SAUNDERS REVIEW

The nurse is counseling the young parent of a small child recently diagnosed with impetigo. The nurse would make which statement that provides the best information about impetigo?

"You will need to prevent any of the fluid from the blisters from coming into contact with your other children."

The nurse determines that the client needs further instruction on cimetidine if which statements were made? Select all that apply.

1. "I will take the cimetidine with my meals. 2 "I'll know the medication is working if my diarrhea stops. 3. "Taking the cimetidine with an antacid will increase its effectiveness."

The nurse is preparing to administer a vaccine to a pediatric client. What actions are essential for the nurse to perform prior to administering the vaccination? Select all that apply.

1. Assess for allergies.2Verify the prescription.3Obtain an immunization history.4Obtain the consent from the parents.5Check the lot number and expiration date.

A client is being transferred from the intensive care unit to a step-down unit. The nurse is performing a final assessment of the client before moving the client to the new unit. The priority components of this final assessment would include which parameters? Select all that apply.

1. The client's vital signs 2. The client's level of consciousness 3. The patency of intravenous lines Submit

The nurse is reviewing the results of the electrolyte panel for a client seen in the health care clinic. The nurse determines that the client's potassium level is normal if which value is noted?

4.0 mEq/L (4.0 mmol/L)

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)?

A client who requires assistance with ambulation every 4 hours

The nurse employed in a surgical unit in a hospital arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and the census on the pediatric unit is unusually high. The nurse has never worked in the pediatric unit and does not want to float to pediatrics. Which action by the nurse is most appropriate?

Call the nursing supervisor to discuss the request to report to pediatrics.

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse would take which best action?

Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment.

The nurse is collecting data on a pregnant client in the first trimester of pregnancy diagnosed with iron-deficiency anemia. The nurse would monitor the client to detect which manifestation indicating that this problem has not yet resolved?

Complaints of daily headaches and fatigue R: Anemia is one of the most common problems in pregnancy, and iron-deficiency anemia and folic acid deficiency anemia are 2 of the most common types. It is estimated that between 20% and 60% of all pregnant clients are anemic at some point during pregnancy, with hemoglobin concentration lower than 10.0 to 11.0 g/dL (100 to 110 mmol/L). Complaints of daily headaches and fatigue are abnormal findings and may reflect complications caused by decreased oxygen supply to vital organs, thus supporting laboratory findings. The incorrect options are expected findings in the first trimester of pregnancy.

The nurse is caring for the client who is suspected of having lung cancer. The nurse would assess the client for which most frequent early symptom of lung cancer?

Cough

The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication?

Disconnection of the ventilator tube

A client is having the dosage of clonazepam adjusted. The nurse would plan to perform which action?

Institute seizure precautions.

Itraconazole is prescribed for a client with a fungal infection of the hands. The nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions?

"If my urine becomes very dark in color, I would contact my primary health care provider (PHCP)."

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.

1. Use nonlatex gloves. 2. Use medications from glass ampules. 3. Keep a latex-safe supply cart available in the client's area. 4. Avoid the use of medication vials that have rubber stoppers

A prescription reads to administer an intravenous (IV) dose of 400,000 units of penicillin G benzathine to a client with an infection. The label on the 10-milliliter (mL) ampule sent from the pharmacy reads penicillin G benzathine, 300,000 units/mL. The nurse prepares how many milliliters (mL) to administer the correct dose? Fill in the blank. Record your answer using 1 decimal place.

1.3

A prescription reads to infuse 1 unit of packed red blood cells over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

10 gtt/min

A student nurse is caring for a hospitalized child who has hypotonic dehydration. Which serum sodium level would the student expect to observe?

125 mEq/L (125 mmol/L)

The nurse in the primary health care provider's office is reviewing the results of a client's phenytoin level determination performed that morning. The nurse identifies that a therapeutic medication level has been achieved if which result is noted?

15 mcg/mL (59.52 mmol/L)

In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the primary health care provider's prescriptions, expecting which type of eye drops to be prescribed?

A mydriatic medication

The nurse is teaching a client with nephrotic syndrome about managing the disorder. What would the nurse instruct the client to adjust according to the amount of edema present?

Activity level

A client with a gastric ulcer is prescribed both magnesium hydroxide and cimetidine twice daily. How would the nurse schedule the medications for administration?

Administer each dose of cimetidine 1 hour prior to the administration of magnesium hydroxide. R: Antacids, such as magnesium hydroxide, can decrease absorption of cimetidine. At least 1 hour needs to separate administration of an antacid and cimetidine

The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions the client that which could cause a false-negative result?

Ascorbic acid

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions?

Droplet

A client is admitted to the medical-surgical unit with an upper gastrointestinal (GI) bleed. The nurse would expect which condition to be the primary cause?

Esophagitis

A client states to the home health nurse that they have not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time?

High-fiber diet

A client is hospitalized with a diagnosis of adrenal insufficiency. Which findings does the nurse identify as supportive of this diagnosis? Select all that apply.

Irritability2Complaints of nausea3Sodium level of 128 mEq/L (128 mmol/L)5Blood pressure lying 138/70 mm Hg and standing 110/58 mm Hg R: Findings consistent with a diagnosis of adrenal insufficiency include nausea, vomiting, and diarrhea; hyponatremia; salt craving; hyperkalemia; and orthostatic hypotension. Irritability and depression may also occur in primary adrenal hypofunction.

The nurse is caring for a 14-year-old child who is hospitalized and has been placed in traction using Crutchfield tongs. The child is having difficulty adjusting to the prolonged hospital confinement. Which nursing action would be appropriate to meet the child's needs?

Let the child wear own clothing when friends visit. R: Adolescents need to identify with their peers and have a strong need to belong to a group. They prefer to dress like the group and wear similar hairstyles, which are different from their parents'. The child needs to be allowed to wear own clothes to feel a sense of belonging to the group. Because Crutchfield tongs require the use of skeletal pins, hair dye is not appropriate. Loud music may disturb others in the hospital. The child's request for a darkened room may indicate a problem with depression that may need further evaluation and intervention.

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?

Move the infant to a private room.

The nurse is instructing a client in diaphragmatic breathing. To reinforce the need for this technique, the nurse teaches the client that in normal respiration, which is an action of the diaphragm?

Moves downward and out as it contracts

The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The PP and RR intervals are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 82 beats/min. The nurse would report the cardiac rhythm to be which rhythm?

Normal sinus rhythm rationale: Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.

The nurse is reviewing the laboratory test results for a client and notes that the differential white blood cell (WBC) count indicates a shift to the right. The nurse suspects that the client's diagnosis is most likely to be which one?

Pernicious anemia

A nurse is caring for a client with thyrotoxicosis who is at risk for the development of thyroid storm. To detect this complication, the nurse would assess for which sign or symptom?

Persistent sweating

The nurse is caring for a client who is pulseless and experiencing dysrhythmia. Which interventions would the nurse anticipate implementing in collaboration with the primary health care provider (PHCP)? Select all that apply. Refer to figure.

Prepare to administer amiodarone.4Prepare to administer epinephrine.5Provide cardiopulmonary resuscitation (CPR).

The client has an impairment of cranial nerve II. Specific to this impairment, what would the nurse plan to do to ensure client safety?

Provide a clear path for ambulation without obstacles

A client has an epidural catheter in place after colon surgery and is receiving pain medication through the catheter. During the night, the client calls the nurse and says, "I have a terrible headache that just started now." The nurse checks the epidural catheter insertion site and notes a small amount of clear drainage leaking from the bandage. What is the first action the nurse would take?

Stop the infusion.

The nurse is performing an assessment on a newborn and is preparing to measure the head circumference of the newborn. Which item is essential to perform this assessment?

Tape measure

Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin would indicate a need for further instruction regarding the management of the disease process?

Telling a family member, who is pregnant, that it is acceptable to visit the infant

A client is tested for human immunodeficiency virus (HIV) infection with an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. What would the nurse tell the client?

The test will need to be confirmed with a Western blot.4

The nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim who is unresponsive. A layperson is attempting to perform resuscitative measures. The nurse would intervene if which action by the layperson is noted?

Use of the head tilt-chin lift: rationale: Whenever a neck injury is suspected, the jaw thrust maneuver needs to be used during basic life support (BLS) to open the airway. The head tilt-chin lift produces hyperextension of the head to neck and could cause complications if a neck injury is present. The scene needs to be checked for safety, and the client needs to be moved away from traffic in order to ensure safety.

The primary health care provider (PHCP) prescribes semaglutide for a client with type 1 diabetes mellitus who takes insulin. The nurse would plan to take which most appropriate intervention?

Withhold the medication and call the PHCP, questioning the prescription for the client.