Missed questions

The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

- headache - swollen hands - blurred vision

A client with atrial fibrillation is scheduled for an elective cardioversion. The nurse inserts two intravenous (IV)catheters and connects the monitoring lead wires to the client in preparation for the procedure. Which action is most important for the nurse to implement prior to deploying the current for the cardioversion ? A Select a monitor lead with a tall R wave B Activate the synchronization mode C Administer prescribed sedative D Verify the prothrombin time (PT)

Activate the synchronization mode

A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? a. Increase the peripheral IV flow rate to 175 ml/hr to prevent hypotension and shock b. Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. c. Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzymes levels. d. Notify the healthcare provider of the client's increase chest pain a call for the defibrillator crash cart.

Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula.

A postpartal client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide to the client? A) Avoid stimulation of the breasts and wear a tight bra. B) Express a small amount of breast milk by hand. C) Take a prescribed analgesic and expose breasts to air. D) Place warm packs on both of the breasts. A) Avoid stimulation of the breasts and wear a tight bra.

Avoid stimulation of the breasts and wear a tight bra.

The nurse is completing a head-to-toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse? a. Sluggish pupillary response to light b. Clear fluid leaking from the nose. c. Complaint of severe headache d. Periorbital ecchymosis of right eye.

Clear fluid leaking from the nose.

Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse lo chain? A Color, clarity and odor of urine. B Clients ablity to increase fluid intake. C Previous history of urinary trat infections. D Client allergies to antiseptic solutions.

Client allergies to antiseptic solutions.

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock? A. Digoxin B. hydrochlorothiazide C. Nadolol D. Captopril

Digoxin

A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication? a. Olanzapine b. Divalproex. c. Lorazepam d. Fluoxetine

Divalproex.

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare? A) IV administration of benztropine. B) IV administration of isotonic crystalloid fluid. C) PO administration of lorazepam. D) PO administration of divalproex.

IV administration of benztropine.

A client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions. Following the therapy, which finding indicates to the nurse that the intervention was effective? A Increase in breath sounds. B Absence of fine crackles. C Increase in respiratory rate. D Absence of coarse crackles.

Increase in breath sounds.

The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness. Following a paracentesis, the nurse receives laboratory results of the ascitic fluid that show the polymorphonuclear leukocytes count is 425/mm (0.42 x 109/L). After notifying the healthcare provider, which action should the nurse take next? Reference range: Polymorphonuclear Leukocytes Count [greater than 250/mm3 (greater than 0.25 x 109 /L)] A Begin abdominal girth measurements. B Review serum protein levels. C Initiate antibiotic therapy. D Assess neurological status.

Initiate antibiotic therapy.

The nurse is preparing a client with breast cancer for BRCA1 and BRCA2 genetic testing. Which pathophysiological process should the nurse use to support client teaching? A The choice of treatment is best determined by the sensitivity of these genetic markers. B Mutations in BRCAl or BRCA2 identify a client's risk for cancerous cell development in breast tissue. C BRCA1 and BRCA2 provide protection of mature, functioning breast and ovarian cells. D The prognosis of breast cancer is most successful when the these markers are inherited mutations.

Mutations in BRCAl or BRCA2 identify a client's risk for cancerous cell development in breast tissue.

A client with deep vein thrombosis (DVT) in the left leg is on heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care? a. Encourage mobilization to prevent pulmonary embolism b. Assess blood pressure and heart rate at least every four hours c. Observe for bleeding side effects related to heparin therapy d. Measure each calf's girth to evaluate edema in the affected leg

Observe for bleeding side effects related to heparin therapy

While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement? a. Determine of aspirin was given prior to radial artery catheter insertion. b. Promptly remove the arterial catheter from the radial artery. c. Irrigate the arterial line using a syringe with sterile saline d. Administer a PRN analgesic and assess numbness in 30 minutes

Promptly remove the arterial catheter from the radial artery.

A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care? A. Provide a flexible activity schedule B. Provide high-calorie nutritional supplements C. Allow the client to eat meals alone in her room D. Allow the client to choose her clothes independently

Provide high-calorie nutritional supplements

When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan? a. Report any signs of cloudy urine output. b. Seek counseling for body image concerns c. Follow instruction for self-care toileting d. Frequently empty bladder to avoid distension.

Report any signs of cloudy urine output.

A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? a) Use a designated stethoscope when caring for the toddler. b) Wear an N95 respiratory mask while caring for the toddler. c) Remove the disposable gown after leaving the toddler's room d) Place the toddler in a room with negative air pressure.

Use a designated stethoscope when caring for the toddler.

a client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. which schedule should the nurse implement to assess the client's blood pressure after this procedure? a. every 5 minutes for 30 minutes, then every 4 hours thereafter. b. every 1 hour for 2 hours. c. every 5 minutes for 1 hour. d. every 15 minutes for one hour, then every 1 hour for 2 hours.

every 15 minutes for one hour, then every 1 hour for 2 hours.