Final

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8 month; febrile seizure; weighs 17 lb; order 270 mg every 12 hr;sends 500 mg; add 2ml; administer how many ml

1.08

recently had a bowel resection; HGB 8, HCT 30%; triple lumen central cath at 125; orders; how many mL to document

1470

weighs 165 with pulmonary embolus; receive heparin 20 units/kg/hr; how many units each hour

1500

deep vein thrombosis has IV infusion of heparin infusing at 1500 units/hr; concentration is 25000 units/500ml; ml after 8 hr shift

240

deep vein thrombosis; heparin 1500 units/hr; concentration 2500/500ml; 12 hr; infuse how many ml

360

furosemide 40 mg; furosemide 10mg/ml available; how many mL

4

acute otitis media; ordered cefpodoxime proxetil 5mg/kg every 12 hours; weight 22 lb; how many mg

50

expectant mother about breastfeeding; immediate follow up

I have been HIV positive for 4 years

childs atopic dermatitis; topical application of hydrocortisone cream twice daily; effective teaching

I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently

new nurse says uncomfortable assessing a fetus from the fetal monitor strip

I'll go with you to interpret this strip and then we'll look at several others

evaluating pregnant clients knowledge of symptoms to report immediately; understands information

If i have blurred or double vision, I should call the clinic immediately

anxious to know her baby's due date; Nageles rule: correct to state which comment when discussing the use of the rule

Nageles rule provides a good approximation of due date I will add 7 days to the first day of my last menstrual period and count back 3 months Nageles rule may be used in conjunction with other assessment findings

antenatal clinic; brother was born with cystic fibrosis; include what information

To inherit CF; each parent must carry a recessive trait for the disease if both parents carry the trait, each offspring has 25% change of inheriting the disease Chorionic villi sampling can identify prenatally if their child carries the trait or has the disease

teaching parents about the risk of airway obstruction in young children; info appropriate to share regarding risk of obstruction

a small airway makes it easier for foreign objects to cause obstruction

ED with crushing chest injuries sustained in a car accident; respiratory status; sign indicates complication to report to HCP immediately

absent breath sounds on affected side

IV antibiotic in ED; 15 min client reports itching, SOB, difficulty swallowing; interventions to implement

administer epi per order discontinue medication apply oxygen

26 year old primigravida 40 weeks; meconium staining; after 1 hour of IV oxytocin; late fetal heart rate decelerations; do next

administer oxygen at 8 to 10 L by mask

active labor suddenly sits up and says "I can't breathe! my chest hurts really bad!" turns dusky gray color

administer oxygen by face mask

3 year old with acetaminophen poisioning; acetylcysteine every 4 hours for 72 hrs; lab finding confirm effectiveness of this drug

alanine aminotransferase and asparate aminotransferase

cesarean birth 12 hours ago; distended abdomen with faint bowel sounds x 1 quadrant, fundus firm at umbilicus, lochia scant; nurse do first

ambulate the client from the bed to the hallway and back

physician orders digoxin for client with HF; immediately before administering this drug; check clients

apical pulse

4 year old, pediatric office; upper respiratory symptoms and fever for 2 days; viral illness and treat with rest, fluids, antipyretics; question what order

aspirin 294 mg q6h with intermittent doses of acetaminophen 217 mg q4h

priority intervention for toddler who has just had hip spica cast

assess sensation, circulation, motion of child's feet and toes

2 hour old newborn; nasal flaring and acrocyanosis; priority intervention

assess the newborns oxygen sat

ECT; most important intervention

assessing the clients vital signs

nurse and NA; task to delegate to NA

assisting adolescent dx with paraplegia with a meal

active genital herpes admitted to labor and birth unit; first stage of labor; type of birth should nurse anticipate

cesarean

actions most likely ensure correct client receives a medication

check the name on armband with name on medication compare date of birth on the clients medical record

deep vein thrombosis; change in assessment findings does the nurse find most concerning

chest pain and dyspnea

highest to lowest priority; after receiving morning report

cirrhosis; confused and disoriented acute pancreatitis 1 day postop cholecystectomy hepatitis B

assessment findings would lead the nurse to suspect that the client has an addiction to pain medication

client compulsively uses the pain medication client loses control of use of pain medication client continues use of pain medication despite of risk or harm

ED with parents; abdominal pain 8 and low grade fever; most serious assessment finding

client has rigid, boardlike abdomen

older adult; acute respiratory distress has become confused and disoriented; picking invisible items off blankets; alprazolam; safety measures

client will be placed on withdrawal precautions and treatment started immediately prescription should be obtained to help with hallucinations client's medical and mental status will be evaluated frequently and treated as needed

late decelerations on external fetal monitor; actions in plan of care

contact HCP administer oxygen change clients position

admitting neonate; mother received mag sulfate; assess baby for what complication

decreased muscle tone decreased respirations

diabetes mellitus who is in labor; trouble controlling blood glucose level; didn't take insulin; fruity odor to breath

diabetic ketoacidosis

13 year old; anorexia nervosa; IV fluid therapy and nutritional mgmt; weight gain; nursing dx

disturbed body image

pneumonia refuses prescribed oral antibiotic; alert and oriented, vital signs within normal range, crackles scattered; nurse perform

document that the client refused to take medication address the clients concern about medication by clarifying its purpose notify physician

vaginal birth 1 hour ago voices anxiety because she has a nephew with down syndrome; additional teaching

down syndrome is an abnormality that can result from a missing chromosome

client in a coma; suffered a closed head injury; intervention implement to prevent increase in ICP

elevate the head of the bed 15 to 30 degrees

ED; right sided dull, abdominal and flank pain, nausea, vomiting; temp 101.2, pain 10, rebound tenderness; orders to question

enemas until clear regular diet

hour old newborn; observations nurse note as being abnormal

expiratory grunting temperature 97.4 nasal flaring

32 year old primigravida 39 weeks; active labor; Leopolds maneuvers; why; major purpose

fetal presentation

administering IV fluids to infant; vulnerable to

fluid overload

celiac disease; how long must I stay on this diet; response

for the rest of his life

neonate 4 hours of age; heart murmur; what should the nurse do

further assess for signs of distress

lung cancer; cared for by wife at home; pain increasing in severity; teaching effective when wife uses which pain relief strategies

gives husband long acting or sustained release oral med around the clock use immediate release med for breakthrough pain uses music for distraction as well as heat or cold has husband use pain rating scale

discharge care with parents of 16 year old; attempted suicide; advise parents to notify HCP immediately for

giving away valued personal items

32 weeks gestation; mild preeclampsia; home with instructions to remain on bed rest; call HCP if she experiences

headache blurred vision epigastric pain severe nausea and vomiting

retroperitoneal abscess; receiving gentamicin 300 mg IV every 8 hrs; monitor

hearing urine output BUN and creatinine

abdominal aortic aneurysm; prior to surgery, assess for what that puts the client at risk for rupture

high blood pressure

dizziness and requests to go back to the room; P 50, BP 80/40; verapamil and atenolol; actions best

hold the medications call HCP and report events and vitals

change of shift report on four clients; assess first

immobile client with a sudden onset of shortness of breath

ammonia level elevated; HCP prescribes 30 mL of lactulose; effect is common

increased bowel movements

expected outcome when a client is receiving IV administration of furosemide

increased urine output

preterm infant 2 hours ago; rapid respirations, grunting, no breath sounds on one side, shift in location of heart sounds; assist with

insertion of chest tube into the neonate

school nurse reporting back pain, fatigue, dyspnea; scoliosis; action

inspect for uneven shoulder height or hip height

diagnosis rule out leukemia and HCP performs bone marrow biopsy; do post biopsy

instruct client on the need to lie still administer analgesics as ordered monitor vital signs and assess site for bleeding

recovering from an acute asthma attack experiences respiratory alkalosis; respiratory rate of 46, HR 110, BP 162/90, temp 98.6; help improve respiratory alkalosis

instruct the client to breathe into a paper bag

11 year old; asthma attack; immediate intervention

intercostal retractions

mental status change may occur; pneumonia is first experiencing hypoxia

irritability

crutches at home for 1 week; trouble using because armpits hurt and fingers tingle; tell client

let me watch you ambulate. your crutches or technique may need some adjustment

postpartum assessment; parameters should nurse include in assessment

lochia fundus bowel sounds bladder

mag sulfate by IV drip; eclampsia at 32 weeks gestation; medication is having therapeutic effect

mag level of 2.4 blood pressure 120/60 absence of seizures

basis for teaching plan about avoiding nonprescription medication for primiparous client who is breastfeeding

medications may be excreted in breast milk to the nursing neonate

receiving dopamine hydrochloride for treatment of shock; action to take

monitor blood pressure continuously

acute myocardial infarction receiving nitroglycerin; statement indicates therapeutic effect

my chest pain is decreasing

assessing neurovascular status of right arm; cast; notify HCP with what symptom

nail bed capillary refill of 10 seconds

neurological assessment on 1 day old; possible asphyxia in utero

neonates toes do not fan out when soles of the feet are stroked neonate doesnt respond when nurse claps her hands above him neonate displays weak, ineffective sucking

LPN acting inappropriately and smells of alcohol; step should charge nurse take

notify shift supervisor and rearrange the client care assignment

assess pain in 18 mon old

observce for behavioral changes

neurological unit completed assessment on five clients; task to delegate to the NA

obtain an oxygen sat

newborn who has developed sepsis; order to implement first

obtain blood cultures

blood gases; acute respiratory distress syndrome; respiratory acidosis

pH 7.25, PACO2 48, HCO3 24

ED receives ABG results on four clients; lab result requires immediate intervention

pH 7.28, PaCO2 60, PaO2 58

ABG on four clients; report immediately to the HCP

pH 7.31, PaO2 84 mm Hg, PaCO2 50, O2 sat 90%

ABG results will the nurse investigate first

pH 7.94, PaCO2 30, PaO2 75, HCO3 22

CPR; finding indicates external chest compressions are effective

palpable pulse

child with tetralogy of Fallot; why clubbed fingers; due to

peripheral hypoxia

findings in newborn would require the nurse to notify HCP

positive ortolani's sign absence of moro reflex

3 year old acute kidney injury; lab finding should immediately report to HCP

potassium level 6.5

fetal malpresentation, green amniotic fluid, FHR 98; priority intervention

prepare for an emergency cesarean birth

what oral contraceptive is considered safe for use while breastfeeding because it will not affect the breast milk once breastfeeding has been well established

progestin

chest pain rated 8 on a 10 scale; 12 lead reveals ST elevation in inferior leads and troponin levels elevated; do first

reduce pain and myocardial oxygen demand

6 year old how to administer eye drops for bacterial conjunctivitis; include

remove any drainage from eye prior to administration of eye drops after administration of eye drops, keep the eye lid closed for several seconds

school teachers about seizures; generalized tonic clonic; action performed first; teaching successful

remove any nearby objects that could harm the child

toddler admitted; physically abused by mother; required to

report the case to local authorities

pneumonia; sudden SOB; ABG pH 7.21, PaCO2 64, HCO3 24; reflects

respiratory acidosis

client after lung biopsy; assessment finding requires immediate intervention

respiratory rate of 44 breaths/minute

after bronchoscopy under local anesthesia; the nurse should

restrict oral intake until the gag reflex returns

administering medication; rights

right client right dose right medication right time right route

suicidal risk in children and adolescents require the nurse to know what information

risk of suicide increases during adolescence, with those who have recently suffered a loss, abuse, or family discord

newborn exposed to drugs while in utero; behaviors expect the newborn to exhibit

tachypnea with excessive secretions sensitive gag reflex hyperactivity and increased muscle tone

throbbing headache when nitroglycerin is taken for angina; nurse instruct client to do

take acetaminophen or ibuprofen

type 1 diabetes monitoring blood glucose level at home; understands appropriate care mgmt strategies; level 250

taking insulin

she fell from the sofa an hour ago and has not been herself since; unsure of time and other facts; most effective in obtaining more info

tell me what was happening before she fell

28 weeks pregnant is admitted for testing; best explains why pregnant should lie on her left side when resting or sleeping in the later stages of pregnancy

to prevent compression of the vena cava

sexually abused as children; mutilate themselves; how does interpret this behavior

use of physical pain to avoid dealing with emotional pain

newly ordered narcotic medication' safety steps included

verify HCP order assess the client for allergies identify the client assess client's pain level

priority instruction; medication for active tuberculosis

you must comply with the medication regimen to treat TB


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