GL Predict
A nurse is caring for a mother who was prescribed methadone during pregnancy : MN pg. 183
- Tachypnea - Irritability - tremors OR Increased seizures, sleep pattern disturbance, higher birth wt
nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. : FUND. pg 58-59 SATA
- nurse should pad the bony prominences. - providers prescription should include the type of restraint to use -remove or replace restraints frequently to ensure good circulation to the area
a nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parent : MN pg. 170 SATA
- swallowing sounds are audible - stools are yellow and seedy after 7 days - maternal breasts become soft following feedings
postpartum unit is caring for several clients (which pt do you see first?)
1 day postpartum has not voiding in 8hrs
primagravida client in the emergency department at 12 weeks of gestation hyperemesis gravidarum
1000ml/hr
orthopedic floor is completing the morning assessments on several clients (priority?)
24-year old male who has a casted femur fracture
nurse is admitting an unidentified female who was brought to the emergency department.
3 months
charge nurse creating assignments for next shift for several nurses and one of the nurses is pregnant :: a pt the nurse should NOT be assigned to
60 year old who is recovering from shingles
medical unit received change-of-shift report ...
68 year old
reviewing data of four young children who are receiving treatment. Which of the following should alert the charge nurse to the possibility of child abuse
A 3-month old infant who has a skull fracture from reportedly rolling off the changing table
Infection control nurse is reviewing care procedures for four clients
A client who has varicella zoster is placed in a negative pressure room
nurse manager is making staffing assignments for the medical-surgical unit. Which of the following clients is appropriate to assign to a float nurse from the postpartum unit.
A client who is 2 days postoperative following a colon resection
In-home assessment for an older adult client who is at risk for falls. Which of the following assessment findings should the nurse identify as a potential hazard
A comp. chair wheels
Client who is 2 days postoperative following a lumbar laminectomy and is reporting nausea
Admin an antiemetic (Aprepitant for nausea)
Caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse "Am I dying?"
Admin. Pain meds
A client hopitialized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The clients sibling comes to visit but has obvious manifestations of an upper respiratory infection.
Allow the sibling to visit after donning a sterile gown, mask, gloves but prohibits physical contact
A nurse is planning to change the dressings on a school-age child who has sustained multiple burns
Apply the dressings in a proximal to distal pattern
recognizes that the teen pregnancy rate in the community has increased. : Community pg. 57
Arrange a meeting with teenage mothers who are high school students in the community Rationale: Provide pregnancy counseling, including alternative course of actions, instructions and encourgament in parenting role in home and peer group settings.
A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit. The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has selected.
Ask the charge nurse to assign an experienced nurse to act as a resource
A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client who has 2 minor children and a limited support system
Ask the client about her understanding of the diagnosis
A nurse is writing a plan of care for a client who is homebound and has stage 2 alzheimer's disease. Which of the following should the nurse include in the plan of care? ?? MS pg 46
Assist with money management
A nurse is assessing a client w/ schizophrenia what is a manifestation?
Auditory hallucinations
A nurse is assesing a client who has an IV infusing per gravity at 125ml/hr
Blood is backing up in the IV tubing
a nurse is analyzing cardiac rhythms of four telemetry clients in the coronary care unit
C looks normal but lots of artifact or Fibs in between QRS's
a nurse is reviewing medical records for four clients. which of the following represents appropriate documentation
Carafate 1g PO 1hr AC
Home health nurse is admitting a client who is prescribed peritoneal dialysis
Clarify the clients actual and perceived health needs
Ileal conduit due to treatment for bladder cancer
Cleanse w/ moisturizing soap
Nurse in an emergency department is assessing a client who has a nasal fracture.
Clear fluid drainage from the nares
Morning lab values to several clients ...
Client who is prescribed digoxin and furosemide
Health nurese is performing a vision screening on a 4 mont old infant. When shining a light source into the infants visual field
Closes eyes
A nurse notices smoke coming from a clients room and discovers a fire in the wastebasket. After moving the client to safety
Co said : Notify the facility operator I found : Activate the fire alarm
A community health nurse is evaluating elgibility for home assistance for a client who is quadriplegic
Determine the client living situation
Assessing client who systemic lupus erythematous SLE which of the following is an expected findings
Dry, raised facial rash
Difficulty falling asleep at night
Eat a bedtime snack
Adolescent client who has no previous history of a seizure disorder and is admitted after having a 3-min tonic-clonic seizure 2 wks after sustaining a mild concussion. EEG
Explain that the client may not have coffee prior to the EEG
A nurse is assessing a client who is 2hr postoperative following insertion of a chest tube connected to chest drainage system as depicted in the diagram above
Fluctuation of the fluid level chamber b (middle)
A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desqumation as an indication of which of the following complications
Graft-verusus host disease
Home health nurse is reviewing treatment goals w/ a client who has diabetes mellitus evaluate lab tests to determine effective long-term management of blood glucose levels
HbA1c
a nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC
Hep A
A nurse is planning care for a client who has a new diagnosis of HIV.
I cant seem to gain any weight
Client who reports the use of chondroitin and glucosamine
Improve joint functioning (pink book pg. 237)
At the start of an evening shift on a cardiac unit, a LPN brings the nurse a list of client reports
Indigestion
After evaluating the morning lab results on several clients, the provider writes prescriptions for 4 clients assigned to the nurses care?
Infuse 10 meQ/l potassium chloride IV over 1 hr to a client who has potassium of 3.2
A nurse delegates tasks to a LPN and an AP. When admitting a client who is experiencing acute liver failure and who has *ascites and an NG tube*, which of the following tasks is most appropriate to *delegate to the LPN*
Insert an indwelling catheter if the client has not voided in 3 hr
a nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport, which of the following should the nurse say?
Let's talk about what happened to you
A nurse is caring for a client who has a typical depression and is taking phenelzine. what can you eat?
Low-fat yogurt
A nurse is teaching a client who has a new prescription for digoxin. Which of the following should the nurse include in the teaching?
Notify your provider if you experience muscle weakness
Child who is unresponsive has increased intracrainal pressure
Pad the side of the bed (peds pg. 72)
education to the mother of a toddler who has pertussis
Pertussis booster
A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy
Place the newborn 45cm or 18 in from the light source
Pt w/ Neutropenia MS pg. 543
Remove fresh flowers from a clients room
A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous central venous catheter
Review the chest x-ray
Community health nurse is completing a NB home visit and observes family members smoking cigarettes in the house
Review the effects of secondhand smoke w/ family members
Discussing care w/ newly licensed nurse for a client who practices orthodox judaism which food not given
Roast beef and ice cream
A nurse at the family planning clinic triages several clients over the phone (priority)?
Sharp pain in RIGHT shoulder
A client ask the nurse if it is safe for him to take glucosamine supplement
Shellfish allergy (pharm pg. 237)
A nurse is caring for a client who has a new prescription for lithium carbonate. PRIOR TO ADMINISTERING THE FIRST DOSE, WHICH OF THE following lab values should the nurse evaluate?
Sodium
a nurse is caring for a preschool-age child who has a short-leg, plaster cast applied 1 hr ago.
Support the affected leg on a pillow
A nurse is providing teaching for a client who has a new prescription for lithium carbonate (further edu?) : Pharm pg.64
Take medication w/ milk Rationale: Taking lithium with *food* would help with decreasing GI distress
Adolescent who has cystic fibrosis and has a prescription for pancrelipase
Take w/ meals
A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest?
Taking walks (physical activity)
A nurse is caring for a client who has a partial laryngectomy and is receiving continuous enteral feedings at 65ml.hr through a gastrostomy tube (intervene??)
The client is lying in a supine position
A nurse in a mental health clinic is reviewing the history and physical for a 17-yr old client who has a new diagnosis of social phobia
The client reports minimal alteration in performance at a part-time job
In patient psychiatric unit is setting short-term goals for an adolescent who was admitted for treatment of anorexi nervosa
The client will develop personalized meal plan
Client reports chest pain. Which of the following lab findings indicates myocardial damage
Troponin 1.8
DI severe head injury
Urine output 250
Preparing to administer eye drops to a client
Use aseptic technique and drop the medication into the conjunctival sac
A nurse educator is discussing modes of transmission w/ nursing students. Which of the following should the nurse educator include as an example of *vector-borne transmission*
West nile virus from mosquito bite
If something happens to me from which I cannot recover, I dont want to go on a ventilator
You're concerned that something may go wrong?
A nurse in a mental health clinic is observing client in the day room. The nurse sits down to talk w/ an adolescent client who was admitted w/ clinical depression. After a few minutes of conversation, the adolescent ask the nurse "why did you choose to talk to me out of this room full of kids"
You're curious why I am interested in you and not the others ?
Charge nurse on pediatric unit is making assignments for a float nurse from the medical unit. Pt to see first?
a 10-year old who has pneumonia and is receiving respiratory treatments.
several client measurements were obtained with morning vital signs *pt priority**
a 4-year old who has closed head injury and heart rate of 60
An emergency department nurse triages a group of school children injured in a school bus crash
a child who reports diplopia and nausea and was unconscious at the scene but is now awake
A community health nurse is planning to make home visits to several clients who all live within a few miles radius of the office
an infant who has failure-to-thrive and was discharged from a facility yesterday to a foster home on daily weights
providing dietary teaching for a client who has a history of nephrolithiasis which of the following is appropriate to include in the teaching? : MS pg. 397
avoid foods that have high levels of oxalates Rationale: avoid foods high in oxalate sources such as spinach, black tea, cocoa, beets, pecans, peanuts, okra etc.
a nurse is providing teaching to the parent of a preschooler who was newly diagnosed with a latex allergy
bananas
recovering from an acute myocardial infarction. left sided heart failure : MS pg. 198
bilateral lung crackles
Disorder of eye postoperative risk
bleeding and infection
Caring for a client who has a new prescription for chlorpromazine by IM injection
check ortho bp 1 hr after administration
referral for a speech language pathologist
client who has difficulty swallowing
a nurse is planning to provide community education about viral hepatitis
clients who have a history of viral hepatisis are unable to donate blood
A nurse is caring for a client who has heart failure and has started taking a loop diuretic
decrease reflexes
a nurse is caring for an infant who is being treated for dehydration (further edu?) : MN pg. 157
flat anterior fontanel Rationale: fontanels should be soft and flat. no tears mean dehydration
a nurse is reviewing the history and physical of a client who has *right* ventricular heart failure : MS pg.198
hepatomegaly (liver enlargement)
a nurse is admitting an infant who has bacterial meningitis. Nursing intervention?
minimize environmental stimuli
Priority action for postoperative ileus
monitor bowel sounds
A nurse is caring for a client who has cirrhosis of the liver
monitor for abdominal ascites
Obsessive compulsive disorder OCD (further education?)
teach the client to meditate about obsessive thoughts
a nurse is electronically documenting assessment findings for a client. ? pain?
the client reports a pain level of 6 on a scale
a nurse in the emergency department is caring for a client who has abdominal pain. which of the following actions by the nurse demonstrates *VERACITY*
the nurse explains the potential risks of treatment Rationale : Veracity > truth, fidelity
recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is *no longer tidaling* MS pg 103
the tubing may be kinked Rationale: Tidaling is expected Cessation of tidaling in water seal chamber signals lungs re-expansion or obstruction. Continuous bubbling indicates an air leak
a nurse is discussing the z-track hydroxyzine hydrochloride with a newly licensed nurse
this technique decrease risk of subcutaneous infiltration
providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in her diet during lactation MN pg.123
Calcium
Pt is Nulliparous and in the first stage of labor the last internal assessment revealed 100% cervical effacement w/ 5cm of dilation. At the end of last contraction, the nurse observes a large gush of fluid coming out of clients perineal area. What should nurse do first?
Check the FHR
Gravida 2, para 1. The client is at 41 wks of gestation and is receiving oxytocin for the augmentation of labor
Contractions occur every 90 sec
hyperthyroidism which of the following rooms is appropriate for the nurse to assign this client
Cool room (MS pg 507: reduced room temp)
Client who is 8hr postoperative following a right-modified radical mastectomy :: report to provider?
Couging Frothy pink secretions
Client who is receving a controlled epidural analgesia infusion
Covering the insertion site with a transparent dressing
Client recovering from closed head injury assumes a decerbrate posture in response to stimuli
D lying flat ?? (Extentend extremities) The client rigidly extends his arm
Creating and activity plan for a homebound older adult client. In the planning, the nurse considers the physiologic changes that may affect pulmonary function related to the normal aging process
Decrease blood oxygenation
nurse is caring for a client who will be receiving a transfusion of platelets
Decrease in bleeding from puncture sites
a nurse is preparing to administer potassium chloride intravenously to a client who has hypokalemia. The client is receiving a current infusion of 0.9% sodium chloride at 125ml/hr. Which of the following actions should the nurse plan to take? : Pharm. pg. 234
Dilute the solution prior to the infusion Rationale: Dilute K+ and give no more than 40mEq/L of IV solution to prevent vein irritation
2 hr postoperative following an ileal conduit procedure bladder cancer
Dusky-colored stoma
Discharge teaching about disease prevention to a client who has active tb
Educating the client how to cover nose and mouth with tissues when coughing (med sug book pg. 138)
Lab data on a client who has dehydration
Elevated BUN
a nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections UTI
Empty the bladder before and after intercourse
a nurse is preparing the auscultate a client's apical pulse at the *point of maximal impulse PMI*
Fifth intercostal space at the left midclavicular line
Education about ECT major depressive disorder
General anestheic admin prior ECT treatments (This treatment are for pts who aren't responding to their pharmaceutical meds) Mental health book pg 51
perform wound irrigation for a client who has an open secondary wound when creating a sterile field
Hold bottle w/ the palm over .... while pouring
A nurse is teaching a family about home hospice care
Hospice care improves the quality of life through palliative care
A home-health nurse is providing teaching about self-administeration of insulin to client who is newly diagnosed w/ diabetes mellitus
I can use the same area as long as I rotate injection sites
providing postoperative teaching to a client who has a newly inserted pacemaker (if for further education this maybe the answer because this is not in the education) :MS pg. 177
I will use my cellphone on the ear opposite of my pacemaker
A client has just returned to the nursing unit following cardiac catheterization. In the immediate postoperative post procedure period which of the following is the priority nursing actions?
Immobilizing the affect extremity
discussing a living will with a client
It communicates my wishes for end of life care
A nurse is caring for a client who has newly implanted sealed internal radiation device to treat cervical cancer
Keep a 3 ft distance from the radiation implant
a nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse
Pain relieved by changing position
A nurse in a pediatric unit is caring for a group of clients. Which of the following diseases should the nurse implement dro*p*let precautions?
Pertussis
A nurse is assessing a client who is postoperative following abdominal surgery. I feel like my incision ripped open.
Place the client in low-fowlers position
Dignosis of complete placenta previa is admitted to the labor and delivery suite at 36wks gestation w/ contractions 5 min in frequency and 1 min in duration
Prepare the client for c-section
Dietary intervention for a client who is immobile due to pelvic and femur fractures
Providde a high-protein diet
preparing a client for surgery and nurse just administered the preoperative injection (what is the next step or first step?) *safety question
Raise the side rails on the bed
Client who has a left femur fracture and is skeletal traction. The clients reports pain due to muscle spasms in affected leg
Realign the extremity in traction
Immediate postoperative period following thorac surgery, a nurse medicates a client for pain on a schedule
Reduces the resp rate
a nurse is caring for a client who is receiving enteral nutrition. What lab level should be reported?
Serum sodium 128
After making morning round, the charge nurse on a surgical unit delegates the follow tasks to the AP.
Set up a room for an expected postoperative admission
A nurse is teaching a client who has low literacy level about home management of diabetes mellitus
Show the client an educational video
Nurse is caring for a client who has end stage liver disease. The daughter of the clients ask about her father DNR request
Tell me your feelingss bout your fathers prognosis
nurse is caring for a client with fractured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time aPTT of 100 seconds
Turn off the heparin drip
an older adult client tells the nurse, "I thought immunizations were for kids." the nurse informs the client that older adults should receive which of the following immunizations
herpes zoster vaccine
nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. For the first 24hr following surgery, the nurse should instruct the client to do which of the following.
intermittenly place ice on the ankle
a nurse is reviewing the employee health program for new employees. which of the following diagnostic assessments should the nurse recommend for all the new employees to screen for the presence of tuberculosis : MS pg. 136
mantoux test
nurse is teaching a client who has left-leg weakness how to use a standard walker (further edu ?)
moves the left leg and walker ahead together
mastitis of left breast does this mean that i must stop nursing my baby
no, you can continue to nurse from both your breasts
Admitting a client to the medical-surgical unit. Which of the following actions should the nurse first take?
observe the client's level of mobility
A nurse is caring for a client who has just returned to the unit following a bronchoscopy
offers oral fluids to the client
Idenfy risk for fat embolism syndrome
older adults 70 or older and hip/pelvis fractures are common causes (turn upside down)?
nutritional assessment on a client who has a calcium deficiency
osteogenesis
"reviewing" medications for a group of clients labor and delivery (which would you NOT give)
phenytoin for seizure disorder
Newborn nursery is performing assessments on four neonates that are all less than *24 hr old* which pt is priority
pinna below the outer canthus of the eye Maternal pg.158 The eye should be even with the upper tip of the pinna of the newborn's ear.
performing postmorten care on an older adult client : Fund. pg 198
place absorbent pads under the buttocks area Rationale: Apply fresh linens w/ aborbent pads on bed and a gown
a nurse is caring for a client who is receiving IV antibiotics and tests positive for clostridium difficile C. difficile . priority ?
place the client on contact precautions
Diagnosis of antisocial personality disorder
poor impulse control
nurse plans to ambulate a client on the third day after cardiac surgery.
premedicate the client with the prescribed analgesic
a nurse is caring for a client who is postoperative and at risk for development of deep-vein-thrombosis DVT. Risk factor?
prolonged bed rest
benefit from a three-way indwelling catheter
prone to development of blood clots in the urine
preparing to obtain informed consent for a colonoscopy from a client who does not speak english.
provide a consent form in the client's spoken language
experiencing acute mania ...
provide high-calorie nutritional supplements (Mental Health book pg 76: provide pt with portable nutritious food because pt may not be able to sit down)
a nurse is planning care for a client who is comatose and has stage II decubitus ulcer on the coccyx
provide the client with an alternating pressure mattress
nurse volunteers to assist after witnessing a mass casualty incident involving a train derailment. Which of the following clients should the nurse immediately and completely immobilize
pt w/ Glasgow coma ?
tetralogy of fallot
pulse oximeter
prescribed furosemide
rales in lower lobes of lungs
school nurse scabies
red itchy papules on childs groin area
ap reports to the nurse that another ap has spent the entire morning on the phone and has not completed the morning assignment
redirect the AP to discuss the issue with the other AP
a nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care? : Fund. pg. 222
remind the client to place the cane on the unaffected side Rationale: Keep the cane on the stronger side of the body 1- Move cane forward 15cm 2- Then, move weaker cane forward 3- Advance stronger cane
Hearing impairment incorporate which communication methods
rephrase sentences the client does not understand
A client who has an abdominal wound and is receiving negative pressure wound therapy
report to the nurse manager Rationale: negative pressure wound therapy is used to reduce edema
Haloperidol for the treatment of schizophrenia
screen the client for tardive dyskinesia (Mental Health pg 140 inform pt to lower doses to decrease the chances of Tardive dyskinesia)
delegates the following tasks to the assistive personnel bathe four clients distribute fresh water obtain morning vital signs
set a clear time frame for the completion of each task
nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease GERD
sleep with the head of the bed elevated
A nurse in the emergency department is caring for a client following a motor vehicle crash. priority?
stabilize the cervical spine
Child who has pediculosis capitis
store nonwashable items in plastic bags for 14 days (pg 265. In pink book)
nurse in a providers office is caring for a client who has parkinson's disease and has been taking levodopa for the past 5 weeks. the client reports a new onset of muscle twitching
this is a manifestation of drug toxicity and may require a dosage reduction
a nurse in the postanesthesia care unit is caring for four postoperative clients. The nurse realizes that coughing poses a risk to which of the following clients
thyroidectomy
a nurse is caring for a client who is receiving *gentamicin.* Which of the following findings indicates the client is developing toxicity
tinnitus
a nurse is caring for a group of clients. which of the following tasks is appropriate for the nurse to delegate to the assistive personnel AP
transfer a client from bed to chair with mechanical lift Provide postmortem care on a client who experienced cardiac arrest
client following an open coletomy
uncontrolled pain
Involuntarily admitted to psychiatric unit following a failed suicide attempt experimental treatment
witness consent before medication administration
A nurse supervisor receives notification of a disaster in the community and the possibility for multiple admissions to the facility (ppl that doesnt need to be there?) SATA
- 1 day post op - laparoscopic - cholecystectomy - temp 98
. urinalysis done for a preschool age child
??
. rising number of sexually transmitted infections in the community
???
Lab values on a client who has taken an overdose of acetaminphine organ damage
ALT
A nurse working in an inpatient mental health facility observes a client who is agitated and threatening staff members in the day room
Accompany the client away from the common area
Client who has given birth to a stillborn
Acknowledging the reality of the nb death
A nurse manager is presenting an in service for newly licensed nurses about advance directives
Advanced directives must be notarized to be legally implemented
A nurse is admitting a client who has chronic gout what med should the nurse admin?
Allopurinol
Disaster triage following a natural disaster
Amputation
A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of deep-vein thrombosis : MS pg. 437
Apply venous plexus foot pumps
Administer an injection to a client when the client states, "I dont want that injection. The last time I got that was sore for a week
Battery
