practice final

the nurse is caring for a client who needs a hypertonic intravenous solution. what solutions are hypertonic?

5% dextrose in Lactated Ringer's solution, 5% dextrose in 0.45% saline, 5% dextrose in 0.9% saline

which action by the AP would indicate a need for further teaching about the indwelling urinary catheter?

allowed the drainage tubing to rest under the leg

using a flashlight to examine CN III, IV, and VI. what should the nurse do?

ask the client to follow the flashlight through six cardinal positions of gaze

The parent of an 8-year-old child is worried that the child is more attentive to friends than anything else. using erikson's psychosocial development theory, what would nurse respond?

at this age, the child is developing his own personality

the nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling catheter. what actions would the nurse plan to include in performing this procedure?

clamping the tubing of the draining bag, explaining the procedure to the client, wiping the port with an alcohol swab before inserting the syringe, aspirating a sample from the port on the drainage tubing

the nurse is planning to test sensory function of the olfactory nerve. what would the nurse gather?

cloves, peppermint, and soap

a postop client on a clear liquid diet is allowed to consume what?

coffee, broth, and gelatin

the nurse is caring for a client with a diagnosis of GI bleeding reviews the client's laboratory results and notes a hematocrit level of 30% (0.30). which action should the nurse take?

report the abnormally low level (37-52%)

the nurse is caring for a client with several broken ribs. the client is most likely to experience what type of acid-base imbalance?

respiratory acidosis from inadequate ventilation

to test for the motor function of cranial nerve V what technique would the nurse use to test?

separate the client's jaw by pushing down on the chin

what item would the nurse use to test for cranial nerve II?

snellen chart

the nurse is caring for a client with a nasogastric tube. the clients potassium level is 4.5 and sodium is 132. based on these findings what solution should the nurse use for irrigation?

sodium chloride

what precautions would be implemented for a patient who is HIV positive and is admitted to the surgical unit after hernia repair surgery?

standard precaution

the nurse is performing a musculoskeletal assessment on a client who is right-handed. what would the nurse document as normal findings?

symmetrical movements bilaterally, increased muscle size on the dominant arm, a 1-cm hypertrophy of the right upper arm, and muscle strength graded 5/5

the nurse is assessing the client's apical pulse. where would the nurse palpate over?

the fifth left intercostal space, mid-clavicular line

knowing that the clients CO2 levels rise, what will occur with the blood pH?

the pH will fall

what characteristic relates to freud's psychosexual stage of development, the anal stage?

this stage is associated with toilet training

the nurse is instructing a client in breast self-examination. the nurse tells the client to lie down and examine the left breast. where should the client place the pillow

under the left shoulder

the nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has had a productive cough. what should the nurse do to collect the specimen?

use a sterile plastic container for obtaining the specimen

after performing an initial abdominal assessment on a client with nausea and vomiting, the nurse would expect to note which finding?

waves of loud gurgles auscultated in all four quadrants

what is seen in a patient with hypomagnesemia?

positive trousseau's sign, tetany, and twitches

the nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload?

presence of dependent edema, neck vein distention in the upright position, difficulty breathing, bounding pulse

what is the appropriate control precautions for MRSA?

private room, gloves, gown, and face shield (contact)

a client is diagnosed with external otitis. what finding would the nurse expect to note on assessment of the client?

redness and swelling in the ear canal -narrows the canal

the nurse notes that the 6 year old child does not recognize objects exist even when they are outside of the visual field. what should nurse do?

report observation to pediatrician

what is the normal sodium level?

135-142 mEq/L

what is the purpose of standard and transmission-based precautions?

-prevent transmission of organisms from health care providers to clients -prevent transmission of organisms from health care providers and clients to people outside of the hospital -precent transmission of organisms from client to client -prevent transmission of organisms from clients to health care providers

a client admits to smoking one pack of cigarettes per day for 10 years. what is the pack-years?

10

a positive romberg's sign is indicative of what data

a significant sway when the client stands erect with feet together, arms at side, and the eyes closed

which item would the nurse obtain to perform a weber test on a client?

a tuning fork

to test for the sensory function of cranial nerve V what item would the nurse obtain?

a wisp of cotton

a client with pneumonia is admitted to the hospital with difficulty breathing. which is the best approach for the nurse to use in obtaining the client's health history?

plan short sessions with the client to obtain data

a clinic nurse is providing instructions to a client regarding the procedure for collecting a midstream (clean-catch) urine specimen. what would the nurse instruct the client to do?

begin the flow of urine and then collect the specimen

the client is dehydrated. what does the nurse see?

changes in mental status, a low blood pressure, tachycardia

during an assessment of an older client, the skin turgor on the pt's forearm is tenting, what should the nurse do?

check skin turgor over the client's sternum

what would the urine specific gravity, 1.032, indicate?

dehydration

the nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. what interventions are appropriate?

ensure comfortable seating at eye level for the client and the nurse, remove distracting objects from the interviewing area, set the room temperature at a comfortable level, provide sufficient lighting

the nurse is preparing to test a client for accommodation, the nurse would ask the client to take which action?

focus on a distant object

the nurse instructs a client suspected of having a urinary tract infection to obtain a clean-catch urine specimen for culture and sensitivity testing. which statement by the client indicates that the client understands the procedure for collecting the specimen?

i need to cleanse the labia using cleansing towels, void into the toilet, and then void into the sterile specimen container

what would the nurse do if the white blood cell count is 2000 mm3?

implement neutropenic precautions to protect from infection, it should be 5000-10,000

the nurse alleviates the anxiety of a patient by providing which information about the pulse oximetry?

it is painless and safe

if the patient's magnesium level is 3.5 mEq/L, what would the expect to see?

loss of deep tendon reflexes, lethargy, bradycardia, and hypotension

a client reports ingesting large amounts of oral antacids on a daily basis because of a gastric ulcer. the nurse plans care, knowing that the excessive use or oral antacids containing bicarbonate can result in which acid-base imbalance?

metabolic alkalosis

the nurse is assessing for changes in skin color in a dark-skinned patient. what areas can the nurse assess for pallor or cyanosis?

mucous membranes, tongue, and nail beds

when performing a weber test, where would the nurse place the tuning fork?

on the clients head over the midline of the client's skull