prepu quiz 2

A client with a history of cocaine abuse is receiving intravenous therapy and exits the hospital "to visit a friend." The client returns to the nursing unit 1 hour later, agitated, aggressive, combative, and reporting "chest pain." Place the nurse's actions in priority order from first to last. All options must be used. Contact the security department. Obtain an ECG. Obtain a urine sample. Initiate a referral to obtain drug rehabilitation counseling.

1 Contact the security department. 2 Obtain an ECG. 3 Obtain a urine sample. 4 Initiate a referral to obtain drug rehabilitation counseling.

A nurse is caring for a client who is having an allergic reaction to a blood transfusion. In what order should the nurse provide care for this client? All options must be used. Stop the transfusion. Keep the vein open with normal saline solution. Administer an antihistamine as directed. Send the blood bag and blood slip to the blood bank.

1 Stop the transfusion. 2 Keep the vein open with normal saline solution. 3 Administer an antihistamine as directed. 4 Send the blood bag and blood slip to the blood bank.

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used. Ease the client to the floor. Maintain a patent airway. Obtain vital signs. Record the seizure activity observed.

1 Ease the client to the floor. 2 Maintain a patent airway. 3 Obtain vital signs. 4 Record the seizure activity observed.

The nurse has just received morning change-of-shift report on four clients. In what order from first to last should the nurse perform the actions? All options must be used. 1 Notify the health care provider (HCP) about a client who has a serum potassium level of 6.2. 2 Assess the client who has been vomiting according to the report from the night nurse. 3 Discuss the plan for the day with the unlicensed assistive personnel (UAP), delegating duties as appropriate. 4 Begin discharge paperwork for a client who is eager to go home.

1 Notify the health care provider (HCP) about a client who has a serum potassium level of 6.2. 2 Assess the client who has been vomiting according to the report from the night nurse. 3 Discuss the plan for the day with the unlicensed assistive personnel (UAP), delegating duties as appropriate. 4 Begin discharge paperwork for a client who is eager to go home.

Knowing Maslow's hierarchy of needs can assist a nurse in understanding a client's behavior. Place the stages of Maslow's hierarchy of needs in order from basic to most complex. Use all options. Physiologic needs Safety and security Love and belonging Self-esteem Self-actualization

1 Physiologic needs 2 Safety and security 3 Love and belonging 4 Self-esteem 5 Self-actualization

A nurse is obtaining an ankle-brachial index for a client with arteriosclerosis. Identify the correct order for obtaining the ankle-brachial index. 1 Place the client in the supine position. 2 Record the highest systolic blood pressure readings in both arms. 3 Place a Doppler probe at a 45-degree angle to the correct pulse (dorsalis pedis or posterior tibial). 4 Record the ankle systolic blood pressure reading when the Doppler sound returns.

1 Place the client in the supine position. 2 Record the highest systolic blood pressure readings in both arms. 3 Place a Doppler probe at a 45-degree angle to the correct pulse (dorsalis pedis or posterior tibial). 4 Record the ankle systolic blood pressure reading when the Doppler sound returns.

A client with a hemorrhagic stroke is slightly agitated, heart rate is 118 bpm, respirations are 22 breaths/min, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88 mm Hg, and oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? All options must be used. 1 Provide sedation. 2 Hyperoxygenate. 3 Suction the airway. 4 Suction the mouth.

1 Provide sedation. 2 Hyperoxygenate. 3 Suction the airway. 4 Suction the mouth.

A nurse is teaching a client to use a metered-dose inhaler (MDI) to administer bronchodilator medication. Indicate the correct order of the steps from first to last the client should take to use the MDI appropriately. All options must be used. 1 Shake the inhaler immediately before use. 2 Breathe out through the mouth. 3 Activate the MDI on inhalation. 4 Hold the breath for 5 to 10 seconds and then exhale.

1 Shake the inhaler immediately before use. 2 Breathe out through the mouth. 3 Activate the MDI on inhalation. 4 Hold the breath for 5 to 10 seconds and then exhale.

The nurse is taking care of a client who has an I.V. infusion pump. The pump alarm rings. What should the nurse do in order from first to last? All options must be used. 1 Silence the pump alarm. 2 Assess the client's access site for infiltration or inflammation. 3 Assess the tubing for hindrances to flow of solution. 4 Determine if the infusion pump is plugged into an electrical outlet.

1 Silence the pump alarm. 2 Assess the client's access site for infiltration or inflammation. 3 Assess the tubing for hindrances to flow of solution. 4 Determine if the infusion pump is plugged into an electrical outlet.

A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order from first to last should the nurse teach the client to perform diaphragmatic breathing and coughing? All options must be used. 1 Splint the incisional site. 2 Inhale through the nose. 3 Exhale through pursed lips. 4 Cough deeply from the lungs.

1 Splint the incisional site. 2 Inhale through the nose. 3 Exhale through pursed lips. 4 Cough deeply from the lungs.

A client who is receiving a blood transfusion suddenly experiences chills and a temperature of 101° F (38.3° C). The client also has a headache and appears flushed. Place the nursing actions in the order in which the nurse should perform them to properly respond to this client's situation. All options must be used. Stop the blood infusion. Infuse normal saline to keep the vein open. Obtain a blood culture from the client. Send the blood bag and administration set to the blood bank.

1 Stop the blood infusion. 2 Infuse normal saline to keep the vein open. 3 Obtain a blood culture from the client. 4 Send the blood bag and administration set to the blood bank.

A client is having a blood transfusion reaction. What must the nurse do in order of priority from first to last? All options must be used. Stop the transfusion. Keep the IV open with normal saline infusion. Notify the health care provider (HCP) and blood bank. Complete the appropriate Transfusion Reaction Form(s).

1 Stop the transfusion. 2 Keep the IV open with normal saline infusion. 3 Notify the health care provider (HCP) and blood bank. 4 Complete the appropriate Transfusion Reaction Form(s).

A nurse has received report on her clients and notices that they're of varying ages. To prepare for the shift, the nurse reviews Erik Erikson's five stages of psychosocial development. Place the stages in chronological order from infancy to adolescence. Use all options. Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion

1 Trust versus mistrust 2 Autonomy versus shame and doubt 3 Initiative versus guilt 4 Industry versus inferiority 5 Identity versus role confusion

The nurse is instructing a client with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. In which order from first to last should the nurse explain the steps to the client? All options must be used. 1 "Relax your neck and shoulder muscles." 2 "Breathe in normally through your nose for two counts (while counting to yourself, one, two)." 3 "Pucker your lips as if you were going to whistle." 4 "Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four)."

1 "Relax your neck and shoulder muscles." 2 "Breathe in normally through your nose for two counts (while counting to yourself, one, two)." 3 "Pucker your lips as if you were going to whistle." 4 "Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four)."

The nurse's assignment consists of four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving morning report? All options must be used. 1 the client with cirrhosis who became confused and disoriented during the night 2 the client with acute pancreatitis who is requesting pain medication 3 the client who is 1 day postoperative following a cholecystectomy and has a t-tube inserted 4 the client with hepatitis B who has questions about discharge instructions

1 the client with cirrhosis who became confused and disoriented during the night 2 the client with acute pancreatitis who is requesting pain medication 3 the client who is 1 day postoperative following a cholecystectomy and has a t-tube inserted 4 the client with hepatitis B who has questions about discharge instructions

Which is the correct order, from first to last, for proper placement of a urinary catheter? All options must be used. Prepare a sterile field. Lubricate the catheter adequately with a water-soluble lubricant. Insert the catheter far enough into the bladder to prevent trauma to the urethral tissue. Ensure free flow of urine

Prepare a sterile field. Lubricate the catheter adequately with a water-soluble lubricant. Insert the catheter far enough into the bladder to prevent trauma to the urethral tissue. Ensure free flow of urine.

A client with malignant pleural effusions has dyspnea and chest pain. In which order of priority from first to last should the nurse manage the client's care? All options must be used. 1 Apply oxygen at 2 L via nasal cannula. 2 Administer morphine sulfate 2 mg IV. 3 Coach the client on deep breathing exercise. 4 Educate the client in anticipation of a thoracentesis.

1 Apply oxygen at 2 L via nasal cannula. 2 Administer morphine sulfate 2 mg IV. 3 Coach the client on deep breathing exercise. 4 Educate the client in anticipation of a thoracentesis.

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the actions? All options must be used. Assess the client's current condition and vital signs. If no acute injury, get help, and carefully assist the client back to bed. Notify the client's health care provider (HCP) and family. 4 Document as required by the facility

1 Assess the client's current condition and vital signs. 2 If no acute injury, get help, and carefully assist the client back to bed. 3 Notify the client's health care provider (HCP) and family. 4 Document as required by the facility

A nurse is assessing a client's abdomen after abdominal surgery. Place the assessment techniques in the order in which the nurse should conduct them. All options must be used. inspection auscultation percussion palpation

1 inspection 2 auscultation 3 percussion 4 palpation

The nurse is assisting a client who has had a spinal fusion apply a back brace. In which order of priority should the nurse assist the client applying the brace? All options must be used. Verify the prescriptions for the settings for the brace. Have the client in a side-lying position. Assist the client to log roll and rise to a sitting position. Ask the client to stand with arms held away from the body.

1 Verify the prescriptions for the settings for the brace. 2 Have the client in a side-lying position. 3 Assist the client to log roll and rise to a sitting position. 4 Ask the client to stand with arms held away from the body.

A client has massive bleeding from esophageal varices. In what order from first to last should the nurse and care team provide care for this client? All options must be used. Maintain a patent airway. Control hemorrhaging. Replace fluids. Relieve the client's anxiety.

1 Maintain a patent airway. 2 Control hemorrhaging. 3 Replace fluids. 4 Relieve the client's anxiety.

A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and an increase in respiratory rate to 40 breaths/min. What should the nurse do in order from first to last? All options must be used. 1 Affirm airway obstruction by the tube. 2 Deflate the tube by cutting with bedside scissors. 3 Remove the tube. 4 Apply oxygen via face mask.

1 Affirm airway obstruction by the tube. 2 Deflate the tube by cutting with bedside scissors. 3 Remove the tube. 4 Apply oxygen via face mask.

The nurse is caring for a client with pneumonia who is confused about time and place and has intravenous fluids infusing. Despite the nurse's attempt to reorient the client and then provide distraction, the client has begun to pull at the IV tubing. After increasing the frequency of observation, in which order should the nurse implement interventions to ensure the client's safety? All options must be used. 1 Assess the client's respiratory status including oxygen saturation. 2 Ensure the client does not need toileting or pain medications. 3 Review the client's medications for interactions that may cause or increase confusion. 4 Contact the health care provider (HCP), and request a prescription for soft wrist restraints.

1 Assess the client's respiratory status including oxygen saturation. 2 Ensure the client does not need toileting or pain medications. 3 Review the client's medications for interactions that may cause or increase confusion. 4 Contact the health care provider (HCP), and request a prescription for soft wrist restraints.

Prior to the client having a pleural effusion drained, and after verifying client identification, the nurse should take the actions in what priority from first to last? All options must be used. 1 Check the primary health care provider's prescription. 2 Gather drainage kit supplies. 3 Perform hand hygiene. 4 Assess the client's respiratory rate, status, breath sounds, and discomfort level.

1 Check the primary health care provider's prescription. 2 Gather drainage kit supplies. 3 Perform hand hygiene. 4 Assess the client's respiratory rate, status, breath sounds, and discomfort level.

A client on telemetry reports that he has been having chest pain. The hospital unit has standing orders that allow the nurse to begin treating the client before notifying the physician. Place the following nursing actions in proper chronological order. Use all options. 1 Check vital signs, particularly blood pressure. 2 Administer sublingual nitroglycerin. 3 Evaluate the effectiveness of the treatment given. 4 Document the effectiveness of the treatment given. 5 Report findings to the physician.

1 Check vital signs, particularly blood pressure. 2 Administer sublingual nitroglycerin. 3 Evaluate the effectiveness of the treatment given. 4 Document the effectiveness of the treatment given. 5 Report findings to the physician.

A client receives 12 units of intermediate- or long-acting insulin and 6 units of fast-acting insulin each morning. Place the following actions in chronological order of how the nurse would demonstrate how to mix insulins. Use all options. 1 Wipe off the vials with an alcohol swab. 2 Inject 12 units of air into the intermediate- or long-acting insulin vial. 3 Inject 6 units of air into the fast-acting insulin vial. 4 Withdraw 6 units of fast-acting insulin. 5 Withdraw 12 units of intermediate- or long-acting insulin insulin.

1 Wipe off the vials with an alcohol swab. 2 Inject 12 units of air into the intermediate- or long-acting insulin vial. 3 Inject 6 units of air into the fast-acting insulin vial. 4 Withdraw 6 units of fast-acting insulin. 5 Withdraw 12 units of intermediate- or long-acting insulin insulin.