fundamentals

Which point requires correction regarding the use of restraints? 1. Less restrictive interventions must have been unsuccessful before applying restraints. 2. All other alternatives must have been tried and exhausted before applying restraints. 3. Restraints may be applied to ensure the physical safety of the resident or other residents. 4. A written order for restraints is not required.

4. A written order for restraints is not required.

Which statement by the patient indicates the development of a deep vein thrombosis? A. "My legs itch." B. "My left leg is swollen compared to my right." C. "The skin on my legs is dry and scaly." D. "My left leg feels cool when I touch it."

B. "My left leg is swollen compared to my right."

The nurse is caring for a child with neutropenia. Which beverage is unsuitable for the client with a low neutrophil count? •A. 2% milk •B. Fresh squeezed lemonade •C. Kool-aid •D. Coffee

B. Fresh squeezed lemonade

breakdown of hemoglobin

Bilirubin

• The hospital readmission reduction program looks at: A) The illness level of all patients admitted to that hospital for the past year. B) The infection rates within the hospital correlated with readmission rates. C) The number of prescriptions the patient filled 30 days prior to readmission. D) Readmission rates of patients during a 30-day period after discharge.

D) Readmission rates of patients during a 30-day period after discharge.

• Antidote for Coumadin-

Vitamin K

An immobile postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? • A. Pneumonia • B. Hypothermia • C. Fluid imbalance • D. Pulmonary embolism

• A. Pneumonia

A primary health care provider writes a prescription of "Restraints PRN (as needed)" for a client who has a history of violent behavior. Which action would the nurse take? 1. Ask the health care provider to specify the type of restraint in the prescription. 2. Notify the provider that PRN prescriptions for restraints are unacceptable. 3. Implement the restraint prescription when the client begins to act out. 4. Ensure that the entire staff is aware of the prescription for the restraints.

2. Notify the provider that PRN prescriptions for restraints are unacceptable.

The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is incorrect to teach? 1. To prevent a confused client from pulling out an intravenous (IV) line 2. To prevent an adult client from getting up at night when there is insufficient staffing on the unit 3. To prevent ventilated patient from dislodging the ventilator 4. To keep an older adult client from falling out of bed after a surgical procedure

2. To prevent an adult client from getting up at night when there is insufficient staffing on the unit

Protein responsible for osmotic/oncotic pressure -

Albumin

Permanent fixation of joints and muscles as a result of disuse —

Contracture

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? A.Prepare to administer an antidote. B.Draw a sample for type and crossmatch and transfuse the client. C.Draw a sample for an activated partial thromboplastin time (aPTT) level. D.Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

D.Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

Which of following interventions would a nurse utilize for a patient with thrombocytopenia A.Instruct the client on foods to eat that are high in iron B.Assess the client for an allergic reaction C.Place the client on neutropenic precautions and limit visitors D.Use an electric razor when shaving and avoid taking rectal temperature

D.Use an electric razor when shaving and avoid taking rectal temperature

Estimate of Renal function-

GFR

A patient with diabetes mellitus self monitors blood sugar at home. Now the primary care provider wants to assess the client's average blood sugar over a 3-month period. The best test for this would be: • Fasting plasma glucose • Urine dipstick for glucose • Glucose tolerance test • Hemoglobin A1C

Hemoglobin A1C

• Drop in systolic BP of 20mmhg or more when going from a sitting to standing position -

Orthostatic Hypotension

Lab value monitoring for Coumadin therapy - •

PT/INR

• Lab value monitoring for Heparin Therapy-

PTT

• Antidote for Heparin -

Protamine Sulfate

The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important? A. If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. B. If you continue to breathe shallowly or cough ineffectively, this can lead to deep vein thrombosis (DVT) by preventing poor oxygen exchange in the cardiac and peripheral circulatory system. C. If you continue to breathe shallowly or cough ineffectively, this can lead to dizziness, falling, or an inability to ambulate because of shortness of breath. D. If you continue to breathe shallowly or cough ineffectively, this can lead to respiratory obstructive disease

A. If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia.

Muscles decrease in size when not used- leading to a loss of both strength and muscle mass

Atrophy

Which intervention should a nurse plan to incorporate in the care of a surgical client to decrease the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE)? A. Use of intermittent compression devices on the lower extremities B. Administration of heparin intravenously C. Coughing and deep breathing exercises D. Turn patient every 2 hours

A. Use of intermittent compression devices on the lower extremities

The implementation of diagnosis-related groups (DRGs) by Medicare in 1983 affected hospitals in which way? A.Medicare pays only the amount of money preassigned to a treatment for a diagnosis. B.This reimbursement method focuses on preventing illness through screening and health promotion. C.It decreased in hospital admission rates significantly D.It offered a discount rate for the beneficiaries.

A.Medicare pays only the amount of money preassigned to a treatment for a diagnosis.

You are giving a community presentation on Medicare Part D. Medicare Part D: A. Pays for over-the-counter medications. B. Pays a portion of prescription drug costs. C. Pays for physical therapy. D. Pays for laboratory work needed for medication monitoring.

B. Pays a portion of prescription drug costs.

An outpatient care nurse is providing instructions to a patient who is scheduled for a colonoscopy to remove a polyp. Which instructions are appropriate for client preparation for this procedure? A.Clear liquids may be consumed starting 24 hours after the procedure. B.A bowel preparation will be required in preparation for the procedure. C.Clear liquids only are allowed on the day of the scheduled procedure. D.You can drive back from the procedure by yourself

B.A bowel preparation will be required in preparation for the procedure.

The nurse is caring for a client with cancer who is neutropenic. Which plan would be inappropriate? A. Notify the doctor of any temperature over 100° F. B. Use sterile technique when performing invasive procedures. C. Avoid any spicy foods. D. Avoid client exposure to anyone who is ill.

C. Avoid any spicy foods.

Mrs. Redor, age 55 years, was hospitalized. She takes 5 medications. She is being discharged home. In preparing her discharge, which of the following is least likely to be helpful? A. Assess her knowledge about the medications B. Explain to her how she should take the medications C. Leave medication brochures by her bed D. Explore her feelings about her medications and diagnoses

C. Leave medication brochures by her bed

A nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which assessment finding, if present, is of greatest concern? A. The client is able to wiggle the fingers. B. The restraint is secured to the bed's frame. C. The skin of the hand feels cool to the touch and is pale. D. The nurse is able to insert two fingers under the restraints

C. The skin of the hand feels cool to the touch and is pale.

A nurse is caring for a client scheduled for a CT scan with contrast. Which action is most appropriate? • A. Checking the history for and asking the patient about metal or clips in or on the body • B. Keeping the patient NPO after midnight the night before the procedure • C. Assessing the client's hemoglobin and hematocrit • D. Checking the client's creatinine level

D. Checking the client's creatinine level

The nurse performs range of motion exercises on an immobile client to avoid which complication associated with immobility? A. Urinary stasis B. Constipation C. Dependent edema D. Contractures

D. Contractures

A patient with atrial fibrillation is receiving warfarin (Coumadin) 5 mg each day. His INR today is 2.4 (N= 0.8-1.2). What is the expected change in medication dosage? A. His INR is too low. His warfarin dose needs to be increased. B. His INR is too high. His warfarin dose needs to be decreased. C. His INR is too high. His warfarin dose needs to be increased. D. His INR is within desired range. No change in warfarin dose is needed.

D. His INR is within desired range. No change in warfarin dose is needed.

A client who is weak, dyspneic, and jaundiced has an elevated bilirubin level. With which problem are these clinical findings consistent? • Hemolytic anemia • Pernicious anemia • Iron Deficiency anemia • Anemia of chronic disease.

Hemolytic anemia

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse explain increases the risk of these thromboses? • Elevated Blood Pressure • Increased Blood Viscosity • Fragility Of The Blood Cells • Immaturity Of Red Blood Cells

Increased Blood Viscosity