Integration Midterm
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching?
" Secure the retainer clip at the level of your baby 's armpits "
A nurse in a long-term care facility has assigned a task to assistive personnel (AP). The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make?
"I need to talk to you about the unit policies regarding client assignments."
A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?
"The newborn might be actively shedding the virus."
A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?
Identify the problem.
A nurse is reviewing car seat safety with the parents of a newborn . Which of the following instructions should the nurse include in the teaching?
Keep the diaper folded below the cord
1. When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?
Measure the circumference of both upper arms.
A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take?
Notify the provider of the situation.
A nurse is preparing a client who is in active labor for an epidural analgesia. Which of the following actions should the nurse take?
Obtain a 30min electronic fetal monitoring (EFM) strip prior to induction.
A nurse is caring for a client with a tracheostomy. The client partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
Performing the procedure independently
A nurse is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take first?
Place the child on droplet precautions
A nurse is teaching the guardian of a newborn about car seat safety. Which of the following pieces of information should the nurse include?
Place the shoulder harness in the slots that are level with the newborn's Shoulders
A nurse is caring for a client who has heart failure and is prescribed furosemide (Lasix) For which of the following findings should the nurse withhold the medication?
Potassium 2.8
causes of peptic ulcers
■ Helicobacter pylori (H. pylori) infection ■ Nonsteroidal anti-inflammatory drug (NSAID) and corticosteroid use ■ Severe stress ■ Hypersecretory states ■ Type O blood ■ Excess alcohol ingestion ■ Chronic pulmonary or kidney disease ■ Zollinger-Ellison syndrome (combination of peptic ulcers, hypersecretion of gastric acid, and gastrin secreting tumors)
A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?
o ANS: stop the infusion of blood
A nurse is developing a teaching plan for a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include in the teaching plan? select all that apply
· Report muscle pain to the provider is correct. · Avoid taking the medication with grapefruit juice is correct · Expect therapy with this medication to be lifelong
A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?
· The nurse should position the client in a sitting or side-lying position with her back curved to widen the intervertebral space. · The nurse should inform the client that the anesthetic effect will last 1 to 3 hr.
A nurse is reviewing a new onset DKA client's laboratory report of blood gas findings: HCO3- 18 mEq/L and PaCO2 28 mm Hg. Which of the following pH values and conditions should the nurse expect when interpreting these findings?
C. Decreased pH and metabolic acidosis
A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this medication?
-Bradycardia
A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)
-Check on the client hourly _ Instruct the client in the use of the call light - Apply an ambulation alarm to the clients leg
A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency.
1.Rescue the clients. 2.Pull the fire alarm. 3.Confine the fire. 4.Extinguish the fire.
A nurse is reviewing data for four children. Which of the following children should the nurse assess first?
A 10-year-old child who has sickle cell anemia who reports severe chest pain
A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child.
A child who has nephrotic syndrome.
A nurse is obtaining informed consent from a client who is pre op, which of the following actions should the nurse take (select all the apply)
A. validate the signature is authentic- B. confirm the consent is voluntary- C. verify the client understand the surgical procedure-
1. In terms of valve disease, when auscultating heart sounds, an extra heart sound is heard, how do we document it or call it.
A heart murmur is a blowing, whooshing, or rasping sound heard during a heartbeat. The sound is caused by turbulent (rough) blood flow through the heart valves or near the heart
a nurse is planning care for a group of clients the nurse should identify which of the following clients as having a contraindication for restraints?
ANS: A client who is recovering from a heroin overdose.
1. The nurse should monitor for which of the following complications of immobility for an older adult client who had a stroke 4 weeks ago and who is unable to move independently?
A reddened area over the sacrum
v While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2 heart sounds. The nurse should document this finding as which of the following?
A systolic murmur
A nurse on a telemetry unit is reviewing laboratory results for a client who has atrial fibrillation and is taking warfarin. Which of the following laboratory values should the nurse report to the provider?
A) PT 45 seconds
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
A. "Information about a client can be disclosed to family members at any time."
A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?
A. "Sounds like you are having a difficult time."
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?
A. A private room in a quiet location on the unit
A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching?
A. Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
A. Dyspnea
A nurse is planning to perform a blood transfusion for a client. Which of the following action should the nurse plan to take? select all apply
A. Insert an IV with 18 gauge needle B. Check the expiration date of the blood product with a second nurse D. Check vital signs before transfusion
1. When assessing the client, who is post op and in a skeletal traction, the nurse should expect which of the following findings that are normal? (Select all that apply.)
A. Monitor peripheral pulses in the affected extremity B.Examine the skin under the traction splint C. Assess the temperature of the affected extremity
A nurse is teaching a parent of a 10-month-old infant about home safety. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
A. Position the car seat so it is rear facing. B. Secure a safety gate at the top and bottom of the stairs. C. Maintain the water heater temperature at 49° C (120° F).
A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include?
A. Position the newborn at a 45-degree angle in the car seat
A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?
A. Remain on bedrest for the first 24 hr. B. Keep the leg in a dependent position. C. Apply ice to the affected area.
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?
A. Respiratory depression
A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?
A. Respiratory rate
A nurse manager is observing the actions of a nurse she is supervising. Which of the following actions by the nurse requires the nurse manager to intervene? (Select all the apply)
A. Reviewing the healthcare record of a client assigned to another nurse B. Making a copy of a client most current laboratory results for the provider during rounds C. Providing information about a clients condition to hospital clergy D. Participating in walking rounds that involve the exchange of client related information outside clients rooms
v A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse expect if an allergic transfusion reaction is suspected? (Select all that apply.)
A. Stop the transfusion. C. Maintain an IV infusion with 0.9% sodium chloride. E. Administer diphenhydramine.
A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds.
A. The fourth heart sound (S4)
A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?
A. The nurse separates the client's labia with her dominant hand.
A nurse is assessing a client who has acute cocaine toxicity. Which of the following findings should the nurse expect? (Select all that apply.)
A. Tremor B. Agitation C.Fever
Know findings that place the patients at risk for pneumonia. Which of the following have an increased risk for developing pneumonia?
A. dysphagia B. AIDS E. Required Ventilation F. Myasthenia Gravis
The nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of the following information should the nurse include in the discharge instructions?
A. the reason why the child is taking the medication B. written information about the medication D. the adverse effects of the medication
A nurse is reviewing the medical record of a client who is to receive the first dose of cefoxitin via intermittent IV bolus. Which of the following findings should the nurse identify as a contraindication for the pt to receive cefoxitin and report to the provider?
ANS: A severe allergy to amoxicillin
A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity?
ANS: Anorexia
A nurse is caring for a client who has absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse implement?
ANS: C) Report a temperature of 38.3° C (101° F) or greater.
A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take?
ANS: C. Explain the risk the client faces if she leaves the facility.
A nurse is having difficulty reading the providers writing one transcribing a prescription for a clients medication. Which of the following actions should the nurse take?
ANS: Contact the provider to clarify the prescription.
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
ANS: Hypotension
A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make?
ANS: I care about you, and I am concerned that you feel so sad."
A nurse is assessing a client who has heart failure and is prescribed furosemide. Which of the following findings is an adverse effect of this medication?
ANS: Leg cramps
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?
ANS: Lock the wheels of the bed and the wheelchair.
A nurse is caring for a client who has a c-diff infection. Which of the following cleansing products should the nurse use for hand hygiene?
ANS: Nonantimicrobial soap
A nurse is caring for a client who is dying of metastatic breast cancer. she has a prescription for an opioid medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the patient's death. Which of the following ethical principles should the nurse use to support the decision to administer the medication?
ANS: Nonmaleficence
A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?
ANS: Remove the catheter and insert another into a different site.
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following action should the nurse take?
ANS: Secure the restraints using a quick-release tie.
A nurse is caring for a client whose family member requests to view the client's medical record. Which of the following responses should the nurse make?
ANS: The client must provide permission to share the records with you
When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?
ANS: The right person is one of the five rights of delegation. The nurse should seek information from the AP about his individual skill level before delegating the task.
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?
B) Identify precipitating factors for ritualistic behaviors.
A nurse manager received a client request not to have a specific staff nurse care for her while attic acute care facility. Which of the following is an appropriate action by the nurse manager?
B. Address the concern with specific staff nurse
A nurse is performing a cardiac assessment on client and auscultation an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?
B. Ventricular gallop
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.)
C.Make sure that the client's call light is within reach. D.Provide the client with nonskid footwear. E.Complete a fall‑risk assessment.
A nurse is teaching a client who has a new prescription for sumatriptan tablets to treat migraine headaches. Which of the following instructions should the nurse include?
C: "Report swelling of eyelids after dosage."
A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess?
C: Aspartate aminotransferase (AST)
Know the situations which requires that the nurse wear gloves? (Select all that apply.)Describe 4 situations when gloves must be worn?
Contact with blood, body fluids, secretions, excretions, tissue specimen.
A nurse is teaching a client who reports taking gingko biloba to improve his memory. Which of the following adverse effects should the nurse include?
D) Bleeding gums
A nurse is completing a medication history for a client who reports using over-the- counter calcium carbonate antacid. Which of the following recommendations should the nurse make about taking this medication?
D. Drink a glass of water after taking the medication
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?
D. Flush the NG feeding tube with 30 mL of water immediately following medication administration Rationale: The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications.
A nurse is reinforcing teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding?
I will warm the crib sheets before putting my baby to bed
The client with bipolar in the psychiatric unit comes to the nurses' station at 0300 demanding that the nurse call the provider immediately. Which is the nurse's most appropriate response?
D. You must be very upset about something.
A nurse teaching the parents of a 10-month-old infant about home safety. Which of the following information should the nurse include in the teaching? (Select all that apply.)
Fit the mattress so that it is snug against the sides of the crib. Serve food in small, non-circular pieces. Tie plastic bags in knots before discarding them.
A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?
I should remove extra blankets from my baby's crib
A nurse is providing teaching about self-administration of insulin to the parent of a school aged child newly diagnosed with diabetes. Which of the following statements by the parent indicates a need for further teaching?
I will be sure my child aspirates before injecting the insulin
A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report?
The date of the incident The time the patient was supposed to receive the medication The client's vital signs
A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia. Know the symptoms.
Tongue thrusting and lip smacking Facial grimacing and eye blinking Repetitive involuntary movements
a charge nurse is teaching a group of healthcare workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching?
Use Chlorohexidine to wash hands if the client is immunocompromised
The nursing student asks the nurse to describe the difference between sinus rhythm and sinus bradycardia on the electrocardiogram strip. What is the nurse's best reply?
a. "The only difference is the heart rate."
A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. which of the ff responses should the nurse make?
a. "it sounds like you're having a difficult time"
A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest X-ray . the nurse should instruct the new licensed nurse to take which of the following actions?
a. Have the client wear a surgical mask
1. A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. How would you manage?
a. Monitor sensory perception of the lower extremities.
A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
a. Yellow-green drainage on the surgical incision
v The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning attempt to a maximum of which time period?
b. 10 seconds
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves?
b. Changing an ostomy pouch c. Providing oral care e. Emptying urine from an indwelling urine collection bag.
A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take?
b. Use a 1.8 mm (0.5 in) needle Rationale: use 22-25-gauge needle, 2 finger breadths below the acromion process, and insert the needle at a 90-degree angle.
A nurse on the postpartum unit is caring for a group of clients with an AP. which of the following tasks should the nurse plan to delegate to the AP?
c. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
A nurse is teaching a newly licensed nurse about reporting suspected child abuse. which of the ff statements indicates an understanding by the newly licensed nurse?
d. "if suspicion of abuse exists then reporting is mandatory
A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take?
d. Wear an N95 respiratory mask.
A nurse in an inpatient mental health unit is planning care for a client who is in restrains. Which of the following findings should indicate the nurse that the client is ready to reintegrate into the unit?
d. the client follows directions
A nurse is providing teaching to a 17-year-old female client who has severe acne about the use of isotretinoin. Which of the following adverse effects should the nurse instruct the client is the priority to report to the provider?
feelings of isolation
A nurse is teaching a parent of a 10-month-old infant about home safety. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
keep toilet lids in the upright position ensure the crib mattress is in the lowest position
