NUR 131 Review

Normal sodium level range

136-145 mEq/L

Normal potassium level range

3.5-5 mEq/L

Hypothyroidism cause

A disorder caused by thyroid gland that is slower and less productive than normal, Hashimoto's disease

Which statement needs correction regarding obtaining informed consent from patients? A. "Obtaining informed consent is an important part of the nurse-patient relationship, it is a vital part of the nursing duty" B. "Consent would be obtained in all situations except during extraordinary circumstances" C. "A patient may give consent based on the full disclosure of risks, benefits, alternatives, and consequences of refusal" D. "The PCP legally has to disclose facts in terms that the patient is able to understand to make an informed choice"

A. "Obtaining informed consent is an important part of the nurse-patient relationship, it is a vital part of the nursing duty"

Which clients would the nurse measure head circumference during the growth and development assessment? A. A 2 mo infant B. A 3 yo preschooler C. A 14 yo adolescent D. An 18 mo toddler E. A 6 yo school aged child

A. A 2 mo infant B. A 3 yo preschooler D. An 18 mo toddler

Based on the nurse's assessment which cues support the decision to provide intervention for the client's pain as the first priority? A. Blood pressure B. Client's reported pain level of 7/10 C. Hx of rheumatoid arthritis D. Recent hip surgery within the last 3 months E. Examination of the client's RLE

A. Blood pressure B. Client's reported pain level of 7/10 C. Hx of rheumatoid arthritis D. Recent hip surgery within the last 3 months E. Examination of the client's RLE

A nurse is assessing a newborn with a myelomeningocele. Which findings can prompt hydrocephalus? A. Bulging fontanels B. High-pitched crying C. Apgar score of less than 5 D. A defect in the lumbosacral area E. Head circumference 2 cm greater than the chest circumference

A. Bulging fontanels, B. high-pitched crying, D. a defect in the lumbosacral area

Which part of a patient's hx would likely lead to development of hemorrhoids? A. Constipation B. Hypertension C. Eating spicy foods D. Bowel incontinence E. Numerous pregnancies

A. Constipation E. Numerous pregnancies

Which findings in a client who has had major abdominal surgery indicate a possible venous thrombosis of the leg? A. Edema of the ankle B. Skin breakdown over the shin C. Pruritus on the side of the calf D. Tender area in the posterior lower leg E. Warmth along the course of the involved vessel

A. Edema of the ankle D. Tender area in the posterior lower leg E. Warmth along the course of the involved vessel

Which activities reflect secondary prevention interventions in relation to health promotion? A. Encouraging regular dental checkups B. Facilitating smoking cessation programs C. Administering influenza vaccines to older adults D. Teaching the procedure for breast self-examination E. Referring clients with a chronic illness to a support group

A. Encouraging regular dental checkups D. Teaching the procedure for breast self-examination

Which is the nurse demonstrating when labeling the African-American client a drug abuser for requesting pain medication? A. Ethnocentrism B. Multiculturalism C. Cultural encounter D. Cultural imposition

A. Ethnocentrism

Which information would the nurse provide a client about tertiary prevention? A. Focuses on preventing complications of illness B. Helps clients achieve as high a level of functioning as possible C. Aims at minimizing the effects of long-term disease or disability D. Applied when the client is physically and emotionally healthy E. Activities are aimed at diagnosis and treatment instead of rehab

A. Focuses on preventing complications of illness B. Helps clients achieve as high a level of functioning as possible C. Aims at minimizing the effects of long-term disease or disability

The nurse is completing the health history of a patient admitted to the hospital with osteoarthritis. Which joints would the nurse expect the patient will report as having been involved first? A. Hips B. Knees C. Ankles D. Shoulders E. Metacarpals

A. Hips B. Knees

The nurse is caring for a child who underwent laparoscopic appendectomy. Which interventions would the nurse document on the child's clinical record? A. I/O B. Pain measurement C. Tolerance of low-residue diet D. Frequency of dressing changes E. Presence or absence of bowel sounds

A. I/O B. Pain measurement E. Presence or absence of bowel sounds

The nurse in the pediatric clinic is assessing an adolescent child with strabismus. Which is one of the priority goals for the surgical correction of this child's disorder? A. Improving appearance B. Preventing the need for glasses C. Preventing legal blindness D. Restoring peripheral vision

A. Improving appearance

Which goals of care are associated with the family health system model? A. Improving family health or well-being B. Preparing for family transitions later in life C. Providing assistance in family management of illness conditions D. Promoting positive family behaviors to achieve essential tasks E. Achieving health outcomes r/t the family's areas of concerns

A. Improving family health or well-being C. Providing assistance in family management of illness conditions E. Achieving health outcomes r/t the family's areas of concerns

Which are the benefits of providing culturally competent care? A. Increased client safety B. Limits number of visitors C. Reduced health disparities D. Increased client satisfaction E. Ensures adequate interpreters

A. Increased client safety C. Reduced health disparities D. Increased client satisfaction

According to Erikson's theory, in which stage would the nurse expect a preschooler to start to pretend? A. Initiative versus guilt stage B. Integrity versus despair stage C. Autonomy versus self-absorption and stagnation stage

A. Initiative versus guilt stage

Indications of increased ICP r/t 6 yo child with meningitis A. Irritability B. Bradycardia C. Hyperalertness D. Decreased pulse pressure E. Decreased systolic b/p

A. Irritability B. Bradycardia

Which action would the nurse take when preparing to change a client's dressing using surgical asepsis? A. Keep the area free of microorganisms B. Protect self from microorganisms in the wound C. Confine the microorganisms to the surgical incision site D. Limit the number of opportunistic microorganisms to a minimum

A. Keep the area free of microorganisms

Which information would the nurse document in the medical record regarding a client's reported allergies? A. Medication names B. Date of allergic reaction C. Type of allergic reaction D. Family hx of allergies E. Epinephrine (EpiPen) use for allergic reactions

A. Medication names C. Type of allergic reaction E. Epinephrine (EpiPen) use for allergic reactions

Reasons for placing an indwelling catheter post-op. A&P cystocele and rectocele A. Discomfort is minimized B. Bladder tone is maintained C. Retention of urine is prevented D. Pressure on the suture line is relieved E. Hourly urine output can be easily measured

A. Minimize discomfort C. prevents retention of urine D. relieves pressure on suture line

The nurse is caring for a child with Reye syndrome. Which interventions would be included in the care plan of the child?

A. Monitoring seizure activity B. Keeping the HOB lowered C. Educating the parents about Reye Syndrome D. Managing fever with 3 doses of acetylsalicylic acid a day E. Monitoring the blood gas concentration and ICP

The nurse is obtaining a health hx from the newly admitted client who has chronic pain in the right knee. Which would the nurse include in the pain assessment? A. Pain hx, including location, intensity, and quality of pain B. Patient's purposeful body movement in arranging the papers on the bedside table C. Pain pattern, including precipitating and alleviating factors D. Vital signs, such as increased blood pressure and heart rate E. The patient's family statement about increases in pain with ambulation

A. Pain hx, including location, intensity, and quality of pain C. Pain pattern, including precipitating and alleviating factors

Which clinical findings would the nurse anticipate when assessing a child with newly diagnosed acute lymphoblastic leukemia? A. Pallor B. Fatigue C. Jaundice D. Multiple bruises E. Generalized edema

A. Pallor B. Fatigue D. Multiple bruises

The client is describing the pain in her right leg as severe and concentrated in her foot and ankle. The nurse receives a prescription from the provider for hydrocodone bitartrate and acetaminophen 5/325 two tabs PO prior to the patient's exam. Before initiating the treatment, it is most important for the nurse to implement which interventions? A. Perform a focused assessment on the LRE B. Implement a numeric pain assessment on a scale of 1 to 10 C. Document a baseline of vital signs including a pulse ox D. Use at least two client identifiers before administering the medication

A. Perform a focused assessment on the LRE B. Implement a numeric pain assessment on a scale of 1 to 10 C. Document a baseline of vital signs including a pulse ox D. Use at least two client identifiers before administering the medication

Another less common complication of heparin therapy is Heparin Induced Thrombocytopenia (HIT). What if the client develops fever and chills? Based on these cues, the nurse recognizes that it is essential to obtain which information first? A. Platelet count B. WBC count C. Renal function tests D. Patient's fluid I/O

A. Platelet count

Which task would be considered developmentally appropriate for a 2 yo to complete? A. Putting socks on feet B. Washing and drying hands C. Using fingers to eat food D. Building a tower of four cubes E. Identifying facial body parts

A. Putting socks on feet B. Washing and drying hands C. Using fingers to eat food D. Building a tower of four cubes E. Identifying facial body parts

Which assessments would the nurse make for a client who has had an open reduction and internal fixation of a fractured hip? A. Skin temperature B. Mobility of the hip C. Sensation in the toes D. Condition of the pins E. Presence of pedal pulse

A. Skin temperature C. Sensation in the toes E. Presence of pedal pulse

Heparin overdose can cause life threatening hemorrhaging, such as nosebleeds, coffee grounds emesis, blood in urine and stools, and bruising. Which of these actions should the nurse take for the patient's safety? A. Stop the heparin infusion B. Obtain a stat APTT C. Assess vital signs D. Anticipate administering a dose of vitamin K E. Decrease the infusion rate and contact the provider F. Anticipate a prescription of protamine sulfate

A. Stop the heparin infusion B. Obtain a stat APTT C. Assess vital signs F. Anticipate a prescription of protamine sulfate

As a part of informed consent, a surgeon explains to the client scheduled for surgery the details of the surgery r/t care. The nurse leader witnesses the complete procedure. Which information would the nurse leader ensure was provided to the client? A. Surgical procedure B. Name of the surgeon C. Explanation of the possible risks D. Anesthetic medication used during the preparation E. Name of the staff members who will be in the surgery

A. Surgical procedure B. Name of the surgeon C. Explanation of the possible risks

The incoming nurse notices which cue as the cause of observable hematuria in the patient's urinary catheter? A. The IV pump infusing at a higher rate than prescribed B. The provider prescribes a lower rate than recommended C. The day shift nurse reported lowering the rate of infusion prior to shift change D. The urinary catheter bag hangs from the side bedrail

A. The IV pump infusing at a higher rate than prescribed

Which feature is associated with the maturation phase of normal wound healing? A. The scar is firm and inelastic on palpation B. Fibrin strands form a scaffold or framework C. WBC migrate into the wound D. Epithelial cells are grown over the granulation tissue bed

A. The scar is firm and inelastic on palpation

Which nursing assessments are indicated for an infant being admitted with pyloric stenosis and 3 days of vomiting? A. Tissue turgor B. Neuro defects C. Time of last feeding D. Amount of last void E. Character of the vomitus

A. Tissue turgor B. Neuro defects D. Amount of last void

Which client conditions are examples of a cell-mediated immunity? A. Tuberculosis (TB) B. Graft rejection C. Allergic rhinitis D. Contact dermatitis E. Anaphylactic shock

A. Tuberculosis (TB) B. Graft rejection D. Contact dermatitis

The nurse is assessing a school age child who suffers from encopresis. Which advice provides effective treatment for this condition? A. You should drink lots of fluid B. You should include milk in your diet C. You should delay the urge to defecate D. You should include cereals in your diet E. You should eat fresh fruit for breakfast

A. You should drink lots of fluid D. You should include cereals in your diet E. You should eat fresh fruit for breakfast

A client develops bacterial meningitis. What is the priority nursing care? A. Monitoring for signs of ICP B. Adding pads to the side of the bed C. Administering prescribed abx D. Administering glucocorticoids

Administering prescribed abx

Leiomyoma S/S A. Abnormal uterine bleeding B. Pelvic pressure C. Pressure during urination D. Painful intercourse E. Palpation of enlarged uterus and nodular masses

All of the above

A patient with a diagnosis of incarcerated hernia asks the nurse for an explanation of the condition. Which description should the nurse give? A. The bowel has twisted upon itself B. A piece of the intestine has become stuck in a hole in the abdominal wall C. The intestinal blood supply has been cut off D. The involved intestine has developed an erosion

B. A piece of the intestine has become stuck in a hole in the abdominal wall

When the heparin therapy is initiated, the nurse analyzes which lab value to determine that a therapeutic heparin level has been reached? A. Hemoglobin 9.0 b/dL B. APTT 65 seconds, control 35 seconds C. INR 1 D. Platelet count 250,000/mm3

B. APTT 65 seconds, control 35 seconds

A pt has surgery for an incarcerated hernia. The provider returns the hernia and uses a mesh to reinforce the muscle wall. Which instructions should be included in the discharge instructions? A. Reduce dietary roughage B. Avoid lifting heavy items C. Increase dietary potassium intake D. Keep the head of the bed elevated

B. Avoid lifting heavy items

The nurse assess a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the mid-abdomen, which type of sound would the nurse expect to hear? A. Tympany B. Borborygmi C. Abdominal bruit D. Pleural friction rub

B. Borborygmi

A child with plumbism is prescribed estate calcium disodium (calcium EDTA). Which assessment would be most appropriate for the nurse to conduct before administering EDTA? A. Reviewing lab results for hypocalcemia B. Checking for protein in the urine C. Looking for signs of bone marrow depression D. Monitoring for increased ICP

B. Checking for protein in the urine

Which are the four core roles for the advanced practice registered nurse? A. Ostomy care nurse B. Clinical nurse specialist C. Certified nurse-midwife D. Certified RN anesthetist E. Certified diabetes educator F. Certified nurse practitioner

B. Clinical nurse specialist C. Certified nurse-midwife D. Certified RN anesthetist F. Certified nurse practitioner

Indicator of moderate dehydration in a 4 mo infant A. Urine output of 50 mL/hr B. Depressed anterior fontanel C. H/o allergies to certain formulas D. Cap refill time of <2 seconds

B. Depressed anterior fontanel

Which non-pharmacologic nursing interventions will reduce pain r/t decreased venous flow? A. Apply cold packs B. Elevate the affected leg C. Gently massage the affected leg D. Encourage occasional ambulation E. Apply a warm compress

B. Elevate the affected leg E. Apply a warm compress

Anticoagulants are the drug of choice for patient's with actual DVT and so the provider prescribed Heparin therapy for the client. Which conclusions regarding Heparin administration are accurate? A. Heparin is administered with oral anticoagulants such as warfarin B. Heparin infusion requires lab monitoring and dose adjustment C. Heparin is known to cause medical complications even deatg D. Heparin therapy is administered via IV route E. Protamine sulfate is the antidote for heparin

B. Heparin infusion requires lab monitoring and dose adjustment C. Heparin is known to cause medical complications even deatg D. Heparin therapy is administered via IV route E. Protamine sulfate is the antidote for heparin

A patient is experiencing both tingling of the extremities and tetany. The nurse will review the lab values to check for what electrolyte imbalance? A. Hypokalemia B. Hypocalcemia C. Hyponatremia D. Hypochloremia

B. Hypocalcemia

Pt teaching to prevent constipation. What pt statements prove that the teaching was understood? A. I can eat potatoes at dinner daily B. I should drink at least 6 glasses of water every day C. I should eat eggs for breakfast three times a week D. I can include bran muffins in my breakfast daily E. I will walk every day as part of my exercise regimen

B. I should drink at least 6 glasses of water every day D. I can include bran muffins in my breakfast daily E. I will walk every day as part of my exercise regimen

Which assessment in a traumatized client does the nurse make with the Glasgow Coma Scale? A. Patency of airway B. LOC C. Breathing abnormalities D. Circulatory abnormalities

B. LOC

Which intervention would the nurse include in the care of a child with Wilms tumor? A. Palpating for liver size B. Monitoring blood pressure C. Obtaining urine for a culture D. Maintaining the prone position

B. Monitoring blood pressure

A pt in the ED is experiencing a seizure. Which action would the nurse take first? A. Ask the provider for a prophylactic anticonvulsant B. Obtain a hx of seizure type and incidence C. Ask the client to remove any dentures and eyeglasses D. Observe the client for increased restlessness and agitation

B. Obtain a hx of seizure type and incidence

Which statements regarding the adverse effects of immunization are true? A. Only diphtheria vaccines cause acute encephalopathy B. Oral poliovirus vaccine causes paralytic poliomyelitis C. Hep B vaccine is the safest vaccine because it does not cause adverse side effects D. Swelling of glands in the cheeks and neck is an AE of the measles vaccine E. Fever and erythema at the injection site are common AE of all vaccines

B. Oral poliovirus vaccine causes paralytic poliomyelitis D. Swelling of glands in the cheeks and neck is an AE of the measles vaccine E. Fever and erythema at the injection site are common AE of all vaccines

Which immunizations would the nurse determine are safe for a child who is receiving prednisone? A. Rubeola B. Pertussis C. Varicella D. Inactivated poliovirus E. Tetanus immune globulin

B. Pertussis D. Inactivated poliovirus E. Tetanus immune globulin

Which action would the nurse take to limit a common complication for a client who had an inguinal hernia repair? A. Apply an abdominal binder B. Place a support under the scrotum C. Teach the client to cough several times an hour D. Encourage the client to eat a high-carbohydrate diet

B. Place a support under the scrotum

Which activities would the nurse perform to meet the client's safety and security needs based on Maslow's hierarchy of needs? A. Providing a cold bath to reduce the client's body temp B. Positioning the bed in a low position and keeping the side rails up C. Monitoring vital signs, such as BP to decrease the risk of falls D. Observing a client who has suicidal tendencies to prevent adverse incidents E. Collaborating with family members to provide emotional support for the patient post-surgery

B. Positioning the bed in a low position and keeping the side rails up C. Monitoring vital signs, such as BP to decrease the risk of falls D. Observing a client who has suicidal tendencies to prevent adverse incidents

A client with severe Crohn disease develops a small bowel obstruction. Which clinical finding would the nurse expect the client to report? A. Bloody vomitus B. Projectile vomiting C. Bleeding with defecation D. Pain in the LLQ

B. Projectile vomiting

Procedure that would confirm the diagnosis of Hirschprung disease in a 1 mo infant? A. Colonoscopy B. Rectal biopsy C. Multiple saline enemas D. Fiberoptic naseonteric tube

B. Rectal biopsy

After consulting with the provider, the nurse is to administer a heparin antagonist. The nurse explains to the patient that protamine sulfate is being administered to obtain which expected outcome? A. Neutralize blood clots B. Reduce hematuria C. Prevent blood clots D. Avoid strokes

B. Reduce hematuria

Which information would the nurse provide for a client who is discharged from the health care facility with a surgical wound? A. Potential drug-drug interactions B. Skill to care for the surgical wound C. Safe and effective use of medications D. List of appropriate community resources E. Need to report any change in the surgical area

B. Skill to care for the surgical wound C. Safe and effective use of medications D. List of appropriate community resources

A pt with hyperthyroidism asks the nurse about the tests that will be ordered. Which diagnostic tests would the nurse include in a discussion with this pt? A. Thyroxine (T4) and x-ray films B. TSH assay and triiodothyronine (T3) C. Thyroglobulin level and PO2 D. Protein-bound iodine and sequential multichannel autoanalyzer (SMA)

B. TSH assay and triiodothyronine (T3)

On the first evening after a lumbar laminectomy, a patient states, "My feet are as numb as they were before the operation". Which response would the nurse make? A. "Let me elevate your feet so the numbness will decrease more quickly" B. That's important to know. I will contact your provider about the numbness" C. "Continue to let me know how you feel. It often takes time before that feeling subsides" D. "There is no cause for concern. The numbness will disappear when the anesthesia wears off"

C. "Continue to let me know how you feel. It often takes time before that feeling subsides"

Which clinical manifestation would the nurse expect in a 3 yo child newly diagnosed with a Wilms tumor? A. Periorbital edema B. Projectile vomiting C. Abdominal swelling D. Low-grade temp

C. Abdominal swelling

Which S/S r/t PUD indicates immediate provider notification? A. Nausea B. Dyspepsia C. Black stools D. Dull abdominal pain

C. Black stools

After several episodes of abdominal pain and vomiting, a 5 mo infant is admitted with a tentative diagnosis of intussusception. Which assessment would the nurse document that will aid confirmation of the diagnosis? A. Frequency of crying B. Amount of po intake C. Characteristics of stools D. Absence of bowel sounds

C. Characteristics of stools

Which childhood disease is best described as a viral disease that starts with malaise and a highly pruritic rash that begins on the abdomen and spreads to the face and proximal extremities and can result in grave complications? A. Rubella B. Rubeola C. Chickenpox D. Scarlet fever

C. Chickenpox

During heparin therapy, the patient's APTT is monitored every 6 hours and the midnight results were APTT 120 seconds, control 35 seconds. Based on these cues, what action should the nurse expect to initiate? A. Increase and maintain this rate of infusion until next APTT check in 6 hours B. Continue and maintain the rate of infusion until the next APTT check in 6 hours C. Decrease and maintain this rate until the next APTT check in 6 hours D. Recalculate the infusion rate and maintain this rate until next APTT check in 6 hours

C. Decrease and maintain this rate until the next APTT check in 6 hours

A client had a rubella infection during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. Which type of infection control precautions would the nurse institute? A. Enteric B. Contact C. Droplet D. Standard

C. Droplet

An adolescent male complains of painful urination and yellow-green mucosal discharge from urethra without abdominal pain. Which condition does the pt likely have? A. Varicocele B. Testicular torsion C. Epididymitis D. Gynecomastia

C. Epididymitis

A patient who is to have a total hip arthroplasty with an uncemented prosthesis asks, "When will I be able to get up and walk?" Which information would the nurse include in a response? A. Full weight bearing is permitted after 2 weeks B. Partial weight bearing begins the day after surgery C. Full weight bearing may begin the day after surgery D. Partial weight bearing progresses to full weight bearing in 2 weeks

C. Full weight bearing may begin the day after surgery

A 6 mo infant is to receive scheduled immunizations. The parents ask why two influenza vaccines are given: Hib and PCV. Which response by the nurse is appropriate? A. PCV prevents influenza B. Hib is given to prevent pneumonia C. Hib and PCV prevent different bacterial diseases D. They are given together to protect against viral and bacterial diseases

C. Hib and PCV prevent different bacterial diseases

The nurse must educate the client about the venous ultrasound by distinguishing it from the venography. Which description accurately expresses these diagnostic tests? A. Doppler studies and venograms are both invasive procedures B. Nursing implications for doppler studies include assessment for allergies to iodine and for adequate renal function C. If doppler studies are negative and a DVT is still suspected, a venogram may be needed to make accurate diagnosis D. The client must sign an informed consent prior to either of these tests

C. If doppler studies are negative and a DVT is still suspected, a venogram may be needed to make accurate diagnosis

Interventions to include in plan of care after closure of a newborn's myelomeningocele? A. Limiting leg movement B. Decreasing environmental stimuli C. Measuring head circumference daily D. Monitoring for serous drainage from the nares

C. Measuring head circumference daily

Which rationale is correct for the nurse to empty a Hemovac wound suction device when it is half full? A. Emptying the unit is safer when it is half full B. Accurate measurement of drainage is facilitated C. Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage D. Fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound

C. Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage

Which parent education would the nurse provide the parents caring for their infant with cerebral palsy? A. Focus on cognitive rather than motor skills B. Maintain immobility of the limbs with splints C. Preserve muscle tone to prevent joint contractions D. Continue to offer a special formula to limit gagging

C. Preserve muscle tone to prevent joint contractions

Five days after a client has abdominal surgery the nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports that the client is experiencing wound dehiscence? A. Increased bowel sounds B. Loosening of the sutures C. Serosanguineous drainage D. Purplish color of the incision

C. Serosanguineous drainage

An adolescent has pain, swelling, and inflammation of the testis, abdominal pain, and occasional immobilization of the scrotum. Which condition does the adolescent likely have? A. Varicocele B. Epididymitis C. Testicular torsion D. Testicular cancer

C. Testicular torsion

According to Erikson's theory, which psychosocial developmental changes are observed in middle childhood? A. The child is highly imaginative B. The child is able to trust others C. The child is engaged in tasks and activities D. The child can differentiate between industry and inferiority E. The child develops self-control and independence

C. The child is engaged in tasks and activities D. The child can differentiate between industry and inferiority

Which clinical manifestations indicate early symptoms of aspirin poisoning in children? A. Hyperactivity B. Seizures C. Tinnitus D. Hyperventilation E. Respiratory failure

C. Tinnitus D. Hyperventilation

Which immunizations would the nurse expect a 5 1/2 month old infant to have already received if the immunization status is considered up to date? A. Measles, mumps, and rubella vaccine B. Booster dose of IPV C. Two doses of diphtheria, tetanus, and pertussis vaccine D. First booster dose of diphtheria, tetanus, and pertussis vaccine

C. Two doses of diphtheria, tetanus, and pertussis vaccine

An infant after being treated for talipes equinovarus (clubfoot) has a cast change q 2-3 weeks. Which assessment would the nurse include at routine visits?

Cap refill of affected limb, color of the toes of the foot in the cast, movement of toes of the foot in the cast, lower extremity skin integrity, pain with vital signs

A client who is scheduled for a bowel resection to receive antibiotics preoperatively. Which explanation would the nurse include when teaching the patient about the purpose of the antibiotics? A. "They prevent incisional infection" B. "Antibiotics prevent postoperative pneumonia" C. "These medications limit the risk of a UTI" D. "They are given to eliminate bacteria from the GI tract"

D. "They are given to eliminate bacteria from the GI tract"

After an open reduction and internal fixation of a fractured hip, the nurse is helping a client get out of bed into a chair. Which action would the nurse use to accomplish this transfer? A. Use a slide board to slide the client from the bed to the chair B. Ask the client to put weight equally on both legs and step to the chair C. Have several people assist with lifting the client from the bed to the chair D. Coach the client to put the most weight on the unaffected leg and pivot to the chair

D. Coach the client to put the most weight on the unaffected leg and pivot to the chair

Which action would the nurse take after observing dehiscence of the patient's abdominal surgical wound with evisceration? A. Obtain vital signs B. Notify the provider C. Reinsert the protruding organs using aseptic technique D. Cover the wound with a sterile towel moistened with NS

D. Cover the wound with a sterile towel moistened with NS

The nurse understands which preparations use toxoids but not live viruses? A. Rotavirus vaccine B. Varicella virus vaccine C. Measles, mumps, and rubella virus vaccine D. Dephtheria, hepatitis B, pertussis (acellular), polio, tetanus E. Diphtheria and tetanus toxoids and acellular pertussis vaccine

D. Dephtheria, hepatitis B, pertussis (acellular), polio, tetanus E. Diphtheria and tetanus toxoids and acellular pertussis vaccine

Which nursing assessment supports a diagnosis of atelectasis in a postoperative client? A. Productive cough B. Clubbing of the fingertips C. Low-pitched expiratory ronchi D. Diminished breath sounds on auscultation

D. Diminished breath sounds on auscultation

Interventions to include in plan of care for post-op prostatectomy pt A. Encourage the client to drink extra fluids B. Institute seizure precautions C. Monitor the plasma pH for acidosis D. Handle the client gently when turning

D. Handle the client gently when turning

Which position would the nurse place a 1 yo infant with a distended abdomen admitted with Hirschprung disease? A. Prone B. Sitting C. Supine D. Lateral

D. Lateral

Clinical findings associated with hypokalemia A. Edema B. Muscle spasms C. Kussmaul respirations D. Muscle weakness

D. Muscle weakness

A pt visits a PCP and reports chills, severe abdominal pain, and increased vaginal discharge. Which infection would the nurse suspect? A. Gonorrhea B. Chlamydia C. Trichomoniasis D. Pelvic inflammatory disease

D. Pelvic inflammatory disease

A patient is diagnosed with testicular cancer. Which treatment would be first? A. Radiotherapy B. Chemotherapy C. Testicular biopsy D. Radical inguinal orchiectomy

D. Radical inguinal orchiectomy

Which S/S would be expected findings for a pt with repaired cystocele and rectocele? A. White vaginal discharge and itching B. Sporadic bleeding and abdominal pain C. Increased temperature and intractable diarrhea D. Stress incontinence and low abdominal pressure

D. Stress incontinence and low abdominal pressure

Which assessment finding would the nurse expect for a 2 mo infant admitted to the Peds unit with gastroenteritis and dehydration A. Bulging fontanel B. Marked restlessness C. Resilient tissue turgor D. Tachycardia

D. Tachycardia

On the third postoperative day after a subtotal thyroidectomy for a tumor, a client complains of a "funny, jittery feeling". Which intervention is appropriate for the nurse to take? A. Explain that this reaction is expected and not a concern B. Take the vital signs and place the pt in a high-fowler position C. Request stat serum calcium and phosphorus levels and chart the results D. Test for Chvostek and Trousseau signs and notify the PCP of the complaints

D. Test for Chvostek and Trousseau signs and notify the PCP of the complaints

A 3.5 yo child is admitted to the hospital for an appendectomy. Which strategy would the nurse use to prepare the child for the hospital experience? A. A diagram B. Puppet play C. A storybook D. Therapeutic play

D. Therapeutic play

S/S of prostate cancer

Dysuria, hesitancy, urinary urgency, leakage, serum PSA level 5ng/mL, and elevated PAP level

Which clinical manifestation will the nurse anticipate when providing care to a toddler who is diagnosed with acute lead poisoning?

Emesis, nausea, anorexia, hypophosphatemia, seizures, pica, irritability

Hyperthyroidism cause

Excessive deliver of thyroid hormones to the tissues, Graves' disease

Early signs of cerebral palsy in a toddler/ child

Excessive drooling, difficulty swallowing, favoring one side of the body, turn from front to back at an early age, involuntary movements such as trembling or seizures, not meeting basic growth and development stages

Which symptom indicates pelvic inflammatory disease?

Fever, elevated ESR, chronic pelvic pain, irregular vaginal bleeding, abnormal vaginal discharge, bilateral adnexal tenderness

The nurse is assessing a patient with impaired hearing. Which action can be used to establish good communication with the client?

Getting the patient's attention before speaking

A nurse is told in report that the pt has a positive Chvostek's sign. What other data would the nurse expect to find during assessment of the pt? A. Coma B. Tetany C. Diarrhea D. Seizure activity E. Hypoactive bowel sounds F. Positive Trousseau's sign

INDICATOR OF HYPOCALCEMIA B. Tetany D. Seizure activity F. Positive Trousseau's sign

Hyperthyroidism s/sx

Increased metabolism, weight loss despite an increased appetite, heat intolerance, reduced or normal TSH levels

Hypothyroidism tx

Levothyroxine (Synthroid)

Hyperthyroidism tx

Pharmaceutical agents, radiotherapy, or surgical removal of the thyroid gland

Which clinical manifestation of increasing ICP will the nurse expect to assess in the 2 y.o. diagnosed with meningitis?

Seizure, decreased RR, difficulty with speech

Hypokalemia s/sx

Serum K <3.5 mEq/L Dilute urine, polyuria, polydipsia N/V Diarrhea/ ileus Leg cramps, muscle weakness Paralysis, poor muscle tone Confusion, depression, lethargy Dysrhythmias Respiratory/ cardiac arrest

Hypomagnesemia s/sx

Serum magnesium <1.8 mg/dL Personality changes Nystagmus Positive babinski, Chvostek, Trosseau signs Hypertension Tachycardia Cardiac dysrhythmias

Hypermagenesemia s/sx

Serum magnesium >3 mg/dL Confusion CNS depression/ lethargy Hypotension Facial flushing/ sweating Cardiac dysrhythmias Coma Cardiac arrest

Hyperkalemia s/sx

Serum potassium >5.3 mEq/L Diarrhea Abdominal cramping Anxiety Paresthesia Irritability Muscle weakness/ paralysis Bradycardia/ irregular EKG

Hypothyroidism s/sx

Slow metabolism, increased weight despite a poor appetite, cold intolerance, elevated TSH levels

S/S r/t E. coli bacteria

Temperature of 102.8, chills, dysuria, urethral discharge, boggy, tender prostate

Which would the nurse include in dietary teaching for a client with a colostomy?

The diet should be adjusted to result in manageable stools

Which clinical finding would the nurse expect when assessing an infant with pyloric stenosis?

Visible peristaltic waves, vomiting after feeding, inadequate weight gain, olive-shaped mass in the RUQ, lack of tears when crying