medsurg final

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?

"Increased pressure from the abscess can cause seizures."

A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client's teaching?

"Monitor your blood glucose levels at least every 4 hours while sick

The nurse is seeking clarification of a statement that was made by a patient. What is the best way for the nurse to seek clarification?

"am I correct in understanding that..."

The nurse is helping a student understand the importance of care coordination. Which of the following is NOT included in the goals of care coordination?

-

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.)

-A 36-year-old woman with systemic lupus erythematosus (SLE) -A 42-year-old man recovering from coronary artery bypass graft surgery -An 80-year-old man with a bacterial infection of the respiratory tract

An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a "steering wheel mark" across the client's chest. Which action should the nurse take?

-Assess the client by gently palpating the abdomen for tenderness -notify the lab to draw for blood type and crossmatch

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately?

Serum potassium level of 2.5 mmol/L

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.)

-Pulmonary crackles -Confusion, restlessness -Cough that worsens at night

A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply the client's shoes before getting the client out of bed. b. Assist the client with ambulation. c. Shave the client with a safety razor only. d. Use a lift sheet to move the client up in bed. e. Use the Waterpik on a low setting for oral care.

Answer: A, B, D

The nurse is caring for a client with metabolic acidosis. Which of the following are appropriate goals for this client?Select all that apply. A) The client will maintain a respiratory rate of 30 or more. B) The client will describe preventative measure for the underlying chronic illness. C) The client will maintain baseline cardiac rhythm. D) pH will range from 7.25 to 7.35. E) The client will take potassium supplements to increase potassium levels.

Answer: B, C B) The client will describe preventative measure for the underlying chronic illness. C) The client will maintain baseline cardiac rhythm.

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?

Are you able to walk upstairs without fatigue?"

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: which action should the nurse take first?

Assess airway, breathing, and level of consciousness.

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?

Assess for symptoms of left-sided heart failure.

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client's teaching?

Gather everything you need for a chore before you begin."

A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen:

Good control of blood glucose

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client?

H 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg

A nurse is teaching the daughter of a client who has Alzheimer's disease. The daughter asks, "Will the medication my mother is taking improve her dementia?" How should the nurse respond?

It will not improve her dementia but can help control emotional responses

The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a4 in each category). What care should the nurse anticipate for this client?

Needs frequent re-orientation

One of the first nurse researchers to document evidence-based practice for nursing was Florence Nightingale. What did Nightingale incorporate into her practice that made her practice different from her colleagues?

Nightingale based her nursing practice on her findings. -Florence Nightingale had tried to develop the role of researcher by using evidence from her practice and implementing these findings. Evidence-based practice (EBP) includes conducting quality studies, synthesizing the study findings into the best research evidence available, and using that research evidence effectively in practice. Although gathering scientific data, calculating statistics to report findings, and communicating findings to powerful others are all important components of conducting research, Nightingale's action that most appropriately reflects the current nursing research priority is that she based her nursing practice on her findings.

A nurse is preparing to hang a blood transfusion. What action is most important?

Putting on a pair of gloves

A patient with a history of epilepsy is taking Phenytoin. The patient's morning labs are back, and the patient's Phenytoin level is 7 mcg/mL. Based on this finding, the nurse will?

initiate seizure precautions

A nurse prepares to discharge a client with Alzheimer's disease. Which statement should the nurse include in the discharge teaching for this client's caregiver?

install deadbolt locks on all outside doors

A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this client's plan of care?

keep the head of the bed at 30 degrees or greater

first question to ask when it comes to a stroke?

last seen well/normal

A nurse manager has recently overheard several negative comments made by nurses on the unit about other nurses on the unit. The manager recognizes that the nurses are exhibiting what type of behavior that is detrimental to collaboration?

lateral violence

Your patient has a history of epilepsy. While helping the patient to the restroom, the patient reports having this feeling of deja vu and seeing spots in their visual field. Your next nursing action is to?

lay the patient down on their side with a pillow underneath the head

A nurse cares for a client with ulcerative colitis. The client states, "I feel like I am tied to the toilet. This disease is controlling my life". How should the nurse respond?

let's discuss potential factors that increase your symptoms

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer?

methylprednisolone (Medrol)

Which of the following is an essential part of medication order sets?

metric dose/strength

The nurse understands that which type of immunity is the longest acting?

natural active

does a CT show an acute ischemic stroke?

not until after 24 hours

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find?

nystagmus

A client is taking furosemide (Lasix) 40mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best?

obtain daily weights of the client

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased ICP?

restlessness

A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this client's discharge education?

use a pill organizer to ensure you take this medication as prescribed

A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device?

use a plastic bag to cover the extremity with the device

A nurse cares for a client with hepatitis C. This client's brother states, "I do not want to contract this infection, so I will not go into his hospital room." How should the nurse respond?

viral hepatitis is not spread through casual contact

what denotes successful swallowing?

weight gain

to promote a safety culture, the nurse manager preparing the staff schedule considers the anticipated census in planning the number and experience of staff on any given shift. What is the human factor primarily addressed with this consideration?

workload fluctuations

After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback?

you cleaned the stoma well. Great job now you need to practice putting on the appliance

A nurse assesses a client with peritonitis. WHich clinical manifestation should the nurse expect to find? (SATA)

-distended abdomen -inability to pass flatus -decreased urine output

The nurse is explaining factors that can influence communication between a patient and a nurse. Which of the following are factors the nurse would include in her discussion?

-education level -anxiety -attitude -physical or cognitive condition

A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (SATA)

-elevated INR -Elevated PT -elevated ammonia

what activities are appropriate for the nurse to collaborate with a patient? (SATA)

-health promotion activities -lifestyle changes to improve health -end-of-life comfort decisions

nurses understand the focus of quality health care should be on which of the following items? (SATA)

-health team collaboration -culturally competent care -comprehensive communication -excellent services (private rooms might be preferred by some patients but do not add to quality of care)

An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (SATA)

-hypotension -tachycardia -confusion

The nurse is assessing what can be done to improve health care quality in the facility? What are the major attributes of health care quality? (SATA)

-identifies adverse events -sound decision making -conforms to standards

liver failure rejection s/s

-jaundice -ascites

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (SATA)

-loosen restrictive clothing -place a pillow under the client's head

The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (SATA)

-my weight should be maintained at a BMI of 30 -I can continue to take aspirin every 4 to 8 hours for my pain

The nurse assesses clients for the cardinal signs of inflammation. What signs/symptoms does this include?

-redness -edema -warmth

A nurse is preparing to give her end of shift report. In the reports, the nurse includes the communication technique of SBAR. Which of the following is included in an SBAR?

-situation -background -recommendation

A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (SATA)

-unique facility identifier -lot number related to the donor -the ABO group and Rh type of the donor

A patient's Brocus area is affected, what can you do to communication with the patient?

-white board -yes/no questions

A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as late signs of increased ICP, a complication of encephalitis? (SATA)

-widened pulse pressure -dilated pupils -bradycardia -irregular respirations

Alteplase (Activase) dosing

0.9mg/kg. Give 10% bolus over 1 min, give the remaining dose as an infusion over 60 mins

The nurse is analyzing the patient's arterial blood gas report, which reveals a pH of 7.15. The patient has just suffered a cardiac arrest. Which consequences of this pH value does the nurse consider for this patient? 1) Decreased cardiac output 2) Decreased potassium levels 3) Increased magnesium levels 4) Decreased free calcium in the ECF

1) Decreased cardiac output The nurse knows that severe acidosis depresses myocardial contractility, which leads to decreased cardiac output.

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates she correctly understands changes associated with this disease?

"He may have trouble chewing, so I will offer bite-sized portions."

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?

"I get short of breath when I climb stairs."

A nurse witnesses a client with late-stage Alzheimer's disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." How should the nurse respond?

"I see you are still hungry. I will get you some toast"

A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.)

-Deep and fast respirations -Tachycardia -Orthostatic hypotension

A student nurse is learning about blood transfusion compatibilities. What information does this include? (SATA)

-Donor blood type O can donate to anyone -Donor blood type A can donate to recipient blood type AB

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.)

-Hematocrit: 32.8%-Serum sodium: 130 mEq/L-Proteinuria-Microalbuminuria

After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.)

-I'll read the nutritional labels on food items for salt content." -"I will eat oatmeal for breakfast instead of ham and eggs." -"Substituting fresh vegetables for canned ones will lower my salt intake."

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.)

-Shortness of breath -Abdominal bloating -New-onset bradycardia

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.)

-Teach the client about dietary restrictions. -Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. -Confirm that an echocardiogram has been completed.

A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (SATA)

-assess vital signs more often -hold other IV fluids running

A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider?

-creatinine of 3.9 mg/dL

A patient with metabolic acidosis has been admitted to the unit from the emergency department (ED). The patient is experiencing confusion and weakness. Which independent nursing intervention is the priority? 1) Protecting the patient from injury 2) Placing the patient in a high-Fowler's position 3) Administering sodium bicarbonate to the patient 4) Providing the patient with appropriate skin care

1) Protecting the patient from injury The patient with metabolic acidosis may have symptoms of drowsiness, lethargy, confusion, and weakness. A priority of care would be preventing injury.

The nurse is caring for a patient admitted with renal failure and metabolic acidosis. Which clinical manifestation would indicate to the nurse that planned interventions to relieve the metabolic acidosis have been effective? 1) Tachypnea 2) Palpitations 3) Increased deep tendon reflexes 4) Decreased depth of respirations

4) Decreased depth of respirations The patient with metabolic acidosis will have an increased respiratory rate and depth. Signs that care has been effective would include a decrease in the rate and depth of respirations.

A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?

A 76 year old who is cognitively impaired

A staff nurse reports a medication error, failure to administer a medication at the scheduled time. An appropriate response of the charge nurse would be a. "We'll do a root cause analysis." b. "That means you'll have to do continuing education." c. "Why did you let that happen?" d. "You'll need to tell the patient and family."

A. "we'll do a root cause analysis"

The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus? a. Young white man b. Middle-aged African-American man c. Young African-American woman d. Middle-aged Native American woman

ANS: D The highest incidence of diabetes in the United States occurs in Native Americans. With age, the incidence of diabetes increases in all races and ethnic groups.

You're assessing your patient load for the patients who are at MOST risk for seizures. Select all the patients below that are at risk: A. A 32-year-old with a blood glucose of 20 mg/dL. B. A 63-year-old whose CT scan shows an ischemic stroke. C. A 72-year-old who is post opt day 5 from open heart surgery. D. A 16-year-old with bacterial meningitis. E. A 58-year-old experiencing ETOH withdrawal.

A. A 32-year-old with a blood glucose of 20 mg/dL. B. A 63-year-old whose CT scan shows an ischemic stroke. D. A 16-year-old with bacterial meningitis. E. A 58-year-old experiencing ETOH withdrawal.

The nurse working with oncology clients understands that which age-related change increases the older clients susceptibility to infection during chemotherapy? a. Decreased immune function b. Diminished nutritional stores c. Existing cognitive deficits d. Poor physical reserves

ANS: A As people age, there is an age-related decrease in immune function, causing the older adult to be more susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves.

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? a. Assessing the IV site every hour b. Educating the client on side effects c. Monitoring the client for nausea d. Providing warm packs for comfort

ANS: A Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse should check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for comfort, but if the client reports that an IV site is painful, the nurse needs to assess further.

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer? a. Epoetin alfa (Epogen) b. Filgrastim (Neupogen) c. Mesna (Mesnex) d. Oprelvekin (Neumega)

ANS: A The clients hemoglobin is low, so the nurse should prepare to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Oprelvekin is used to increase platelet count.

Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) a. Tremors b. Nervousness c. Extreme thirst d. Flushed skin e. Profuse perspiration f. Constricted pupils

ANS: A, B, E When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia.

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings.

ANS: A, D, E "Mild TBI" is a term used synonymously with the term "concussion." A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

ANS: A, D, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.

The nursing student learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? (Select all that apply.) a. Differentiated function b. Large nucleus-to-cytoplasm ratio c. Loose adherence d. Nonmigratory e. Specific morphology

ANS: A, D, E Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth.

A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication? a. Serum electrolyte levels b. Kidney function tests c. Complete blood cell count d. Antinuclear antibodies

ANS: B Adverse effects of levetiracetam include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam.

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. Make certain that your bath water is warm. b. Avoid straining while having a bowel movement. c. Limit your intake of caffeinated drinks to one a day. d. Avoid strenuous exercise such as running.

ANS: B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

ANS: B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take?

Administration of intravenous insulin

After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing AssessmentTime: 0800Temperature: 98 FHeart rate: 68 beats/minBlood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96%Oxygen therapy: 2 L nasal cannulaTime: 1000Temperature: 98.2 FHeart rate: 50 beats/minBlood pressure: 132/57 mm HgRespiratory rate: 16 breaths/minOxygen saturation: 95%Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented.Cardiac rhythm: normal sinus rhythm.Skin: warm, dry, and appropriate for race. Respirations equal and unlabored.Client denies shortness of breath and chest pain.Time: 1000Client alert and oriented.Cardiac rhythm: sinus bradycardia.Skin: warm, dry, and appropriate for race. Respirations equal and unlabored.Client denies shortness of breath and chest pain.Client voids 420 mL of clear yellow urine.Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.

ANS: B IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the clients heart rate.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)

ANS: B Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure' c. Myoclonic seizure d. Absence seizure

ANS: B Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment

When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dl? a. "Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity." b. "The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel." c. "Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP." d. "The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis."

ANS: B The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system.

A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information

ANS: B The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 - 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take? a. Start fluids via a large-bore catheter. b. Turn the client's head to the side. c. Administer IV push diazepam. d. Prepare to intubate the client.

ANS: B The nurse should turn the client's head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and should be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.

A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.) a. Demonstrating breast self-examination methods to women b. Instructing people on the use of chemoprevention c. Providing vaccinations against certain cancers d. Screening teenage girls for cervical cancer e. Teaching teens the dangers of tanning booths

ANS: B, C, E Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods.

A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home

ANS: B, D, E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.

A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Intermittent rigidity b. Lip smacking c. Sudden loss of muscle tone d. Brief jerking of the extremities e. Picking at clothing f. Patting of the hand on the leg

ANS: B, E, F Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atonic seizures.

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

ANS: C A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light- headedness, confusion, syncope, and seizure activity.

The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells? a. Benign tumors grow through invasion of other tissue. b. Benign tumors have lost their cellular regulation from contact inhibition. c. Growing in the wrong place or time is typical of benign tumors. d. The loss of characteristics of the parent cells is called anaplasia.

ANS: C Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

ANS: C Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

ANS: C Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, Why do you want to know if I use cocaine? How should the nurse respond? a. Substance abuse puts clients at risk for many health issues. b. The hospital requires that I ask you about cocaine use. c. Clients who use cocaine are at risk for fatal dysrhythmias. d. We can provide services for cessation of substance abuse.

ANS: C Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the clients question.

A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis? a. Oral temperature of 38.9° Celsius b. Severe orthostatic hypotension c. Increased rate and depth of respiration d. Extremity tremors followed by seizure activity

ANS: C Ketoacidosis decreases the pH of the blood, stimulating the respiratory control area of the brain to buffer the effects of the increasing acidosis. The rate and depth of respirations are increased (Kussmaul's respirations) to excrete more acids by exhalation.

A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate? a. Administer a dose of allopurinol (Aloprim). b. Assess the clients serum potassium level. c. Gently inquire about advance directives. d. Prepare the client for emergency surgery.

ANS: C Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable, the nurse should initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome.

The nurse associates which assessment finding in the diabetic patient with decreasing renal function? a. Ketone bodies in the urine during acidosis b. Glucose in the urine during hyperglycemia c. Protein in the urine during a random urinalysis d. White blood cells in the urine during a random urinalysis

ANS: C Urine should not contain protein. Proteinuria in a diabetic heralds the beginning of renal insufficiency or diabetic nephropathy with subsequent progression to end stage renal disease. Chronic elevated blood glucose levels can cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. This leaking allows protein to be filtered into the urine.

A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures

ANS: C, D Complications of surgery to implant a vagal nerve stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures. Bleeding is not a common complication of this procedure, and infection would not occur during the recovery period.

A student nurse asks the nursing instructor what "apoptosis" means. What response by the instructor is best? a. Growth by cells enlarging b. Having the normal number of chromosomes c. Inhibition of cell growth d. Programmed cell death

ANS: D Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

ANS: D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.

A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients cart prior to administering the medication: Based on the information provided, which action should the nurse take?

Administer the prescribed medication

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?

Atrial fibrillation

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this client's teaching?

Avoid using salt substitutes.

You're educating a 25-year-old female about possible triggers for seizures. Which statement requires you to re-educate the patient about the triggers? A. "I'm at risk for seizure activity during my menstrual cycle." B. "I will limit my alcohol intake to 2 glasses of wine per day." C. "It's important I get plenty of sleep." D. "I will be sure to stay hydrated, especially during hot weather."

B. "I will limit my alcohol intake to 2 glasses of wine per day."

Neurons in the brain are tasked with handling and transmitting information. There are different types of neurons, such as excitatory and inhibitory. Excitatory neurons release the neurotransmitter _____________, while inhibitory neurons release the neurotransmitter ________________. A. GABA, glutamate B. Norepinephrine, GABA C. Glutamate, GABA D. Dopamine, glutamate

C. Glutamate, GABA

Keeping the previous question in mind, the patient is now experiencing characteristics of a tonic-clonic seizure. The seizure started at 1402 and it is now 1408, and the patient is still experiencing a seizure. The nurse should? A. Continue to monitor the patient B. Suction the patient C. Initiate the emergency response system D. Restrain the patient to prevent further injury

C. Initiate the emergency response system

A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a "fruity" odor. Which action should the nurse take?

Consult the provider to test for ketoacidosis.

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed?

Dyspnea on exertion

A nurse cares for a client with advances Alzheimer's disease. The client's caregiver states, "she is always wandering off. What can I do to manage this restless behavior?" How should the nurse respond?

Engage the client in scheduled activities throughout the day

A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow up visit. The nurse evaluates that the client practices good self care when the client makes which statement?

I always wear long sleeves, pants, and a hat when outdoors

A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care?

I know I can take care of all these needs by myself."

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?

I may have been exposed when we ate shrimp last weekend

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?

I must stop halfway up the stairs to catch my breath.

A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, "All of my family hates me." How should the nurse respond?

I will help you identify a support system during this difficult time

After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

I will take a laxative nightly at bedtime to avoid becoming constipated

An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition?

Increased rate and depth of respiration

A nurse is assessing clients on a medical surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?

anxious client who has tachypnea

A client has a traumatic brain injury. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time?

Risk for acquiring an infection

Which patient scenario describes the best example of professional collaboration?

The nurse and physician discuss the patient's muscle weakness and initiate a referral for physical therapy

The nurse is presenting an in-service on the importance of collaborative communication. The nurse includes which critical event identified by the Joint Commission as an outcome of poor communication among health care team members?

The occurrence of a patient event resulting in death or serious injury

A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How should the nurse respond?

Weight is the best indication that you are gaining or losing fluid.

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How should the nurse respond?

Would you like information about advance directives?"

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How should the nurse respond?

Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes."

Which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation? a. Change in level of consciousness b. Inability to focus visually c. Loss of primitive reflexes d. Unequal pupil size

a. Change in level of consciousness

When caring for a patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes along with what other findings?a. Hypertension and bradycardia b. Hypertension and tachycardia c. Hypotension and bradycardia d. Hypotension and tachycardia

a. Hypertension and bradycardia

A 7-year-old male patient is being evaluated for seizures. While in the child's room talking with the child's parents, you notice the child appears to be daydreaming. You time this event to be 10 seconds. After 10 seconds, the child appropriately responds and doesn't recall the event. This is known as what type of seizure?

absence

A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client's care?

allow the client to be as independent as possible with activities

A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client's care? a. "Allow the client to be as independent as possible with activities." b. "Assist the client with frequent and meticulous oral care." c. "Assess the client's ability to eat and swallow before each meal." d. "Schedule appointments early in the morning to ensure rest in the afternoon."

allow the client to be as independent as possible with activities

Only drug used for stroke

alteplase

A client has a long hx of htn. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)?

angiotensin-converting enzyme (ACE) inhibitor

The nurse is assessing a client who was diagnosed with Alzheimer's disease (AD) and notes the client has difficulty finding the correct words at times during conversation. What communication alteration would the nurse document?

anomia

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best?

assess medication records for steroid use

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first?

assess the client for airway patency

A nurse is assessing an older client for the presence of infection. The client's temperature is 97.6. What response by the nurse is best?

assess the client for more specific signs

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). What statement should the nurse include in this client's teaching?

avoid carrying your grandchild with the arm that has the central catheter

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Ctyoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching?

avoid crowds and people with colds

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I am experiencing right flank pain and have a temperature of 101° F." How should the nurse respond? a. "The anti-rejection drugs you are taking make you susceptible to infection." b. "You should go to the hospital immediately to have your new liver checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen (Tylenol) every 4 hours until you feel better."

b. "You should go to the hospital immediately to have your new liver checked out."

The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? a. Aligning the neck with the body b. clustering many nursing activities c. Elevating the head of the bed 30 degrees d. Providing stool softeners or laxatives as ordered

b. Clustering many nursing activities

A nurse assesses a client who is prescribed a medication that inhibits angiotensin 1 from converting into angiotensin 11 (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?

blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg

A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ?

bone marrow

A nurse assesses a client with multiple sclerosis after administering prescribed fingolomod (Gilenya). For which adverse effect should the nurse monitor with in the first 8 hours after administration?

bradycardia

A patient states, "I had a bad nightmare. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which response by the nurse would be an example of interpersonal therapeutic communication?

can you give me an example of what you mean by a "bad nightmare"?

the nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding?

client with Kussmaul respirations

Which statement correctly describes the nurses' role in collaboration?

collaboration occurs in any health care setting as well as community and home settings

The nurse just received a verbal order from the primary care provider. The nurse repeats back to the primary care provider the verbal order for clarification. The nurse supports the safety culture in the health care organization. Which of the following is included in the aspects of safety?

communication -Aspects that contribute to a culture of safety include leadership, teamwork, an evidence base, communication, learning, a just culture, and patient-centered care. Fear of professional or personal punishment and concern about malpractice implications are considered barriers to a culture of safety. No model of nursing care has been related to a culture of safety.

A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?

connect the client to a cardiac monitor

The nurse in the outpatient setting would like to conduct a research study that compares patients who take tramadol (Ultracet) to patients who take oxycodone hydrochloride and acetaminophen (Percocet) for managing back pain. Which quantitative research method should yield the best results?

controlled study - A controlled study is a type of quantitative research that seeks to control and examine the variables to determine effectiveness. In this case, the variables would be those that were administered tramadol (Ultracet) and those that were administered hydrochloride and acetaminophen (Percocet) for managing back pain. Correlational research methods help determine association between or among variables. A longitudinal study examines variables over a designated course of time. A systematic reviews/meta-analysis is a type of literature review and not a research method. A survey study is a type of qualitative research method.

Components of the Glasgow Coma Scale (GCS) the nurse would use to assess a patient after a head injury include which assessment? a. Blood pressure b. Cranial nerve function c. Head circumference d. Verbal responsiveness

d. Verbal responsiveness

The nurse is conducting a review of the literature for pain management techniques. Which of the following would the nurse consider when conducting research that yields solid EBP? (Select all that apply.)

develop an answerable question, search the literature to uncover evidence to answer the question , evaluate the outcome, apply the evidence to the practice situation, evaluate the evidence found

A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?

dialysis

The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse?

dialysis works by movement of wastes from lower to higher concentration

A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, "I do not want to take this medication because it causes diarrhea." How should the nurse respond?

diarrhea is expected; that's how your body gets rid of ammonia

A male client with chronic kidney disease (CKD) is refusing to take his medications and has missed two hemodialysis appointments. What is the best initial action for the nurse?

discuss what the treatment regimen means to him

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?

double-checking the client and blood product identification

A nurse is caring for a client who just had a central venous access line inserted. Which action should the nurse take next?

ensure an x-ray is completed to confirm placement

A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the student that which is the priority when working as a professional nurse?

ensuring client safety

A nurse is preparing to administer a blood transfusion. What action is most important?

ensuring informed consent is obtained if required

A nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital. Which primary psychosocial assessment should the nurse complete?

evaluate the client's reaction to a change of environment

A patient who is experiencing a tonic-clonic seizure is experiencing a focal (partial) seizure. T/F

false

The patient's perception of his or her care is not as important as the outcome of the care.

false The patient's perception of his or her care is just as important as the outcome of the care. If the patient perceives the care as meeting the aspects of quality, then patient satisfaction increases.

If patient is allergic to avocados

give them a latex allergy band and alert kitchen

While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?

grade 3 phlebitis at IV site

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first?

heart rate and rhythm

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best?

help the client create backup plans to minimize disruption

Apraxia

inability to perform particular purposive actions, as a result of brain damage. aka can't use tools right

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" How should the nurse respond?

increased risk of MI

A student nurse is talking with his instructor. The student asks how quality of care is evaluated. Which of the following would the instructor emphasis?

on the basis of process and outcomes. -Quality of care is evaluated by process and outcomes. If the outcomes are achieved, then the care has achieved what is was designed to do. The patient getting well may be an action of the body doing what it is supposed to do and not quality of care; the same can be said of the physician's assessment. The patient's satisfaction is subjective according to his or her perceptions and not the quality of care.

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

place a pillow under the client's head

A nurse prepares to insert a peripheral venous catheter in an older adult. Which action should the nurse take to protect the client's skin during this procedure?

place a washcloth between the skin and tourniquet

A client you are caring for has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse?

place the client on a cardiac monitor immediately.

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

place the client on his side

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first?

prepare to administer dextrose 20% and 10 units of regular insulin IV push

A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?

purulent drainage

A student nurse and clinical instructor are discussing quality in health care. The instructor knows the student understands when the student states which of the following?

quality care is seen and unseen in health care -Quality in health care is tangible and intangible. Quality in health care is not apparent in all health care, as many areas of health care are lacking. Quality of care does not always affect the outcome of care; the patient may recover no matter what care is given. Quality is not always achieved by collaboration.

A nurse delegates care for a client with early-stage Alzheimer's disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client's care?

reorient the client to the day, time, and environment with each contact

The nurse is teaching a new nurse about the seven rights of drug administration, which include right patient, right medication, right time, right dose, right education, right documentation. Which of the following would the nurse teach as the seventh right?

route -The right route (e.g., oral or intramuscular) is an essential component to verify prior to the administration of any drug. The patient does not need to be in a specific location. There may be a number of physicians caring for a patient who prescribe medications for any given patient. A similar drug may be made by a number of different companies, and checking the manufacturer is not considered one of the seven rights. However, the nurse will want to be aware of a difference, because different companies prepare the same medication in different ways with different inactive ingredients, which can affect patient response.

A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. What documentation should alert the nurse to urgently contact the provider for additional prescriptions?

serum potassium of 2.6 mEq/L

The nurse is instructing a student nurse about errors. Which of the following would help the nurse define a sentinel event?

signals the need for immediate investigation and response -a sentinal event is an unexpected occurrence involving death or serious physical or psychologic injury or risk thereof called

A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care?

skin protection

A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse?

take a sample of the effluent and send to the lab

The nurse is caring for a patient experiencing an allergic reaction to a bee sting who has an order for BenaDRYL. The only medication in the patient's medication bin is labeled BenaZEPRIL. The nurse contacts the pharmacy for the correct medication to avoid what type of error?

treatment

communication is a frequently cited cause of errors in the delivery of health care. T/F

true

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

turn the client's head to the side

A nurse is assessing client who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?

upper extremity swelling is noted