish rapport through active, listening, and honest communication Allow survivors to talk about their experience Offer resources to help survivors gain, a sense of personal control Provide a sense of safety and security Request crisis, counselors, respond to assist, survivors and families by providing compassionate support

which drug does the nurse prepared to minister to a postoperative client who has received an overdose of a benzodiazepine?

flumazenil

which side effect will the nurse teach a male client receiving androgen therapy to expect?

gynecomastia

which signs of trafficking with the ED nurse watch for when interviewing in assessing an 18-year-old? Select all that apply.

headache and dizziness Missing patches of hair Vaginal or rectal trauma Burns and bruises Unusual tattooing

which instruction would the nurse give to the assistive personnel after giving a client with a migraine headache medication for the pain?

help, the client out of the bed, set them up slowly and dangle the feet then assist them to stand

which tissues or organs does the nurse expect will be evaluated in a male client who begins to have fluid secretions from the breast? Select all that apply.

hypothalamus Anterior pituitary

which are common predisposing factors that the nurse knows can cause hypothermia in a client exposed to prolonged cold? Select all that apply.

immobilization Traumatic injury Use of barbiturates Malnutrition

what type of PPE for a tire with the nurse where to provide care for a motor vehicle crash victim with severe chest trauma who is coughing up blood and has a crush injury to the right leg?

impervious cover gown, gloves, eye protection, facemask, cap, and shoe covers are required

which assessment findings would indicate to the nurse that the administered acetazolamide treatment given to a client for acute mountain sickness, was effective?

increase urine output, and increase respiratory rate

which changes in laboratory values will the nurse expect in a client who has untreated SIADH? Select all that apply.

increase urine sodium Serum potassium, 2.9. Urine specific gravity, 1.053. Serum sodium 119

In collaboration with the registered dietitian nutritionist, which dietary modifications will the nurse suggest to a client with hyperthyroidism? Select all that apply.

increased overall calories Increased carbohydrates Increase protein

what is the most important action for the ED nurse to take for a client admitted with repeated kicks to the abdomen and for whom testing currently reveals no life-threatening damage?

initiate serial, abdominal assessment, every hour

which actions are appropriate for the ED Charge Nurse of a large suburban Hospital, who is informed at 3 AM that a commercial airplane just crashed outside the city limits? Select all that apply.

initiate the staff telephone tree Collaborate with the triage officer Organize nursing and ancillary services Collaborate with the medical command physician

which actions or behaviors by nurse who was involved in a mass casualty event are most consistent with practice is recommended to reduce the risk for development of post traumatic stress disorder? Select all that apply.

interacting with a crisis intervention specialist weekly Hugging a fellow nurse, when here she burst into tears of the sound of an alarm Bringing a fruit basket to work and sharing the content with all coworkers for snacks Changing his or her work schedule from 2 16 hour shifts per week to 4 8hour shifts per week

which information would the nurse on a medical surgical unit expect to be included in a client handoff report from a postanesthesia care unit nurse? Select all that apply.

is drowsy but coherent Had a left total hip replacement Received two units of packed red blood cells in the PACU

which statements best describe the pre-operative period when a client is being prepared for surgery.

it ends when the client is transferred to the surgical suite. During this time, the client receives testing and education related to the impending surgery It begins when the client is scheduled for surgery

which action will the nurse take to prevent harm from the risk of injuries to clients in the ED? Select all that apply.

keep rails up on the stretcher Frequently re-orient any client who is confused Ask your family member to remain with a confused client Reposition any client who is at risk for skin breakdown every one or two hours

which actions with the nurse take to reduce the potential for medical errors or adverse events in the ED? Select all that apply.

look for a medical alert, necklace or bracelet when I client has altered mental status Perform a two person surge of belongings, looking for a medication list or container Search among belongings for the name of the clients, healthcare provider or pharmacy Try to find out the name of the person who provides in-home care for the client Check clients belongings for drugs, or drug paraphernalia, as well as weapons

which are the manifestations of death? Select all that apply.

loss of heartbeat Absence of spontaneous respirations Irreversible brain dysfunction

Which hormone changes does the nurse expect when a client receives a continuous cortisol infusion for 24 hours when his or her in the current feedback mechanisms are functioning normally

lower than normal ACTH levels and lower than normal CRH levels

when the nurse collaborates with the ED healthcare provider, which procedures must he or she be prepared to assist with?

lumbar puncture Wound closure by suturing Chest tube insertion Central line insertion

which actions with the nurse used to promote trust with a homeless client? Select all that apply.

make eye contact Speak calmly Be patient Show care by listening Follow through on promises

which are examples of external disasters? Select all that apply.

malfunction of a nuclear reactor with radiation Ebola virus crisis Terrorist act using explosive advice

which surgical approach does the nurse expect will be used for a client having an uncomplicated cholecystectomy at the same day surgery clinic

minimally invasive

Which condition, when assessed in a client who is dying requires the nurse to take action?

moaning

Which postoperative actions are appropriate for the nurse to take when caring for a client who is recovering from a transsphenoidal hypophysectomy

monitoring fluid and electrolyte balance closely Performing neurologic checks hourly for first 24 hours Encouraging the client to perform, hourly deep, breathing exercises

what complications will the nurse expect that are related to a black widow spider bite? Select all that apply.

muscle rigidity and spasms Hypertension Severe abdominal pain Severe tinnitus Nausea and vomiting

Which condition is the nurse recognize as a life-threatening emergency and serious complication when I clients hypothyroidism is not treated or is under treated

myxedema coma

what is the nurses best response when a client who is about to have a unilateral adrenalectomy for an adenoma that is causing hypercortisolism asks if she will have to continue the severe restriction after surgery?

no, once the tumor has been removed, and your cortisol levels have normalized you will not retain excess sodium anymore

which nursing action would be incorrect when a client is likely to be the subject of a forensic investigation?

nurse gives the clients clothes and belongings to the family of the deceased

A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention will the nurse implement?

offer ice chips

which signs and symptoms support The nurses suspension that a client has developed a heat stroke.

oliguria Hypotension Acute confusion Body temperature of 104°

which actions are within the scope of practice for an emergency medical technician as a pre-hospital care provider? Select all that apply.

oxygen application Splinting BLS CPR

The use of medical marijuana is increasing and palliative and end of life care. For which symptoms with the nurse expect to see these drugs prescribed for a dying client?

pain Fatigue Loss of appetite Anxiety Difficulty sleeping

which technique with the nurse use to estimate the systolic blood pressure for a client who was transported to the ED on a stretcher in a resuscitation situation?

palpate the client for the presence of a radial pulse

which action is the nurse take to prevent home from skin irritation wound contamination an infection for a postoperative client who has a Penrose drain?

places absorbent pads under in around the exposed drain

which action will the nurse take to help prevent strain on the suture line for a client who had a total thyroidectomy for thyroid cancer yesterday? Select all that apply.

placing a small pillow under the clients head Instructing the client, place both hands on the back of the neck while moving

which assessment finding is most important for the nurse to report in a client with diabetes insipidus?

poor skin turgor

A client who has been receiving bromocriptine therapy for one month to manage. Hyperpituitarism now has all of the following symptoms or changes. Which ones will the nurse report to the primary health care provider immediately to prevent harm?

possible pregnancy Irregular heartbeat Watery nasal drainage

Which assessment findings that are unique to Graves' disease will the nurse expect in a client who has hyperthyroidism

protruding eyes Dry waxy swelling on shins

which additional health problems will the nurse expect the client with chronic hyperparathyroidism to be at risk for if management is not effective? Select all that apply.

psychosis Kidney stones Bone deformities Peptic ulcer disease

which assessment findings in a client with myxedema coma indicate to the nurse that therapy is effective? Select all that apply.

pulse is 62 Blood pressure is 98/60 Core body temperature is 98.6°F.

which precaution or issue will the nurse reinforced to the postoperative client about correct use of the PCA device?

push the button when you feel the pain beginning rather than waiting until the pain is that it's worst

what is the most appropriate category of surgery for a client who can barely ambulate with a walker at home who is having a left total knee replacement?

reconstructive

which statements regarding hypothyroidism are accurate? Select all that apply.

reduces cardiac and central nervous system function Often occurs weeks after a bacterial or viral infection Is much more common among women than among men

What is the nurses best action when I client with a living will and do not resuscitate order is dying in the daughter tells the nurse that she wants everything done to save her parents life

respect the clients wishes and ask the chaplain to stay with the daughter

which are the most sensitive indicators of malignant hyperthermia at the nurse should monitor for in a client? Select all that apply.

rise in the end tidal carbon dioxide level with a decrease in oxygen saturation Tachycardia

which signs and symptoms does the nurse expect when assessing a client admitted to the emergency department with mild hypothermia?

shivering, slurred speech, and mental slowness

A dying client receiving morphine sulfate for pain is at increase risk for acute renal failure. Which assessment finding will the nurse observe that indicates worsening of renal failure and failure to excrete the morphine?

signs of confusion or delirium

for which complications will the nurse assess when planning prevention strategies with other interprofessional team members for client with hypercortisolism?

skin breakdown infection, G.I. ulceration

which assessments are most important for the nurse to perform on an older client who's vasopressin levels are lower than normal?

skin turgor and urine output

which actions with the nurse assigned to the assistive personnel for postmortem care of a client?

straighten the client and lower the bed to a flat position Wash the client and comb the hair place pads under the hips and around the perineum Clean and straighten of the clients room or unit

which injuries with the ED nurse categorized as intentional injuries? Select all that apply.

suicide Assault Homicide

which signs and symptoms indicate to the nurse that a client has developed high altitude pulmonary edema? Select all that apply.

tachypnea at rest Cyanotic lips and nail beds Persistent, dry cough

which task with the nurses onto the assistive personnel when the emergency department team is giving a emergency care to a drowning victim?

take, report, and record vital signs every 15 minutes

what are the most common environmental factors that cause heat related illnesses? Select all that apply.

temperature above 95 High humidity above 80%

which actions are examples of passive euthanasia? Select all that apply.

terminating IV fluids Suspending telemetry heart monitoring Discontinuing a mechanical ventilator Turning off a temporary pacemaker

which assessment findings with the nurse expect to see in a 30-year-old client who has just been diagnosed with acromegaly? Select all that apply.

thickened lips Hyperglycemia Protruding, lower jaw

for which suspected client condition will the nurse expect a needle biopsy of the thyroid gland to be performed in addition to imaging assessment?

thyroid cancer

Which laboratory values does the nurse specifically expect to find in a client who has primary hypothyroidism?

thyroid stimulating hormone level 8

After a mass casualty disaster, what is the purpose of conducting the post plan administrative review?

to provide all employees the opportunity to express positive and negative comments

what action does the nurse avoid to prevent harm when caring for a client with an enlarged thyroid gland who has indications of hyper thyroidism?

touching or palpating the front of the neck

which common laboratory test does the nurse expect will be completed on a client prior to surgery? Select all that apply.

urinanalysis Metabolic panel Clotting studies Complete blood count

which instruction would the nurse give to an assistive personnel, who is providing morning care to a client with severe hypoparathyroidism to prevent harm?

use a lift sheet when moving the client in bed

which action will the nurse suggest to an older client to prevent harm as a result of decreased estrogen levels? Select all that apply.

use a skin moisturizer daily Drink at least 2 L of water a day Increase your intake of calcium and vitamin D Walk a mile a day at least four times per week Be sure to urinate immediately after sexual intercourse

which factors will help an older adult client to avoid a heat related injury? Select all that apply.

use a sunscreen with an SPF of at least 30 Limit activity at the hottest time of day wear lightweight light colored, and loosefitting clothing Pay attention to personal physical limitations Take breaks from being in a hot environment

what assessment criteria indicate to the nurse that the client who had surgery 12 hours ago is experiencing respiratory difficulty? Select all that apply.

use of accessory muscles during respiratory effort Presence of a high-pitched crowing sound on exhalation Respiratory rate is 29 per minute

Which action taken by the nurse is most likely to reduce skin complications in a client who has hypercortisolism

using roller gauze, to anchor an IV

which intervention in the ED is least likely to be covered by standing protocol for the nurses win the healthcare provider is not readily available?

ventilate with bag valve mask at 100% oxygen and intubate client

what is the nurses best response when a client with a sprained ankle complains that several clients who arrived later have been admitted before him or her?

we must attend to the clients who are unstable with life-threatening conditions first

Which information would the nurse be sure to include when teaching a client about how to avoid cold injury during cross country skiing? Select all that apply

wear layered clothing so it can easily be added or taken off as the temperature changes keep water, extra clothing, blankets, food, and essential personal medication's in your car when driving in cold climates Body heat is lost through the head, so a hat should always be worn wear synthetic clothing because it moves moisture away from the body and dries fast

Which instructions will the nurse give to a group of community dwelling adults, preparing for a field trip to a farm to prevent wasp and bee stings? Select all that apply.

wear protective clothing in areas where wasps and bees can be found Keep leftover food and cover containers Inspect clothes and shoes for insects before putting them on Do not swipe and bees or wasps there Carry a prescription of epinephrine, auto injector if you are allergic to bee or wasp

which priority question must a nurse be sure to ask the paramedics when an older adult is brought to the ED alert, but with the lower left leg, swelling and deformity in an air splinters in place?

what was the mechanism of the injury?

In which newly admitted client situations does the nurse initiate a conversation about advance directives? (Select all that apply.)

• A client with a non-life-threatening illness • A person who currently has advance directives • The client with end-stage kidney disease • The laboring mother expecting her first child