MSH

A patient surgery for more than 2 hours, what implementation or intervention?

Put padding to the bony prominences

PARKINSON PT WALKING

REASURE THAT STEPPING ON CRACKLES IS NOT HARMFUL

ACUTE AGN DIET

RESTRICT NA INTAKE

UROLITHISIS O LITHOTRIPSY PROCEDURE

RESTRICT PHYSICAL ACTION

Two unlicensed assistive personal (UAP) are arguing loudly in the hallway of an extended care facility about who will shower a male resident who defecated in his bed. What action is best for the charge nurse to take? A) Instruct both UAPs are to shower the client immediately. B) Shower the client with the help of a practical nurse. C) Document the conflict in the employee personnel files. D) Reassign the client's care to another staff member.

Instruct both UAPs are to shower the client immediately

When assessing a client who had a supratentorial craniotomy, what action should the nurse implement when determining the client's Glasgow coma scale (GCS) rating? A- Determine the intracranial pressure. B- Check the patellar and radial reflexes. C- Inject cold water into the client's ear. D- Instruct the client to raise an arm.

Instruct the client to raise an arm.

2 year old child with nephrotic syndrome taking corticosteroids is edematous and fatigue. What action the nurse implement first. A- Sign and symptom of Cushing B- Restrict sodium C- Intake and output... D- Measure abdominal girth for 2 days

Intake and output...

An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for discharge what important aspect regarding his medication therapy should the nurse explain? a. AZT therapy must be stopped when IV aerosol pentamine is being used. b. IV pentamine will be given until oral pentamine can be tolerated c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month d. Iv pentamine may offer protection to others aids related conditions such as kaposis sarcoma

It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month

PATIENT THAT HAVE THE K= 6.7 WHAT MEDICATION PROVIDE

KAYELAXATE (TREATS HYPERKALEMIA

RENAL INJURY

KAYELAXATE MED

COLON CANCER PT

KAYELAXATE Med

CHEST TUBE W/ A DRAINAGE CHANGING FROM CLEAR TO GREEN

KEEP IV FLUIDS

Burns-hydrotherapy

Let the child touch the water

Child taking Lasix. Nurse look for effective of the medicine

Lose 2 pounds weekly

After receiving shift report, the nurse working on a postpartum unit should assessment first? A) Vaginal birth today whose infant is refusing to breastfeed. B) Cesarean birth of twin today who is new complaining of pain. C) Post-cesarean birth today with fundus at the umbilicus. D- Multipara vaginal birth yesterday saturating two pads hours

Multipara vaginal birth yesterday saturating two pads hours

The UAP find a patient (chest tube) with shortness of breath call the RN. What is the first thing that the nurse implements? A- 2 L Oxygen B- Check the tube connection

Check the tube connection

A client who has a history of aggressive and hostile behavior is in the triggering phase of the aggression cycle. Which action should the nurse implement first? A) Encourage the client to verbalize angry feeling. B) Obtain staff assistance to confront the client. C) Administer a PRN medication to the client D) Physically escort the client to a quiet cooling off area.

Encourage the client to verbalize angry feeling.

The school nurse knows that many children with attention deficit problems are also learning disabled. The nurse should teach the parents that a child with a learning deficit will:

Experience perceptual difficulties that make learning problematic

LARGE BLISTER (BACK) CHEST SOAKED SEROSANGUINIOUS DURING ASSESSMENT. WHAT FINDING REQUIRES IMMEDIATE INTERVENTION? A- HEADACHE B- FEVER/CHILLS C- DECREASE BLOOD PRESSURE D- DIZZNESS

FEVER/CHILLS

The nurse is assessing a primigravida at 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider? A) Reports intermittent low back pain. B) Fetal heart rate of 200 beats/minutes C) Complains of early morning heartburn D) Maternal hemoglobin of 11.0 g/ dl or 110 g/l (SI)

Fetal heart rate of 200 beats/minutes Normal FHR pregnant women: 120-160

BONE CANCER TYPE IV

GIVE OPIODS- NON OPIODS ANALGESICS

A client who had a biliopancreatic diversion procedure (BOP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?

Gastroccult positive emesis

A client with eczema is using an over-the-counter (OTC) topical product with urea 10% OTC (Aqua Care Cream) to the affected skin areas. Which finding reflects the expected therapeutic response? • Decreased weeping of ulcerations in affected area • Healing with a return to normal skin appearance • Reduced pain in eczematous areas • Hydration of affected dry skin areas

Healing with a return to normal skin appearance

Which laboratory test result is most important for the nurse to report to the surgeon prior to a client's scheduled abdominal surgery? • Potassium level of 4 mEq/liter • Blood glucose of 90 mg/dl • Serum creatinine of 5 mg/dl • Hemoglobin level of 13 grams

Hemoglobin level of 13 grams

A female client is being treated for tuberculosis with rifampin (rifadin) which statement indicates that further teaching is needed?

I will take my usual contraceptive for birth control

A PATIENT WITH CYSTIC FIBROSIS IS... HUMAN DEOXYRIBONUCLEASE. WHAT FINDING REQUIRE THE NURSE INTERVENTION? A- INCREASE MUCUOS THINNED B- INCREASE 2 POUNDS C- DECREASE FREQUENCY STEATORRHEA

INCREASE MUCUOS THINNED

A 5-year-old child with a ventricular septal defect (VSD) is scheduled for cardiac catheterization. The parents ask the nurse why this test is being done. In formulating a reply, the nurse recalls that it:

Identifies the specific location of the defect

A group of students along with the nurse are on a tour of the hospital in the area of psychiatry and while they were down the hall one patient says "want to see a crazy patient" and start to jump and scream and make hands like a chicken . What should the nurse do? A- Ignore the patient and continue with a tour B- Give PRN anxiety medication C- Call the security D- shake it and bring it to normal state

Ignore the patient and continue with a tour

In planning care for a client with pneumonia, which nursing problem should the nurse identify as the priority? • Impaired gas exchange related to the effects of alveolar-capillary membrane changes • Acute pain related to the effects of inflammation of the parietal pleura • Deficient fluid volume related to fever, infection, and increased metabolic rate • Disturbed sleep pattern related to pain, dyspnea, and hospitalization

Impaired gas exchange related to the effects of alveolar-capillary membrane changes

RA

Impaired peripheral mobility relate to join pain

When teaching a client with osteoporosis to increase weight-bearing exercise, how should the nurse explain the purpose of this activity? • Strengthen leg muscles • Promote venous return • Increase bone strength • Restore range of motion

Increase bone strength

A patient with chemicals in the eyes and is in the hospital. What the nurse tells to the UAP to do to help the patient with the food? A- Give food to the patient in the mouth B- Indicate to the patient where is the tray ( reorient ) C- Look how the patient eat D- Finger food

Indicate to the patient where is the tray ( reorient )

To prevent deep vein thrombosis following knee replacement surgery, an adult male client is receiving enoxaparin (Lovenox) subcutaneously daily. Which laboratory finding requires immediate action by the nurse? a. blood urea nitrogen (BUN) 20mg/dl or 7.1 mmol/L (SI) b. Hematocrit 45% c. Serum creatinine 1.0 mg/dl or 88.4 mol/L (SI) d. Platelet count of 100,000/mm3 or 100x10??/ L (SI)

Platelet count of 100,000/mm3 or 100x10??/ L (SI)

After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? A. Send another nurse for an emergency tracheotomy set B. Call respiratory therapy to give a breathing treatment C. Review the client's complete list of allergies D. Prepare a dose of Epinephrine (Adrenalin

Prepare a dose of Epinephrine (Adrenalin

What is the nurse's priority responsibility when abuse of an 8-year-old child is suspected?

Protecting the child from future abuse

ABG (PH 7.25 PCO2 50 SODIUM 60

TACHY AND CONFUSION/ RESPIRATORY

ALLOPURINOL FOR GOUT

TAKE MEDS ALWAYS

Pt WITH ALS WHAT TO DO TO PREVENT RESPIRATORY COMPLICATIONS:

TEACH BREATHING TECNIQUES, USES SPIROMETER, AUSCULTATE FOR BREATH OR LUNG SOUNDS.

Shingles

Teach the pt about phantom pain

ACUTE ABDOMINAL PAIN, NAUSEA, PROJECTILE VOMITING

SEVERE HEADACHE AND PHOTO Sensitivity

A Hindu patient... what can the nurse do? A- REMOVE BEEF FROM PT MEAL TRAIL B- ENCOURAGE FAMILY TO BRING FOOD FROM HOME C- SHOW THE CARDIAC MENU TO THE PATIENT D- GIVE TO THE PATIENT WHAT HE WANTS

SHOW THE CARDIAC MENU TO THE PATIENT

ABDOMINAL LEFT FEMORAL ANGIOPLASTY: A- SURGEON NEEDS TO SEE B- LEFT PHERIPHERAL PULSES

SURGEON NEEDS TO SEE

CARPO TONIC SYNDROME

WEAR BRACE IN BOTH WRIST

The nurse in the outpatient unit is caring for a client who had a right femoral cardiac cauterization two hours ago .What assessment findings requires immediate intervention? A. The client wants assistance walking to the bathroom B. Clients pulse oximeter is 98% C. The client right feed is warn to touch D. The client B/P is 110/70 and pulse 90

The client wants assistance walking to the bathroom

A nurse is preparing for discharge a school-aged child who has undergone splenectomy for β-thalassemia (Cooley anemia). What information should the discharge teaching include?

A high fever should be reported to the child's health care provider

BMI: COLON CANCER

Large waist circumference with central fat

When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. What action should the nurse take? a. Remove the patch and consult with the healthcare provider about the client pain resolution b. Place the patch on the clients shoulder and leave both patches in place for 12 hours c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch d. Apply a new patch in a different location after removing the original patch

Apply a new patch in a different location after removing the original patch

An older male resident of a long-term care facility has been scratching his legs for the past 2 days. Which intervention should the nurse implement? A) Explain the importance of bathing or showering daily. B) Keep the legs covered as much as possible. C) Apply emollient to affect area at least twice daily. D) Encourage fluid intake of at least 2,000 ml daily

Apply emollient to affect area at least twice daily.

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing diagnosis of, "Risk for injury related to impaired judgment." Which intervention is most important for the nurse to include in this client's plan of care? A.Offer the client frequent reassurance that he/she will be safe. B.Assign a UAP to provide the client with total personal care. C.Engage the client in regularly scheduled activities during the day. D.Arrange the client's environment so the client can move about freely.

Arrange the client's environment so the client can move about freely.

The patient was in pain and mom was saying she was ready for cesarean because she knew what had already had 8 children. A- Call the security B- Ask her to leave the room C- Call the charge nurse

Ask her to leave the room

A parent tearfully tells a nurse, "They think our toddler is developmentally delayed. We're investigating a preschool program for cognitively impaired children." What is the most appropriate response by the nurse?

Asking for more specific information related to the developmental delays

A male tells the clinic nurse that he is experiencing burning on urination, and assessment that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement? • Observe the perineal area for a chancroid-like lesion • Obtain a specimen of urethral drainage for culture • Identify all sexual partners in the last four days • Assess for perineal itching, erythemia, and excoriation

Assess for perineal itching, erythemia, and excoriation

Patient with pneumonia ABG ph 7.24, CO2 65, CO3 24. Which intervention...plan of care daily A. Hypertension B. Maintain IV C. Check electrocardiogram daily D. Assess lung for increase pulmonary secretion

Assess lung for increase pulmonary secretion

The nurse applies an automatic external defibrillator (AED) to a client who collapsed in an exam room at a community clinic. What action should the nurse take next? • Determine the defibrillator reading • Assess the client's oxygen saturation • Bring a crash cart to the exam room • Measure the client's blood pressure

Assess the client's oxygen saturation

A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt? a. discontinue intravenous therapy b. Assess for abdominal distension and tenderness c. Obtain a prescription for a diet change d. Auscultate bowel sound in all four quadrants

Auscultate bowel sound in all four quadrants

A male client with angina pectoris is being discharged from the hospital. What instructions should the nurse plan to include to the discharge teaching? a. Engage in physical exercise immediately after eating to help decrease cholesterol levels. b. Walk briskly in cold weather to increase cardiac output. c. Keep nitroglycerin in a light-colored plastic bottle and readily available. d. Avoid all isometric exercises, but walk regularly.

Avoid all isometric exercises, but walk regularly.

What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? a. Sexual activities may be resumed upon return home b. Light housekeeping is permitted but avoid heavy lifting c. Use a metal eye shield on operative eye during the day d. Administer eye ointment before applying eye drops

Light housekeeping is permitted but avoid heavy lifting

A nurse is caring for a school-age child with Reye syndrome. For what complication should the nurse be particularly alert?

Bleeding and ecchymoses from liver involvement

A client with pheocromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain first?

Blood pressure

A patient get to ER and had a week before a bariatric surgery, patient is shortness of breath and has abdominal pain. A. Blood pressure 88/50 B. Left shoulder pain C. Sustained sinus tachycardia D. 101 temperature

Blood pressure 88/50

A newborn with an anorectal anomaly undergoes anoplasty. At the 2-week follow-up visit, a series of anal dilations is started. What should the nurse recommend to the parents to help prevent the infant from becoming constipated?

Breastfeed if possible.

The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in the client's history is a contributor to the osteoarthritis? a. Lactose intolerant since childhood. b. Recently treated for deep vein thrombosis. c. Long distance runner since high school. d. Photosensitive to a drug currently taking.

Long distance runner since high school.

Following involvement in a motor vehicle collision, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administer if the clients begins to exhibit signs and symptoms of delirium tremens (DT s)? a. Lorazepam (Ativan) 2mg IM b. Chlorpromazine (thorazine) 50 mg IM c. Prochlorperazine (Compazine) 5 mg IM d. Hydromorphone (Dilaudid) 2 mg IM

Lorazepam (Ativan) 2mg IM

An adult woman with Grave's disease is admitted with severe dehydration is currently restless and refusing to eat. Which action is most important for the nurse to implement? • Keep room temperature cool • Determine the client's food preferences • Maintain a patent intravenous site • Teach the client relaxation techniques

Maintain a patent intravenous site

The parents of a 6-year-old boy tell the nurse in the pediatric clinic that their son has recently started to wet the bed at night. What is the most helpful response by the nurse?

Have there been any changes in his life recently?

A client whose history includes IV drug abuse is admitted to the intensive care unit (ICU) with Kaposi's sarcoma associated with Acquired Immune Deficiency Syndrome (AIDS). Which intervention is most important for the nurse to include in the client's plan of care? • Observe for adverse medication reactions • Assess for signs of AIDS dementia • Identify signs of opportunistic infections • Locate local HIV support groups

Identify signs of opportunistic infections

A client who has a history of long-standing back pain treated with methadone (Dolophine), is admitted to the surgical unit following urological surgery. What modifications in the plan of care should the nurse make for this client's pain management during the postoperative period? • Use minimal parenteral opioids for surgical pain, in addition to oral methadone • Maintain client's methadone, and medicate surgical pain based on pain rating • Consult with surgeon about increasing methadone in lieu of parenteral opioids • Make no changes in standard pain management for this surgery and hold methadone

Maintain client's methadone, and medicate surgical pain based on pain rating

The school nurse is implementing standards to manage students and provide a safe and healthy school setting. Which action is most important for the nurse to implement? A- Maintain student immunization records B- Develop an emergency plan for the school C- Ensure that medical supplies are available D- Conduct annual student health assessments

Maintain student immunization records

The nurse reports that a client is at risk for a brain attack (stroke) finding? • Jugular vein distention • Palpable cervical lymph node • Carotid bruit • Nuchal rigidity

Nuchal rigidity

RIGHT HIP FRACTURE

O2 SAT LEVEL

PNEUMONIA IS DIAPHORETIC AND CONFUSED

OBSERVE FREQUENTLY

A male client with a long history of alcoholism is admitted because of mild confusion and fir motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurse to include in the client's plan of care? A) Observe for changes in level of consciousness B) Provide grief counseling for client and his family C) Involve the client's family in healthcare decision D) Determine client's current blood alcohol level.

Observe for changes in level of consciousness

A client is admitted with a sudden onset of right sided the nurse complete first?

Observe for peripheral edema

An infant has noncommunicating hydrocephalus, and a ventriculoperitoneal shunt is inserted. What should the nurse do when caring for the infant during the initial postoperative period?

Place the infant flat with the head on the unaffected side.

A pt with possible pneumonia come to the hospital and the nurse need to do an assessment but the family don't want to leave the room, what the nurse need to do first? A -Call the security B- Put the family out of the room C- Put a pneumonia droplet sign in the door D - Continue with the assessment and put mask to the family

Put a pneumonia droplet sign in the door

Peripheral neuropathy Pregabalin 4 days, what indicate med is effective? A. GRANULATING TISSUE IN FOOT ULCER B. IMPROVED VISUAL ACUITY C. FULL VOLUME OF PEDAL PULSES D. REDUCE LEVEL OF PAIN

REDUCE LEVEL OF PAIN

PREGNANT WOMEN WITH 8 CM DE DILATATION Y 100%, SHE WANTS TO GET HYDROCHLORIDE (DON'T REMEMBER THE EXACTLY NAME) FOR PAIN A- ADMINISTER EPIDURAL B- ADMINISTER HYDROCHLORIDE C- RELAXATION TECHNIQUE

RELAXATION TECHNIQUE

HYPOTHYROIDISM

RESTRICT SODIUM NA 122

PT WITH OSTEOMALCIA

RISK FOR INJURY

OSTEOARTHRITIS

RISK FOR INJURY RELATED TO JOINT PAIN

An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose? a. BUN creatinine specific gravity b. White blood count, hemoglobin hematocrit c. PH,PCO2, HC03 d. LDH OR LD, SGOT OR ALT, SGPT OR AST

LDH OR LD, SGOT OR ALT, SGPT OR AST

TRACHESTOMY CARE

LEAVE OLD TIES ON UNTIL NEW ONES BE ON PLACE OR SECURE

Finger stick glucose finding 50

LOC-->Level of conscious

Pt. DIAGNOSED RECENTLY W/ DM HAVE NOT BEEN ABLE TO CONTROL GLUCOSE LEVEL DURING 3 MONTH WHAT SHOULD BE DONE

- CHECK FOR A1C LEVEL - (OTHER SAY ASSESS FOR WHAT SHE HAVE BEEN EATING 3 DAYS AGO).

PT VOMITING BLOOD LIKE THE PICTURE SAME AS HEMATENSIS

- CHECK VITAL SIGNS - AUSCULTATE LUNGS SOUNDS

Fifteen minutes after receiving sulfa athenozole. A male client report a burning sensation over his abdomen chest and groin. Which intervention is most important for the nurse to implement? a. Auscultate lung sounds for wheezing b. Review the clients list if drugs allergies c. Add sulfamethinozole to clients allergies d. Check neurological vital signs

Review the clients list if drugs allergies

A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? a. collect a clean catch specimen b. palpate the suprapubic region c. instruct to wipe from front to back d. inquire about recent sexual activity

collect a clean catch specimen

Which assessment finding indicates to the nurse that the muscarinic agent bethanechol (Urecholine) is effective for a client diagnose with urinary retention? a. urinary output equal to intake b. no terminal urinary dribbling c. denies stress incontinence d. absence of xerostomia

urinary output equal to intake

MULTIPLE SCLEROSIS (MS)

ADMINISTER ANTIMEDICS/ PRN AS PRESCRIBED

EXTERNAL FIXATION

ADMINISTER PRN MEDS

A female adult who is undergoing chemotherapy tells the nurse that she plans to volunteer at elementary school this winter. Which question is best for the nurse to ask this client? a) "Do you realize that you will be exposed to many different kinds of germs?" b) "Have you considered that you are putting yourself at risk for developing infections?" c) "Are you aware that you do not have a fully functioning immune system?" d) "Is it possible that you will be in direct contact with the children at the school?"

"Have you considered that you are putting yourself at risk for developing infections?"

An infant with a myelomeningocele undergoes surgery and is returned to the pediatric unit. The father appears anxious and tends to avoid physical contact with the infant. Later he says to the nurse, "My wife seems so wrapped up with the baby; I hope she has time for me." What is the most therapeutic response by the nurse?

"I can understand your concern about the changes you'll have to make

The nurse is evaluating medication teaching. Which statement by a female who takes a barbiturate for sleep indicates she understands the teaching? a) "I should ensure that I do not become pregnant while taking this medication." b) "I must take my birth control pill in the morning and my sleeping pill at night." c) "I will increase the amount I take in small doses if I can't sleep through the night." d) "I should take my anxiety pill, alprazolam, only when I really need it."

"I should ensure that I do not become pregnant while taking this medication."

The spouse of a client with Parkinson's wants to know how to best assist her husband during feeding as he is having "increasing problems with drooling and swallowing." What instruction should the nurse provide to the family member? A) "Use thickened liquids along with upright positioning during feeding." B) "It might be time to switch to enteral feedings if you are afraid that your husband may choke." C) "Increase the amount of fluids he receives to decrease saliva formation and improve swallowing." D) "Use a straw during feedings to facilitate swallowing."

"Use thickened liquids along with upright positioning during feeding."

A practitioner prescribes an initial loading dose of 75 mcg of oral digoxin (Lanoxin) for a school-aged child. The medication is supplied as an elixir, 50 mcg/mL. How many milliliters of solution should the nurse administer? Record your answer using one decimal place. ___ mL

1.5

After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with a severe migraine headache the nurse should explain that relief can be expected within what time frame? a. 2 hours b. 5 minutes c. 1 hour d. 15 minutes

15 minutes

SLE (lupus)

ASSESS FOR HEMATURIA

RESTLESS LEG SYNDROME

ASSESS FOR IRON AND FERRITIN

PATIENT ALLERGIC TO BANANA (LATEX

CALL TO MD AND OR STAFF TO BE CHANGE EVERYTHING FOR SYNTHETIC MATERIALS

A client with type 2 diabetes mellitus is managed with metformin (Glucophage), an oral hypoglycemic agent. The primary health care provider prescribes ad additional medication injected exenatide (byetta). Which information is most important for the nurse to teach this client? a. Administer subcutaneously after meals b. Consume additional sources of potassium c. Notify the healthcare provider if anorexia occurs d. Watch for signs of jitteriness or diaphoresis

Consume additional sources of potassium

During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement? • Palpate for abdominal distention • Clamp drainage tube for 5 minutes • Continue to monitor the fluid output • Send fluid to the lab for analysis

Continue to monitor the fluid output

A client who suffered an electrical injury on the left foot is admitted to the burn include in this client's plan of care? • Assess lung sounds q4 hours • Perform passive range of motion • Evaluate level of consciousness • Continuous cardiac monitoring

Continuous cardiac monitoring

NGT proper tube procedure

Elevate dead 60 to 90 degree

A nurse is assessing a 2 year-old child with left sided heart failure. Which assessment finding should the nurse report to the healthcare provider immediately? a. Penorbital edema noted bilaterally after napping b. Crackles heard in lower lobes of lungs bilaterally c. An apical heart rate of 120 beats per minute d. Liver palpated 2 cm below right costal margin

Crackles heard in lower lobes of lungs bilaterally

PT WITH A BRONCHOSCOPY AND DRINK A GLASS OF JUICE

DELAY THE PROCEDURE 6 HOURS

A client's morning laboratory test results include leukocytes 3,500/mm3 or 3.5 x 10???/L (SI). Based on this laboratory result, which complaint is this client most likely to report to the nurse? a) Inability to walk without shortness of breath. b) Superficial cuts do not readily stop bleeding. c) A red streak and pain in right calf muscle. d) Persistent cough with yellow-colored sputum.

Persistent cough with yellow-colored sputum.

A young adult male is brought to the emergency room with a multiple gunshot wounds in the chest abdomen, and head. After collecting the client's bloodsaturated clothing as forensic evidence or the medical examiner, which action should the nurse implement? A) Drop the clothes in a plastic bag and seal the bag with transported tape. B) Place clothing in a large specimen container and send to the pathology lab. C) Place the folded clothes in a paper bag transfers it to red biohazard bag. D) Roll the clothing in a towel and cover it with an impermeable drape.

Place the folded clothes in a paper bag transfers it to red biohazard bag.

A client with symptoms of influenza that started the previous day ask the clinic nurse about taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse provide? a. Advise the client once symptoms occur is too late to receive an influenza vaccination b. Refer the client to the healthcare provider at the clinic to obtain a medication prescription c. Explain to the client that antibiotics are not useful in treating viral infections such as influenza d. Instruct the client that over the counter medications are sufficient to manage influenza symptoms

Refer the client to the healthcare provider at the clinic to obtain a medication prescription

Which instruction is most important for the nurse to provide a client who receives a prescription for risendronate sodium to treat osteoporosis? a. Remain upright after taking the medication. b. Begin a weight-bearing exercise plan. c. Increase intake of foods rich in calcium. d. Schedule a bone test every year.

Remain upright after taking the medication.

At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on data contained in the record, what action should the nurse take before assisting the client with ambulation (click on each chart tab for additional information, be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record) A) Remove sequential compression devices B) Apply PRN oxygen per nasal cannula C) Administer a PRN dose of an antipyretic D) Reinforce the surgical wound dressing

Remove sequential compression devices

A newborn has just been admitted to the pediatric surgical unit from the birth hospital with a diagnosis of tracheoesophageal fistula. In what position should this child be maintained?

Semi-Fowler, to reduce the risk of chemical pneumonia

A 4-YEAR-OLD child hospitalized with asthma is receiving theophylline. Which observation by the nurse warrants immediate intervention? A) The child heart rate is 110. B) The child's breath sounds indicate bilateral expiratory wheezing. C) The child is sitting straight up in bed. D- The child is nauseated and irritable.

The child is nauseated and irritable.

The child at school said that had a lot of headache and go to the nurse. What comment made by the child concerned the nurse?

The child says something that wants to see his mom

Head injury-diabetes insipidus

The more common causes are excretion of excess fluid administered during surgery and an osmotic diuresis, resulting from treatment aimed at minimizing cerebral edema using mannitol or glucocorticoids

RN needs to go 4 patients and which one needs to see first: A. The patient discharge yesterday and dehydrated B. The patient start a new medication and is incontinence C. The patient that doesn't want to take a shower

The patient start a new medication and is incontinence

Patient with rheumatoid arthritis joint pain and swelling, taking prednisone and ibuprofen, self management pain what information obtain A. Presence of bruising, weakness B. Amount of protein C.Therapeutic exercise daily D.Existence GI discomfort

Therapeutic exercise daily

Cataract extraction-nausea

ZOFRAN OR ANTIEMETIC

An antacid is prescribed for a client with gastro esophageal reflux (GERD). The client asks to the nurse, "How does this help my GERD? What is the best response by the nurse? A."Antacids decrease the production of gastric secretions." B. "It will improve the emptying of food through your stomach." C. "This medication will coat the lining of your esophagus." D."Antacids will neutralize the acid in your stomach."

"Antacids will neutralize the acid in your stomach."

A patient is diagnosed with MALIGNANT HYPERTENSION, patient likes skiing and asks if is ok to continue: A. "COLD WEATHER MAY CONSTRICT YOUR BLOOD VESSELS AND INCREASE BP" B. "SKIING MIGHT PRODUCE TOO MUCH EXERTION" C. "SHOULD BE OK AS SOON AS YOU CONFINE SKIING D. "GO FOR IT IS A TERRIFIC WORKOUT

"COLD WEATHER MAY CONSTRICT YOUR BLOOD VESSELS AND INCREASE BP"

Ketoacidosis Diet A- Banana, whole bread... B- Oatmeal...... C- 6 oz Coffee, strawberry, artificial sweetening D-Egg, butter

6 oz Coffee, strawberry, artificial sweetening

The mother of an infant with hypertrophic pyloric stenosis states that she has never heard of this disorder and asks many questions. What should the nurse emphasize when responding?

"This disorder has an excellent prognosis."

PREOPERATIVE NURSING CARE

- ASSESS EMOTIONAL PREPAREDNESS - ALSO CAN BE CONCERNS AND ANXIETY FOR SURGERY

INTERMITENT CLAUDICATION TEACHING

- BANDAGE ELASTIC WRAPED AROUND LEGS - PAIN TRACTION CAST NOTIFY MD (CAST NO MORE THEN 4HR)

DISCHARGE FOR VENOUS ULCERS SELECT ALL APPLY?

- ELEVATE THE FEET WHEN LAYING DOWN - CHECK BROWNISH SKIN AROUND THE ANKLES - VITAMINS

PT W/ OPEN ANGLE GLAUCOMA SELECT ALL THAT APPLY

- FREQUENT EYE EXAM TO ASSES FOR VISSION, - USE DROPS TO DIMINSH IOP, - AVOID EXTRENOUS EXERCICES LIKE JOGGING OR RUNNING

PT ARRIVES TO CLINIC W/ NUCHAL RIGIDITY FEVER FOR 6 HOURS. WHAT TO DO?

- PREPARE FOR ISOLATION PRECAUTIONS - ( I PUT THIS ONE AND NO LUMBAR PUNCTURE)

PT W/ RAYNAUD SYNDROME WHICH WORK AS A DATA ENTRY CLERK

- PROVIDE A SPACE TO WARM THE ENVIROMENT NEXT TO HER - KEEP MONITORING

Shingles Select all the apply

- pain - ability - skin integrity

Airbourne Precautions

-measles -TB -varicella

A client returns from surgery following a hiatal hernia repair via Nissen fundoplication. Which position should the nurse implement for this client? • Right side-lying to promote stomach emptying • Prone to apply external pressure to the suture line • Left side-lying to reduce stress on the suture line • 30 degree semi-Fowler's to drop the diaphragm

30 degree semi-Fowler's to drop the diaphragm

Lower abdominal pain (Order): 1. Ask for last food that eat 2. AUSCULTATE 4 QUADRANTS 3. DETERMINE BOWEL MOVEMENT 4. POSITION BENT KNEES 5. INSPECT ABDOMINAL

4, 1, 3, 5, 2

Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first? a) A 41-week multigravida who is scheduled induction of labor today. b) A 38-week primagravida who reports contractions occurring every 10 minutes. c) A 36-week multigravida with a prescription for serial blood pressure. d) A 39-week primigravida with biophysical profile score of 5 out of 8

A 39-week primigravida with biophysical profile score of 5 out of 8

As team leader, the nurse is caring for a group of clients with the help of a practical nurse (PN) and experienced unlicensed assistive personnel (UAP). Which nursing actions should the nurse assign to the PN? (Select all that apply) A- Change surgical dressing daily for a client who had an abdominal hysterectomy B- Obtain postoperative vital signs for a client with an epidural analgesic after having a knee arthroplasty C- Start a blood transfusion for client who just returned to the room following a below knee amputation D- Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM)

A, B, D

An older female client with long term type 2 diabetes mellitus (DM) is seen in the doctor routine health assessment. To determine if the client is experiencing any long-term complications of DM, which assessments should the nurse obtain? Select all that apply: • Visual acuity • Serum creatinine and blood urea nitrogen (BUN) • Signs of respiratory tract infection • Sensation in feet and legs • Skin condition of lower extremities

A, B, D, E

PATIENT DIES AND FAMILY WANT TO SEE HIM BEFORE THE HOME FUNERAL ARRIVED, THE NURSE SHOULD ENTER FIRST TO THE ROOM (SELECT ALL THAT APPLY): A- REMOVE THE RESUSCITATION EQUIPMENT B- REMOVE THE DENTURES C- CLOSE HIS EYES D- PUT A PILLOW UNDER THE HEAD E- USE A SHROUD BAG

A, C, D

During an annual health check, the clinic nurse updates an adult female's health history. When discussing the woman's history of lactose intolerance, the client reports that it has been years since she last consumed dairy products. What dietary suggestions should the nurse recommend to help ensure that the client receives an adequate intake of calcium? Select all that apply: • Increase intake of salmon, sardines, tofu, and leafy green vegetables • Sip a half-cup of mil during a mid-day meal at least every other day • Eat at least six servings of citrus fruits weekly • Include 2 to 3 servings of yellow and green squash weekly • Take a calcium supplement with vitamin D daily

A, C, E

A patient recovering left femoral atrial sheath. What finding requires immediate intervention (Select all that apply?) A. Tenderness on insertion site B. Left groin egg size C. Quarter size of drainage D. Unrelieved back, flank pain E. Cool/pale left foot

A, E Arterial sheath : Pedal pulses and color, warmth movement and sensation of affected leg & foot. Assess insertion site for bleeding, pain, tenderness, swelling or hematoma.

WHEN BP IS HIGH

ADMINISTER (LASIX)

STERNAL TRACTION COMPLAINS OF PAIN

ADMINISTER PRN MEDS

BNP

ADMINISTRATIVE FUROSEMIDE LASIX IV

Which symptoms is a characteristic of urethral colic in the client diagnosed with renal calculi? a. symptoms of irritation associated with urinary tract infection b. Acute, excruciating pain, wave-like pain radiating to the gemnitalia c. intense, deep ache in the cost vertebral region d. chills, fever and dysuria

Acute, excruciating pain, wave-like pain radiating to the gemnitalia

SUBCUT EMPHYSEMA- TORACOTOMY WAS A SELECT ALL THAT APPLY

ASSESS FOR LUNG SOUNDS

PT WITH AN EXTERNAL DEVICE COMPLAINING OF PAIN

ASSESS FOR PHERIPHERAL PULSES

FEMALE PATIENT HOW HAVE EPIGASTRIC PAIN FOR 3 DAYS HAVE BEEN TAKIN ANTACIDS AND NO RESOLVE ARRIVE TO HOSPITAL W/HR;128 BPM, BP110/70 WHAT IS THE MOST IMPORTANT INTERVENTION FINDING IN ASSESSMENT

ASSESS FOR RADIATING JAW PAIN

NEW PATIENT DIAGNOSES WITH DM TYPE IS RECEIVING TEACHING IN WHICH GLUCOMETER WILL BE THE BEST

ASSESS FOR VISUAL ACUITY AND ABILITY TO READ OR SOMETHING LIKE THAT

The nurse is taking a client's blood pressure sphygmomanometer cuff is inflated. What (incomplete) • Administer a prescribed PRN antianxiety • Assess the client's recent serum calcium • Notify the healthcare provider of the • Prepare to implement seizure precautions

Administer a prescribed PRN antianxiety or B

A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? • Encourage frequent mouth care • Administer a topical analgesic per PRN protocol • Cleanse the tongue and mouth with glycerin swabs • Obtain a soft diet for the client

Administer a topical analgesic per PRN protocol

Client was admitted to the cardiac observation unit 2 hour ago complaining of chest pain .On admission the client EKG showed bradycardia ,ST depression ,but no ventricular ectopic .The client reports a sharp pain ,telling the nurse ,I feel like an elephant just stepped on my chest .The EKG now shows Q waves and ST elevations in the anterior leads .What intervention should the nurse perform ? A. Administer prescribed morphine sulfate IV and provide oxygen at 2L per minute per nasal cannula B. Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzyme levels C. Notify the HCP of the clients increased chest pain and call for defibrillator crash cart D. Increased the peripheral IV rate to 175 ml/hr. to prevent hypotension and shock

Administer prescribed morphine sulfate IV and provide oxygen at 2L per minute per nasal cannula

A male client reports to the nurse that he is experiencing GI distress from high dose of a corticosteroid and is planning to stop taking the medication. In response to the client's statement what nursing action is most important for the nurse to take? a. Encourage the client to take medication with food to decrease GI distress b. Advice the client that the medication should be stopped gradually rather than abruptly. c. Review the clients dosing schedule to ensure he is taking the prescribed amount d. Assess the client for other indication of adverse effects of corticosteroid

Advice the client that the medication should be stopped gradually rather than abruptly.

The nurse is with a patient doing a CAGE questionary 3 positive response. What the nurse.... A- Is a questionary for substance abuse B- 1 positive seek help for alcohol dependence C- All least 2 positive strongly alcohol dependence D- All positive suggest alcohol dependence

All least 2 positive strongly alcohol dependence

A nurse is assessing an infant with suspected developmental dysplasia of the hip. What does the nurse expect the infant's orthopedic status to reveal?

An infant needs emergency surgery.

A young adult female client with recurred pelvic pain for 3 years returns to the clinic for relief of severe dysmenorrheal. The nurse reviews her medical record which indicates that the client has endometriosis. Based on this finding, what information should the nurse provide this client? A- Oral contraceptives increase the symptoms of endometriosis B- An option to diagnose disease extent and provide therapeutic treatment is laparoscopy C- Infertility is successfully treated with removal of intra-abdominal endometrial lesions D- The symptoms of endometriosis can increase with menopause

An option to diagnose disease extent and provide therapeutic treatment is laparoscopy

A 6-year-old child undergoes supratentorial craniotomy for evacuation of a subdural hematoma. In what position should the nurse place the child during the first 24 hours after surgery?

Angulo 45 grades

A male client, who had a total laryngectomy two days ago, is transferred from the intensive care unit to a private room close to the nurse's station. The nurse recognizes that the client is anxious. Which intervention should the nurse implement? a. Encourage a family member to stay with the client at all times b. Answer the client's call signal in person quickly after the calls c. Explain the emergency procedure for loss of airway to the client d. Provide the client with a suction catheter to allow for self-suctioning

Answer the client's call signal in person quickly after the calls

An elderly patient who lives alone and falls, hip fractures and goes to hospital. She was worried about her dog. (Select all that apply): a- Put 2 pillows b- PRN med c- Contact social worker d- Ignore the patient

B, C

Which conditions are most likely to respond to the treatment with antihistamines? (Select all that apply) A) Otitis media B) Allergy rhinitis C) Contact dermatitis D) Myocarditis E) Bronchitis

B, C

A male client recently release from a correctional facility arrives at the clinic with a cough, fever, and chills, active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply) A- Administer a purified protein derivate (PPD) test B- Schedule the client for a chest radiograph C- Obtain sputum for acid fast bacillus (AFB) testing D- Place a mask on the client until he is moved to isolation E- Send client home with instructions for a prescribed antibiotic

B, C, D

Following an esophagogastroduodenoscopy (EGD), a male client is drowsy and difficult to and his respiratory are slow and shallow. Which action should the nurse implement (Select all that apply?) A) Initiate bag valve-mask ventilation. B) Prepare medication reversal agent. C) Apply oxygen via nasal cannula. D) Check oxygen saturation level. E) Begin cardiopulmonary resuscitation.

B, C, D

A PATIENT WITH HIGH BP, THE NURSE GIVE A TEACHING FOR WHAT CAN HE EAT FOR LUNCH?

BAKED SWEET POTATO

An unconscious toddler requires intermittent nasogastric feedings. When should the nurse check placement of the tube?

Before each feeding

CENTRAL FALL RISK

CARDIOVASCULAR DISEASE

PT WITH OBESITY HIGH GLUCOSE LEVEL IS AT RISK FOR?

CARDIOVASCULAR DISEASE

PT ARRIVE TO PACU POSTOP MOANING WHAT TO DO

CHECK PULSE, BP AND RESPIRATIONS

ANTIBIOTICS

CLEAR DRAINAGE IMPROVE

A PATIENT SCHEDULED MRI AND SAID THAT HAS A METAL TOOTH. WHAT THE RN NEED TO DO? A- ASSESS PT FEAR TO THE TEST B- CONSULTS RADIOLOGY C- SEND PT TO X-RAY INSTEAD D- CANCEL THE TEST.

CONSULTS RADIOLOGY

PT W/ A EXPRESSIVE APHASIA IS ANGER WHAT SHOULD DO THE NURSE

CVA- COMMUNICATE W/ PICTURE BOARDS

The nurse assesses the dressing of a client who has just returned from post-anesthesia and finds that the dressing is wet with a moderate amount of bright red bloody drainage. What action should the nurse take? • Replace dressing with a new sterile dressing, and monitor the wound hourly until bleeding is stopped • Call surgery and request that the surgeon see the wound prior to leaving the hospital • Reinforce the dressing and document that a moderate amount of sanguineous drainage was on the dressing • Document that the dressing was saturated with serious drainage, and do not change the dressing

Call surgery and request that the surgeon see the wound prior to leaving the hospital

A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. What action should the nurse implement?

Call the PACU nurse to prepare for prolonged ventilatory support Also know that PACU is BP, Respiration and Pulse

The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are eligible and it appears the healthcare provider used several abbreviations in the prescription. What action should the charge nurse take? a. Report the situation to the house supervisor b. Complete and incident (variance) report c. Call the healthcare provider who wrote the prescriptions d. Contact the healthcare provider review board for instructions

Call the healthcare provider who wrote the prescriptions

While taking routine vital signs at 0400 AM, the nurse notes that a client who had a total knee replacement the previous day has a heart rate of 126 beats/minute. What action should the nurse take first? • Compare heart rate trends with blood pressure trends • Review the medical record for a history of cardiac disease • Check surgical drainage system and bandage for bleeding • Determine current pain level using a 10-point scale

Check surgical drainage system and bandage for bleeding

The nurse is caring for a client with hyperparathyroidism. Which assessment should the nurse include the plan of care? A) Chvostek's sign B) Brudzinski's sign. C) Battle's sign. D) Pupillary response.

Chvostek's sign

Patient involves in an accident... which indicate increase of ICP: A. Nuchal rigidity/dystonia B.Confusion/papilledema C.Periorbital eccymocis D.Increase Glasgow scale

Confusion/papilledema

A client with type 2 diabetes mellitus is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with initial dose of Humulin insulin at 8:00 at 16:00 the client complains of diaphoresis, rapid heart beat, and feeling shaky. What should the nurse do first?

Determine the client current glucose level

The charge nurse observes a newly employed nurse gathering equipment to obtain a venous blood sample from a client's implanted port. The nurse has obtained the equipment seen in the photo. What actions should the charge nurse take? (Select all that apply) • Guide the nurse in inserting the needle at a 45 degree angle • Remind the nurse to wear sterile gloves for this procedure • Instruct the nurse to obtain several red-topped tubes • Determine if the nurse has ever performed this skill • Assist in obtaining the correct needle to access the port

D, E

2 days old infant legs flexed with limited abduction, what is the next action that the nurse take: A- Range of motion exercise B- Notify MD C- Document as an normal finding D- Continue with the care

Notify MD

AT THE 1 MONTH OLD CLINIC VISIT, AN INFANTS NUDE WEIGHT IS 600 GRAM MORE THAT AT BIRTH. WHICH INTERVENTION SHOULD THE NURSE IMPLEMENT? A. ENCOURAGE GIVING 2 OUNCES OF WATER BETWEEN FEEDINGS. B. RECOMMENDED ADING KARO SYRUP TO EACH FORMA FEEDING C. DOCUMENT INFANT'S WEIGHT ON GROWTH CHART D. CHECK THE INFANT'S WEIGHT USING A METRIC SCALE.

DOCUMENT INFANT'S WEIGHT ON GROWTH CHART

When caring for a client with nephrotic syndrome which assessment is most important for the nurse to obtain?

Daily Weight

After receiving IV fluids in the emergency department, an elderly client is admitted to the acute care unit with a medical diagnosis of dehydration. The client is receiving 0.9% normal saline at 125ml/hr. via a saline lock and has a bounding pulse, tachycardia, and pedal edema. When contacting the healthcare provider, the nurse anticipates a prescription for what intervention? a. Decrease the rate of the normal saline infusion b. Increase the rate of the normal saline solution c. Change the IV solution to 0.45 saline solution d. Remove the saline lock from the client's arm

Decrease the rate of the normal saline infusion

When planning care for a client newly diagnose with open angle glaucoma, the nurse identifies a priority nursing diagnosis of " Visual sensory/perceptual alterations". This diagnosis is based on which etiology?

Decreased peripheral vision

Which change in lab values would indicate to the nurse that treatment for gout is successful? • Decreased serum uric acid • Decreased serum purine • Increased serum uric acid • Increased serum purine

Decreased serum uric acid

The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that she will be done before administering the medication. A- Determine which side of the body is weak B- Auscultate and breathe sounds C- Obtain and record client vital sign D- Ask the client about soft food preferences

Determine which side of the body is weak

A 4-year-old child is admitted to the pediatric unit with a diagnosis of Wilms tumor. Considering the unique needs of a child with this diagnosis, the nurse should place a sign on the child's bed that states:

Do not palpate the abdomen

Patient with influenza. Dehydrated and pneumonia

Droplet precaution Droplet precautions should be implemented for patients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility.

The nurse is palpating the lymph nodes of a 10 month old. Which findings should the nurse call to the attention of the health care provider? a. Enlarged, warm, tender preauricular node b. Enlarged no tender mobile occipital node c. Small discrete, mobile, no tender, inguinal node d. Small, firm, mobile nodules in the axial

Enlarged, warm, tender preauricular node

An 8-year-old child undergoes tonsillectomy. What is the priority action in the immediate postoperative period?

Ensuring airway patency by placing the child in a side-lying position

When the nurse manager and the nursing staff review entries into the electronic medical records (EMR), they determine that procrastination is often the reason for late-entries. What recommendation should the nurse manager offer to the nursing staff? A- Document routine care as provided and complex care at the end of shift B- Enter tasks in the EMR as the client's priority needs are addressed C- Document nursing care procedures between time-dependent cares D Keeps notes and enter all documentation at the end of the shift

Enter tasks in the EMR as the client's priority needs are addressed

The health care provider prescribe a medication for an older adult client who is complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should question which prescription? a. Eszoplicone (Lunesta)10 mg orally at bed time b. Zolpidem 10 mg orally at bed time c. Temazepan orally at bed time d. Ramelteon orally at bedtime

Eszoplicone (Lunesta)10 mg orally at bed time

A female client with chronic pyelonephritis expresses concern that she may have to undergo dialysis. What is the best initial response by the nurse? a. Offer to introduce the client to a dialysis nurse who can provide teaching about dialysis b. Explain the relationship between chronic kidney infection renal failure and dialysis c. Provide assurance that dialysis is not the usual treatment for kidney infections d. Assist the client to reduce anxiety and gain control by using guided imagery exercise

Explain the relationship between chronic kidney infection renal failure and dialysis

An 11-year-old child has gained weight. The mother tells the nurse that she is concerned that her child, who loves sports, may become obese. What is the most appropriate response by the nurse?

Explaining that this is expected during preadolescence

The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which physiologic action? a. Facilitates transport of glucose into the cell b. Increases intracellular receptor site sensitivity c. Stimulates function of beta cells in the pancreas d. Delays carbohydrates digestion and absorption

Facilitates transport of glucose into the cell

The RN sends the UAP to the room to do care to the patient but the patient was anger and yelling to the UAP. What can the UAP do? A- Schedule the care daily B- Not enter more in the room C- Give care earlier D- Give care options participate

Give care options participate

The nurse is evaluating the home care teaching of a family who has a child with cystic fibrosis. Which parental action indicates correct understanding of the child's home care? a. Performs postural drainage after meals b. Supplements diet with water-soluble vitamins and fluids c. Plans a diet high in fat and calories d. Gives pancreatic enzymes before every meal and snack

Gives pancreatic enzymes before every meal and snack

Pediatrics-Immune/Hematology- von Willebrand's disease-POC (Bleeding disorder) A- Decrease exposure to infection B- Decrease contact with other children C- Decrease contact with cold graft D- Guard against bleeding injuries

Guard against bleeding injuries

PT W/ SIADH

HARD CANDY FOR THIRST

PATIENT W/ EZCEMA APPLYING CREAM TTO IS WORKING:

HEALING WITH A RETURN SKIN TO NORMAL APPEARANCE.

The nurse is assessing a group of older adults. What factor in a male client's history puts him at greatest risk for developing colon cancer? • Is excessively exposed to sunlight • Eats a high-fat diet • Smokes cigars • Has intestinal polyps

Has intestinal polyps

After suctioning the patient with an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?

Increase in breath sounds

A child is admitted to the hospital with a tentative diagnosis of meningitis, and a lumbar puncture is performed to confirm the diagnosis. What finding from the spinal fluid report should lead the nurse to conclude that bacterial meningitis is present?

Increased protein

The healthcare provider prescribes atenolol 50 mg PO daily for a client with angina pectoris. Which finding should the nurse report to the healthcare provider before administering the medication? a) Chest pain. b) Urinary frequency. c) Tachycardia. d) Irregular pulse.

Irregular pulse

After a discussion with the health care provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond?

It is a connection between the pulmonary artery and the aorta.

PT WITH LEFT LEF ULCER

KEEP LEG ELEVATED AS MUCH AS HE CAN

A woman who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. She states that she is pain free. Which intervention should the nurse include in the client's plan of care? a. Maintain the client on a NPO status b. Administer daily vitamin supplements c. Determine if the client is over-hydrating to feel satiated d. Encourage positive self-accolades for dietary adherence

Maintain the client on a NPO status

The drainage in the chest tube of a client with emphysema has changed from clear watery fluid. What action would be best for the nurse to take

Maintain the current IV antibiotic schedule

The parents of a newborn discuss their infant's need for immunizations with the nurse. Which vaccine will not be administered until the child is at least 12 months of age?

Measles

What teaching must the nurse emphasize to the family when preparing a school-aged child with persistent asthma for discharge?

Medications must be continued even when the child is asymptomatic.

The nurse is reviewing blood pressure readings for a group of client's on a medical unit. Which client is at the highest risk for complications related to hypertension? A. Young adult Hispanic female who has a hemoglobin of 11 gm and drinks beer every day B. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL C. Older Asian male who eats a diet consisiting of smoked, cured, and pickled foods. D. Post-menopausal Caucasian female who overeats and is 20% above ideal body weight

Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL

A 3-year-old child is scheduled for cardiac catheterization. What is the priority nursing care after this procedure?

Monitoring the site for bleeding

Pt. W. RADIACTIVE THERAPY WHAT TO TEACH/ RECOMMEND TO

PROTECT THAT PART OF THE SKIN SPECIALLY FROM THE SUN

A client with superficial burns to the face, neck, and hands resulting from a house fires is admitted to the burn unit. Which assessment finding indicates to the nurse that the client should he monitored for carbon monoxide poisoning? A- Expiratory stridor and nasal flaring B- Mucous membranes cherry red color C- Carbonaceous particles in sputum D- Pulse oximetry reading of 80 percent

Mucous membranes cherry red color

HEART SOUND A- Murmur B-S1, S2 C- S1, S2, S3 D- Peripheral

Murmur

DESCRIBE PAIN NEUROPATHY

NERVOUS SYSTEM

FOR ANEMIA WHAT DOESN'T HAVE IRON, WHICH FOODS ARE NOT RICH IN IRON?

NO ORANGE

PT AFTER TTO OF SOMETHING AND WANTS TO EAT

NURSE ASSESS FOR BOWEL MOVEMENTS

PATIENT W/ ML FELL AND WHEN RECEIVING THE NURSE HE HAVE 2 PROJECTILE VOMITS WHAT SHE DO

PROVIDE ANTIEMETICS PRN

A female client with pancreatic cancer is NPO for implantation of a venous sedation. Suddenly, the client becomes unresponsive, and her skin is cool pulse 96 beats/minute, respiratory rate 18 breaths/minute, which are within her outpatient surgery nurse implement first? A- Administer glucagon 0.5 mg IM B- Infuse a 200 ml NS IV fluid bolus C- Obtain a finger stick blood glucose D- Insert a second peripheral IV catheter

Obtain a finger stick blood glucose

A neonate whose mother used cocaine during pregnancy is demonstrating excessive shrill cry, and frequent vomiting. What action should the nurse perform first? A. Request a neurology assessment. B. Wrap the infant in warm blankets. C. Obtain a serum screen. D. Burp the infant to eliminate gas.

Obtain a serum screen.

A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first? a. Obtain a sputum sample for culture b. Check his oxygen saturation level c. Administer an oral antipyretic d. Auscultate bilateral lung sound

Obtain a sputum sample for culture

Insulin for a glucose level of 255

Obtain capillary glucose

The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority in providing care for this client? • Administer initial dose of broad-spectrum antibiotic • Instruct the client to force fluids hourly • Obtain results of culture and sensitivity of CSF • Assess the client for symptoms of hyponatremia

Obtain results of culture and sensitivity of CSF

A female client with possible acute renal failure (ARF) is admitted to the hospital and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? • No specific nursing action is required • Instruct the client to empty the bladder • Collect a clean catch urine specimen • Obtain vital signs and breathe sounds

Obtain vital signs and breathe sounds

A nurse is caring for an 11-year-old child with type 1 diabetes. Two hours after breakfast the child becomes pale, diaphoretic, and shaky. What action should the nurse take?

Obtaining a current blood glucose level

PATIENT W/ ESOPHAEGAL VARICES HAVE NOT BE BLEEDING FOR 3 DAYS

PROVIDE LUKE WARM BROTH, ICE TEA AND LEMON POPSICLE

A client with a history of upper respiratory symptoms is admitted to the unit with chest tightness, productive cough and difficult breathing. The client ABG is respiratory acidosis. What lab the nurse expects to be high? a. Ph b. Arterial ph. c. HCO3 d. Paco2

Paco2

A nurse is caring for a 7-year-old child in the pediatric intensive care unit who has increased intracranial pressure as a result of head trauma. The practitioner prescribes intravenous mannitol. The nurse monitors the child's intracranial pressure and urine output because mannitol belongs to the classification of diuretics known as:

Osmotic

EXAMPLES OF DASH DIET

PEEL FRUITS AND VEGETABLES

MID ABDOMEN BURNING PAIN

PEPTIC ULCER

PT. W/ RISK OF DVT

PERFORM ROM EXERCISES ALSO LEGS EXERCISE CAN BE OTHER WAY TO ANSWER

INTESTINAL BOWEL OBSTRUCTION

PLACE THE PT 90 DEGREES SITTING

PT W/ HYPERTHYROIDISM DEVELOPING EXOSPHTALMUS:

PRESCRIBE TEAR EYE DROPS.

While the home health nurse is making a home visit, a client with a history of seizures demonstrates tonic-clonic seizure activity. What action should the nurse implement first? • Direct a family member to call emergency services • Ascertain the trigger event • Protect the client's head with a pillow • Observe the postictal breathing pattern

Protect the client's head with a pillow

The nurse observes an increase number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action?

Provide additional oral fluid intake Also with TURP you must know that 3l of water a day is needed

A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement? • Inform the client that it is the nurse's responsibility to reposition • Provide an overhead trapeze to the bed for the client to use • Place a draw sheet under the client to assist with repositioning • Administer an intravenous PRN anti-anxiety medication

Provide an overhead trapeze to the bed for the client to use

A child that resists taking the medication: a. Parents help the nurse holding him b. Provide the child juice with the medication c. Explain to the child that if he doesn't take the medication, he won't feel better.

Provide the child juice with the medication

What should the nurse do to meet the emotional needs of a 4-year-old child who is receiving daily injections?

Provide the child with a doll and related equipment, and observe what happens.

Patient in hospice care at home fear dying will be painful... A- Encourage to talk about.... B- Explain that pill will be given... C- Provide therapeutic touch with comfort and support

Provide therapeutic touch with comfort and support

A female client with breast cancer who completed her first chemotherapy treatment out-patient cancer treatment center is preparing for discharge. Which behavior the client understands her care needs for the next week? a. Invite friends and family to visit while she is at home for the next week b. Rent movies and borrow books to use while passing time at home c. Schedule a lunch date with her best friend for 2 days from now d. Stock her refrigerator with healthy foods including fruits and vegetables

Rent movies and borrow books to use while passing time at home

The nurse is reinforcing home care instructions with a client who is being discharged following transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the clients discharge instructions? A- Avoid strenuous activity for 6 weeks B- Report fresh blood in the urine C- Take acetaminophen for fever 101 D- Consume 6 to 8 glasses of water daily

Report fresh blood in the urine

Patient that had a vaginal birth, diaphragm. What teaching the nurse need to give to the patient? A- 2 or 6 hours before intercourse B- Re-adapt C- Resisted diaphragm D- Is no anticoncertive

Resisted diaphragm

A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 72 hours indicates 5mm of erythema without induration. What is the best initial nursing action? • Review client's history for possible exposure to TB • Instruct the client to return for a repeat test in 1 week • Refer client to a healthcare provider for isoniazid (INH) therapy • Document negative results in the client's medical record

Review client's history for possible exposure to TB

Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction?

Risk for injury related to effects of thrombolysis

An adult arrives at the urgent care clinic after being bitten on the hand by an aggressive dog that escaped from a neighbor's fenced yard. The nurse cleanses the wound with providone-iodine and administers Human Rabies Immune Globulin (HRIG) and the first injection of the rabies vaccine. Which intervention is most important for the nurse to implement? A- Determine if the client has any allergies to antibiotics. B- Send client for a magnetic resonance image (MRI) of the hand C- Schedule administration of remaining rabies vaccine injections D- Notify local Animal Control Bureau about the dog bite

Schedule administration of remaining rabies vaccine injections

A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritis caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement? • Schedule an appointment for the client to see the healthcare provider • Advise the client to apply plastic wrap over the ointment to promote healing • Explain that the client needs to complete all prescribed doses of the medication • Instruct the client to continue the ointment until all erythema is relieved

Schedule an appointment for the client to see the healthcare provider

The home care nurse go to visit a patient with Alzheimer's and find the wife crying, what happen with your husband and the wife respond "watch it with your own eyes". What action should the nurse...? A- Encourage wife to leave home B- Ask the wife to observe the assessment to learn how to take deal with the situation C- As soon as the client care is completed provide wife with family support group D- Sit with the wife and talk about her concerns

Sit with the wife and talk about her concerns

Pediatrics-GI/Hepatic-Diarrhea-specimen

Stool specimens are frequently collected in children to identify parasites and other organisms that cause diarrhea, to assess gastrointestinal function, and to check for occult (hidden) blood

A client receiving a blood transfusion complains of itchy skin and appears flushed. What action should the nurse take first? A- Check the blood type on the bag B- Notify the healthcare provider C- Assess the client's temperature D- Stop the blood transfusion.

Stop the blood transfusion

A client who is receiving packed red blood cells develops nausea and vomiting. What action should the nurse take first?

Stop the infusion of blood

The nurse positions a male client for a lumbar puncture by placing him in the side-lying position with his knees flexed and pulled toward his trunk. What action should the nurse implement next? • Call another nurse to assist the healthcare provider • Provide a small pillow for the client to curl around • Instruct the client to perform a Valsalva maneuver • Support the client's head bent forward to the chest

Support the client's head bent forward to the chest

PARKINSON AND ALZHEIMER PT

TACHYCARDIA AND CONFUSION

ADDISON DISEASE

TAKE CORTICOSTEROID MEDS

NURSE IS TEACHING THE WIFE IF A PATIENT DIAGNOSED W/ SEIZURE WHAT TO DO

TEACH HER HOW TO POSITION HIM

SBAR—EXPLAIN SPECIFIC REASON FOR URGENT NOTIFICATON

TEMPERATURE

UAP: ABD PAIN LARGE TARRY STOOL

TEST STOOL FOR OCCULT BLOOD

Which instructions should the nurse include in the teaching plan of a client who is taking the diuretic spironolactone (Aldactone)? a. call the healthcare provider f you develop gynecomastia b. Take the medication in the morning c. Avoid caffeine and smoking d. Increase your consumption of bananas and oranges

Take the medication in the morning

Child 9 years old: A- Talk directly to the child B- Ask the child if the parents are saying the true C- Tell the parents to get out of the room

Talk directly to the child

A 3-month-old infant has a ventriculoperitoneal shunt inserted. What should the nurse include in the infant's plan of care?

Teaching the parents signs of increased intracranial pressure

A nurse is aware that the child's mother is 13 years old and the father is 16 years old. The father and the paternal grandmother, who both take care of the infant, are the only family members at the bedside. From whom should the nurse obtain the informed consent?

The 16-year-old father

A nurse assessing a newborn reports an asymmetric Moro reflex, and Erb palsy is diagnosed. What does the nurse understand about the origin of this problem?

The cause is an injury to the shoulder during birth.

The nurse is assessing a client who has returned from surgery following a thoracotomy. Which finding indicates the client is experiencing adequate gas exchange?

The client demonstrates effective coughing and deep breathing exercises

Which expected outcome statement should the nurse include in a teaching plan of care. A client with management of an acute attack of gout? A.The client will avoid use of alcohol in managing stress B.The client will implement a high purine daily dietary regimen C. The client will use local heat application for acute pain D.The client will stop antigout medication once pain subsides

The client will avoid use of alcohol in managing stress

A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What explanation should the nurse provide? a. The eye drops slow pupil response to accommodate for darkness b. The drops increase the fluid in the eyes and cloud the visual field c. The drug can cause lens to become more opaque d. The medication causes pupils to dilate which reduces night vision

The eye drops slow pupil response to accommodate for darkness

A client is newly diagnosed with open-angle glaucoma and receives a prescription for the meiotic pilocarpin. The client asks how the eyes pressure will be controlled when the eyes drops are used on the surface. What explanation should the nurse offer when teaching about the therapeutic action of the ophthalmic drops? A- Once the pupil gets smaller, the amount of liquid made inside the eyes is reduced B- It is necessary to open the pupil to allow movement of the fluid from behind the iris C- The drops will reduce eye swelling which is causing increased ocular pressure D- The iris will constrict and contract away from the opening, thereby allowing it to drain

The iris will constrict and contract away from the opening, thereby allowing it to drain

The mother of a school-age child asks the school nurse how her child got head lice. What should the nurse explain to the mother?

Transmission occurs through contact with contaminated children and objects.

MYASTHENIA GRAVIS TAKING (MESTINON). WHAT FINDING REQUIRES INTERVENTION BY THE NURSE? A. EYELID DROOPING B.TINGLING EXTREMITIES C.UNCONTROLLED DROOLING

UNCONTROLLED DROOLING

Diabetic,renal no function,decrease urine or not urine, septic shock, check urine specific Gravity and osmolarity urine. Acute Renal Failure: Low Protein Chronic Renal Failure: NOT Protein at all

Urine claude and check input and output

When administering a new medication to a client, the nurse uses a scanner to register the nurse? A) Use the scanner to register the bar code on the client's identification bracelet. B) Document the medication administration on the client's computerized record. C) Remove the medication from the unit dose packaging while verifying the dose. D) Reconcile the medication to be administered with the initial client prescription.

Use the scanner to register the bar code on the client's identification bracelet.

A public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? A. Case management and screening for clients with HIV. B. Regional relocation center for earthquake victims. C. Vitamin supplements for high-risk pregnant women. D. Lead screening for children in low-income housing

Vitamin supplements for high-risk pregnant women.

The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. What instruction should the nurse include in this teaching plan? A- Stop taking the medication when the edema in the lower extremities subsides. B- Take the diuretic every day, regardless of weight loss or muscle weakness. C- Limit fluid intake while taking the diuretic to reduce fluid retention. D- Weight yourself daily at the same time and report excessive weight loss.

Weight yourself daily at the same time and report excessive weight loss.

The patient from college that was drinking last night with friends. Go to the hospital... A- I'm sorry to hear this B- You remembered if someone put something in the drink or if she remember what she drink C- You know the people who did this D- You feel guilty about what happened to you

You remembered if someone put something in the drink or if she remember what she drink

During a home visit the nurse assesses the skin of a client with eczema who reports than an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? a. an old friend with eczema came for visit b. recently received an influenza immunization c. corticosteroid cream was applied to eczema d. a grandson and his new dog recently visited

a grandson and his new dog recently visited

A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? a. offer the client reassurance that this information indicates that the clients cancer cells are benign b. explain that these tissue cells often respond more effectively to radiation than to chemotherapy c. ask the client in the healthcare provider has giving her any information about the classification of her cancer d. help the client make plans to begin inmediate treatment since her cancer is likely to spread quickly

ask the client in the healthcare provider has giving her any information about the classification of her cancer

After taking orlistat (Xenical) for one week a femela client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. What action should the nurse take? a. obtain stool specimen to evaluate for occult blood and fat content b. instruct the client to increase her intake of saturated fats over the next week c. ask the client to describe her dietary intake history for the last several days d. advice the client to stop taking the drug and contact the healthcare provider

ask the client to describe her dietary intake history for the last several days

Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide iodine (Betadine) solution. Which intervention should the nurse implement first? a. determine if the client has a history of diabetes b. assess airway patency and oxygen saturation c. review recent medication history and allergies d. obtain samples for complete blood count and cultures

assess airway patency and oxygen saturation

A client is discharged with a prescription for warfarin (Coumadin). What discharge instructions should the nurse emphasize to the client? a. take a multi vitamin supplement daily b. use an astringent for superficial bleeding c. avoid going barefoot especially outside d. include large amounts of spinach in the diet

avoid going barefoot especially outside

Antibiotic resistant organism are a major infection control problems. To help minimize the emergence of resistant bacteria what instruction should the nurse provide to the clients? a. stop taking prescribed antibiotics when symptoms decrease b. avoid using antibiotics when suffering from colds or the flu c. ask the healthcare provider to prescribe the newest antibiotic when needed d. request a prescription for first time vancomysin for a sore throat

avoid using antibiotics when suffering from colds or the flu

A client with hypertension who has been taking labetalol for two weeks, reports a five pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to obtain? a. capillary refill b. body temperature c. muscle strength d. breath sounds

breath sounds

A client diagnose with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart? a. drive to the nearest emergency department b. take another NTG SL tablet and lie down until angina subsides c. call primary healthcare provider d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg

call 911 pain is unrelieved and chew a tablet of aspirin 325mg

Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2 grams using an infusion pump to deliver the dose in one hour, the client reports feeling nauseated. What action should the nurse implement? a. stop medication infusion and notify the healthcare provider of the adverse effect b. increase the rate of the infusion to complete the dose of the medication more rapidly c. continue the infusion and administer a prn antiemetic prescription d. reassure the client that the nausea is not related to the iv infusion

continue the infusion and administer a prn antiemetic prescription

A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic syndrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the client's central venous catheter. When the client's respirations become labored and his lungs sound indicate crackles what action should the nurse take? a. collect a specimen for a white blood cell count and cultures b. determine the clients glycosylated hemoglobin (A1C) c. administer insulin IV push until the clients fluid volume is adjusted d. decrease infusion rate to address fluid overload

decrease infusion rate to address fluid overload

A client with hyperthyroidism is being treated with radioactive iodine (I- 131). Which explanation should be included in preparing this client for this treatment? a. describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider b. explain the need for using lead shields for 2 to 3 weeks after the treatment c. describe the signs of goiter because this is a common side effects of radioactive iodine d. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately

describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider

The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimer's disease as an intervention for which client problem? a. fluid volume excess b. disturbed thought processes c. chronic pain d. altered breathing patterns

disturbed thought processes

A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cell. When notifying the healthcare provider what information should the nurse provide first using the SBAR communication process? a. explain specific reason for urgent notification b. preface the report by stating the clients name and admitting diagnosis c. communicate the pre-transfusion temperatures d. optain prn prescription for acetaminophen for fever 101f

explain specific reason for urgent notification

An elderly post-operative female client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a nurse to administer the prescribed PRN medication naloxone? a. her respiratory rate is 7 breath/minute b. she indicates that she feels as if she cannot get enough air to breath c. she has intercostal retractions and bilateral wheezing is auscultated d. her pulse oximeter is 89% on room air

her respiratory rate is 7 breath/minute

A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report? a. jaundice sclera b. intestinal cramping c. weakness and fatigue d. weight loss

jaundice sclera

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a. low back pain and hypotension b. rhinitis and nasal stuffiness c. delayed painful rash with urticarial d. arthritic joint changes and chronic pain

low back pain and hypotension

A client is who is diagnose with schizophrenia receives a prescription for an atypical antipsychotic drug aripipazole (Abilify). Which assessment should the nurse perform to monitor for an adrenergic receptor antagonist side effect that commonly occurs atypical antipsychotic agents? a. observe the client hallucinatory behaviors b. obtain the client finger stick glucose levels c. measure the clients lying and standing blood pressure d. determine the clients abnormal involuntary movements scale (AIMS)

obtain the client finger stick glucose levels

In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone intranasal which serum lab test is most important for the nurse to monitor? a. osmolality b. calcium c. platelets d. glucose

osmolality

An elder male client tells the nurse that he is loosing sleep because he has to get up several times at night to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? a. collect a urine specimen for culture analysis b. obtain a fingerstick blood glucose level c. palpate the bladder above the symphysis pubis d. review the client fluid intake

palpate the bladder above the symphysis pubis

Fat embolism: A process by which fat tissue passes into the bloodstream and lodges within a blood vessel. Signs and symptoms: include central nervous system dysfunction that may progress to coma or death, irregularities in the heartbeat, respiratory distress, and fever. Anemia and thrombocytopenia (low platelet count) are common. Commonly, small hemorrhages are seen on the neck, shoulders, armpits, and conjunctiva.

possible answer - low fever

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary Tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? a. blood ph of 7.30 b. glucose of 350 mg /dl c. white blood cell count of 15000mm d. potassium of 2.5 meq/l

potassium of 2.5 meq/l

Symptoms of a spinal cord injury may include: -Head that is in an unusual position -Numbness or tingling that spreads down an arm or leg -Weakness -Difficulty walking -Paralysis (loss of movement) of arms or legs -Loss of bladder or bowel control -Shock (pale, clammy skin; bluish lips and fingernails; acting dazed or semiconscious) -Lack of alertness (unconsciousness) -Stiff neck, headache, or neck pain

sharp pain

A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was 78/36.What action should the nurse implement? a. obtain blood pressure q5 minutes using duranap machine b. change the dilution of the nitroglycerin infusion c. reduce the rate of the nitroglycerin infusion d. begin dopamine infusion at 5mcg/kg per minute

reduce the rate of the nitroglycerin infusion

The Multiple Organ Dysfunction Syndrome (MODS) can be defined as the development of potentially reversible physiologic derangement involving two or more organ systems not involved in the disorder that resulted in ICU admission, and arising in the wake of a potentially life-threatening physiologic insult.

shock

When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching? a. select a protein rich food daily b. restrict sodium intake c. eat high potassium foods d. Avoid foods high in carbohydrate

restrict sodium intake

A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30. Which action should the nurse take first? a. monitor bp q45 minutes b. lower the head of the chair and elevate feet c. stop dialysis treatment d. administer 5%albumin IV

stop dialysis treatment

The nurse is providing preoperative education for a jewish client schedule to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? a. the xenograft is taken from nonhuman sources b. grafting increases the risk for bacterial infection c. as the burn heals the graft permanently attaches d. grafts are later removed by debriding procedure

the xenograft is taken from nonhuman sources

A client who is taking and oral dose of tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? a. toasted wheat bread and jelly b. cheese and crackers c. cold cereal with skim milk d. fruit flavored yogurt

toasted wheat bread and jelly

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this diagnosis? a. upper mid abdominal gnawing and burning pain b. severe abdominal cramps and diarrhea after eating spicy foods c. marked loss of weight and appetite over the last few months d. use of chewable and liquid antacids for indigestion

upper mid abdominal gnawing and burning pain

A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client to take the glucagon? a. after meals to increase endogenous insulin secretion b. after insulin administration to prevent hypoglycemia c. when recognized signs of severe hypoglycemia occur d. when unable to eat during sick days

when recognized signs of severe hypoglycemia occur

A client with a 40 pack year history of smoking does not want to have a pulmonary function test conducted. Which of the following should the nurse explain to the client regarding this diagnostic test? A- ¨It is used to diagnose lung cancer so treatment can be started B- ¨It is used to determine the amount of oxygen that is in your lungs with every breath¨. C- ¨It measures your lung functioning¨. D- ¨It identifies the best interventions to help you quit smoking.

¨It measures your lung functioning¨.