Q Review 2

Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection? 1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. 3. Places the top of the diaper just above the umbilicus. 4. Wraps sterile petroleum gauze around umbilical cord. 5. Submerges newborn in warm water up to the chest for first bath.

1,2

A client arrives at the emergency department after sustaining partial and full-thickness burns over the anterior neck, chest, and right arm. Which interventions will the nurse initiate? 1. Administer oxgen 2. Start two intravenous lines 3. Remove necklace 4. Elevate right arm 5. Debride wounds

1,2,3,4

Which intervention can the nurse safely delegate to an unlicensed assistive personnel (UAP)? 1. Irrigate a colostomy in a client who is 2 days postoperative. 2. Remove a fecal impaction in a client. 3. Apply a condom catheter to an incontinent client. 4. Insert a urinary catheter to obtain a urine sample.

3

Which pediatric client should the nurse see first? 1. Six year old with a femur fracture. 2. Two year old with a fever of 102 ° F (38.8 ° C) 3. Three year old with wheezes in right lower lobe. 4. Two year old whose gastrostomy tube came out.

3

A client arrives in the emergency department with fever, nuchal rigidity, and seizures. What action should the nurse take first? 1. Administer Penicillin IVPB. 2. Obtain blood cultures from two sites. 3. Place on droplet precautions. 4. Set up for lumbar puncture.

3

A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B12 intramuscularly. What should the nurse include in discharge instructions? 1. B12 can be stored in a lighted area. 2. The B12 injections will be stopped when symptoms disappear. 3. The B12 injections will be continued for the client's life. 4. Vitamin B12 will be taken by mouth once the maintenance dose is determined.

3

The nurse is caring for a client with pneumococcal pneumonia. Which nursing observations would indicate a therapeutic response to the treatment regime for the infection? 1. Dyspnea on exersion with nonproductive cough 2. Tachypnea with use of accessory muscles 3. Expectorating moderate amounts of thin, white sputum 4. White blood cell count of 18,000 cells per mcL 5. Crackles clearing with cough

3,5

Which home routines help reduce the risk of skin damage in a client with impaired sensation? 1. Using a hot water bottle to help warm up when first going to bed. 2. Hot water heater set at a temperature of 140 °F (60 °C) 3. Open flame heaters in the living areas of the home. 4. Testing the water with the back of the wrist and forearm before getting in the shower. 5. Check condition of all equipment used in the home.

4,5 2 is wrong bc its 120F

What should the nurse teach a pregnant client who comes to the clinic reporting hemorrhoids and constipation? 1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. The client needs more fiber in the diet. 4. A mild laxative is recommended to alleviate constipation. 5. The client needs to increase fluid intake.

1,2,3,5

An elderly client arrives in the emergency department (ED) after a fall. What assessment findings would lead the nurse to suspect that the client has a fractured right hip? 1. Severe pain in the right hip and groin. 2. Inability to bear weight on the right leg. 3. Right leg slightly longer in length than the left leg. 4. External rotation of right lower leg. 5. Bruising and swelling around the right hip.

1,2,4,5

A nurse is instructing a client who had a cesarean birth 2 days ago about adverse signs that should be reported to the primary health care provider. Which signs should the nurse include? 1. Fever greater than 100.4° F (38° C) for 2 or more days. 2. Change in lochia from rubra to serosa. 3. Calves with localized pain, redness, and swelling. 4. Burning with urination. 5. Feeling of apathy toward newborn. 6. Able to provide self care.

1,3,4,5

The primary healthcare provider is preparing to drain a large abdominal abscess. The client has dementia and moves about on the bed frequently. Which personal protective equipment (PPE) should the nurse wear while holding the client for the procedure? 1. Face shield 2. Sterile Gloves 3. Gown 4. Mask 5. Regular exam gloves

1,3,4,5

The occupational health nurse is leading a group discussion about addiction. What should the nurse include as the primary barrier to the client with alcohol addiction seeking treatment? 1. Co-dependency 2. Denial 3. Depression 4. Stigma

2

The nurse is providing care to a client who has a large abdominal dressing. Which intervention is most likely to reduce the risk of skin irritation due to frequent dressing changes? 1. Use a paper tape for adhering the dressing. 2. Use tape sparingly. 3. Secure the dressing with Montgomery straps. 4. Change the dressing only if it becomes saturated with drainage.

3

What statements by a new nurse would indicate to the charge nurse an understanding of how to maintain skin integrity for a client on bedrest? 1. "Clients on bedrest should be placed on therapeutic mattresses." 2. "I will assess for the skin every 4 hours." 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry."

1,3,4,5

What should the nurse include in the post-op care of a client following the removal of the posterior pituitary gland? 1. Monitor intake and output. 2. Restrict fluids to no more than 1500 ml/day. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully.

1,3,4,5,6

The nurse is providing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider? 1. Difficulty waking up 2. Headache (3/10 on the pain scale) 3. Blurry vision 4. Achy feeling all over 5. Vomiting

1,3,5

A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients from a culture other than the nurse's culture. Which points should the nurse include in the presentation? 1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 2. Follow cultural beliefs when caring for all clients of that particular culture. 3. Ethnocentrism facilitates therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences.

1,4,5

An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this? 1. Encourage the family to accept nursing home placement as the best option for their loved one. 2. Listen to the family's concerns and report those to the primary healthcare provider. 3. Ask the client what she wants and tell the family to abide by the client's wishes. 4. Realize that the nurse does not need to be involved in this decision.

2

An elderly client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action? 1. Intake and output every shift. 2. Lung assessments every 2-4 hours. 3. Vital signs every shift. 4. IV site assessment every 2-4 hours.

2

The nurse is administering the prescribed Mantoux tuberculin skin test to a client. The nurse does not observe the tense blister-like formation at the injection site. Which action should the nurse take? 1. Chart the injection site response as the only action. 2. Administer another Mantoux tuberculin skin test at a different site. 3. Circle the area, wait 48 to 72 hours, and assess for a reaction. 4. Call the primary healthcare provider.

2

A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take? 1. Obtain consent from the social worker on duty in the emergency department. 2. Begin treatment by inserting two large bore IVs of Normal Saline. 3. Give glucogon IM and wait for the arrival of a parent to consent to further treatment. 4. Withhold treatment until a parent arrives to the emergency department.

2

A client has been prescribed chlorpromazine for the treatment of schizophrenia. The nurse makes afternoon rounds and finds the client's temperature to be 104.7º F/40.4º C. The client has extreme muscle rigidity, and the vital signs have been fluctuating for the last four hours. What should the nurse do first? 1. Provide a tepid sponge bath. 2. Notify the primary healthcare provider immediately. 3. Administer an antipyretic immediately. 4. Administer the chlorpromazine as prescribed.

2

A client is in the surgical suite to have a left total knee replacement. Prior to the surgeon initiating the first incision, what should the circulating nurse remind the surgical team to perform? 1. Surgical scrub 2. Time-out 3. Sponge and instrument count 4. Inspection of the surgical site

2

A client received a leg cast that was applied following fracturing the left femur. What assessment finding would be a priority for the nurse to report to the primary healthcare provider? 1. Reports of a feeling of warmness under the cast after application. 2. Pain not relieved by elevation, cold packs, and pain medication. 3. Reports of itching under the cast not relieved by cool air. 4. Slight swelling of the toes of the affected extremity.

2

A client who has developed hypovolemic shock is receiving albumin. What assessment finding by the nurse indicates that the albumin has been effective? 1. Swelling in the legs 2. Increase in uninary output 3. Proteinuria 4. Increase in waist measurement

2

The charge nurse is evaluating knowledge of tracheostomy suctioning of a new nurse prior to that procedure being performed. Which statement by the new nurse would indicate to the charge nurse that additional education is needed? 1. "Prior to suctioning, I will hyper-oxygenate the client." 2. "I will instill normal saline bullets to liquefy secretions." 3. "I will allow at least 20 seconds between suctioning passes." 4. "Suctioning will be limited to a maximum of three catheter passes."

2 humidify the secretions!!

The nurse is teaching a client regarding buspirone. The nurse recognizes that teaching has been effective when the client makes which statements? 1. "I should start feeling better in two or three days." 2. "I should not drink alcohol while taking this medication." 3. "I will rise slowly from lying to sitting or standing." 4. "I will notify my primary healthcare provider of any unusal facial movements." 5. "I need to keep the medication in a closed container in the refrigerator."

2,3,4

The nurse is caring for a newly diagnosed diabetic in diabetic hyperosmolar hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate the immediate treatment plan for this client will include? 1. NPH insulin. 2. Potassium 40 mEq (40 mmol/L) slow intravenous push. 3. Intravenous administration of isotonic saline. 4. Intravenous sodium bicarbonate.

3. Correct: Clients who present with HHNK are severely dehydrated.

A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal? 1. "I should wrap the needle in a paper towel and place in the trash." 2. "I should use a hospital issued biohazard container for all needles." 3. "I may use any hard plastic container with a screw-on cap." 4. "I should take my needles to the nearest hospital for disposal. "

3

A teenage client is placed on life-support as a result of a motor vehicle accident (MVA). Following an electroencephalogram (EEG), the client has been declared brain dead. Which action by the nurse would take priority? 1. Call the respiratory department to have the ventilator removed. 2. Notify the facility's pastoral personnel. 3. Contact the regional organ procurement team. 4. Ask the family to select a funeral home.

3

The nurse is caring for a client with renal failure. The client has a 24 hour intake of 2500 mL and a 24 hour urinary output of 200 mL. What is the priority nursing assessment? 1. Assess for dependent edema. 2. Monitor for cardiac arrhythmias. 3. Auscultate breath sounds. 4. Monitor sodium and potassium levels

3

The nurse is preparing to provide oral care to an unconscious client. What is the most important step for the nurse to provide? 1. Performing hand hygiene. 2. Explaining the procedure to the family. 3. Positioning the client in side-lying position. 4. Raising the head of bed 30 degrees.

3

Which findings would indicate to the nurse that a client with Addison's disease has received too much glucocorticoid replacement? 1. Dry skin and hair 2. Hypotension 3. Rapid weight gain 4. Decreased blood glucose level 5. Increased cholesterol

3,5

A client admitted with a myocardial infarction has developed crackles in bilateral lung bases. Which prescription written by the primary healthcare provider should the nurse complete first? 1. Draw blood for arterial blood gases. 2. Place compression hose on legs. 3. Insert indwelling catheter for hourly urinary output. 4. Administer furosemide 20 mg intravenous push (IVP).

4

The nurse is caring for a client while fluorouracil is being infused. The client reports burning at the intravenous (IV) site. What should the nurse do first? 1. Apply warm compresses. 2. Slow the infusion. 3. Inspect the IV site. 4. Stop the infusion.

4

The nurse will be admitting a client from the operating room following a left total pneumonectomy for adenocarcinoma. Which type of chest drainage should the nurse anticipate that the client will have? 1. Bilateral chest tubes. 2. One chest tube on the operative side 3. Two chest tubes on the operative side 4. No chest drainage will be necessary.

4

What is most important for the nurse to do prior to initiating peritoneal dialysis? 1. Aspirate for placement. 2. Have the client void. 3. Irrigate the catheter for patency. 4. Warm the dialysate fluid.

4

What is most important for the nurse to have at the client's bedside when inserting a large orogastric tube for rapid gastric lavage? 1. Emesis basin 2. Portable x-ray machine 3. Oxygen 4. Suction equipment

4

Which actions by the nurse, working in the recovery room, should be performed to prevent injury from a needle stick? 1. Recap the needle after use to prevent injury. 2. Reinsert the sylet if it becomes loose in the vascular assess device. 3. After drawing up saline to flush an intravenous (IV) line, place the syringe in a pocket to prevent possible injury. 4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible.

4,5

A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected? 1. Ensure a do-not-resuscitate prescription has been provided. 2. Report client wishes during the end-of-shift report. 3. Have the client sign an advanced directive. 4. Ask the client who holds the durable power of attorney for health care decisions.

1

A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client? 1. Ask the primary healthcare provider to prescribe a diabetes educator consult. 2. Increase home health visits to monitor the healing process of the open wound. 3. Suggest nursing home placement to the family until wound has healed. 4. Suggest that the client's family hire sitters to assist with hygiene care.

1

A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse? 1. Undergoing surgery for placement of a central venous catheter. 2. Diagnosed with leukemia, hospitalized for induction of high-dose chemotherapy. 3. Receiving IV heparin for left leg thrombosis. 4. Admitted with a cerebrovascular accident.

1

While performing a vaginal examination on a client in labor, the nurse feels soft, squishy tissue instead of a head. What conclusion should the nurse make based on this assessment finding? 1. Breech presentation 2. Edema of cervix 3. Closed cervix 4. Bulging membranes

1

A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action? 1. Hug the client to provide support. 2. Take the client to the emergency department for sedation. 3. Decrease stimuli in the room. 4. Teach the client deep breathing exercises.

1 4 is wrong bc you need to wait until panic is over to teach

The nurse is planning health promotion strategies for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time. Which interventions would help the client get more regular physical activity into the day? 1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. 4. Suggest waking one hour earlier in the morning to go to the gym. 5. Suggest walking for 30 minutes with a buddy each afternoon before leaving work.

1,2,3

A nurse has just inserted an indwelling urinary catheter in a client scheduled for surgery. What should the nurse document? 1. Perineal skin assessment 2. Client teaching 3. Color of urine 4. Date and time of insertion 5. Type catheter inserted 6. Infusing rate of IV fluid

1,2,3,4,5

The home care nurse visits a client who has moderate cognitive impairment and whose family provides care for the client. Which suggestions would be helpful for this family to reduce the risk of injury? 1. Suggest that the family lock up medications and poisons and keep the keys. 2. Encourage the family to place locks high on the door frame to make it difficult for the client to leave. 3. Suggest that the family talk with the client weekly about safety issues around the house. 4. Suggest that the family remove knobs from stove when not in use. 5. Keep fire extinguishers present and in working order.

1,2,4,5

What statements by a client diagnosed with a hiatal hernia would indicate to the nurse that the discharge teaching was effective? 1. "I should eat six small meals a day." 2. "Sitting up for an hour after I eat will decrease symptoms." 3. "Eating a grapefruit for breakfast will help digest the rest of my food." 4. "Ten inch blocks need to be placed under the head of my bed." 5. "I will get assistance for lifting heavy objects." 6. "I will avoid using laxatives."

1,2,4,5

Which interventions should the nurse include when planning care for a client diagnosed with paranoid personality? 1. Develop a trusting relationship. 2. Be honest when communicating with the client. 3. Encourage the client to participate in group therapy. 4. Encourage the client to clean the day room daily. 5. Give clear explanations of procedures before hand.

1,2,5

Which tasks would be appropriate for the nurse to assign to an LPN/VN? 1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 3. Teach insulin self administration to a diabetic client. 4. Administer IV pain medication to a two day post op client. 5. Check for urinary retention. 6. Remove wound sutures.

1,2,5,6

The nurse is caring for a client in an outpatient clinic. The client is being treated with warfarin for prevention of a stroke due to atrial fibrillation. The international normalized ratio (INR) was noted to be 4.6. What should the nurse do? 1. Inform the primary healthcare provider immediately. 2. Instruct the client to continue medication as ordered. 3. Inform the client to watch for signs of bleeding. 4. Inform the client to return to the clinic per routine monitoring schedule. 5. Take no action as this value is within target range.

1,3

The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications? 1. Kidney stones 2. Diarrhea 3. Osteoporosis 4. Tetany 5. Fluid volume deficit

1,3

A client has been admitted to the medical unit and placed on airborne precautions for suspected pulmonary tuberculosis (TB). The nurse will assess for which signs and symptoms? 1. Weight gain 2. Fatigue 3. Hemoptysis 4. Diaphoresis during sleep 5. Anorexia

2,3,4,5

A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest pain two days post total knee replacement. Which statements by the nurse are appropriate according to the communication tool SBAR (Situation, Background, Assessment and Recommendation)? You answered this question Incorrectly 1. "Hello Dr, I am calling about one of your clients." 2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?"

2,3,4,5

A client was prescribed thioridazine hcl five days ago and presents to the emergency department with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication does the nurse suspect? 1. Akinesia 2. Neuroleptic malignant syndrome 3. Pseudoparkinsonism 4. Oculogyric crisis

3

What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the outpatient surgical center? 1. Client's prior experiences with outpatient surgery. 2. Medical plan and the extent of insurance coverage for outpatient surgery. 3. Client's plan for transportation and care at home. 4. Client's plan to spend the night at the surgical center.

3

The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Mantoux test. What precautions should the nurse take when administering the Mantoux test? 1. Don sterile gloves. 2. Place the client on reverse isolation. 3. Wear a particulate respirator 4. Obtain a consent form. 5. Initiate airborne precautions.

3,5

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure? Place actions in the correct order. Have client swallow ice as NG tube advances into stomach. Rotate catheter and advance into nasopharynx. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches of distal NG tube. Insert NG tube into unobstructed naris. Secure NG tube. Advance NG tube upward and backward until resistance is met. Elevate head of bed to fowler's position.

Elevate head of bed to fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches of distal NG tube. Insert NG tube into unobstructed naris. Advance NG tube upward and backward until resistance is met. Rotate catheter and advance into nasopharynx. Have client swallow ice as NG tube advances into stomach. Secure NG tube.