Q-trainer 4

The nurse cares for clients on a med-surg unit. The nurse determines several situations need to be addressed. In which order will the nurse address the situations? 1. the client's spouse reports the client's nose is bleeding 2. the HCP asks the nurse to obtain the clients latest serum electrolyte 3. an angry adult child is threatening to sue the hospital because the confused parent fell out of bed 4. the nursing assistive personnel is 30 mins late for the third time

1 3: important issue that needs to be addressed after tending to the client who is bleeding 2: last client issue to address or can be delegated to another staff member 4 *Identify the least stable clients to see first and the most stable to see last*

A client at 32 weeks' gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, indicates a possible complication? 1. the client's urine test is positive for glucose and acetone 2. the client has 1+ pedal edema in both feet at the end of the day 3. the client complains of an increase in vaginal discharge 4. the client says that she feels pressure against her diaphragm when the baby moves

1 Abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency

An extremely agitated client receives haloperidol (haldol) IM every 30 min while in the psychiatric ER. It is MOST important for the nurse to take which of the following actions? 1. monitor BP every 30 min 2. remain at the client's side to provide reassurance 3. tell the client the name of the medication and its effects 4. assess for anticholinergic effects of the medication

1 Assessment Monitoring VS is of utmost importance to ensure client safety and physiological integrity Rapid neuroleptization is a pharmacological intervention used to rapidly diminish severe symptoms that accompany acute psychosis Alpha-adrenergic blockade of peripheral vascular system lowers BP and causes postural hypotension *Answers are a mix of assessments and implementations. Is this s situation that requires assessment? Yes. Is there an appropriate assessment? Yes*

The nursing assistant reports to the nurse that a client who is 1 day postoperative after an angioplasty refuses to eat and states, "I just don't feel good." Which of the following actions by the nurse is BEST? 1. talk w/the client about how the client is feeling 2. instruct the nursing assistant to sit w/the client while the client eats 3. contacts the physician to obtain an order for an antacid 4. evaluate the most recent VS recorded in the chart

1 Assessment required Monitor for closure of vessel, bleeding, hypotension, dysrhythmias

A child returns to the recovery room after a bronchoscopy. The nurse should position the client in which of the following positions? 1. semi-fowler's position 2. prone w/the head turned to the side 3. HOB elevated 45 degrees w/the neck extended 4. supine w/the head in the midline position

1 Check VS every 15 min. until stable, assess for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema or laryngospasm)

The nurse supervises the staff providing care for an 18-month-old hospitalized w/hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. the child is placed in a private room 2. the staff removes a toy from the child's bed and takes it to the nurse's station 3. the staff offers the child french fries and a vanilla milkshake for a midafternoon snack 4. the staff uses standard precautions

1 Contact precautions required for all diapered or incontinent clients *All answers are implementations. Determine the outcome of each answer choice. Is it desired?*

A client has a hx of oliguria, HTN, and peripheral edema. Current lab values are BUN 25 and K+ 4.0. The nurse should restrict which of the following in the client's diet? 1. protein 2. fats 3. carbohydrates 4. magnesium

1 Decreased production of urea nitrogen can be achieved by restricting protein Metabolic wastes cannot be excreted by the kidneys *Determine which system is involved and then determine which nutrients require restriction*

The nurse cares for a postcholecystectomy client who had the T-tube removed this morning. Two hrs after removal of the T-tube, the nurse notes that the 4x4 dressing covering the stab site is saturated w/dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions? 1. remove the dressing, and replace it w/a more absorbent dressing 2. collect a culture and sensitivity specimen of the drainage 3. observe the wound for dehiscence 4. reinforce the dressing w/an 8x10 dressing

1 Expected that a stab wound will continue to drain until the wound seals Nurse should keep wound clean and dry *Answers are a mix or assessments and implementations. Does this situation require assessment? No. Determine the outcome of each implementation*

The nurse cares for pt placed in balanced suspension traction w/a Thomas splint and Pearson attachment because of a fractured right femur. The nurse notes that the pt's left leg is externally rotated. The nurse should take which of the following actions? 1. place a trochanter roll on the outer aspect of the thigh 2. perform resistive ROM of the left leg 3. adduct and internally rotate the left leg 4. instruct the pt to maintain the left leg in a neutral position

1 Holds hip in neutral position and leg in normal alignment entire weight of leg cannot be held by props placed below knee *Answers are implementations. Determine the outcome of each answer choice. Is it desired?*

Which of the following assessment findings indicates to the nurse the need for more sedation for a client withdrawing from alcohol dependence? 1. steadily increasing VS 2. mild tremors and irritability 3. decreased respirations and disorientation 4. stomach distress and inability to sleep

1 Indication that the client is approaching delirium tremens, which can be avoided w/additional sedation

The nurse administers terbutaline (brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. Which of the following actions should the nurse take FIRST? 1. withhold the medication 2. decrease the dose by half 3. administer the medication 4. wait 15 mins, and then recheck the rate

1 Maternal tachycardia is a SE of brethine Other maternal SE includes nervousness, tremors, HA, and possible pulmonary edema Fetal SE include tachycardia and hypoglycemia Brethine is usually preferred over ritodrine (yutopar) because it has minimal effects on BP

The nurse cares for a pt following an appendectomy. The pt takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the pt, is BEST? 1. take three deep breaths, hold your incision, and then cough 2. that was good. do that again and soon it won't hurt as much 3. it won't hurt as much if you hold your incision when you cough 4. take another deep breath, hold it, and then cough deeply

1 Most effective way of deep breathing and coughing, dilates airway and expands lung surface area *Answers are implementations. Determine the outcome of each answer choice. Is it desired?*

A woman at 38 weeks' gestation comes to the ER w/complaints of vaginal bleeding. Which of the following statements, if made by the client, suggests to the nurse placenta previa as the cause of the bleeding? 1. I feel fine, but the bleeding scares me 2. I've been more nauseated during the past few weeks 3. the bleeding started after I carried four bags of groceries 4. I've been having severe abdominal cramps

1 Placenta previa is characterized by painless vaginal bleeding

A 4-month-old child is admitted w/a tentative dx of meningitis. To confirm the dx, a lumbar puncture (LP) is ordered. While assisting the physician w/the procedure, it is MOST important for the nurse to take which of the following actions? 1. appropriately restrain the child 2. instruct the parents about the procedure 3. provide support to the child 4. elevate the HOB

1 Primary objective is to prevent trauma to child during the procedure Child must be restrained

The newborn infant of an HIV-positive mother is admitted to the nursery. The nurse should include which of the following in the plan of care? 1. standard precautions 2. testing for HIV 3. transfer to an acute care nursery facility 4. place the infant in isolation

1 Provides immediate protective care for the staff members

The clinic nurse performs diet teaching for an older client w/acute gout. The nurse should teach the client to limit the intake of which of the following? 1. red meat and shellfish 2. cottage cheese and ice cream 3. fruit juices and milk 4. fresh fruits and uncooked vegetables

1 Should be on low-purine diet, should avoid red and organ meats, shellfish, oily fish w/bones

The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse considers the assignments appropriate if the nursing assistant is assigned to care for which of the following clients? 1. a client dx w/Alzheimer's requiring assistance w/feeding 2. a client dx w/osteoporosis complaining of burning on urination 3. a client dx w/scleroderma receiving a tube feeding 4. a client dx w/cancer who has Cheyne-Stokes respirations

1 Standard, unchanging procedure

When assisting w/a bone marrow aspiration, the nurse should take which of the following actions? 1. drop additional sterile supplies onto a sterile tray 2. unwrap all sterile packs for the procedure in case they are needed 3. reach over the tray, and remove contaminated supplies 4. place the bottle of sterile liquid on the sterile filed so that it does not splash

1 Sterile articles should be dropped at a reasonable distance from the edge of the sterile area *All answers are implementations. Determine the outcome of each answer choice. Is it desired?*

The home care nurse visits a client w/newly diagnosed T1DM. The HCP's orders include a 1,200-caloire ADA diet, 15 units of intermediate-acting insulin before breakfast, and checking blood glucose qid. At 1700, the client performs a blood glucose analysis. The result is 50. The nurse observes for which information? 1. confusion; cold, clammy skin; and an elevated pulse 2. lethargy; hot, dry skin; rapid deep respirations 3. alert and cooperative, BP and pulse w/in normal limits 4. SOB, distended neck veins, and a bounding pulse of 96

1 Symptoms of hypoglycemia, normal blood glucose 70-110

The nurse identifies which of the following is MOST likely to help the family of an emotionally disturbed client manage behaviors at home after discharge from inpatient tx? 1. refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups 2. provide the family w/pamphlets that describe the desired action and SE of medications the client is taking 3. tell the family that it is not their fault that the client behaves inappropriately 4. involve the family in the assessment of the client when he/she is first admitted to the hospital

1 This group provides ongoing support and educational information People who attend have common needs and goals focused on managing the client's behavior at home

The nurse performs an assessment of an 8-yr-old girl dx w/scoliosis. Which of the following observations is expected w/scoliosis? 1. the girl's thoracic area is asymmetrical 2. the girl walks w/a waddling gait 3. the girl's lower legs are edematous 4. the girl has a protruding sternum

1 Thoracic area becomes noticeably distorted

The multidisciplinary team decides to implement behavior modification w/a client. Which of the following nursing actions is of primary importance during this time? 1. confirm that all staff members understand and comply w/the tx plan 2. establish mutually agreed-upon, realistic goals 3. ensure that the potent reinforcers (rewards) are important to the client 4. establish a fixed interval schedule for reinforcement

1 To implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member Consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program *All answers are implementations. Determine the outcome of each answer choice. Is it desired?*

A client returns to the room following a myelogram. The nursing care plan includes which intervention? *select all that apply* 1. encourage oral fluid intake 2. maintain the prone position for 12 hrs 3. elevate HOB 30-45 degrees 4. monitor vital and neurological signs 5. encourage the client to ambulate after the procedure 6. evaluate the client's distal pulses on the affected side

1, 3, 4 This is an implementation. Fluids should be encouraged to facilitate dye excretion and to maintain normal spinal fluid This is an implementation. Bed rest is usually 24 hrs, but the head is elevated at least 30 degrees, and bathroom privileges are permitted This is an assessment. It will identify abnormalities early

The client is admitted w/a dx of subdural hematoma and cerebral edema after a motorcycle accident. Which symptoms should the nurse expect to see *initially*? *select all that apply* 1. decreasing LOC 2. fine tremors of the extremities 3. decerebrate posturing 4. ipsilateral pupil dilation 5. HA 6. tonic/clonic seizures

1, 4, 5 As pressure increases, the LOC decreases This is pupil dilation on same side as the hematoma HA is the first symptom *Think of head injury and ICP symptoms*

During a first aid class, the nurse instructs clients on the emergency care of partial thickness burns. The nurse identifies which of the following interventions for partial thickness burns of the chest and arms BEST prevents infection? 1. wash the burn w/an antiseptic soap and water 2. remove clothing, and wrap the victim in a clean sheet 3. leave the blisters intact and apply an ointment 4. take no action until the victim arrives in a burn unit

2 After fire is out, remove clothing and cover victim w/a clean sheet

A client takes perphenazine by mouth for 2 days. The client now reports the head turned to the side, the neck arched at an angle, and stiffness and muscle spasms in the neck. The nurse *expects* to give which PRN medication? 1. promazine 2. benztropine 3. thiothixene 4. haloperidol

2 Benztropine is an anti-parkinsonian agent It is used to counteract the extra-pyramidal adverse effects the client is experiencing

The home health care nurse provides care for a client dx w/T1DM. The client is maintained on a regimen of intermediate-acting insulin and short-acting insulin and a 1,800-calorie diabetic diet w/normal blood glucose levels. Morning self-monitored blood glucose (SMBG) readings the past 2 days were 205 and 233. The nurse expects the HCP to take which action? 1. reduce the client's diet to 1,500 calorie ADA 2. order three additional units of intermediate-acting insulin at 2200 3. order an additional 10 units of short-acting insulin at 2000 4. eliminate the client's bedtime snack

2 Dawn phenomena, tx is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia

The nurse performs triage on a group of clients in the ED. Which of the following clients should the nurse see FIRST? 1. a 12-yr-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can 2. a 19-yr-old w/a fever of 103.8 degrees F (39.8 degrees C) who is able to identify her sister but not the place and time 3. a 49-yr-old w/a compound fracture of the right leg who is complaining of severe pain 4. a 65-yr-old w/a flushed face, dry mucous membranes, and a blood sugar of 470

2 Disoriented, requires immediate assessment to determine underlying cause

A client dx w/AIDS is seen in the ER w/complaints of mouth pain, difficulty swallowing, and a white discharge in the back of the throat. The nurse expects the physician to order which of the following? 1. metronidazole (flagyl) 7.5 mg/kg q6h 2. ketoconazole (nizoral) 200 mg daily 3. trimethoprim-sulfamethoxazole (bactrim) 800 mg PO q12h 4. rifampin (rifadin) PO 10 mg/kg daily

2 Drug of choice for tx of candidiasis *The topic of the question is unstated*

Which of the following observations BEST indicates to the nurse that a client diagnosed w/paraplegia can adequately carry out ADL at home after discharge? 1. the client shaves and brushes his teeth 2. the client transfers himself into and out of his wheelchair 3. the client maneuvers the wheelchair w/o difficulty 4. the client prepares well-balanced meals

2 Essential if client is to perform ADLs *Think about the outcome of each answer*

A pt is admitted to the surgical unit w/a dx with r/o intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the pt in which of the following positions? 1. HOB elevated 30-45 degrees 2. HOB elevated 60-90 degrees 3. side-lying w/head elevated 15 degrees 4. lying flat w/head turned to the left side

2 Facilitates swallowing and movement of tube through GI tract *Remember the positioning strategy*

The parents of a 1-month-old boy bring their son to the clinic for evaluation of a possible developmental dysplasia of the right hip. The nurse should observe for which of the following? 1. limited adduction of the right leg 2. uneven gluteal fold and thigh creases 3. increase in length of the right limb 4. internal rotation of the right leg

2 Folds and creases will be longer and deeper on affected side *Think about each answer choice*

After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a 5-yr-old is admitted to the ER. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse 3 hrs after admission, should be reported to the physician? 1. the client has slight edema of the eyelids 2. there is clear fluid draining from the client's right ear 3. there is some bleeding from the child's lacerations 4. the client withdraws in response to painful stimuli

2 Indicates a rupture of meninges and presents a potential complication of meningitis

The nurse returns to the desk and finds four phone messages to return. Which message should the nurse return FIRST? 1. a woman in the first trimester of pregnancy complains of heartburn 2. a man complains of heartburn that radiates to the jaw 3. a woman complains of hot flashes and difficulty sleeping 4. a boy complains of knee pain after playing basketball

2 Indicates chest pain, needs to seek medical attention immediately

The nurse cares for an elderly client diagnosed w/Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for the client? 1. return the client to usual ADLs 2. maintain optimal function w/in the client's limitations 3. prepare the client for a peaceful and dignified death 4. arrest progression of the disease process in the client

2 Irreversible disease that leads to permanent physical limitations

The nurse provides care for a client w/left-sided hemiparesis from a stroke. The nurse notes a decrease in muscle tone on the client's left side. The nurse determines which nursing dx is the *priority*? 1. altered mobility 2. skin integrity 3. depression 4. altered verbal communication

2 Leading causes of skin breakdown is a decrease in tissue perfusion and movement *Think about each answer choice*

A client diagnosed w/multiple sclerosis (MS) is at 39 weeks' gestation. The client is admitted to the labor and delivery unit in active labor. The client's VS are BP 127/72; pulse 72 bpm; cervix is 4 cm dilated; FHT 124 bpm; moderate contractions are 4 min apart. The nurse should anticipate the need for which of the following? 1. prepare to administer IV pitocin to the client 2. a reduction in the amount of pain medication administered 3. check the client's BP every 5 min 4. prepare an isolette for the infant

2 Less pain medication is required because of overall decrease in pain perception due to MS *Answers are a mix or assessments and implementations. Does the assessment make sense? No. Determine the outcome of each intervention*

The nurse in the outpatient clinic instructs the mother of a school-aged child diagnosed w/asthma how to prevent future asthmatic attacks. The nurse is MOST concerned if the mother states which of the following? 1. my son plays the tuba in the grade school band 2. my son loves to help his dad rake leaves 3. my son participates in after-school activities 3 days a week 4. my son walks 1 mile to school every day w/his friends

2 Main cause of asthma is inhaled allergens (animal dander, mold, pollen, dust), would expose child to pollen and dust from leaves

After a client has a positive Chlamydia trachomatis culture, the client and partner return for counseling. It is MOST important for the nurse to ask which of the following questions? 1. do you have contacts to identify? 2. what is your understanding regarding how chlamydia is transmitted? 3. do you have questions about the culture and its validity? 4. do you have allergies to the medications?

2 Means of transmission of chlamydia may or may not have been made clear to both partners Nurse should assess this first Is a STD

The nurse prepares to administer an injection of haloperidol decanoate (haldol D) to a client. Which of the following actions by the nurse is MOST apropriate? 1. massage the injection site 2. give deep IM in a large muscle mass 3. use a 2-inch 25 gauge needle 4. administer the medication in divided doses

2 Medication is very irritating to SQ tissue

The young adult is brought to the ED after a motorcycle accident. A closed head injury w/suspected subdural hematoma is dx. The client is alert and answers questions appropriately and reports a severe HA. The nurse questions which order? 1. promethazine (phenergan) 25 mg IM 3 h 2. morphine sulfate 10 mg IM q3-4h 3. docusate sodium (colace) 50 mg PO bid 4. ranitidine (zantac) 50 mg IVPB q12h

2 Narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased ICP *"Question which of the following orders" indicates an incorrect order*

A middle-aged woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician's office a month later for a routine checkup, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery? 1. I have been helping my family deal w/their feelings about the surgery 2. I have been having difficulty coping w/the surgery and cry frequently 3. I have been unable to leave the house or talk to my friends about the surgery 4. I am doing just great since the surgery and have gone back to work at my job

2 Normal reaction 1 month later *Think about each answer choice. Does it describe an expected response to a crisis situation?*

The nurse should explain to a client that glipizide is effective for diabetics who 1. can no longer produce any insulin 2. produce minimal amounts of insulin 3. are unable to administer their injections 4. have a sustained decreased blood glucose

2 Oral hypoglycemic agents are administered to clients diagnosed w/T2DM who are able to produce minimal amounts of insulin *Think about each answer choice*

A 48-yr-old woman is seen in the outpatient clinic for complaints of irregular menses. The client's hx indicates an onset of menses at age 14, para 2 gravida 2, and regular periods every 28-30 days. The client is divorced and works full time as a bank teller. The nurse identifies the MOST probable cause of the client's symptom is which of the following? 1. emotional trauma and stress 2. onset of menopause 3. presence of uterine fibroids 4. possible tubal pregnancy

2 Ovarian function gradually decreases and then stops, usually 45-50 yrs old

An adolescent client is ordered to take tetracycline HCL (achromycin) 250 mg PO bid. Which of the following instructions should be given to the client by the nurse? 1. take the medication on a full stomach or w/a glass of milk 2. wear sunscreen and a hat when outdoors 3. continue taking the medication until you feel better 4. avoid the use of soaps or detergents for 2 weeks

2 Photosensitivity occurs w/the use of this medication *Think about each answer choice*

The nurse in a psychiatric ER cares for a client who is a victim of interpersonal violence. The INITIAL priority of the nurse is which of the following? 1. encourage the client to verbalize feelings 2. assess for physical trauma 3. provide privacy for the client during the interview 4. help the client identify and mobilize resources and support systems

2 Physical, victim may have physical trauma and concealed injuries Assessment is of utmost importance so that the client's physiologic integrity is maintained *Think "Maslow"*

A young adult pt constantly seeks attention from the nurses, stomping away from the nurses' station and pouting when requests are refused. Which of the following responses by the nurse is MOST appropriate? 1. encourage the pt to establish trust w/one staff person w/whom therapeutic interventions should occur 2. give the pt unsolicited attention when the pt is exhibiting acceptable behaviors 3. ignore the pt when the pt exhibits attention-seeking behavior 4. rotate the staff so that the pt will learn to relate to more than one nurse

2 Reward non-attention-seeking behaviors by giving the pt unsolicited attention

A client in the ICU is given procainamide HCl (Pronestyl) slowly by IV push. The nurse should withhold the next dose if which of the following is observed? 1. presence of premature ventricular contractions. 2. occurrence of severe hypotension. 3. recurring paroxysmal atrial tachycardia. 4. a sedimentation rate of 10.

2 Severe hypotension or bradycardia are signs of an adverse reaction to this medication

A woman has been recently dx w/systemic lupus (SLE) and shares w/the nurse, "I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy because I have lupus." Which of the following responses by the nurse is BEST? 1. most women find that they feel better when they are pregnant 2. how long have you been in remission 3. women w/lupus frequently have slightly longer gestations 4. it is best to become pregnant w/in the first 6 months of dx

2 Should be in remission for at least 5 months prior to conceiving *Answers are a mix of assessments and implantations. Does this situation require assessment? Yes*

The nurse in the outpatient clinic instructs a client dx w/a sprained ankle to walk w/a cane. What behavior, if demonstrated by the client, indicates to the nurse that teaching is effective? 1. the client advances the cane 18 inches in front of the foot w/each step 2. the client holds the cane in the left hand 3. the client advances the right leg, then the left leg, and then the cane 4. the client holds the cane w/elbows flexed 60 degrees

2 Should hold cane on strong side, widens base of support, reduces stress on affected side *"Teaching is effective" indicates a correct behavior*

An elderly client returns from surgery after a hysterectomy due to cancer, and there is an order for antiembolism stockings. Which of the following should the nurse include when instructing the client about wearing the support stockings? 1. wear the stockings when your legs cramp 2. wear the stockings during your hospitalization 3. put the stockings on prior to going to bed 4. put the stockings on after you get out of bed in the morning

2 Stockings should be worn the entire time that client is in the hospital Should be removed for baths and replaced after the skin is dry, and before the client gets out of bed

After abdominal surgery, a client has a NG tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions is MOST appropriate? 1. irrigate the NG tube w/distilled water 2. aspirate the gastric contents w/a syringe 3. administer an antiemetic medicine 4. insert a new NG tube

2 To confirm placement, nurse should aspirate and test the pH of the aspirate Results should be 0-4 *All answers are implementations. Determine the outcome of each answer choice. Is it desired?*

The nurse assesses the development of a 3-month-old boy in a well-child clinic. Which of the following behaviors, if observed by the nurse, is UNEXPECTED? 1. the boy holds his head erect when sitting on the examination table 2. the boy tried to grasp a toy just out of reach 3. the boy turns his head to try to locate a sound 4. the boy smiles spontaneously when he sees his mother

2 Unexpected until 6 months of age *Picture the infant*

The school nurse instructs a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates further teaching is necessary? 1. the poison control number is stored on all phones in our house 2. I should induce vomiting if my child swallows lighter fluid 3. if I carry medication in my purse, it should be in a child-proof container 4. proper storage is the key to poison prevention in the home

2 Vomiting contraindicated when child ingests hydrocarbons because of danger of aspiration *"Further teaching is necessary" indicates an incorrect statement"

An older adult client receives IV fluids after surgery. The nurse monitors the fluid status. Which symptoms suggest the client has an overload of fluid? 1. temperature 101 degrees F (38.3 degrees C), BP 96/60, pulse 96 bpm and thready 2. cool skin, respiratory crackles, pulse 86 bpm, and bounding 3. reports a HA, abdominal pain, and lethargy 4. urinary output 700 mL/24 h, CVP of 5, and nystagmus

2 W/an overload of fluid, the nurse will see a bounding pulse, elevated BP, distended neck veins, edema, HA, polyuria, hiarrhea, and liver enlargement

An older man is seen in the outpatient clinic for tx of an acute attack of gout. Which of the following nursing interventions is MOST beneficial in decreasing the client's pain during ambulation? 1. perform passive ROM exercises before walking 2. encourage partial weight bearing while amublating 3. immobilize the extremity between activities 4. restrict the amount of time and the distance the man walks

2 Would relieve weight, pressure, and stress on affected leg, may use walker

The client develops right-sided HF. The nurse expects to observe which symptoms? *select all that apply* 1. increased respiration w/exertion 2. peripheral edema and anorexia 3. polycythemia 4. cough producing large amount of thick, yellow mucus 5. twitching of extremities 6. distended neck veins

2, 3, 6 Edema caused by decreased heart pumping action and accumulation of fluid; malaise causing anorexia Increased RBC as compensation for decreased oxygenation R/T HF *All assessments, do they relate to HF?*

The nurse cares for clients in the skilled nursing facility. In which order does the nurse see the clients? 1. the client who has dysuria and foul-smelling, cloudy, dark amber urine 2. the client admitted for a stroke has a prescription for warfarin that expired 2 days ago 3. the client who received IV morphine and is transferred w/a prescription for acetaminophen w/codeine 4. the client who has not received an annual influenza immunization

2: the duration of warfarin is 2-5 days, and the client's warfarin prescription expired 2 days ago. this client is at risk for a subsequent stroke 1: dysuria and foul-smelling, cloudy, dark amber urine indicate a UTI is likely present. a UA is needed, but this client's condition is not the most urgent 3 4

A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority? 1. administer O2 2. turn her to the right side 3. provide adequate hydration 4. start antibiotics

3 Adequate hydration is a priority for any client w/sickle cell crisis

A nurse cares for a client diagnosed w/metastatic ovarian cancer admitted for n/v. The HCP orders parental nutrition (PN), a nutritional consult, and diet recall. Which is the BEST indication that the client's nutritional status has improved after 4 days? 1. the client eats most of the food served 2. the client has gained 1 pound since admission 3. the client's albumin level is 4.0 4. the client's hemoglobin is 8.5

3 Albumin levels are best indicators of long-term nutritional status

The nurse provides care for a client prescribed gemfibrozil. Which lab value does the nurse review based on this prescribed medication? 1. serum creatinine 2. erythrocyte sedimentation rate (ESR) 3. aspartate aminotransferase (AST) 4. arterial blood gasses (ABG)

3 An AST is a lab that is monitored to assess liver function The normal range is 10-30 Lipid-lowering agents such as gemfibrozil are prescribed for clients w/high serum triglyceride levels Adverse effects for this medication include abdominal pain and cholelithiasis The client is instructed to take the medication 30 min before breakfast and dinner

The nurse observes care given to a client experiencing severe to panic levels of anxiety. The nurse should intervene in which of the following situations? 1. the staff maintains a calm manner when interacting w/the client 2. the staff attends to client's physical needs as necessary 3. the staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety 4. the staff assesses the client's need of medication or seclusion if other interventions have failed to reduce anxiety

3 At this level of anxiety, client is unable to process thoughts and feelings for problem solving *"Nurse would intervene" indicates that you are looking for an inappropriate response*

The nurse in the well-baby clinic observes a group of children. The nurse notes that one child is able to sit unsupported, play "peek-a-boo" w/the nurse and is starting to say "mama" and "dada." The nurse determines the infant's behaviors are consistent w/which of the following ages? 1. 5 months of age 2. 6 months of age 3. 9 months of age 4. 12 months of age

3 Can pull self up and assume a sitting position at 8 months, can say few words

The nurse cares for a client receiving IV antibiotics for 4 days. Which of the following should cause the nurse to be concerned about postinfusion phlebitis? 1. tenderness at the IV site 2. increased swelling at the insertion site 3. reddened area or red streaks at the site 4. leaking of fluid around the IV catheter

3 Characterized by inflammation and reddened areas around site and up length of vein

A psychiatric nurse is assigned to conduct an admission nursing hx on a new client. The admission should include which of the following? 1. the nurse's opinion regarding the mental and emotional status of the client 2. data addressing the client's emotional state 3. data addressing a biopsychosocial approach, including a family system assessment 4. specific data detailing the client's mental status

3 Complete nursing hx includes biopsychosocial data Client's psychosocial and physical status are evaluated along w/an assessment of the client's family system and social support network Evaluation of the client's cognitive ability is important during the physiological status assessment *Think about each answer choice*

The nurse prepares a pt for a C-section. The pt says that she had major surgery several yrs. ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a C-section 1. contains a lower overall dosage of medication than is given before general surgery 2. contains lower amounts of sedatives and hypnotics than are given before general surgery 3. contains lower amounts of narcotics than are given before general surgery 4. contains medications similar in type and dosages to those given before general surgery

3 Decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant *Think about the action of the medications*

The nurse cares for clients in the pediatric clinic. A mother reports that her infant's smile is "crooked." The nurse should assess which of the following cranial nerves? 1. III 2. V 3. VII 4. XI

3 Facial Provides motor activity to the facial muscles

The nurse recognizes which of the following as a positive response to fluoxetine HCl (prozac)? 1. the nurse notes hand tremors and leg twitching 2. the client states that he is able to sleep for longer periods of time 3. the client has an increased energy level and participates in unit activities 4. the nurse observes that the client is hypervigilant and scans the environment

3 Fluoxetine HC (prozac) is an "energizing" antidepressant As client begins to demonstrate a positive response, he has an increased energy level, is able to participate more in milieu

The nurse administers morphine 6 mg IV push to a pt for postoperative pain. Following administration of the drug, the nurse observes the following: BP 100/68, pulse 68, respirations 8, client is sleeping quietly. Which of the following nursing actions is MOST oppropriate? 1. allow the client to sleep undisturbed 2. administer O2 via face mask or nasal prongs 3. administer naloxone (narcan) 4. place epinephrine 1:1,000 at the bedside

3 IV naloxone (narcan) should be given to reverse respiratory depression RR of 8 is too low and necessitates a nursing action

A client has a prescription for prochlorperazine 10 mg IM and butorphanol 2 mg IM. Before administering these medications, the nurse takes which action? 1. measures the client's pulse and temperature 2. dilutes both medications w/9mL of 0.9% sodium chloride 3. selects sites w/large muscle masses 4. verifies client is not allergic to derivative of promethazine

3 If they are administered IM, both prochlorperazine (an antiemetic) and butorphanol (an opioid analgesic) should be administered deeply into a large muscle mass *Determine the outcome of each answer choice. Is it desired?*

The nurse observes an LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, is performed by the LPN/LVN, indicates an understanding of proper technique? 1. a clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes 2. the incision is packed w/sterile gauze, and then sterile saline is poured over the dressing 3. the nurse packs wet gauze into the incision w/o overlapping it onto the skin 4. the old dressing is saturated w/sterile saline before it is removed

3 If wet dressing touches skin, it could cause skin breakdown

An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which of the following requires an intervention by the nurse? 1. the client complains of pain during the inflow of the dialysate 2. the client complains of constipation 3. the dialysate outflow is cloudy 4. there is blood-tinged fluid around the intra-abdominal catheter

3 Indicates peritonitis, also will see n/v, anorexia, abdominal pain, tenderness, rigidity

A 2-month-old w/a temperature of 102 degrees F (39 degrees C) is brought to the ED by his mother. The mother tells the nurse that the infant had a DPaT injection 1 week ago, and asks if this fever is r/t the immunization. The nurse's response should be based on which of the following? 1. if a fever does occur in a child after a DPaT, it usually occurs w/in the first 2 hrs 2. an elevated temperature is very rarely seen in a child after a DPaT immunization 3. if there is a fever after a DPaT, it is usually low-grade and appears w/in the first 48 hrs 4. the child's high fever is a direct response to the DPaT immunization and should be treated

3 Low-grade fever and irritability frequent response to immunization

Which *initial* action does the nurse take when managing a physically assaultive client? 1. restrict the client to the room 2. place the client under one-to-one supervision 3. speak calmly and assertively to encourage client control 4. clear the immediate area of other clients to prevent harm

3 Maintain the client's dignity and self-esteem by speaking assertively, not aggressively Keep a safe distance from the client, and continue to assess if the behavior is escalating or decreasing *All answers are implementations. Determine the outcome of each answer choice. Is it desired?*

A client is scheduled for a left lower lobectomy. The physician orders diazepam (valium) 2 mg IM for anxiety. The nurse determines the medication is appropriate if the client displays which of the following symptoms? 1. agitation and decreased LOC 2. lethargy and decreased RR 3. restlessness and increased HR 4. hostility and increased BP

3 Observation most indicative for antianxiety drugs is restlessness and increase in HR due to circulating catecholamines (fight or flight) *Determine if the answer choice relates to valium*

The nurse counsels an elderly client who comes to the outpatient clinic for a routine examination. The hx indicates the client takes a laxative tablet twice a day and a laxative suppository once a day. The nurse should suspect which of the following about the client? 1. the client has an anal fixation resulting from recent loss of a spouse 2. the client is depressed because of alterations in intestinal absorption and excretion 3. the client is experiencing excessive concern w/body function because of physical changes 4. the client has regressed because of a fear of losing the ability to have bowel movements

3 Physical changes occur in late adulthood causing changes in body image Constipation frequent problem in elderly, but reaction by this client is excessive *Think about each answer choice*

A client who is positive for HIV is to be discharged and will be taking zidovudine (AZT) at home. Which of the following actions by the nurse is BEST? 1. review the importance of adhering to a 4-hr schedule 2. advise the client to buy a timed pill dispenser 3. write the schedule of when the medicine should be taken 4. encourage self-medication prior to discharge

3 Planned and written schedule of administration is more effective for adherence to time frames *Answers are implementations. Determine the outcome of each answer choice. Is it desired?*

A client received six units of regular insulin 3 hrs. ago. The nurse is MOST concerned if which of the following is observed? 1. kussmaul respirations and diaphoresis 2. anorexia and lethargy 3. diaphoresis and trembling 4. HA and polyuria

3 Regular insulin peaks in 2-3 hrs Indicates hypoglycemia Give skim milk *"MOST concerned" indicates a complication*

A client dx w/bipolar disorder receives haloperidol (haldol) 2 mg PO tid. The client tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. you are seeing things that aren't real 2. why don't we go make some fudge? 3. you are experiencing a SE of haldol 4. I'll contact your physician to change your medication

3 SE include galactorrhea (excessive or spontaneous flow of milk), lactation, gynecomastia (excessive growth of male mammary glands)

Which of the following nursing actions has the HIGHEST priority for a teenager admitted w/burns to 50% of the body? 1. counseling regarding problems of body image 2. maintain airborne precautions 3. maintain aseptic technique during procedures 4. encourage peers to visit on a regular basis

3 Safety is a priority for the client who is at high risk for infection *Think "Maslow"*

The nurse learns a client has a hx of HF, is on a low sodium diet, and is taking chlorothiazide 500 mg. Diagnostic tests indicate sodium 127, potassium 3.8, glucose 110, and normal chest x-ray. It is *most* important for the nurse to assess for which signs? 1. sticky mucous membranes; decreased urinary output; and firm, rubbery tissues 2. cool, moist skin; fine hand tremors; and mental confusion 3. HA, apprehension, and lethargy 4. SOB, chest pain, and anxiety

3 Symptoms of hyponatremia along w/muscle twitching, convulsions, diarrhea, fingerprinting of skin

When a nurse is using restraint's for an agitated/aggressive pt, which of the following items should NOT influence the nurse's actions during this intervention? 1. the restraints/seclusion policies set forth by the institution 2. the pt's competence 3. the pt's voluntary/involuntary status 4. the pt's nursing care plan

3 The need for restraints is based on pt's behavioral status and condition, not the pt's voluntary/involuntary status *Think about each answer choice*

The nurse cares for clients in outpatient surgery. The mother of a 4-yr-old asks the nurse how to prepare her daughter for eye surgery. Which of the following statements by the nurse is BEST? 1. draw a picture of the eye to explain what will happen 2. tell your daughter that the procedure will take 1 hr 3. use dolls or puppets to explain how to get ready for surgery 4. read an age-appropriate illustrated book about eye surgery to your daughter

3 Use puppet or doll to show where procedure is performed Explain procedure in simple terms and what the child will see, hear, taste, smell, and feel

A mother brings her 2-yr-old to the pediatrician's office. Which of the following symptoms suggests to the nurse that the child has strabismus? 1. the child places his head close to the table when drawing 2. the child rubs his eyes frequently 3. the child closes one eye to see a poster on the wall 4. the child is unable to see objects in the periphery of his visual field

3 Visual axes are not parallel, so the brain receives two images *Think about each answer choice*

The nurse provides care for a client diagnosed w/an abruptio placenta. Which is the *priority* nursing dx for this client? 1. infection 2. fetal demise 3. altered tissue perfusion 4. fluid volume deficit

4 Abruptio placenta is premature separation of a normally implanted placenta leading to hemorrhage Fluid volume deficit is a major nursing concern w/these clients

A school-age client injured the right knee yesterday. The client's right knee is painful, swollen, and bruised. The parent says that the child has hemophilia A. The nurse determines which medication is safest for this client? 1. aspirin 2. ibuprofen 3. naproxen 4. acetaminophen

4 Acetaminophen is a non-opioid, non-salicylate analgesic that can be effective in treating mild to moderate pain *Think about the action of each medication*

The nurse cares for a child several hrs after the application of a hip spica cast. the pt turns on the call light and complains of pain in the left foot. Which of the following actions should the nurse take FIRST? 1. elevate the left leg on two pillows 2. palpate the cast for warmth and wetness 3. administer pain medication as ordered 4. check the blanching sign on both feet

4 Assessment Pain main symptom of circulatory impairment from cast Pressing nail of great doe indicates circulatory function, compare speed w/which color returns w/result on the opposite side Sluggish return indicates circulatory impairment, too rapid return indicates venous congestion

The nurse is assigned to work w/the parents of a child diagnosed w/mental retardation. Which of the following should the nurse include in the care plan for the parents? 1. interpret the grieving process for the parents 2. discuss the reality of institutional placement 3. assist the parents in making decisions and long-term plans for the child 4. perform a family assessment to assist in the planning of intervention

4 Assessment This will help the nurse to know where the family is in regard to grieving, coping, etc.

The nurse cares for clients in the student health center. A client confides to the nurse that the client's boyfriend informed her that he tested positive for hepatitis B. Which of the following responses by the nurse is BEST? 1. that must have been a real shock to you 2. you should be tested for hepatitis B 3. you'll receive the hepatitis B immune globulin (HBIG) 4. have you had unprotected sex w/your boyfriend?

4 Assessment Transmitted through parenteral drug abuse and sexual contact Determine exposure before implementing *Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes*

A client diagnosed w/a peptic ulcer has a partial gastrectomy and vagotomy (billroth I). In planning the discharge teaching, the nurse should caution the client about which of the following? 1. sit up for at least 30 mins after eating 2. avoid fluids between meals 3. increase the intake of high-carbohydrate foods 4. avoid eating large meals that are high in simple sugars and liquids

4 Basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 mins after meals, drinking fluids between meals, and reducing intake of carbohydrates

The nurse prepares a child for emergency surgery. The informed consent for surgery has been signed by one parent. Which action by the nurse is *best*? 1. notify the HCP 2. notify the surgical team 3. contact the other parent to obtain consent 4. continue the child's preoperative preparation

4 Because the child requires emergency surgery, the nurse's priority is to continue the child's preoperative preparation

A client is transferred to a psychiatric crisis unit w/a dx of a dissociative disorder. The nurse identifies which of the following comments by the client is MOST indicative of this disorder? 1. I keep having recurring nightmares 2. I have a HA, and my stomach has bothered me for a week 3. I always check the door locks three times before I leave home 4. I don't know who I am, and I don't know where I live

4 Dissociative disorders characterized by either a sudden or a gradual disruption in the integrative functions of identify, memory, or consciousness Disruption may be transient or may become a well-established pattern Development of these disorders is often associated w/exposure to a traumatic event

The HCP prescribes famotidine 40 mg PO daily for a client. At which time does the nurse advise the client to take the medication for the *best* results? 1. after breakfast 2. w/lunch 3. w/dinner 4. at bedtime

4 For the best results, famotidine, an H2-histamine blocker, should be taken before meals or at bedtime Doing so decreases food-induced acid secretion Famotidine may be prescribed to treat gastric or duodenal ulcers *All answers are implementations. Determine the outcome of each answer choice. Is it desired?*

The nurse cares for clients on the neurology unit. What is the MOST appropriate action for the nurse to take after noting that a client suddenly develops a fixed and dilated pupil? 1. reassess in 5 min 2. check the client's visual acuity 3. lower the head of the client's bed 4. contact the physician

4 Implementation Fixed and dilated pupil represents a neurological emergency

The nurse monitors a client's EKG strip and nots premature ventricular contractions greater than 10 per min. The nurse should expect to administer which of the following? 1. atropine sulfate (atropine) IV 2. isoproterenol (isuprel) IV 3. verapamil (calan) IV 4. lidocain hydrochloride (xylocaine) IV

4 Lidocaine is the drug of choice for frequent premature ventricular contractions (PVC) occurring in excess of 6-10 per min For coupled PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia

The home care nurse instructs a client recently diagnosed w/TB. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 1. the client should cover the mouth and nose when coughing or sneezing during the first 2 weeks of tx 2. it is necessary for the client to wear a mask at all times to prevent transmission of the disease 3. the family should support the client to help reduce feeling of low self-esteem and isolation 4. the client will be required to take prescribed medication for 6-9 months

4 Necessary to take medication for 6-9 months

An elderly client returns to the room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include which of the following? 1. high-protein, low-residue diet 2. position client on unaffected side 3. exercise the client's arms and legs 4. encourage the client to cough and deep breathe

4 Prevents respiratory complications due to immobility following surgery *All answers are implementations. Determine the outcome of each answer choice. Is it desired?*

The nurse cares for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 1. take the client to the dining room w/1:1 supervision 2. inform the client that he may go to the dining room when he controls his behavior 3. hold the meal until the client is able to come out of seclusion 4. serve the meal to the client in the seclusion room

4 Should eat at regular time Remain in the seclusion room for client's safety

The nurse performs discharge teaching for a client diagnosed w/Addison's disease. It is MOST important for the nurse to instruct the client about which of the following? 1. s/s of infection 2. fluid and electrolyte balance 3. seizure precautions 4. steroid replacement

4 Steroid replacement is the most important information the client needs to know

The nurse supervises the staff caring for four clients receiving blood transfusion. In which order should the nurse visit each client? 1. the client w/neck vein distention 2. the client reporting itching 3. the client reporting a HA 4. the client vomiting

4: acute hemolytic reaction; most dangerous type of transfusion reaction, symptoms include n/v, pain in lower back, hematuria; tx is to stop blood, obtain urine specimen, and maintain blood volume and kidney perfusion 1: circulatory overload; tx is to adjust rate of infusion, position in an upright position, and administer O2 and possibly diuretics 2: allergic reaction; symptoms include urticaria, pruritus, fever; tx is to stop blood, give antihistamine, and restart transfusion slowly 3: febrile reaction; symptoms include fever, chills, nausea, HA; tx is to stop blood and administer antipyretics *Identify the most critical type of transfusion reaction*