MSII-Kaplan
The nurse teaches a client diagnosed with sickle cell anemia. Which statement made by the client indicated a need for further teaching?
"I should restrict my intake of oral fluid."
A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?
"I will monitor my blood pressure while taking this medication"
A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
"I will wear clean graduated compression stockings every day"
A client is diagnosed with HTN. The client says, "I have trouble remembering to take my medications, but I am now only smoking 5 cigarettes a day instead of 2 packs." Which response by the nurse is best?
"It is good that your smoking has decreased. Let's talk about ways to remember the medication."
A client is diagnosed with HTN. The client says, "I think I can stop taking my medication now. I don't have those headaches anymore, so I must be over this." Which is the nurse's best response?
"tell me what you remember from our conversation about HTN"
A client is diagnosed with glaucoma. The client asks the nurse why eye drops are necessary. Which response by the nurse is best?
"the drops keep your eye pressure low and help maintain your vision."
A client with liver cancer receives chemotherapy. The client is scheduled for a chemoembolization procedure. The nurse teaches the client which information about this procedure?
"this procedure allows more chemotherapy to remain in the tumor cells."
The nurse cares for a client with a diagnosis of Bell's palsy. During the visit, the client burst into tears and states "I am so ugly now, I just want to hide." What is the best response for the nurse?
"you seem upset today, tell me how you feel."
The nurse cares for a client diagnosed with asthma. The client is taking 20 mg of oral prednisone daily. Which statements should be included in the teaching? (Select all that apply.)
- You may experience some stomach upset when taking prednisone. - The medication will need to be slowly decreased before it is disconnected. - You are at greater risk for infection while you are taking this medication.
A client is diagnosed with Meniere's disease. The client has a sudden attack of vertigo, nausea, vomiting, and sweating. The nurse provides which intervention during the attack? (select all)
- a dark, quiet environment - lorazepam and meclizine - IV fluids and medications
brachytherapy - actions that are not ok
- ambulation in hallways - family asks for cot - kid on lap
retinal repair / detached retina s/s
- floaters and light flashes - curtain shadow on one side
what is Presbycusis?
- hearing impairment in old age - unable to hear high pitched tones
The nurse suctions a client's tracheostomy. Which technique does the nurse use? (SATA)
- routinely instills sterile normal saline before suctioning - uses sterile technique when suctioning - rotates the catheter when withdrawing - uses intermittent suctioning
The nurse cares for a client diagnosed with severe acute pancreatitis. What will the nurse expect to see during the assessment? (Select all that apply.)
- serum calcium 5.8mg - serum glucose 148mg - vomiting and nausea - localized L upper quadrant abdominal pain - white cell count 7500?
A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.)
- visual spatial defecits - left hemianopsia - one sided neglect - impulsive decisions?
Nurse instructs client starting hemodialysis. The client has an AV fistula in the R arm. (SATA)
- your BP should be checked on the L arm only - you should not use ur R arm to lift heavy objects
The nurse performs cardiopulmonary resuscitation (CPR) on a 62 year old man. What is the correct compression depth?
2 inches or more
bell's palsy is from damage to cranial nerve
7 (facial nerve)
A nurse has received a change-of-shift report for a group of clients. Which of the following clients should the nurse assess first?
A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet
The nurse cares for a client who had a tonic-clonic lasting 90 seconds followed by a period of decreased consciousness lasting 2 minutes followed by another seizure. What is the priority action the nurse should take?
Administer Diazepam (Valium) as ordered
The nurse obtains a specimen for ABG from a pt. Which principle guides the nurse?
Air in the syringe will alter the blood values
Before doing ABG you need to do what?
Allen's test
A client is diagnosed with myasthenia gravis. The client says, "I am tired all the time and I don't want to live any more. If I stop taking my medication, I can stop breathing." Which is the nurse's best response?
Ask the client about feelings of hopelessness
What test do we do for seizures to monitor brain activity
EEG
A client is diagnosed with varicose veins. Education is provided by the nurse. The nurse continues teaching the client when the client makes which statement?
I can stop wearing my elastic stockings when the pain is gone
Client recently diagnosed with dm type 1 reports awakening with headache and frequent nightmares
Instruct client to check blood sugar between 0200 and 0400
A client is unresponsive after a closed-head injury. The Glasgow Coma Scale score is 7. The nurse identifies the client's state as which best description?
Is identified as comatose
Nurse cares for the patient immediately after cardiac cath using the left femoral artery. Which finding requires immediate intervention?
L extremity is cooler to touch than R
autoimmune disorder that results in the breakdown of acetylcholine
MG
Murmur heard at apex on 3rd beat
Mitral valve regurgitation
A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan?
Monitor the client's temperature every 4 hr
The nurse cares for a 78 year old client with the diagnosis of colostrum deficile (c.diff)infection. What action is most appropriate for the nurse to take while caring for this client?
Wear a gown and gloves while assisting the client with bathing
A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care?
Wear a lead apron while providing care to the client
A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions?
Wear a mask
brachytherapy - nurse action
Wear film badge
A client reports recurrent headaches with the following symptoms: headache located in "hat band" area with squeezing, tight sensation last 2 hours and causing stiff neck muscles. Which medication prescription does the nurse anticipate?
acetaminophen, butalbital, caffeine
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend?
add cabbage to the diet
A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client to avoid?
aged cheese
what is the priority for a pt with Myasthenia gravis
airway
What are we worried about in a myasthenic crisis or acetylcholine crisis?
airway and respiratory failure
how to dx meningitis
analyze CSF for glucose via lumbar puncture
detached retina
any placement
left sided stroke sx
aphasia, slow intellect, cautious behavior
Closed head injury - priority intervention is when
apical pulse drops from 88 to 60
ABG puncture - nursing intervention
apply pressure to the puncture site for 3-5 minutes
A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent Pseudomonas aeruginosa infection?
avoid placing plants or flowers in the pt's room
The nurse teaches a client about surgical repair of a detached retina. What instructions should be included in the teaching?
avoid reading and writing for one week
CSF
basilar damage; leak from ears and nose
cystic fibrosis - chest physiotherapy. when should pt do this
before meals and before bed
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad?
bradycardia
A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range?
calcium
Pregnant 14 y/o getting CPR check which pulse
carotid pulse
tx for pneumothorax
chest tube insertion
Nurse cares for a client just admitted after a car crash. Family reports client hit head on dashboard.
clear, watery fluid is dropping / draining from the ear
Nurse cares for a client with a closed head injury after a car accident. Which observation made after 48 hours requires immediate intervention?
client complains of dizziness and headache
A client is diagnosed with epilepsy following a series of seizures. The nurse identifies which client goal as the priority?
client will take all medications as directed
ABG shows pneumonia. what is the tx plan?
continue treatment
Nurse cares for the client with a chest tube drainage system. Which observation requires intervention?
continuous bubbling in water seal chamber
main sign of lung cancer
cough that doesn't go away
intervention for pt with parkinson's diz
cut food small
Intracranial tumor
damage to the frontal lobe causes loss of concentration / personality
goal for pt parkinson's diz
decrease in anxiety
A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take?
demonstrate ways to deep breathe and cough
cataract teaching
don't bend at waist
A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings?
dysphagia
sx of parkinson's disease
early: bradykinesia, tremors late: memory loss
Nurse instructs a client who had a subtotal gastrectomy. Which statement should be included?
eat a low carb diet
A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?
ensure the client has a patent IV
A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider?
heart rate 55/min
tracheostomy suction
hyper-oxygenate
A client is newly diagnosed with COPD. The client's blood gas values are: PaO2 - 55 mm Hg (7.32 kPa) and PaCO2 - 49 mm Hg (6.52kPa). The client says, "I usually have headaches when awakening in the morning." The nurse identifies a nursing diagnosis related to which information?"
hypoventilation
what are you concerned about w/ a tracheostomy?
if secretions are thick, yellow, and dry
What is the first thing you do with a spinal cord injury
immobilize right after, before moving or touching
The nurse cares for a client diagnosed with a left sided stroke. What will the nurse expect to observe?
impaired speech
The nurse cares for a client diagnosed with severe Parkinson's disease. What will the nurse expect to observe?
increased salivation
A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding Which of the following actions should the nurse take first?
instruct the client to allow the machine to breathe for them
A client with heart failure is to be weighed daily. The client asks why this is necessary. Which is the best information for the nurse to give the client?
is an indication of the fluid status in the body
A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days ago. Which of the following actions should the nurse take first after hearing the following sound?
listen with the client on their left side
A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
loosen restrictive clothing
Epilepsy starts having seizure
lower to the ground
The nurse teaches a client about metered dose and dry powder inhalers. Which information is included?
metered dose inhaler may use a spacer for inhalation
Abnormal condition within the labyrinth of the inner ear that can lead to a progressive loss of hearing. The symptoms are dizziness or vertigo, hearing loss, and tinnitus (ringing in the ears).
minere's disease
epi pen
monitor respiratory rate
A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify which of the following client medications interacts with feverfew?
naproxen
A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?
non rebreather mask
COPD - best oxygenation device
non-rebreather mask
A client has a chest tube attached to wall suction. The nurse observes continuous bubbling in the water chamber. Which action does the nurse take next?
notifies HCP to replace tube
A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?
obtain vital signs
How do you transfer a pt who has had a stroke?
on their stroke side
The nurse cares for a 32 year old client diagnosed with bacterial meningitis. Which observation requires an immediate action by the nurse?
oral temperature of 101.2*F
A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication?
orthostatic hypotension
A client reports that the migraine headaches have become more severe. Which clinical manifestations will the nurse expect the client to report?
pain in one eye and one side of the face
A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse take?
perform synchronized cardioversion
The nurse teaches a client who had a stapedectomy. The teaching is understood when which client request is made?
physical therapy for the vertigo
What vaccine do you get at 62 y/o?
pneumonia
pt has a central line placed and then o2 drops to 76%. what would you expect the pt is experiencing?
pneumothorax
cardiac dysrhythmias
pt in afib need to assess LOC
The nurse cares for a client diagnosed with right pneumothorax. What will the nurse expect to observe?
rapid shallow respirations
cardioversion
recaptures the normal rate of heart
A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?
remain with the client for the first 15 min of the infusion
A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?
report of a night cough
A client is diagnosed with a stroke. The nurse observes while the client eats lunch. The client coughs after many bites, swallows solids very slowly, but swallows liquids without difficulty. The client makes strange movements of the tongue during eating. Which action does the nurse take next?
requests a dietary consultation
A client experiences anaphylactic shock caused by a reaction to a medication. IV diphenhydramine is administered, and the client appears to be recovering. Which Vital Sign is the most important for the nurse to monitor for the next several hours?
respirations
hyperventilation or response to respiratory drug can cause
respiratory alkalosis
A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effects should the nurse monitor?
respiratory paralysis
A client reports difficulty speaking and swallowing. The client is diagnosed with a stroke. The nurse expects to find weakness in which extremities?
right-sided extremities
intracranial tumor
seizure precautions
Meningitis: Brudzinski's sign
severe neck stiffness causes a pt hip and knees to flex when the neck is flexed
The nurse instructs a client with cataracts. Which should be included in the nursing instructions?
some itching and redness of the eyes is expected after surgery
surgical removal of stapes and replacement with a prosthesis to treat hearing loss caused by otosclerosis
stapedectomy
accessing a port is what type of procedure?
sterile
COPD teaching
stop smoking
what should you teach a pt dx with meniere's disease
stop taking sodium
A nurse is preparing to admit a pt who has dysphagia. The nurse should plan to place which of the following items at the client's bedside?
suction machine
The nurse cares for a client diagnosed with a stroke 48 hours ago. What is the most appropriate position for this client?
supine with the head of bed elevated 15-30 degrees
planning safety for pt with parkinson's diz
swallowing and ambulating
What might you see in a pt with MG
swallowing issues and drooping eye lid
What is important to stress to a pt who has MG
take the right dose of medications at the right time
A client diagnosed with lung cancer tells the nurse that he has replaced his prescribed medications with herbal syrup recommended by an herbalist. What is the initial action the nurse should take?
tell the pt to discuss the herbal syrup with his physician
heart failure (pt telling nurse sx)
tell the pt to tell the HCP exactly what they told the nurse
A client is diagnosed with a flaccid neurogenic bladder due to a spinal cord injury. The client has had several urinary tract infections. A bladder training program has been established. Which documentation indicates the client's bladder function is currently satisfactory?
the client empties the bladder completely every 2-3 hours
The nurse supervises a nursing assistant caring for a client immediately following a radioactive implant from uterine cancer. Which observation requires an intervention by the nurse?
the nursing assistant leaves the door open when leaving the room
comatose pt status change
the pt can answer questions
Pressure ulcers - concerened if?
there is blanching of the coccyx
The COPD pt reports what statement indicating further teaching is needed
they will cut down on smoking only 3 pack cigarettes / day
A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching?
try to walk at least three times per week for exercise
A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority?
turn the client to the side
sx of Migraine headache
unilateral eye pain, photophobia, noise sensitivity
What are the symptoms of Meniere's Disease
vertigo, tinnitus, unilateral hearing loss
Spinal cord injury depends on
where the injury takes place depends on waht is affected
