nursing

A client is unwilling to go out of the house for fear of making a fool of me in public. Because of this fear the client remains homebound. Based on these data which mental health disorder done is the client experiencing

social phobia

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the clients condition has progressed to hepatic encephalopathy ?

- Ask if the client knows what day it is - Ask the client to extend the arms - Assess for telangiectasia (spider nevi)

The obstetric nurse is reviewing phone messages. Which client should the nurse call first?

Client at 32 weeks gestation taking ibuprofen for moderate back pain

A nurse educator is developing materials for hospital wide campaign about zero tolerance for lateral violence and bullying among staff. Which ACTIONS will the nurse educator include in teaching about what staff members should do if they experience workplace violence? SELECT ALL THAT APPLY.

1. Document the interactions with the bully 3. Observe interactions between the bully and other colleagues 5. Tell the bully you will not tolerate the unprofessional behavior.

A nurse is observing a nursing student reinforce teaching to a client on how to take sucralfate. Which statement made by the student would require intervention by the nurse?

Take this with your other stomach medications

The nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes. Which cranial nerves is the nurse assessing?"SELECT ALL THAT APPLY"

2. 111 3. IV 5. VI

During the charge nurse's morning rounds, a client says, "I hope you will take better care of me than the nurse I had last night." What should be the charge nurse's initial response?

2. Ask the client to describe what happened last night

Which category of medication used to treat anxiety has a potential for addiction?

Benzodiazepines

the healthcare provider orders a small bowel following-through SBFT for a client. which instruction should the nurse include when teaching the client about this test

During the test a series of x-ray will be taken to assess the function of the small bowel

The health care provider (HCP) orders a small bowel follow-through (SBFT) for a client. Which instructions should the nurse include when teaching the client about this test?

During the test, a series of x-rays will be taken to assess the function of the small bowel.

what is an algorithm?

Step-by-step guide lines in the flowchart

The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction?

This medication will help me lose weight

The initial prenatal laboratory screening results of a client at 12 weeks gestation indicate a rubella titer status of nonimmune. What will the nurse anticipate as the plan of care for this Client?

administer MMR vaccine immediately postpartum

the nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis) which of the following lifestyle change should the nurse recommend

eat several small meals each day eliminate fried, fatty food

Which of the following is the primary consideration with client taking antidepressant ? suicide

suicide

An anxiolytic agent, lorazepam (Ativan), has been prescribed for the client. Which of the following statements by the client would indicate to the nurse that client education about this medication has been effective?

"This medication will relax me, so I can focus on problem solving."

The nurse is caring for a client with an exacerbation of asthma following a viral respiratory illness. When collecting data, the nurse expects to find which clinical characteristics of a severe asthma exacerbation? Select all that apply.

*Accessory muscle use *chest tightness *high pitched expiratory phase *tachypnea

The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? select all that apply.

- Call for help - Prepare for suctioning - Turn the client on the side

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply

-Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis -Document the time the fetal head was born -Request additional assistance form the other nurses immediately

The nurse is providing postmortem care for a client who had died after a long hospitalization the client had a do not resuscitate prescription in place at the time of birth which of the following intervention should the nurse include during postmortem care in preparation for transferred to the funeral home select all that apply

-allow family member to assist with care -gentle close the clients eyes -place a pad under the perineum

The nurse assesses a child with intussusception. Which assessment findings require priority intervention? 1. Abdominal rigidity with guarding 2. Absence of tears in crying child with IV start 3. Blood-streaked mucous stool in diaper 4. Sausage-shaped right-sided mass on palpation

1 perforation of the intestinal

The emergency department triage nurse is assessing 4 pediatric clients. Which client is a priority for further diagnostic workup and definitive care?

1 year old with ventriculoperitoneal shunt who has "lethargy" and has been vomiting and pulse of 78/min

The nurse assesses a client receiving peritoneal dialysis. Which assessment findings are most important for the nurse to report to the health care provider? SATA

1) Cloudy outflow 2) Low grade fever 3) Tachycardia

A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate?

1) Flush the NG tube before and after the feeding 2) Place the patient in semi fowlers 3) Start the feeding after obtaining gastric residual volume of 75 mL

The nurse is reviewing anticipatory guidance with the parents of a 6-month-old infant with phenylketonuria. Which statements by the nurse are appropriate? Select all that apply. 1. A low phenylalaline diet is required 2. Meat and dairy products should not be introduced into the diet 3. Phenylketonuria is self limiting and usually resolves by adulthood 4. Special infant formula is required 5. Tyrosine should be removed from the diet

1, 2, & 4

The parents of a 2-year-old client ask how they can help their child cope with hospitalization. Which of the following suggestions should the nurse give the parents? Select all that apply. 1. Follow as many home routines as possible 2. Organize a visit from a playgroup friend 3. Sleep in the child's hospital room at night 4. Take the child on regular visits to the playroom 5. Tell the child they did not cause the illness

1, 3, & 4

A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are APPROPRIATE to include in the client's care plan to help prevent a hip fracture? "SELECT ALL THAT APPLY" #72116868 (20) 1. Calcium supplement 2. Encourage bed rest 3. Use of full bed rails during the night 4. Vitamin D supplements 5. Weight-bearing exercises.

1,4,5

A client with a severe exacerbation of asthma following influenza infection is transferred to the intensive care unit due to rapidly deteriorating respiratory status and the possible need for mechanical ventilation. Which clinical manifestations does the nurse assess that support the presence of impending respiratory failure? Select all that apply.

1. PaCO2 55 mm Hg 2. PaO2 58 mm Hg 3. Paradoxical breathing 5. Restlessness, drowsiness 6. Silent chest and absence of wheezing

Which client condition is concerning and requires further nursing assessment and intervention?

1. before liver bx, pulse is 80/min and bp is 120/80 mm Hg; 1 hour afterward, pulse is 112/min and BP is 90/60 mm Hg Elderly client with black stools; pulse is 112/min

The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed. Which IV catheter size is best?

18-gauge

The nurse assesses a client with suspected acute pancreatitis and anticipates the client reporting pain in which anatomical area? 1. Left flank radiating to the left groin area 2. Left upper quadrant radiating to the back 3. Periumbilical area shifting to the right lower quadrant 4. Right upper quadrant radiating to the right shoulder

2 Left upper quadrant radiating to the back

The nurse prepares to administer a dose of radioactive iodine (RAI) to a 39-year-old female client with Graves' disease. Which action is most important for the nurse to take? 1. Ask client when her last menstrual cycle occurred 2. Confirm pregnancy test result is negative 3. Obtain a baseline assessment of the mouth and throat 4. Teach the client the signs and symptoms of hypothyroidism

2. Confirm pregnancy test result is negative

The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct the client to avoid the VALSALVA MANEUVER when defecating?

22 year old man with a head injury sustained during a college football game. 56 year old man 2 weeks post myocardial infarction. 74 year old man with portal hypertension related to alcohol induced cirrhosis 82 year old woman 1 week post cataract surgery.

When performing developmental screenings in the well-child clinic, the registered nurse understands that which child is at highest risk of developing autism spectrum disorder?

4 year old whose father has the disorder

A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client? 1. Alprazolam 2. Dextromethorphan 3. Lisinopril 4. Valsartan

4. Valsartan

The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first?

7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow

A laboring client reports feeling the need to have a bowel movement and begins vomiting. The nurse notes that the client's legs are trembling. What cervical examination finding would the nurse most expect this client to have?

8 cm, 100% effaced, and +1 station

A client has diabetic ketoacidosis and manifests Kussmaul respirations. What action by the nurse takes priority?

Administration of intravenous insulin

A client is receiving normal saline 75 mL/hr and morphine sulfate via patient-controlled analgesia (PCA) bolus doses. The PCA and normal saline tubing are connected at the "Y" site. The nurse reviews a prescription from the health care provider to discontinue the normal saline. What is the most appropriate nursing action?

Clarify the prescription with the HCP

The client with schizophrenia believe that the student nurses are there to spy on the client the client is suffering from which of the following ?

Delusions

The health care provider prescribe phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse remind the client to expect while taking this medication?

Discoloration of urine

A registered nurse is precepting a new graduate nurse on the orthopedic unit. Which action by the graduate nurse requires the registered nurse to intervene?

Elevating a client's residual limb

A client with terminal cancer arrives in the emergency department unresponsive and in respiratory distress. The client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time?

Get directions about care from the client's sister

The nurse is teaching a client with insomnia techniques to improve sleep habits. Which statement by the client indicates a need for further teaching?

I will read in bed if I can't fall asleep."

A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted?

Improvement in spontaneous activity

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client?

Inability to cough or lift the head

A nurse is caring for a client at 30 weeks gestation who is admitted for preterm labor. Which of the following interventions should the nurse anticipate? Select all that apply

Initiating IV magnesium sulfate administering penicillin via IV piggyback Administering 1M betamethasone

Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the health care provider?

Keep the infant warm

Because he works with the young men in a treatment center for domestic abuse, and I still is always careful to be respectful of both patients and staff especially woman he tells a coworker which educational tool is Ernesto demonstrating most clearly?

Modeling

A client in active labor who received an epidural 20 minutes ago reports feeling nauseated and lightheaded. Which action should the nurse perform first?

Obtain BP

The nurse performing an initial newborn assessment observes a bluish discoloration Of the hands and feet. The trunk has a pink color. which action by the nurse is appropriate?

Place the newborn skin to skin with the mother

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate?

Prepare intubation and suction supplies at the bedsite

A 16-year-old walks in unaccompanied by a parent and approaches the clinic nurse. The adolescent asks to be tested for a sexually transmitted infection (STI). How should the clinic nurse respond?

Provide requested service

The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? Select all that apply.

Pt is easily frustrated while attempting to speak Pt's speech os limited to short phrases that require effort

At 8 AM medication to prescribe for some kind which medication should the nurse administer first?

Pyridostigmine for a client with Myasthenia gravis exacerbation who reports difficulty swallowing

Interdisciplinary client care rounds and hand-off communication are examples of strategies used to improve communication in health care settings. What is the most important outcome of effective communication among care givers?

Reduced number of medical errors

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?

Refer employee to the employee health provider

A client is brought to the emergency department due to loss of consciousness after binge drinking at a college party and then taking alprazolam. Pulse oximetry shows 87% on room air. Which findings would the nurse expect to assess on a

Respiratory acidosis and hypoventilation

The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow-up?

Small tuft of hair at the base of the spine

A client diagnosed with schizophrenia is laughing and talking while sitting alone. Which of the following is the best response by the nurse?

State, Tell me what's happening

A newborn had a bowel resection with temporary colostomy for Hirschsprung's disease. The nurse should alert the health care provider (HCP) for which assessment finding postoperatively?

Stoma is gray-tinged at the edges but pink at the center on postoperative day 5.*hence, colostomy stoma should be beefy red in immediate postop

The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client w/diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription?

Sucking lip motions(Tardive dyskinesia/TD)

John an emergency department nurse, has just worked an eight hour shift in the ED. After a five car wreck during his mid shift, five patients have been transported to the hospital with multiple injuries and one fatality. John looks exhausted and his hands are tremulous. He insist that he is scheduled to work six hours. As the nurse manager what is your best action?

Tell him that he needs to end his shift right away

the nurse is caring for a client with acute pancreatitis admitted 2 day ago which assessment finding is most concerning

Temperature of 102.2 F (39 C) with increasing abdominal pain

The psychiatric nurse is working in an outpatient mental health clinic which client should the nurse intervene with first?

The client who's wife just died and who wants to go to heaven to be with her

the nurse observed at a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent just use at other client. Which statement would be most appropriate to make to this client?

You seem restless tell me what is happening

the nurse is working on a busy medical surgical unit and is responding to the client call lights which statement would be priority to assess first

a 65 year old female client recently started on celecoxib

a client with a history of heavy alcohol use, whose last drink was 48 hours ago, as seen in the emergency department. The client is oriented but it's from Alice weak and sweaty and has some gastrointestinal symptoms. Which of the following is typical of these symptoms?

alcohol withdrawal syndrome

a priority nursing assessment for a patient who is to receive a beta blocker such as metoprolol would be what

assessing heat rate

Four clients arrive in the urgent care clinic. which does the nurse anticipate to be the priority or intervention

child who is confused and irritable and whose parent claims 2 glyburide pills are missing

the nurse receives a report on the assigned clients for the shift which client should the nurse assess first

client who underwent thyroidectomy yesterday and now has positives trousseau's sign

The client is watching emergency department with multiple trauma injury the nurse is the client Giovani's witness identification card as part of providing culturally competent care the nurse will dissipate the client accepting which of the following select all that apply

normal saline Expiation alfa

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate

vaginal hematoma

A nurse cares for a patient who presents with bradycardia secondary to hypothyroidism. Which medication does the nurse prepare to administer? A. Propranolol (Inderal) B. Epinephrine (Adrenalin) C. Levothyroxine sodium (Synthroid) D. Atropine sulfate

C.

The nurse plans care for a pediatric client who has just undergone a cleft palate repair. Which interventions should the nurse include in the plan of care?

remove elbow offer pacifier

The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse CLARIFY with the health care provider? #71941465 (22) 1. Clopidogrel for client with history of stroke and platelet count of 154,000/mm 2. Losartan for client with hypertension who is 8 weeks pregnant. 3. Prednisone for client with herpes simplex lesions and bells palsy. 4. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease.

2. Losartan for client with hypertension who is 8 weeks pregnant.

All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which tasks are appropriate for the registered nurse (RN) to delegate to the UAP to promote client safety? Select all that apply.

2. Place the bedside commode as close to the bed as possible 3. Remind the client to change position slowly 4. Report observations of changes in client's condition immediately

The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply.

2. The LPN has the client's report sheet in a pocket when going home 3. THe nursing assistant tells a client that the hospital roommate went for a gallbladder test

Which nursing instruction is the highest priority when teaching a 38-year-old female client newly diagnosed with stress incontinence?

2. Importance of voiding every 2 hours

The nurse assesses 4 infants. Which assessment finding would require FOLLOW-UP by the health care provider? 1. 3 week old whose anterior fontanelle bulges with crying. 2. 4 week old whose posterior fontanelle is soft 3. 6 month old with birth weight of 7 lb 3 oz (3.3kg) who now weighs 12 lb (5.4 kg) 4. 12 month old with birth weight of 6 lb 4 oz (2.8 kg) who now weighs 20 lb (9.1 kg)

3. 6 month old with birth weight of 7 lb 3 oz (3.3kg) who now weighs 12 lb (5.4 kg)

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor. which finding would be most concerning to the nurse?

Cessation of contractions and maternal tachycardia

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time?

Check marked insertion depth of the tube

The male client diagnosed with major depression is returning to the psychiatric unit from a weekend pass with his family. Which intervention should the nurse implement first?

Check the quiet for sharps or dangerous objects

Which one of the following drugs should the nurse expect the patient to require serum level monitoring?

Lithium

The client screams at the nurse, "you are all incompetent here , I have been waiting for 2 hours"How should the nurse respond "INITIALLY"?

it is upsetting to wait so long. how can i best help you

The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings?

single transverse crease across palm of the hand

Rene, a restaurant manager, is hospitalized after working 15-hour days for several weeks. Her anxiety level is severe upon admission. She has not slept well during the past 2 weeks. Her psychiatrist has ordered amitriptyline (Elavil) 25 mg, to be administered orally, three times daily. Rene asks you, her nurse, why she is so drowsy. What is your best response?

"Drowsiness is a side effect of this medication."

A nurse is reinforcing instruction regarding home management to a client newly diagnosed with severe psoriasis. Which client statement indicates that further teaching is needed?

"Exposure to sunlight will worsen my psoriasis"

A nurse is teaching the parent how to care for a newly circumcised newborn. Which statement by the parent indicates that further teaching is need

"I will clean the area with alcohol-based wipes or soap water"

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed?

"Losing weight may reduce my reflux, so I plan to take a weight-lifting class."

The nurse is caring for a client taking tamoxifen for breast cancer. Which client statement is most concerning and a priority to report to the HCP?

"My periods have been heavy lately

Charlie asks you, "How will I ever be able to go to the beach or be with a girl with this gross bag hanging on my stomach?What is your best therapeutic response?

"This has to be extremely difficult for you to face."

The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers?

- First and last name - DOB - Medical record number

A client is hospitalized for a broken leg. The client has a history of breast cancer and o receiving outpatient chemotherapy; the last infusion was about a week ago. Which staff members can safely care for this client?

- Nurse floated from another medical surgical floor - Nurse who is 24 weeks pregnant - UAP who just received the yearly injectable flu vaccination

the nurse is caring for a client with tuberculosis who is on airborne isolation precaution the nurse can delegate which tasks to experienced unlicened assistive personnel

- post signs for airborne isolation precautions on the pt's door and stock necessary equipment - remind visitors to wear a respirator and mask and keep the door closed while in the pt's room

The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply.

-Accepting a birthday gift of a gold bracelet from a client -Soliciting a wealthy client to invest in a company -Staying after work hours and drinking wine with a client

The nurse plan of care for a client newly admitted with obsessive compulsive disorder who is repeatedly counting magazines in the comment room. Which of the following should the nurse include in the initial plan of care?

-Assisted client to identify circumstances that increase anxiety -Refrain from judgmental comments about counting magazines -Teach the client how to use a technique of thought stopping -provide positive feedback on the quiet attend a group activity

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply.

-Client receives 1 mg morphine instead of prescribed 0.5 mg morphine -Nurse did not report client's new hemoglobin result of 6 g/dL (60 g/L) to oncoming nurse -Provider was not notified of client's positive blood culture results

During change of shift report, the nurse going off duty notes that the nurse coming on has alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take

-Do not continue the handoff report with the oncoming nurse -Document the incident according to facility policy -Notify the charge nurse

A client with chronic kidney disease has a subcutaneous arteriovenous fistula (AVF) placed in the nondominant left wrist for hemodialysis. Which of the following statements indicate the client understands how to care for the fistula properly

-I will not take my blood pressure in my left arm -I will squeeze a small sponge several times a day in my left hand -I will touch the site and feel for vibration several times a day -I will try not to sleep on my left arm

The nurse is reinforcing strategies to manage symptoms for a client with irritable bowel syndrome. Which of the following instructions should the nurse include? Select all that apply.

-Keep a record of symptoms, diet, and stress levels -Limit dietary intake of gas-producing foods like legumes -Perform aerobic exercise at least three times weekly -Reduce the amount of caffeine consumed each day

the clinic nurse supervises a student nurse who is preparing to administer routine vaccinations to a child diagnosed with hemophilia. which instructions should the clinic nurse provide to the student

-administer vaccines via the subcutaneous route -hold firm pressure on the site 5 min

the nurse assists with a staff education conference about appropriate nonpharmacological pain management interventions for a newborns and infants. which of the following strategies should be included in the presentation

-offer a pacifier to an infant while performing venipuncture -swaddle an infant while leaving one arm unwrapped during an IV dressing change -assist the parent to hold a newborn skin to skin during an immunization injection -administer an oral sucrose solution to a newborn during a circumcision procedure

A client at 9 weeks gestation arrives at the clinic for an initial obstetric appointment. The nurse reviews the client's medical history and obtains a list of current medications. The nurse recognizes that which of the following medications should be clarified with the health care provider immediately?

1) Lisinopril (ACE inhibitors are contraindicated in pregnancy) 2) Doxycycline 3) Isotretinoin

The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan? Select all that apply.

1. helps prevent colorectal cancer 2. improves glycemic control 3. promotes weight loss 4. reduces risk of vascular disease 5. regulates bowel movements

A laboring client weighing 187 1b is 5 cm dilated and having contractions every 2-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push 1 is prescribed by the health care provider Nalbuphine hydrochloride 10 mg/l ml is available, how many milliliters does the nurse administer?

1.214 mL (round down 1.2 mL)

The health care provider orders 2 mEq/kg (2 mmol/kg) of 8.4% sodium bicarbonate IV to be administered over the next 4 hours. The client weighs 150 lb and the pharmacy supplies the following IV solution: 8.4% sodium bicarbonate in 1000 mL D5W with 150 mEq (150 mmol) sodium bicarbonate. At what rate should the nurse set the infusion pump?

1.3 mL

The nurse receives report on 4 clients. Which client should be seen first?

15-year-old with painful right hip, fever, and limited range of motion

A 10-year-old is implementing behavioral strategies to manage nocturnal enuresis. The client tells the nurse, "I want to go to sleep-away camp during the summer, but if I have an 'accident,' I'm afraid that other kids will tease me." What is the best response by the nurse? 1. "Don't worry. Your problem will be resolved by then." 2. "It would be better if you thought about going to day camp instead." 3. "We can ask your health care provider about a medication trial that may help." 4. "You could always wear a pull-up just in case."

3

A 15-month-old begins to seize during assessment for a high-grade fever. What is the most appropriate nursing action? 1. Administer aspirin to lower the client's body temperature 2. Prepare client for administration of anti-seizure medication 3. Stay with the client and monitor oxygen saturation levels 4. Use a bag valve mask to ensure proper ventilation

3

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client has oliguria, dark amber urine, and muscle pain. The nurse should implement which prescription first? 1. ECG 2. IV morphine 2 mg 3. Normal saline bolus 4. Urine sample

3. Normal saline bolus

The nurse has just completed discharge teaching about sublingual nitroglycerin (NTG) tablets to a client with stable angina. Which statement by the client indicates the need for further teaching?1. " I will call 911 if my chest pain isn't relieved by NTG." 2. "If I have chest pain, I can take up to 3 pills 5 minutes apart." 3. "I'll call my doctor if I start having chest pain at night." 4. "I'll keep one bottle in the house and one in the car."

4. "I'll keep one bottle in the house and one in the car."

A pediatric client weighing 66 lb is prescribed ibuprofen 5 mg/kg by mouth every 6 hours PRN for fever. It is available as a 20 mg/mL oral solution. How many milliliters (mL) of this medication should be given to the client per dose? Record your answer using one decimal place.

7.5mL

What drug might the nurse administer for both analgesic and antitussive effects? A) Codeine B) Aspirin C) Ibuprofen D) Acetaminophen

A

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention?

A structured program of activities in which the client can participate

A 20-year-old female patient has been diagnosed with multiple sclerosis. What drug will most likely be prescribed? A) Baclofen (Lioresal) B) Cyclobenzaprine (Flexeril) C) Metaxalone (Skelaxin) D) Orphenadrine (Banflex)

A) Baclofen (Lioresal)

A person suffering from schizophrenia has little emotional expression when interacting with others. The nurse would document the client's affect as which of the following? Select all that apply.

A) Flat B) Blunt

As the nurse settles the patient into his room after returning from the post-anesthesia care unit (PACU), the patient says he is in severe pain. The nurse checks the medical record and sees the patient has an order for morphine 4 to 8 mg every 1 to 2 hour IV as needed for pain. The nurse sees this medication has not been administered yet so the nurse administers 4 mg. After administering the drug, the PACU nurse calls to say a dose of morphine was given and not documented. What drug will the nurse be prepared to administer if the patient's respiratory rate is depressed? A) Naloxone hydrochloride tartrate (Narcan) B) Butorphanol C) Buprenorphine (Buprenex) D) Nalbuphine hydrochloride (Nubain)

A) Naloxone hydrochloride tartrate (Narcan)

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first?

A. Client who had a below the knee amputation today and is complaining of left shoulder and jaw pain radiating down the arm

the nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of the teaching. Select all that apply.

A. I need to avoid taking medicine like ibuprofen without a prescription B. I should avoid drinking excess coffee or Cola C. I should enroll in a smoking cessation program D. I should reduce or eliminate my intake of alcoholic beverages

A patient is experiencing bronchospasms after running half a mile. He has several inhalers with him. Which one would be appropriate for treatment at this time? A. albuterol B. salmeterol C. fluticasone D. salmeterol and fluticasone combination (Advair Diskus)

A. albuterol

The nurse assesses a child with intussusception. Which assessment findings require priority intervention?

Abdominal rigidity with guarding

A nurse is preparing to administer an oxytocin IV infusion to a client for labor induction. The nurse recognizes that an oxytocin infusion may increase the client's risk for which of the following? Select all that apply.

Abnormal or indeterminant FHR pattern PPH Uterine tachysystole

A client with type 1 diabetes has a prescription for 20 units of NPH insulin daily at 7:30 AM and regular insulin before meals, based on a sliding scale. At 7:00 AM, the client's blood glucose level is 220 mg/dL (12.2 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take? Click on the exhibit button for additional information.

Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the regular insulin first

A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes about 18 hours ago. The client's group B Streptococcus status is unknown. What intervention is a priority for this client?

Administration of prophylactic antibiotics

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client MOST LIKELY suffers from which psychological disorder?

Agoraphobia

The nurse is caring for an exclusively breastfed, small-for-gestational age, term newborn at 6 hours of life. The newborn has a capillary blood glucose (BG) of 30 mg/dL (1.67 mmol/L) and is asymptomatic. Which action is most appropriate for the nurse to take at this time?

Allow the newborn to breastfeed

An 80-year-old patient has been brought to the emergency department in shock. The patient is receiving dopamine (Intropin). What potentially serious adverse effect will the nurse monitor for?A)Blood dyscrasia B)Cardiac arrhythmia C)Hepatic toxicity D)Renal insufficiency

Ans: B

The nurse is performing an Apgar assessment on a newborn client at 1 minute of life, The newborn is completely blue, has a heart rate of 110/mim and is emitting a weak cry. Active movement and flexion of extremities are noted and the newborn grimaces when nares are suctioned, Which Apgar score should the nurse assign this newborn?

Apgar score of 6

The nurse answers a call light on a client not assigned to the nurse. The client, who was just admitted from the emergency department, requests a cup of coffee. What is the appropriate intervention?

Ask the client to wait until the health care provider's (HCP's) prescriptions can be verified

A client with end-stage liver disease is admitted for a transplant workup. The client's spouse states that the client has not stopped drinking alcohol and may be unable to quit for 6 months before the transplant. Which is the most appropriate action for the nurse to implement?

Assess the client's motivation to make the necessary self-care changes before and after the transplant

The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer. The client is receiving IV Ringer's lactate at 100 mL/hr and continual epidural morphine for pain control. The Foley catheter urine output has decreased to <20 mLhr over the past 2 hours. The postoperative hematocrit is 36% (0.36), and the hemoglobin is 12 gIdL (120 g/L). Which action should the nurse carry out first?

Assess vital signs

A pregnant client comes to the labor and delivery unit stating, "My water just broke at home." On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate?

Assist client to knee chest position

The client with schizophrenia makes the following statement, i find books in school many school are in Florida, I go to school a Essential school of nursing, I inc. Those documents this entire statement as an example of?

Associative looseness

A young spanish speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client.

Attempt to use a female interpreter to avoid gender sensitivity Make good eye contact with the client (rather than the interpreter) when speaking Teach about one intervention at a time and in order it will occur

A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H2O (11 mm Hg) positive end-expiratory pressure (PEEP). The nurse should assess for which complication associated with PEEP?

Barotrauma

the student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for treatment of depression. which statement by the student indicates a need for further teaching

Because this client has a mental illness the agent will medical power of attorney should sign the information consent document

Which client finding would be a contraindication for the nurse to administer dicyclomine hydrochloride for irritable bowel syndrome?

Bladder scan showing 500mL

the nurse auscultates the lung sounds of a newly admitted client. the nurse understands that the lung sounds heard are consistent with which health condition

Bronchitis

Which statement about ARBs does the nurse identify as being true? a. Hyperkalemia is more likely to occur than when using ACE inhibitors. b. Cough is more likely to occur than when using ACE inhibitors. c. Chest pain is a common adverse effect. d. Overdose is usually manifested by hypertension and bradycardia.

C. Chest pain is a common adverse effect.

What information will the nurse include when teaching the patients about taking beta2-blocking drugs for the treatment of angina?

Call your health care provider if you experience a weight gain of 2 pounds or more in 24 hours or 5 pounds or more in 1 week."

The labor and delivery (L&D) nurse is floated to a medical-surgical floor for a shift. Which client most appropriate for the charge nurse to assign to the L&D nurse?

Client with pyelonephritis who is febrile and receiving IV antibiotics

When making assignments in the labor and delivery unit, the charge nurse should assign the most experienced newborn admit nurse to attend to the birth of which client?

Client with spontaneous rupture of membranes with greenish amniotic fluid.

A pregnant client admitted for induction of labor is receiving an oxytocin infusion. The baseline fetal head rate is 140/min and the strip is shown in the exhibit. What is the nurse's best course of action?

Continue to monitor the client

The nurse is administering morphine to a trauma patient for acute pain. Before administering the morphine, what common adverse effect should the nurse inform the patient about? A) Paresthesia in lower extremities B) Occipital headache C) Increased intracranial pressure D) Drowsiness

D

A graduate nurse is caring for a client at 39 weeks gestation who is receiving an oxytocin infusion, Oxytocin is infusing at 20 mU/min. Based on the electronic fetal monitoring strip, which action by the graduate nurse would cause the registered nurse to intervene?

Decreases oxytocin to 10 mU/min

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? SATA

Dental decay Loss of tooth Electrolyte imbalances

A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take?

Discard urine and container, and restart the 24-hour urine collection tomorrow morning

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse?

Enteral feedings maintain gut integrity and help prevent stress ulcers.

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes were much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior?

Evidence of the client's disturbed body image

A nurse is assessing a 58-year-old client with blurred vision and reduced visual fields. Which manifestation is of most concern to the nurse?

Extreme eye pain

What is the major distinction between here and anxiety?

Fear is a response to specific danger anxiety is a response to an unknown source

Which herbal supplements pose an increase risk for bleeding in surgical clients and should be discontinued prior to major surgery

Gingko biloba Garlic Ginseng Ginger Feverfew

The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse?

Half of my vision looks like it's being blocked by a curtain

A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next?

Have CT scan performed to rule out an intracranial bleed

The practical nurse is assisting the registered nurse with completing a health history of a client with suspected rheumatic fever. Which question is most important to ask the client in order to establish a diagnosis

Have you recently has a streptococcal throat infection

The client is scheduled to have a cardiac catheterization. Which findings will cause the nurse to question the safety of the test proceeding? Select all that apply.

History of previous reaction to IV contrast Serum creatinine of 2.5 mg/dL (221 µmol/L) Received metformin today for type 2 diabetes

The nurse is teaching the mother of a newborn about gastroesophageal reflux, What does the nurse suggest to help prevent reflux?

Hold baby upright 20-30 minutes after each feeding Burp during and after feeds offer smaller but more frequent feeds

The nurse is monitoring a hospitalize who abuses alcohol. Which fighting should alert the nurse to the potential for delirium tremens?

Hypertension, changing level of consciousness hallucination

What other clinical condition listed below is associated with an increased risk of reoccurence of Helen's arrhythmia?

Hypokalemia

Which statement made by the client demonstrates a correct understanding of the home care of an ascending colostomy?

I will avoid eating foods such as broccoli and cauliflower."

The nurse is reinforcing discharge teaching with a client who has been prescribed warfarin for chronic atrial fibrillation. The client should avoid excess or inconsistent intake of which foods?

Large amount of vitamin K rich food can decrease the anticoagulant effect of warfarin therapy. Client are not instructed to remove such foods from their diet but are encourage to be consistent in the intake of food high in Vitamin K, including leafy green vegetables,asparagus, broccoli, kale, brussels, sprout and spinach

The nurse cares for a client with type 2 diabetes mellitus and hemoglobin A1C results of 8% at an outpatient health clinic. Which statement by the nurse will best address these results?

Let's review your diet, exercise, and medication regimen over the past 2-3 months."

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Mrs. Jones in Room 312 doing?" Which response by the nurse is appropriate?

Let's step away from the crowd to discuss it

which one of the following drugs should the nurse expect the patient to require serum level monitoring

Lithium

The nurse is assisting with cardiopulmonary resuscitation of a client in cardiac arrest. The rhythm in the exhibit is displayed on the cardiac monitor. Which medication administration should the nurse anticipate?

Magnesium IV

The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate?

Nonmaleficence

The nurse is caring for a 72-year-old client with a history of renal calculi and diabetes mellitus who was admitted for acute pyelonephritis. The nurse assesses shaking chills, temperature of 101.2 F (38.4 C), and flank pain. Which of the following is the priority nursing intervention?

Obtain blood and urine cultures

A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. The client is diaphoretic; grunting and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take?

Obtain fetal heart tones via Doppler

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time?

PLACE ONE AED PAD ON THE CHEST AND THE OTHER ON THE BACK

During a camping trip, a camp counselor falls and gets a small splinter of wood embedded in the right eye. What action should the volunteer camp nurse take first?

Patch both eyes with eye shields

Which of the following is an appropriate expected outcome when working with a patient but dissociative identity disorder?

Patient will verbalize clear sense of personal identity

The charge nurse is reviewing events that staff nurses experienced during the shift. Which events require an incident/occurrence report to be completed?

Patient with alcohol intoxication assaulted a nurse Troponin level was ordered but never obtained Visitor fell and refused care in the ER

A 64-year-old hospitalized client with chronic obstructive pulmonary disease (COPD) exacerbation has increased lethargy and confusion. The client's pulse oximetry is 88% on 2 liters of oxygen. Arterial blood gas (ABG) analysis shows a pH of 7.25, PO2 of 60 mm Hg, and PCO2 of 80 mm Hg. Which of the following should the nurse implement first?

Place client on the bilevel positive airway pressure (BIPAP) machine

The nurse is caring for a client who has been receiving mechanical ventilation (MV) for 4 days. During multidisciplinary morning rounds. the health care provider questions the development of a ventilator associated pneumonia (VAP). Which of the following manifestations does the nurse assess as the best indicator of VAP?

Positive purulent sputum culture

At 8AM , medication are prescribed for assigned clients. Which medication should the nurse admi-nister FIRST?

Pyridostigmine for a client with myasthenia gravis exacerbation who reports difficulty swallow-ing .

the nurse is assessing the cranial nerves and begins testing the facial nerve (cranial nerve VII) which direction should the nurse give the client to test this cranial nerve

Raise your eyebrowns, smile, and frown

The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease. Of the following prescriptions, which one is transcribed correctly?

Ranitidine 150 mg PO at bedtime

A client was treated in the emergency department 2 days ago. The nurse makes a follow-up call to say that a culture shows that the client needs an antibiotic. The client's spouse answers the phone, says that the client is at work and doing fine, and that the client does not need the antibiotic. Which is a priority action for the nurse?

Request that the spouse tell the client to call back

The nurse is caring for a group of 1-day-old clients in the newborn nursery. Which finding requires immediate attention?

Respirations of 68/min with grunting in a newborn post cesarean birth

A nurse is caring for an older client admitted for failure to thrive and a history of recent falls and weight loss. The client lives in the child's home, but the nurse is questioning the safety of the home. The nurse needs to assess the appropriateness of the living situation and arrange for an alternate living situation or additional support if needed. It is most appropriate for the nurse to consult with which interdisciplinary team member during the assessment?

Social worker

The nurse is caring for a I-day-old client at term gestation who is irritable, feeding poorly. and only sleeping for very short intervals. The newborn's mother informs the nurse that she has been taking hydrocodone on a regular basis for several years. Which intervention is appropriate to include in the newborn's plan of care?

Swaddle and gently rock the newborn

The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke (acute brain attack)?

Take prescribed antihypertensive medications

The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth protruding her tongue and grimacing as she watches TV. The nurse determined that the client is experiencing which medication complication?

Tardive dyskinesia

A young client is diagnosed with MAJOR DEPRESSIVE DISORDER.. Three weeks prior, the client's fiance' broke off their engagement, claiming the client was "too fat and ugly." During a one on one interaction with the nurse , the client says. "My fiance' is really wonderful and is not to blame for calling off the engagement. I look awful and I'm not much good for anything" What is the BEST r

Tell me how you felt when your fiance broke up with you."

The charge nurse in the medical-surgical unit is evaluating client safety. Which actions by unlicensed assistive personnel (UAP) would require the nurse to intervene?

UAPs log rolling a patient with a cervical collar to reposition them UAP repositioning a patient who is 8 hours postop total hip replacement

The nurse prepares a client for discharge following a vasectomy. The client asks, "When can I have sexual intercourse with my wife without using a condom?" What is the best response by the nurse?

USE ALTERNATIVE BIRTH CONTROL UNTIL CLEARED BY THE HCP

The nurse is monitoring a client who is 6 cm dilated with recurrent variable decelerations on the fetal heart rate monitor. The health care provider (HCP) places an intrauterine pressure catheter and prescribes an amnioinfusion. After the amnioinfusion bolus is complete, which assessment finding should the nurse report to the HCP immediately?

Uterine resting tone baseline has increased to 45 mmHg and perineal pads are dry

The nurse is providing education about the vitamin K injection to the parents of a newborn client.

Vitamin K is essential for preventing bleeding, which can occur spontaneously or after procedures such as circumcision

A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse?

Wheezing and hives

What is an appropriate nursing intervention after the birth of a newborn with anencephaly?

Wrap the newborn in warm blankets for the parents to hold

graduate nurse is reinforcing education to a pregnant client with hepatitis B who expresses concern about transmitting the virus to the newborn after birth. Which statement about newborn care made by the graduate nurse should cause the precepting nurse to intervene?

You will need to formula feed your newborn to reduce the risk of transmitting e virus via breast milk

the nurse is caring for a busy medical surgical unit which client would be priority to assess first

a client with sepsis who is developing petechiae

a patient with depression has been takin paroxetine SSRI for the last 3 month and has noticed improvement of symptoms. which of the following side effects would the nurse expect the patient to report

a decrease in sexual pleasure during intimacy

A Client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client plan of care? Select all that apply.

a. Assess deep tendon reflexes hourly. b. Ensure availability of calcium gluconate. c. Have supplemental oxygen at bedside. d. Limit visitors to minimize stimulation.

the nurse is caring for a ventilator dependent client with neuromuscular degenerative disease and observes the plethysmograph waveform in the image below what is the nurse immediate action

assess level of consciousness, skin temperature and color

an elderly client is brought to the emergency department with a lethargy, chill, and sharp chest pain with deep breathing. pulse oximeter shows 93% on the room air and respiration are 24/min that is the nurse initial action

auscultate the client's lung sounds

what client should the nurse assess first

client with third-degree heart block with a pulse of 42/min

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm, Which uterine assessment finding requires an intervention by the nurse? contraction duration of 95 seconds

contraction duration of 95 seconds

A client who suffers from frequent panic attack describe the tech as feeling disconnected from himself. The nurse said that in the contract that the client reports experiencing?

depersonalization

The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa the nurse enters the clients room and knows that the client is engage in a rigorous push-up. Which nursing action is most appropriate

interrupt the quiet and offered to take her for a walk

A client calls the emergency department of the local hospital reporting that after 16 years of heavy drinking he is tired and wants to quit cold turkey. What would be the best response by the nurse?

it is not safe to stop drinking suddenly without medicine

The nurse is teaching a class of expectant parents about infant safety. Which statement by a class participant indicates a need for further instruction?

l will tie bumper pads to the sides of the crib to protect my baby's head

the nurse is caring for a client who has undergone a colonoscopy. which client assessment finding should most concern the nurse

positive rebound tenderness

The nurse is observing a student nurse care for a mother who has been unsuccessful with breastfeeding her newborn infant. Which action by the student would require the nurse to intervene?

provides supplemental formula feedings until improved breastfeeding occurs

The nurse is performing an assessment on a neonate shortly after delivery The nurse is most concerned about which assessment finding?

ptosis of right eyelid found on facial inspection

the nurse is caring for a client with a pulmonary contusion. assessment reveals restlessness chest pain on inspiration, diminished breath sounds and oxygen saturation of 86% which acidbase imbalance does the nurse correctly identify

respiratory acidosis

The nurse is teaching the parents of a toddler about health promotion. Which statement by one parent requires clarification?

"If my child refuses a meal, I will wait a few minutes and try again ."(avoid giving toddlers options that allow them to say "no" and refrain from forcing toddlers to eat, allow them a 15-30 minute period to calm down before meals and use time outs for management of temper tantrums"

A client diagnosed with hypertension has been prescribed a CLONIDINE PATCH. Which instructions should the nurse include? SELECT ALL THAT APPLY #71914832 (63) 1. Apply patch to the upper arm or chest. 2. Fold used patches in half with sticky sides together before discarding. 3. Remove patch if dizziness occurs when getting up 4. Rotate sites each time a new patch is applied 5. Shave hair before applying patch.

1,2,4

The clinic nurse prepares to teach the parent of a child who has been diagnosed with SCABIES. Which instructions should the nurse include in the teaching plan? SELECT ALL THAT APPLY#70769904 (51) 1. All persons in contact with the child need treatment. 2. Apply permethrin to all body areas below thehead. 3. Discard the stuffed animals 4. Fumigate all the living areas 5. Wash the child's bedding in hot water.

1,2,5

The emergency department nurse is caring for a client who has been recently prescribed methadone forchronic severe back pain. The client ingested extra tablets tonight because the pain returned. Whichassessment findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply. 1. Falls asleep when the nurse is talking 2. Frequently scratches due to pruritus 3. Has third emesis since taking medication 4. Monitor shows occasional premature ventricular contractions 5. Pulse oximetry reading is 92%

1,3,5

The nurse is reinforcing discharge teaching for the parents of a 1-year-old with a newly diagnosed cow's milk allergy. Which nutrients normally provided by milk should be obtained from other sources? Select all that apply. 1. Calcium 2. Fiber 3. Iron 4. Vitamin D 5. Vitamin K

1,4

A client with a history of degenerative arthritis is being discharged home following an exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should educate the client about which topics? Select all that apply. Click on the exhibit button for additional information. 1.Dryness of the mouth and throat may occur 2.Ringing in the ears is an expected, transient side effect 3.The albuterol canister should not be shaken before use 4.The health care provider should be notified if stools are black and tarry 5.Tiotropium capsules should not be swallowed

1,4,5

The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The clinic nurse should educate the teen about which topics? Select all that apply. 1. Not taking tetracycline with dairy products 2. Taking tetracycline at bedtime 3. Taking tetracycline with food4. Using additional contraceptive techniques 5. Using sunblock

1,4,5

The nurse has provided instructions about home care management for the parents of a child dx'd w/rotavirus infection. Which statements by the parents indicate that teaching has been effective?

1. "Hand washing is extremely important in slowing the spread of rotavirus." 2. "I will observe my child for decreased urination and dry mucous membrantes." 3. "My child can spread the infection with contaminated hands, toys, and food."(easily spread via the fecal-oral route. It is not treated with abx b/c it is a viral infection. Vaccinations available for <8mo old. Infected are at risk for dehydration)

The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant notification of the supervising registered nurse? 1. "I am going for repeat testing to confirm glaucoma." [25%] 2. "I am not able to exercise as much as I used to." [7%] 3. "I started taking esomeprazole for heartburn." [49%] 4. "My bowel movements are not regular." [17%]

1. "I am going for repeat testing to confirm glaucoma."

The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority? 1. Administer IV normal saline 2. Determine if urinary occult blood is present 3. Perform a neurological assessment 4. Verify that there is no stool impaction

1. ADMINISTER IV NORMAL SALINE

The nurse receives new prescriptions for a 6-month-old client with bacterial meningitis. Which action is the priority of care? 1. Administer 400 mg ceftriaxone IV every 12 hours 2. Apply padding to the crib siderails 3. Implement low-stimulation environment 4. Monitor head circumference daily

1. Administer 400 mg ceftriaxone IV every 12 hours administer antibiotics

The nurse is caring for a client who is in active labor at 39 weeks gestation and receiving a continuous intravenous (IV) infusion of oxytocin. The nurse notes frequent and persistent late decelerations on the fetal monitor. What actions should the nurse take? Select all that apply.

1. Administer oxygen via a nonrebreather face mask 2. Change the maternal position to the lateral side 3. Discontinue oxytocin infusion 4. Notify the health care provider (HCP)

The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply.

1. Age>50 2. Family history of skin cancer 3. High number of moles 5, Immunosuppresant medication use 6. Outdoor occupation

A client is brought to the emergency department following a motor vehicle collision. The client's admission vital signs are blood pressure 70/50 mm Hg, pulse 123/min, and respirations 8/min. The nurse anticipates the results of which diagnostic test to best evaluate the client's oxygenation and ventilation status?

1. Arterial blood gases

The nurse is preparing to infuse 2 units of packed red blood cells (PRBCs) to a client with a gastrointestinal bleed. Which actions should the nurse take? Select all that apply.

1. Assess client's vital signs 3. Obtain a Y tubing set and prime with normal saline (NS) 4. Plan to remain with client during the 1st 15 minutes of transfusion

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occuring? #70666278 (20) 1. Auscultate breath sounds to assess for crackles 2. Monitor for >50 mL/hr urine output 3. Monitor Glasglow Coma Scale increasing from 8/15 to 9/15. 4. Press over the tibia to assess for pitting edema.

1. Auscultate breath sounds to assess for crackles

A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube." What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.

1. Document this communication in the electronic health record 2. Encourage the client to discuss this decision with the health care proxy 3. Facilitate completion of an advance directive that reflects the client's decision

The nurse is caring for a 2 year old who is receiving a saline enema for treatment of intussusception. Reporting which client finding to the health care provider (HCP) is MOST IMPOR-TANT ? 1. Passed a normal brown stool 2. Passed a stool mixed with blood 3. Stopped crying 4. Vomited a third time.

1. Passed a normal brown stool

A client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse? 1. "After taking this medication, I will rinse my mouth with water." 2. "At the first sign of an asthma attack, I will take this medication." 3. "I have been smoking for 12 years, but I just quit a month ago." 4. "I received the pneumococcal vaccine about a month ago."

2. "At the first sign of an asthma attack, I will take this medication."

A client is being discharged on ENOXAPARIN therapy following total knee replacement surgery. Which TEACHING INSTRUCTION does the nurse include in the teaching plan? #71914832 (75) 1. "Eliminate green, leafy vitamin K rich vegetables from your diet." 2. "Mild bruising or redness may occur at the injection site." 3. "You can take over the counter drugs such as ibuprofen to relieve mild discomfort." 4. "You will need PT/INR assessments at regular intervals while on enoxaparin therapy. "

2. "Mild bruising or redness may occur at the injection site."

The nurse is teaching an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply.

2. Limiting alcohol intake 3. Losing weight

A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has completed discharge teaching related to this medication. Which statement by the client indicates that the teaching has been effective? 1. "I can keep a few pills in a plastic bag in my pocket in case I need them while I'm out." 2. "I can still take this with my vardenafil prescription." 3. "I can take up to 3 pills in a 15-minute period if I am experiencing chest pain." 4. "I should stop taking the pills if I experience a headache."

3. "I can take up to 3 pills in a 15-minute period if I am experiencing chest pain."

A nurse is teaching the parent of a child who has a new diagnosis of absence seizures. Which statement by the parent indicates understanding of the teaching? 1. "My child may experience incontinence." 2. "My child may seem confused afterwards." 3. "My child may stare and seem inattentive." 4. "My child will notice unusual odors prior to the event."

3. "My child may stare and seem inattentive." My child may have a brief sudden lapses of consciousness

The nurse teaches the client taking atorvastatin to call the health care provider (HCP) if experiencing which symptom associated with a serious adverse effect of atorvastatin? 1. Diarrhea 2. Headache 3. Muscle aches 4. Numbness in the feet

3. Muscle aches

Which prescriptions for these clients does the nurse question? Select all that apply. 1. Client with Clostridium difficile colitis, prescribed vancomycin 125 mg PO 2. Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units subcutaneously 3. Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous 4. Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO 5. Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO

4,5

Which client should the nurse assess first? 1. client with afib with a new prescription of warfarin 2. client with COPD and O2 sat of 91% 3. client with postoperative pain rated 8 out of 10 4. client with third-degree heart block with a pulse of 42/min

4. client with third-degree heart block with a pulse of 42/min

The clinic nurse educator is developing a teaching plan for the following six clients the nurse should instruct which client to avoid the Valsalva maneuver when defecating ? Select all that apply

74-year-old man with portal hypertension way to alcohol induced cirrhosis 56 years old meant to expose myocardial infarction 82-year-old woman one week post cataract surgery 22-year-old man with a head injury sustained doing a college football game

A patient is brought to the emergency department in the midst of an active clonictonic seizure. What is the most appropriate antiseizure drug for the nurse to administer intravenously to terminate acute convulsive seizures? A) Diazepam (Valium) B) Phenytoin (Dilantin) C) Ethosuximide (Zarontin) D) Gabapentin (Neurontin)

A

The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate? Select all that apply.

A - Chest painB - DyspneaD - HypoxemiaE - Tachypnea

What action do sympathomimetic drugs have in the body? A) Decreased heart rate B) Decreased blood pressure C) Increased respirations D) Increased intraocular

Ans: CFeedback:Sympathomimetic drugs increase respirations. Heart rate and blood pressure are also increased and intraocular pressure is decreased.

The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective? 1. "I need to continue to avoid eating spinach and kale." 2. "I probably will have some weakness in my legs when I take this medicine." 3. "I should avoid taking aspirin while receiving this medication." 4. "I will have to get blood drawn routinely to check my clotting levels."

Answer: 3

The charge nurse should intervene if the new graduate nurse performs which action when caring for a jaundiced newborn being treated with phototherapy?

Applying a shirt while the newborn is exposed to phototherapy [88%]

Andrew a hospice nurse for 5years in a member of your nursing team, is demonstrating a blunted affect and is not completing patient care documentation in the required timeframe. As a peer what is your best action?

Ask Andrew what he feels is causing him to fall behind in his work

A patient comes to the clinic complaining of seasonal rhinitis. What adrenergic agonist would be prescribed for treatment of seasonal rhinitis? A) Dobutamine (Dobutrex) B) Ephedrine (generic) C) Dopamine (Intropin) D) Norepinephrine (Levophed)

B) Ephedrine (generic)

What medication used to treat rheumatic arthritis not only has anti-inflammatory effects but is also used in premature infants to close a patent ductus arteriosus? A) Penicillamine B) Indomethacin C) Antimalarials D) Prednisone

B) Indomethacin

The nurse knows that the adverse effects of a nonselective beta blocker are likely to be the most immediately life threatening in which patient? A) Patient with Type I diabetes B) Patient with asthma C) Patient with gastroesophageal reflux disease D) Patient with hypertension

B) Patient with asthma

When administering an alpha blocker for the first time, it is most important for the nurse to assess the patient for the development of A. renal failure. B. hypotension. C. blood dyscrasia. D. dysrhythmias.

B. hypotension

Patient with schizophrenia is being treated with olanzapine 10 mg daily. The patient asks the nurse how this medication works. The nurse explained that the medic the mechanism by which the olanzapine have been controls the patient's psychotic symptoms is believed to be?

Blocking dopamine receptors in the brain

A patient on a dobutamine (Midodrine) drip starts to complain that he feels a "tightness" in his chest that he had not felt before. What will the nurse do first? A. Check the infusion site for possible extravasation B. Increase the infusion rate C. Check the patient's vital signs D. Order an electrocardiogram

Correct answer: C

Eileen works with youth in a residential treatment center. When Amber, a new patient of hers, does not want her parents to visit, Eileen says, "I know how you feel. Did your dad molest you too?" Eileen's reaction is an example of which behavior?

Countertransference

A client with blunt trauma undergoes an exploratory laparotomy to repair the intraabdominal injury. After 24 hours, the client has a nasogastric tube attached to continual low suction, 2 Hemovac closed-wound suction abdominal drains, and is receiving IV Ringer's lactate and continual epidural morphine. The client now develops hypotension, tachycardia, oliguria, and severe nausea. What is the client's priority nursing diagnosis (ND) at this time?

Deficient fluid volume

A parent brings a 6-month-old child to the primary health care provider after the child abruptly started crying and grabbing intermittently at the abdomen. The client's stool has a red, currant jelly appearance. What intervention does the nurse anticipate?

Give air (pneumatic enema)

The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome. Which personal protective equipment will the nurse use when providing care to the client?

Gown, gloves, N95 respirator, and eye protection

The nurse assesses a client at term gestation who reports having contractions for the last 2 hours. The pt. states "I'm not sure, but i think my water broke." The nurse performs a nitrazine pH test, which turns blue. When documenting the results of the test, which client statement is most concerning to the nurse?

I did have sexual intercourse w/ my partner 1 hr before coming in today

The same day surgery nurse performed the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy which statement made by the client is critical to report to the healthcare provider before the surgery

I didn't take the club Clopidogrel pill for my heart yesterday or today

The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time?

ask the interpreter to explain the discussion

A laboring client with epidural anesthesia experiences spontaneous rupture of membranes, immediately followed by an abrupt change in the fetal heart rate. The nurse knows that considering the probable cause of the change in fetal heart rate, which action should be taken first?

assess for umbilical cord prolapse

the nurse on the orthopedic unit receives information during evening report which client should the nurse assess first

client 3 hours postoperative tibial fracture repair who reports severe pain and pressure under the cast and is requesting opioids every hour

The charge nurse is in an intensive care unit is surrounding and reviewing hemodynamic data for the clients in the unit which client require immediate intervention

client with a gastrointestinal bleed and mean or to your pressure of 58

the nurse receives report on 4 client which client should be seen first

client with amyotrophic lateral sclerosis experiencing increased dysarthria

Which pediatric respiratory presentation in the emergency department is a priority for nursing care?

client with an acute asthma exasperation but no wheezing

the night nurse receives the hand-off report on assigned client. which client should the nurse assess first

client with spinal cord injury above T6 requiring intermittent catheterization report a throbbing headaceh and nausea

The nurse has received report for a term newborn after a vaginal birth Maternal history includes diagnosis of gestational diabetes at 25 weeks gestation and poorly controlled blood glucose during pregnancy When assessing the newborn, which finding should the nurse most likely expect?

elevated hematocrit level

A 37-weeks-pregnant woman comes to the emergency department with a fractured ankle. Which assessment finding is most concerning and requires the nurse to follow up?

fetal heart rate remains 206/min

Based on the progress note documentation to 2+ bilateral lower extremity edema shortness of breath on minimal exertion which priority intervention does the nurse anticipate

furosemide 40 mg intravenous push

The register nurse and license practical nurse account for several clients the registered nurse delegates client positioning to the LPN while evaluating the delegate tasks the RN realize that which client positions require intervention select all that apply ?

high follow position in preparation for a paracentesis left side lying position after percutaneous liver biopsy semi Fowler after cardiac colorization via femoral entry

the nurse is teaching a client with insomnia about to improve sleep habits. which statement by the client requires further teaching

i will read in bed before trying to go to sleep

A client is recovering at home following a left total knee replacement seven days ago is using a cane to go up and down the stairs under the supervision of the home health nurse which quiet action indicate a need for further instruction

leads with left leg follow necks with cane and finally right leg when going up the stairs

the nurse assesses a client with suspected actute pancreatitis and anticipates the client reporting pain in which anatomical area

left upper quadrant radiating to the back

An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with the unlicensed assistive personnel (UAP), who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the registered nurse. Which statement would be the most appropriate response?

let's go together to talk about the client's concerns

For 75-year-old client is hospitalized with chronic obstructive pulmonary disease exacerbation the healthcare provider initiate non-invasive positive airway pressure ventilation with a bilevel positive airway pressure device prescribed medication are shown in the exhibit which parameter is most important for the nurse to monitor frequently in this client

mental status

a client is admitted for a drug overdose with barbiturate which is the priority nursing action when planning care for this client

monitor respiratory function

Which statement by a client with a diagnosis dependent personality disorder with the nurse recognizes progress towards a positive therapeutic outcome ?

my mother could not drive me here today so I took the bus

The nurse is planning care for a client with bipolar disorder and acute mania who is being admitted involuntarily after attempting to run across a five-lane highway. Which intervention is the priority to include in the care plan?

offer high calorie snack

the nurse is assessing a client risk factors for developing a substance abuse disorder. which family characteristics would the nurse identify as a significant risk factor

one parent who is an alcoholic

A nulliparous client asks about being in "real" labor. The nurse should teach that which signs are most indicative of true labor?

pain in lower back that moves to lower abdomen Progressive cervical effacement and dilation Contractions that increase in frequency

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off?

partial thromboplastin time of 110 seconds

The nurse is caring for a client in the first trimester during an initial prenatal clinic visit. Based on the information provided by the client. which factor places the client at an increased risk for preterm labor?

periodontal disease

When unlicensed assistive personnel (UAP) assist a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidentally falls over and cracks. The UAP immediately report this incident to the nurse. What is the nurse's immediate action?

place distal end of the tube in bottle of sterile saline

which is an example of patient advocacy

the nurse respect the patient's decision to refuse treatment

the nurse enters a client room in fines at the client and spouse of crying the spouse is that the healthcare provider just diagnosed a client with Alzheimer disease what is the best response by the nurse?

this new diagnosis must be frightening for you

The nurse teaches a patient with rheumatic disease who is being prescribed salicylate therapy to monitor themself for:

tinnitus.

an 80 year old client has been hospitalized with pneumonia and malnutrition. physical assessment findings include weakness and decreased muscle mass. which finding best indicates that the client is responding to treatment

weight gain of 2lb (0.9kg) in 2 weeks

The nurse is evaluating a client understanding of post circumcision care for a 24-hour-old newborn. Circumcision was performed using the clamp method. Which statement by the client demonstrates a need for further teaching?

yellow exudate on the glans-penis indicates infection

The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which INTERVENTION should the nurse implement? "SELECT ALL THAT APPLY " #71941465 (09) 1. Encourage the parents to leave the child's favorite stuffed animal. 2. Establish a daily schedule similar to the child's home routine. 3. Give the child time to calm down alone when visibly upset. 4. Provide frequent opportunities for play and activity. 5. Remove visual reminders of the parents from the room

1,2,4

Which discharge teaching instructions should the nurse provide to the parents of a 2-year-old with group A streptococcal pharyngitis? Select all that apply. 1. Complete all the antibiotics even if your child is feeling better 2. Cool liquids and soft diet are recommended 3. Keep your child home from daycare for at least a week 4. Replace your child's toothbrush 24 hours after starting antibiotics 5. Throat lozenges may soothe your child's sore throat

1,2,4

A nurse teaches a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? Select all that apply. 1. "Antibiotics can affect my INR value." 2. "I am going to eat more leafy greens." 3. "I will shoot for my INR value to be between 4 and 5." 4. "I will take warfarin at the same time daily." 5. "If I miss a dose, I can double it on the following day."

1,4

The nurse is providing teaching for parents of a child diagnosed with fifth disease. Which statement by a parent indicates a need for further teaching? 1. "Our child should be feeling much better in 7-10 days." 2. "Our child's condition is communicable until the rash disappears." 3. "We will ensure our child covers the mouth and nose when coughing or sneezing." 4. "We will give our child ibuprofen to treat the joint pain."

2. "Our child's condition is communicable until the rash disappears."

The most recent laboratory results for a 12-month-old who is HIV-positive show a CD4 lymphocyte count of 500/mm3 and a CD4 lymphocyte percentage of 10%. The nurse anticipates administering which immunizations? Select all that apply. 1. Haemophilus influenzae type b (Hib) 2. Hepatitis A (Hep A) 3. Measles, mumps, rubella (MMR) 4. Pneumococcal conjugate vaccine (PCV)5. Varicella

1,2,4

A nurse is caring for an intubated client receiving a continuous sedative infusion. Which interventions by the nurse reflect correct understanding of preventing ventilator-acquired pneumonia? Select all that apply.

-Elevating the head of the bed 30-45 degrees - Practicing strict hand hygiene - Providing frequent oral care w/ chlorhexidine - Scheduling daily sedation vacations

The nurse evaluating a 52-year-old diabetic male client's therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply.

-Low-density lipoprotein cholesterol from 176 mg/dL (4.61 mol/L) to 98 mg/dL (2.54 mmol/L) -Total cholesterol from 250 mg/dL (6.47 mmol/L) to 180 mg/dL (4.66 mmol/L) -Triglycerides from 180 mg/dL (2.03 mmol/L) to 149 mg/dL (1.68 mmol/L)

The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom? 1. Atropine sublingual drops 2. Lorazepam sublingual tablet 3. Morphine sublingual liquid 4. Ondansetron sublingual tabl

1

The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder. Which assessments would support this diagnosis? Select all that apply. 1. Difficulty concentrating 2. Feeling detached from others 3. Feeling lethargic and apathetic 4. Flashbacks of the traumatic event 5. Persistent angry, fearful mood

1, 2, 4, 5

The nurse plans care for a 3 year old who was admitted with suspected pertussis infection. Which instructions will the nurse include in the plan of care? SELECT ALL THAT APPLY 1. Institute droplet precautions 2. Monitor for signs of airway obstruction 3. Offer small amounts of fluids frequently 4. Place the child in a negative-pressure isolation room.5. Request an order for cough suppressant.

1,2,3

The clinic nurse evaluates a client's response to levothyroxine after 8 weeks of treatment. What therapeutic responses to the medication should the nurse expect?

1. Apical heart rate of 88/min 2. Elevation of mood 3. Improved energy levels(used to treat hypothyroid. Notify HCP is HR is >100 or if the pt reports c/p, nervousness, or tremors...dose may be too high)

A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority for this client?

1. Bleeding risk

The nurse prepares to draw up regular and NPH insulins into one syringe. Place in order the steps the nurse should take when mixing the insulins. All options must be used.

1. Clean the vial tops with alcohol swabs 4. Inject air into the NPH insulin vial 5. Inject air into the regular insulin vial 3. Draw up the regular insulin solution 2. Draw up the NPH insulin solution

A client is having a severe asthma attack lasting over 4 hours after exposure to animal dander. On arrival, the pulse is 128/min, respirations are 36/min, pulse oximetry is 86% on room air, and the client is using accessory muscles to breathe. Lung sounds are diminished and high-pitched wheezes are present on expiration. Based on this assessment, the nurse anticipates the administration of which of the following medications? Select all that apply. 1. Inhaled albuterol nebulizer every 20 minutes 2. Inhaled ipratropium nebulizer every 20 minutes 3. Intravenous methylprednisolone 4. Montelukast 10 mg by mouth STAT5. Salmeterol metered-dose inhaler every 20 minutes

1. Inhaled albuterol nebulizer every 20 minutes 2. Inhaled ipratropium nebulizer every 20 minutes 3. Intravenous methylprednisolone

A child with autism spectrum disorder is being admitted to an acute care unit. Which is the most important nursing action? 1. Placing the child in a private room away from the nurses' station 2. Placing the child in a private room near the playroom 3. Placing the child in a semi-private room near the nurses' station 4. Placing the child in a semi-private room with another child with autism spectrum disorder

1. Placing the child in a private room away from the nurses' station Autistic children are very sensitive to noise - alarms, monitors, etc..

A nurse is caring for a 3-month-old infant who has bacterial meningitis. Which clinical findings support this diagnosis? Select all that apply. 1. depressed anterior fontanelle 2. frequent seizures 3. high pitched cry 4. poor feeding 5. presence of the babinski sign 6. vomiting

2,3,4,6 Frequent seizures High-pitched cry Poor feeding Vomiting

The nurse is preparing for the admission of a 9-year-old client with new-onset tonic-clonic seizures. It is important for the nurse to ensure that what is in the room? Select all that apply. 1. Oral bite prevention device 2. Oxygen delivery system 3. Padding on the bed siderails 4. Soft arm and leg restraints 5. Suction equipment

2,3,5

The nurse provides teaching for the parents of a 6-year-old diagnosed with nocturnal enuresis. What instructions will the nurse include? Select all that apply. 1. "Allow your child to wear a diaper at bedtime for emotional security." 2. "Have your child assist with wet linen changes." 3. "Prepare a calendar with your child for logging wet and dry nights." 4. "Restrict oral fluids to 8 ounces with each meal."5. "Wake your child at a specified time each night to void."

2,3,5

What communication strategies would the nurse have in place when establishing rapport with the caregiver and an 8-year-old during a health history interview? Select all that apply. 1. Ask only closed-ended questions to obtain information 2. Allow the child to describe their current issue 3. Isolate the child from the parents and interview them separately 4. Maintain an eye level position when speaking with the child 5. Use language that both the child and caregiver can understand

2,4,5

The registered nurse is teaching the parent of a 6-year-old about behavioral strategies for treating fecal incontinence due to functional constipation. Which statement by the parent indicates a need for further teaching? 1. "I will give my child a picture book to look at during toilet time." 2. "I will give my child a reward for each bowel movement while sitting on the toilet." 3. "I will keep a log of my child's bowel movements, laxative use, and episodes of soiling." 4. "I will schedule regular toilet sitting time for my child."

2. "I will give my child a reward for each bowel movement while sitting on the toilet." [34%]

A child with cystic fibrosis is to receive a dose of pancrelipase at 12:00 PM. The client states that he is not hungry and will eat his lunch in an hour. Which action is appropriate for the nurse to take? 1. Administer the prescribed pancrelipase 2. Hold the pancrelipase until the client eats 3. Notify the health care provider 4. Skip this dose of the pancrelipase

2. Hold the pancrelipase until the client eats

The nurse is reinforcing education with the parents of a 2-year-old child about diet choices to promote growth. The family observes a strict vegan diet. Which of the following statements by the nurse are appropriate? Select all that apply. 1. "Diets consisting of legumes as the only protein source are sufficient for growth." 2. "It is important to feed your child fortified breads and cereals to help with iron intake." 3. "Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake." 4. "Try to pair foods high in iron with foods high in vitamin C to aid iron absorption." 5. "Your child may require calcium and vitamin D supplementation due to lack of dairy intake."

245 With careful monitoring of nutritional intake, a vegan diet (ie, excluding all animal-derived products [eg, meat, dairy, eggs]) can be appropriate for clients in all age groups. Pediatric clients consuming a vegan diet are at increased risk for nutritional deficiencies(eg, protein, calories, calcium, vitamin D, iron, vitamin B12) due to rapid growth and development. Nurses educating clients about preventing nutritional deficiencies in vegan diets should include information about:Iron: Plant sources of iron, which are in smaller quantities and difficult to absorb, should be supplemented with fortified cereals and breads to decrease risk of iron-deficient anemia (Option 2)Vitamin C: Iron absorption is improved when dietary sources of iron and vitamin C are taken together (Option 4)Calcium: Without animal sources of calcium (eg, dairy, eggs, fish), vegan diets require supplementation of calcium and vitamin D for bone healthEducational objective:Pediatric clients consuming a vegan diet are at risk for dietary deficiencies (eg, iron, protein, calories, vitamin B12, calcium, vitamin D). Parent education about supplementation and adequate food sources of these nutrients is necessary.

A client is in the cardiovascular clinic for a 3-month follow-up visit. At the first visit, the client was prescribed hydrochlorothiazide and amlodipine for hypertension. Which statement by the client would be concerning to the nurse and should be reported to the primary health care provider (PHCP)? 1. "I like to have a banana every morning with my breakfast." 2. "I occasionally experience slight dizziness when I get up in the morning." 3. "I started taking licorice root for my occasional heartburn." 4. "I usually take my hydrochlorothiazide first thing in the morning."

3

A nurse is preparing to administer 2 continuous IV meds concurrently via a 20 guage IV. What is the nurse's priority action? 1. Assess the condition of the IV site2. Check 2 client identifiers before administering meds 3. Consult a med guide for compatibility 4. Wash hands prior to administering meds

3

The mother of a 6 year old child with CYSTIC FIBROSIS (CF) has received instruction on the use of pancreatic enzymes. Which statement made by the mother indicates a "NEED FOR FURTHER TEACHING" #72116868 (19) 1. "I need to monitor the total amount of this medication that I give to my child everyday." 2. "I should give this medication with or just before my child has a meal or snack." 3. "It is okay for my child to chew this medication." 4. "It is okay to open the capsule and sprinkle the medicine on a tablespoon of applesauce."

3

The nurse is caring for a 10-year-old diagnosed with osteomyelitis. What is the best activity the nurse can suggest to promote age-specific growth and development during hospitalization? 1. Fantasy play with puppets 2. Invite friends to come visit 3. Provide missed schoolwork 4. Watch favorite movies

3

Which of the following statements made by the mother of a child recently diagnosed with celiac disease indicates a need for further teaching? 1. "I will need to read the labels of all processed foods." 2. "It is okay if my child eats rice, corn, and potatoes." 3. "My child can have small amounts of foods containing wheat as long as she remains symptom free." 4. "My child will need to be on a gluten-free diet for the rest of her life."

3"My child can have small amounts of foods containing wheat as long as she remains symptom free."

The mother of a 6-year-old child with cystic fibrosis (CF) has received instruction on the use of pancreatic enzymes. Which statement made by the mother indicates a need for further teaching? 1. "I need to monitor the total amount of this medication that I give to my child every day." 2. "I should give this medication with or just before my child has a meal or snack." 3. "It is okay for my child to chew this medication." 4. "It is okay to open the capsule and sprinkle the medicine on a tablespoon of applesauce."

3. "It is okay for my child to chew this medication."

The registered nurse is counseling the parent of a child recently diagnosed with attention-deficit hyperactivity disorder (ADHD), combined type. Which statement by the parent requires an INTERVENTION? 1. "I should offer a choice between 2 things for my child's clothes or meals." 2. "I will need to advocate for an individualized educational plan for my child." 3. "My child will outgrow this disorder around age 20." 4. "When talking with my child, I should not be multi-tasking."

3. "My child will outgrow this disorder around age 20." only behavior therapy is used in the treatment of this condition

An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation; confusion, and disorientation to time and place. What is the MOST IMPORTANT nursing action? 1. Encouraging frequent fluid intake 2. Keeping the bed elevated with the side rails raised 3. Providing one-on-one supervision 4. Turning lights off in client's room to reduce stimulation

3. Providing one-on-one supervision

The nurse taught the caregiver of a child with a ventriculoperitoneal (VP) shunt about when to contact the health care provider (HCP). The caregiver shows understanding ofthe instructions by contacting the HCP about which symptom? 1. A temperature of 99 F (37 C) that occurs during the evening 2. The child cannot recall items eaten for lunch the previous day 3. The child vomits after awakening from a nap and 1 hour later 4. The VP shunt is palpated along the posterior-lateral portion of the skull

3. The child vomits after awakening from a nap and 1 hour later unrelenting head ache

A nurse is giving instructions related to antibiotic eye drops to the parent of a 5-year-old with bacterial conjunctivitis. Which instruction is most important? 1. Discard tissues used to blot excess medication from the eye immediately 2. Have your child lie down before you instill the eye drops 3. Use warm, moist compresses to remove crusting on eyelids 4. Wash hands before and after eye drop instillation

4

The public health nurse has received a referral to make a follow-up home visit to a 1-year-old recently diagnosed with failure to thrive (FTT). Which intervention is the prioritynursing action for this child? 1. Assess overall parenting skills 2. Complete a 24-hour dietary intake 3. Measure the child's height, weight, and head circumference 4. Observe the child feeding

4. Observe the child feeding

The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider? 1. Vancomycin trough 10 mg/L (6.9 µmol/L), creatinine 1.1 mg/dL (97.2 µmol/L), BUN 6 mg/dL (2.1 mmol/L) 2. Vancomycin trough 14 mg/L (9.7 µmol/L), creatinine 1.2 mg/dL (106.1 µmol/L), BUN 10 mg/dL (3.6 mmol/L) 3. Vancomycin trough 18 mg/L (12.4 µmol/L), creatinine 0.6 mg/dL (53 µmol/L), BUN 18 mg/dL (6.4 mmol/L) 4. Vancomycin trough 23 mg/L (15.9 µmol/L), creatinine 1.5 mg/dL (132.6 µmol/L), BUN 24 mg/dL (8.6 mmol/L)

4. Vancomycin trough 23 mg/L (15.9 µmol/L), creatinine 1.5 mg/dL (132.6 µmol/L), BUN 24 mg/dL (8.6 mmol/L)

The nurse is preparing to administer an IM immunization to a 6-month-old infant. Which needle length and injection site would be the most appropriate to minimize a local reaction to the vaccine components?

A 1 inch (25mm) needle in the anterolateral thigh

A patient is brought to the emergency department having a cholinergic reaction, which includes a severe drop in blood pressure. What drug will the nurse expect to administer? A) Atropine (generic) B) Edrophonium (Enlon, Reversol) C) Propranolol (Inderal) D) Succinylcholine (Anectine)

A. Atropine

The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?

Client's respiration status 60 min later.

the nurse is caring for an infant diagnosed with hirschsprung disease who is awaiting surgery. which assessment finding is consistent with the diagnosis

Clinical symptoms of Hirschsprung's disease during infancy include failure to thrive, constipation, abdominal distention, episodes of diarrhea and vomiting, signs of enterocolitis, explosive and watery diarrhea, and fever. The infant appears significantly ill. Intolerance to wheat occurs in celiac disease.

The nurse is caring for a patient who is receiving an opioid analgesic. What are the nurse's priority assessments? A) Pain intensity and blood glucose level B) Level of consciousness and respiratory rate C) Respiratory rate and electrolytes D) Urine output and pain intensity

B

A patient with type 2 diabetes is taking a beta blocker as part of treatment for hypertension. Which complication is most likely to develop?

C. Hypoglycemia

An overweight toddler is diagnosed with iron deficiency anemia. Which is the most likely explanation for the anemia?

Excessive intake of milk.

A 7-month-old infant is admitted to the unit with suspected bacterial meningitis after receiving an initial dose of antibiotics in the emergency department. Frequent monitoring of which of the following is most important?

Fontanel assessment

A nurse is teaching the parent of an 2-year-old infant who had a febrile seizure about management of future fevers. Which instruction is appropriate to include in the teaching?

Give acetaminphen or ibuprofen Q6H to control the fever-

The women's health nurse is caring for a 30-year-old client who wants to use the ethinyl estradiol and norelgestromin patch for contraception. Regarding this method of birth control, which finding should be most concerning to the nurse?

History of DVT

a 5 year old child has 1 day history of diarrhea with inadequate oral intake and confusion during assessment the parent state that they have recently dined out in a restaurant which is the mostly likely cause for the infant sysmptoms

Hyponatremia

The nurse is caring for a client with sepsis and acute respiratory failure who was intubated and prescribed mechanical ventilation 3 days ago. The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation (PPV)?

Hypotension- Positive pressure ventilation causes increased intrathoracic pressure and reduced venous return and cardiac output, which can result in hypotension.

The health care provider (HCP) prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication?

I need a healthy diet and regular exercise to combat weight gain

The nurse reinforces medication instruction to a client with primary adrenal insufficiency (Addison Disease) who is presribed hydrocortisone 10 mg orally 3 times a day. Which instruction should be included.

Make an appointment with an optometrist yearly to assess for cataracts Report s/s of hyperglycemia, including increased urine, hunger, and thirst Report even a low grade fever to the health care provider immediately

A nurse in the cardiac intermediate care unit is caring for a client with acute decompensated heart failure (ADHF). The client also has a history of coronary artery disease and peripheral vascular disease. The nurse is preparing to administer medications. Based on the assessment data, the nurse should question which medication?

Metoprolol

A client with gout who was started on allopurinol a week ago calls the health care provider's (HCP's) office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up?

Mild red rashes have developed over the torso

The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time?

Monitor for widened QT intervals and hypotension monitor for ECG chages

When phentolamine is used to diagnose the presence of pheochromocytoma, the nurse will assess for what indicative finding?

Rapid decrease in blood pressure

Antipyretic drugs, such as aspirin, ibuprofen, and acetaminophen, often are used to alleviate the discomforts of fever and protect vulnerable organs, such as the brain, from extreme elevations in body temperature. However, the use of aspirin in children is limited due to the possibility of what disease?

Reye's Syndrome

the expected outcome for a patient taking benztropine as a drug therapy for parkinsons disease would be what?

decrease in rigidity

A patient with type II diabetes has a new prescription for the angiotensin-converting enzyme (ACE) inhibitor lisinopril. She questions this order because her physician has never told her that she has hypertension. What is the best explanation for this order?

This medication has a protective effect on the kidneys for patients with type II diabetes.