Week 1 Test
The nurse provides care for a client admitted with left sided paralysis and impaired speech. Which nursing diagnosis should the nurse assign the highest priority for this client? 1- Impaired swallowing. 2- Risk for injury. 3- Self-care deficit. 4- Ineffective coping.
1) difficulty talking makes pt high right for aspiration. **This stroke or CVA** 2 things to watch for w/CVA: --speech/swallowing & ICP b/c @ risk for aspiration.
The nurse observes the client crutch walk down the stairs. The client stands at the top of the stairs placing body weight on the good leg and the crutches. Which does the client do next? 1- Put the crutches down on to the next step of the stairs. 2- Bring the unaffected leg down on the step with the crutches. 3- Transfer the injured leg down on the step with the crutches. 4- Put weight on crutch handles after placing on the next step.
1) pt transfers down stairs w/crutch 1st
The nurse is providing care for several clients that arrived at the urgent care clinic at the same time. Which client will the nurse assess first? 1- 16-year-old with a severe headache, fever, and stiff neck. 2- 30-year-old with a fever, vomiting and diarrhea. 3- 66-year-old with a swollen, bruised knee reporting severe pain. 4- 41-year-old with severe burning with urination, fever, and chills.
1) symptoms indicate meningitis, should assess first 2--indicates dehydration (assess 2nd) 4-- indication UTI (assess 3rd)
The nurse prepares a client for surgery. Which task is appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1- Performing a clean catch urinalysis. 2- Collecting vital signs. 3- Monitoring lung sounds. 4- Applying compression stockings. 5- Educating on incentive spirometer use.
1,2,4
The nurse is preparing to move a client from the bed to a wheel chair. Which technique does the nurse use to ensure proper body mechanics? (Select all that apply.) 1- Create a wide stance with one foot forward and one back. 2- Use back muscles when lifting client to a standing position. 3- Stand between the client and the wheelchair. 4- Hold client at arm's length when standing. 5- Pivot toward the wheelchair using leg muscles.
1,5 Steps to transferring (Bed to Chair) --create wide stance w/1 foot forward&1 foot back --use leg muscles when lifting --stand directly in front of pt& stand close --pivot towards chair using leg muscles
The nurse identifies the nursing diagnosis of Stress Urinary Incontinence related to weakened pelvic musculature for a client. Which goal is most appropriate for this client? 1- Engage in a bladder retraining program. 2- Reduce the frequency of urinary incontinence episodes through exercises. 3- Use adaptive clothing for quick removal. 4- Undergo urodynamic testing to assess urine speed and volume.
2) The appropriate goal is to reduce stress incontinence episodes. This goal can be accomplished through repetitive exercises to strengthen the muscles of the pelvic floor. --might take 2 weeks to see improvements
The nurse provides care for a client diagnosed with emphysema. The client becomes anxious and confused. What is the first action the nurse should take? 1- Increase the client's oxygen flow rate to 4 liters per minute. 2- Encourage the client to do pursed-lip breathing. 3- Assess the client's sodium level. 4- Take the client's blood pressure.
2) This prevents the collapse of the alveoli and helps the client control the depth and rate of breathing (washed out CO2). --low-flow O2 should be <3L **COPD pt's have HIGH CO2 b/c they retain CO2**
The nurse provides care for a client diagnosed with cutaneous Kaposi sarcoma lesions. The nurse notes that the lesions are open and draining small amounts of serous fluid. Which personal protective equipment (PPE) does the nurse use when bathing and changing the linens for this client? 1- Gloves. 2- Gown and gloves. 3- Gown, gloves, and mask. 4- Gown and gloves to change the linens; gloves when bathing
2) gown & gloves
The nurse plans care for an older adult client. Which intervention does the nurse implement to reduce this client's risk for falls? 1- Elevate bed to waist height. 2- Ensure socks are worn when ambulating. 3- Position commode close to the bed. 4- Place a chair and overbed table close to the commode.
3) --bed in LOW position --wear NONSKID footwear --CLEAR PATH to commode free of obstacles
A client receives an antibiotic every 8 hours. The antibiotic has an onset of action of 2 hours and a duration of action of 8 hours. The client is prescribed a peak blood level. If the medication is provided at 1000, at which time will the nurse schedule the peak level to be drawn? 1-1100 2- 1200 3- 1400 4- 1800
3) Peak concentration occurs after the onset but before the end of the duration.
A client says, "I promise not to touch the intravenous catheter anymore because I don't want to be slapped again." Which action does the nurse take first? 1- Complete a neurological assessment. 2- Ask the nursing assistive personnel (NAP) if the client was slapped when providing care. 3- Ask the client where the slap occurred and under what conditions. 4- Document the client's statement and report it to the nurse manager.
3) The nurse needs to assess if assault and battery occurred and by whom. This should be done prior to documenting and reporting the event to the nurse manager.
The nurse provides care to victims of a disaster. Which client will the nurse assess first? 1- An 8-month-old client with a laceration over the left eye, a blood pressure of 84/50 mm Hg, and a pulse of 105 beats/min. 2- A 6-year-old client with crush injuries to both legs, fixed and dilated pupils, and an absent pulse. 3- A 20-year-old client with a traumatic left below the knee amputation, a blood pressure of 70/46 mm Hg, and a pulse of 124 beats/min. 4- A 28-year-old client with a hematoma on the forehead, a Glasgow Coma Scale of 11, and is crying.
3) VS could indicate the below knee amputation could be hemorrhaging.
The nurse provides care for a client who takes potassium chloride 40 mEq by mouth twice daily. The client's serum creatinine level is 1.9 mg/dL. Which action is the priority for the nurse? 1- Obtain an order for a renal consultation. 2- Administer the potassium as prescribed. 3- Monitor the client's intake and output. 4- Notify the client's health care provider (HCP).
4) An elevated serum creatinine level indicates possible impaired kidney function, which could result in hyperkalemia. The nurse should notify the HCP before administering potassium. **HyperK+== Tented T-waves** --creatinine [0.6-1.2], giving K+ ->hyperK d/t possible impaired kidney function
The nurse performs a newborn assessment. Which finding does the nurse report to the health care provider? 1- Pink patch on the nape of the neck. 2- Bluish skin over the sacral and gluteal area. 3- An axillary temperature of 97.8°F (36.2°C). 4- A respiratory rate of 26 breaths per minute.
4) Report abnormal RR-- normal range {30-60 breaths/min} --normal Newborn temp. (36.4-37.2C) Some normal findings: -Telangiectases-- (1) pink patch on back of neck -Mongolian spots-- (2) bluish skin over sacral & gluteal area -rectal temp. of 36.6C
The nurse provides care for a client experiencing acute anxiety. It is most important for the nurse to assess the client for which acid-base imbalance? 1- Respiratory alkalosis. 2- Respiratory acidosis. 3- Metabolic alkalosis. 4- Metabolic acidosis.
1) Anxiety causes hyperventilation, which results in a loss of carbon dioxide. Respiratory alkalosis is caused by decreased carbon dioxide in the blood. 2--hypo ventilation 3--vomit/suction 4--everything else
The nurse provides care for a client with diabetes insipidus (DI). Which nursing diagnosis is most appropriate for this client? 1- Fluid volume deficit related to excess urine output. 2- Hyponatremia related to increased sodium excretion. 3- Risk for fluid overload related to low urine output. 4 -Hyperglycemia related to reduced insulin production.
1) DI- deficiency of secretion of antidiuretic hormone or decrease response to ADH. -This results-->excessive water excretion -->FVD --2,3,4 are not nursing Dx.
The parents bring their 4-month-old infant to the clinic for a wellness visit. They report trying to give the infant prepackaged baby food a couple of weeks ago, but the infant stuck out the tongue and would not take the food. Which response by the nurse is appropriate? 1- "That's a natural reflex; it will soon disappear and then your baby will be ready for solid foods." 2- "Try introducing another food. Your baby probably doesn't like the taste of what you tried." 3- "Keep introducing foods, as it may be the texture of the food you tried." 4- "Try pureeing your own food instead of giving the prepackaged baby food."
1) The tongue extrusion reflex is a natural reflex for an infant who is not developmentally ready for solid foods. Reflex disappears at about 4-6 months when solid food can be safely introduced into the diet.
Which action will the nurse take to maintain safety when providing a client with a blood product? (Select all that apply.) 1- Verify client's identification according to institutional policy. 2- Administer blood product as soon as it arrives on the care area. 3- Transfuse blood products in less than 2 hours for maximum effect. 4- Stay with the client during the first 15 minutes of the transfusion. 5- Obtain an order for oxygen 2 L via nasal cannula during transfusion.
1,2,4 **RATIONALES:** --1-Positive identification of the client is a gold standard when transfusing blood products. --2- Blood products are administered as soon as they arrive on the care area. --3-There is no set length of time to transfuse blood products. It depends on the type of product transfused and the client's clinical status. --4- Staying with client for the first 15 minutes is part of transfusion best practices and provides the nurse with the opportunity to detect a reaction. --5-Oxygen is not routinely administered when providing a blood product.
The nurse provides preoperative teaching for a client having surgery. Which type of anesthesia does the nurse explain as altering the level of consciousness? (Select all that apply.) 1- General anesthesia. 2- Regional anesthesia. 3- Local anesthesia. 4- Conscious sedation. 5- Topical anesthesia.
1,4 -General--alters LOC -Regional--loss of sensation in specific areas -used w/ spinal injury (C-section) -Local--loss of sensation at local site -Conscious--alters LOC -Topical--loss of sensation in specific area
The nurse provides care for a client diagnosed with neonatal abstinence syndrome (NAS). The newborn experiences drug withdrawal. Which nursing intervention does the nurse include in the newborn's plan of care? (Select all that apply.) 1- Swaddle the newborn in a flexed position during sleep and feedings. 2- Keep the newborn in a prone position. 3- Feed the newborn frequently with high-calorie formula. 4- Place newborn's crib in the quietest corner of the nursery. 5- Lowered lighting around newborn's crib provides a more restful environment.
1,4,5 **RATIONALES:** --1-swaddling in flexed position decreases movements so not to startle, awaken, &/agitate --2-should NOT lie prone if unattended --3-do not wake/disturb if sleeping --4-they are easily overstimulated by noise & activity. So place them in the quietest corner --5-keep lights turned down, partially cover crib w/ blanket to decrease light--> more restful environment
The nurse is teaching a client diagnosed with end stage renal disease about hemodialysis. Which statement indicates that teaching has been effective? 1- "I should have a treatment once a week." 2- "I might have muscle cramps after a treatment." 3- "The treatment could make my blood clot faster." 4- "The treatments reduce my risk of getting infections."
2) Muscle cramping can occur because of the rapid removal of fluid, electrolytes, and body wastes.
The nurse provides care for a client who has norepinephrine infusing through a peripheral intravenous catheter (IV). The client reports pain at the IV insertion site. The nurse stops the infusion. Which action does the nurse take next? 1- Apply a cold compress to the IV insertion site. 2- Notify the health care provider. 3- Use a skin marker to outline the affected area. 4- Position the extremity in a dependent position.
2) pt displays signs of extravasation. Notify HCP promptly to determine Tx. plan before tissue damage occurs. OTHER ACTIONS (after stop): --warm compress --circle affected site w/skin marker, monitor effectiveness Tx. --elevate affected extremity *Norepi, a vasopressor, causes vasoconstriction when extravasated into tissues.
The nurse provides care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which finding indicates that the treatment has been effective? 1- Serum osmolality is decreased. 2- Serum sodium is decreased. 3- Urinary output is increased. 4- Urine osmolality is increased.
3) **indications SIADH Tx. works: -serum osmolality increases -serum sodium increases -urine output increases -urine osmolality decreases
The oxygen saturation level of a client with lung cancer drops from 93% to 86% during ambulation. Which action does the nurse take next? 1- Continue ambulation, as this is a normal response to activity among lung cancer clients. 2- Move the oximetry probe from the finger to the earlobe for accurate monitoring during activity. 3- Obtain a prescription for supplemental oxygen to be used during ambulation and other activity. 4- Request a prescription for arterial blood gases to verify the arterial oxygen saturation.
3) supplemental O2 is needed to increase the supply of oxygen during activity --1-warrants rest&stopping activity
The nurse provides care for several clients. Which task does the nurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1- Determine client's pain level. 2- Perform walker use training. 3- Assist with meal trays. 4- Bathe a client with wounds. 5- Obtain routine vital signs.
3,4,5
Some hemodialysis teaching points:
--Hemodialysis treatments are typically scheduled every other day or three times a week. *is the main teaching point* --Muscle cramping can occur because of the rapid removal of fluid, electrolytes, and body wastes. --The anticoagulants within the dialysate prevent clotting and the risk for bleeding. --Hemodialysis treatments actually increase the risk of hepatitis and other blood-borne pathogen infections.
Rationales for other choices from ? 75 2- Client who had laparoscopic bariatric surgery 1 hour ago and is sleeping in a semi-Fowler position. 3- Client who had a left pneumonectomy 14 hours ago and is positioned on the left side. 4- Client who had an appendectomy 10 hours ago and has vesicular breath sounds over peripheral lung fields
-2-- recovering from bari surgery, in no acute distress, and correct position to improve breathing and decrease the risk for sleep apnea or other pulmonary complications, such as pneumonia or atelectasis. -3--recovering from pneumonectomy, in no acute distress, and appropriately positioned to allow fluids to fill in the space formerly taken up by the lungs. -position pt on opposite side of lobectomy/pneumothorax -4--vesicular breath sounds are considered normal
The nurse teaches a group of nursing assistive personnel (NAP) about preventing venous thromboembolism (VTE). Which action does the nurse delegate to the NAP? (Select all that apply.) 1- Reposition the client at least every 2 hours. 2- Assist the client with ambulation as needed. 3- Provide the client with teaching materials on VTE. 4- Apply sequential compression devices (SCDs). 5- Help the client in putting on compression stockings.
1,2,4,5
The nurse on an inpatient unit prepares to deliver a urine specimen to the laboratory. Which nursing action is necessary? 1- Place the urine specimen container in a small biohazard bag. 2- Hand-deliver the specimen to the laboratory within an hour. 3- Send the specimen through an automated delivery system. 4- Mark the urine specimen container with the room number.
1) ALL specimen containers use biohazard symbol on outside. --specimens difficult to recollect must be hand-delivered, such as pleural fluid. --any urine that cannot be delivered w/in 1 Hr should be refrigerated, for up to 24 Hr. **Containers are labeled w/: --specimen type, source, date, time, nurses initials, & prescribed test needed
The nurse provides care to a client diagnosed with second- and third-degree burns on the anterior thorax and legs. Which finding will the nurse expect to observe during the emergent phase of the burn injury? 1- Elevated hematocrit. 2- Decreased heart rate. 3- Increased blood pressure. 4- Increased urinary output.
1) An elevated hematocrit occurs because of hemoconcentration that takes place as the result of the large fluid shifts from intravascular to interstitial spaces during the emergent phase of a burn injury. --HR increases/BP decreases: b/c fluid shifts --UO decrease because blood is shunted away from the kidneys, and renal perfusion& glomerular filtration is decreased.
The nurse provides care to several clients. Which client will the nurse assess first? 1- Client with heart failure and reports substernal pain. 2- Client who had laparoscopic bariatric surgery 1 hour ago and is sleeping in a semi-Fowler position. 3- Client who had a left pneumonectomy 14 hours ago and is positioned on the left side. 4- Client who had an appendectomy 10 hours ago and has vesicular breath sounds over peripheral lung fields.
1) CHF at risk for MI. Chest pain=cardiac=PRIORITY! until ruled out. !LOOK @ ADDED SLIDE TO EXPLAIN THE OTHERS!!
The nurse is discussing infection control guidelines with a group of student nurses. Which information is most important for the nurse to include in the discussion? 1- "A gown should be worn when measuring the blood pressure of a client with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection." 2- "The door should be kept closed to the room of a client with a clostridium difficile (C. diff) infection." 3- "Disposable dishes should be provided for a client with a hepatitis B infection." 4- "A surgical mask should be worn when providing care for a client with pulmonary tuberculosis."
1) Contact precautions-- are used to minimize spread of pathogens that are acquired from direct or indirect contact, especially multidrug-resistant organisms such as MRSA/C-dif. Hep B--standard precautions Pulmonary tuberculosis-- airborne precautions
The nurse provides care for a client receiving external radiation to the chest wall. Which action by the nurse is best? 1- Perform a thorough assessment and ongoing monitoring of the client's skin. 2- Isolate the client from people with infections such as the cold virus. 3- Prevent the client from eating or drinking for 2 hours after radiation. 4- Dispose of the client's excretions in a specific lead-lined container.
1) External radiation is damaging to skin, like sunburns, & should be assessed carefully --not excreted in bodily fluids Isolate (2)-more for chemo pts
A client claims to feel ugly because of hair lost after receiving chemotherapy for breast cancer. Which statement does the nurse make to help the client cope with these feelings? 1- "Let's see how you look with a scarf or hat." 2- "Your hair will grow back after your treatments are over." 3- "Many women choose to shave their head when this starts to happen." 4- "Just think how much easier it will be to not have to do your hair every day."
1) The client has feelings of low self-esteem because of the hair loss. The nurse needs to make a statement that will help the client improve these feelings. Suggesting a scarf or hat is appropriate. It offers an immediate solution to a client. **Therapeutic Communication- addresses pt's feelings & gives solutions**
Add subPrior to the beginning of a site survey, the charge nurse advises the nurse to deny any knowledge of a recent sentinel event if asked by the surveyor. Which action will the nurse take? 1- Notify the unit manager. 2- Notify the medical director. 3- Tell the charge nurse about being uncomfortable lying to the surveyor. 4 -Tell the surveyor the nurse is not allowed to talk to them.
1) always follow the direct chain of command. Nurses have a legal, professional, & ethical obligation to tell the truth under any circumstances.
The nurse auscultates a client's bowel sounds during a comprehensive assessment. Which finding is most important for the nurse to report to the health care provider (HCP)? 1- Bruit over the aorta. 2- Irregular pattern of bowel sounds. 3- Continuous bowel sounds over the ileocecal valve. 4- Absence of bowel sounds for 60 seconds.
1) bruit over aorta indicates turbulence w/in major artery. HCP needs to be notified. *Bruits & vibration==Thrill --Bowel sounds silent for 3-5 minutes= abnormal
The nurse administers a unit of red blood cells to a client. The client reports sudden pain at the peripheral intravenous (IV) insertion site. The nurse documents edema at the site. Which action does the nurse take first? 1- Stop the infusion. 2- Flush the IV catheter with preservative-free normal saline solution. 3- Apply pressure to the site. 4- Elevate the extremity.
1)Stop immediately. NEVER flush or put pressure. Elevate extremity after caths removed to encourage lymphatic reabsorption of fluids.
The nurse provides care to a client diagnosed with acute pancreatitis. Which intervention will the nurse include in the client's care plan? (Select all that apply.) 1- Monitor for signs of hypocalcemia. 2- Observe for manifestations of respiratory infection. 3- Provide a diet low in carbohydrates. 4- Position side-lying with the head elevated 45 degrees. 5- Provide a diet high in fats
1,2,4 1) low calcium--> tetany 2) respiratory infection is common because retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. 4) side-lying position decreases tension, may help w/pain --Diet: high in carbs& restricted in fats
The nurse provides discharge instructions to an adult client hospitalized for pneumococcal pneumonia. Which instruction does the nurse include in the teaching plan? (Select all that apply.) 1- "Finish all of the antibiotics, even if you start to feel better." 2-"Continue doing your breathing exercises and using the spirometer." 3- "Report any cough or mucous production to your health care provider." 4- "Avoid large crowds because your immune system is weakened." 5- "Report any increase in shortness of breath to your health care provider."
1,2,4,5 --3- is expected outcome w/ resolving pneumonia --5-An increase in dyspnea, fever, chest pain, or chills, or the persistence of a productive cough, may indicate the infection is not resolving as anticipated (& antibiotic isnt working)
The nurse reviews care needed for a client recovering from surgery. Which task does the nurse delegate to nursing assistive personnel (NAP)? (Select all that apply.) 1- Apply antiembolic stockings. 2- Measure height and weight. 3- Instruct how to perform breathing exercises. 4- Use a bladder ultrasound to check for urinary retention. 5- Assist in removing a leg prosthesis.
1,2,5
The nurse provides care for a client in the end stages of dying. The family asks the nurse how they can provide comfort to the client in the client's final hours. Which intervention will the nurse recommend the family implement? (Select all that apply.) 1- Reading to the client. 2- Encouraging the intake of fluid. 3- Giving a gentle massage. 4- Holding the client's hand. 5- Talking to the client.
1,3,4,5 --2- is a normal part of dying & should not be forced
The nurse provides care for a 65-year-old client with no high-risk factors. The nurse evaluates the client's immunization status. Which of the client's immunizations should the nurse determine are current? (Select all that apply.) 1- Last tetanus booster at age 60. 2- Has not received the hepatitis A vaccine. 3- Received the herpes zoster vaccine at age 60. 4- Has not received the hepatitis B vaccine. 5- Receives a flu shot every year.
1,3,5 --tetanus booster every 10 yrs --hep A/B vaccine only if @ risk --over 60 get herpes zoster --flu shots, yearly, over 21
The nurse provides care to a client diagnosed with a clostridium difficile (C. diff) infection. Which precaution will the nurse take? (Select all that apply.) 1- Wear a protective gown when entering the client's room. 2- Put on a particulate respirator mask when administering medications to the client. 3- Wear gloves when feeding the client a meal. 4- Ask the client's visitors to wear a surgical mask when in the client's room. 5- Wear sterile gloves when removing the client's wound dressing.
1,3-- Contact precautions
A client, who takes medication for hypertension, develops a cough. Which medication will the nurse suspect as the cause for the cough? 1- Losartan. 2- Lisinopril. 3- Nifedipine. 4- Propranolol.
2) [ACE inhibitor]. one of the most common SE is non-productive cough --dry cough is SE of HTN -1-- H2 receptor blocker -3--CCB -4--Beta blocker
The nurse teaches a class about birth control. Which client statement about the use of a male condom requires follow-up by the nurse? 1- "Condoms are the only birth control method that prevents the spread of sexually transmitted infections." 2- "I will put the condom on before I have an erection to collect all sperm. 3- "I will leave a space at the tip for the condom to collect the ejaculate." 4- "I will hold the condom firmly at the base of the penis and withdraw the penis before the erection ends."
2) condom should be rolled onto an erect penis
The nurse observes a graduate nurse care for a client receiving continuous feedings via a nasogastric (NG) tube. Which action by the graduate nurse requires the nurse to intervene immediately? 1- Aspirates a small amount of the gastric contents prior to instilling the tube feeding. 2- Administers two medications together after instilling 5 mL of water to flush the tube. 3- Maintains the head of the bed elevated at 45 degrees. 4- Checks for gastric residual every 4 to 6 hours and measures the gastric content.
2) each med is followed w/water before next med is given. to prevent clumping or interaction, meds are not combined. **PROPER INTERVENTIONS:** --obtaining/measure GI contents --HOB at least 30 degrees --check gastric residual every 4-6 Hrs
The nurse provides care to a newly admitted client. Which action is the best example of a culturally appropriate nursing intervention? 1- Insist that family members provide most of the client's personal care. 2- Ask permission before touching the client during the physical assessment. 3- Maintain a personal space of at least 3 feet when assessing the client. 4- Consider the client's ethnicity as the most important factor in planning care.
2) many cultures find it disrespectful to touch w/out asking permission
The nurse plans to delegate a task to a new nursing assistive personnel (NAP). The nurse discovers that the NAP has never performed the task and changes the assignment. Which right of delegation does the nurse follow in this scenario? 1- Right supervision. 2- Right person. 3- Right circumstance. 4- Right direction.
2) right person--choosing correct personnel to complete task. --right supervision-- providing appropriate monitoring, intervention, & follow-up. --right circumstance-- using appropriate pt&setting to determine if task appropriate. --right direction-- giving clear, concise description of task
The nurse delegates care of a stable client to nursing assistive personnel (NAP). Which right of delegation is the nurse following? 1- Right supervision. 2- Right circumstance. 3- Right person. 4- Right direction/communication.
2) since pt's stable --theres not enough info or a task given for the others--
The nurse reviews ways to prevent client medication errors with a student nurse. Which response by the student indicates that additional teaching is necessary? (Select all that apply.) 1- " I will prepare medications for each client separately." 2- " I should compare the medication administration record against the drug label at least two times before giving the medication to a client." 3- " I should trust the health care provider and not question a medication or dose ordered." 4- " I will document all medications as soon as I give them." 5- " I should use at least two patient identifiers whenever administering medications."
2,3 --prepare meds separately --check minimum of 3 times --question any med order --documented as soon as provided to pt --@ least 2 pt identifies
The nurse reviews a list of client activities. Which activity does the nurse delegate to nursing assistive personnel (NAP)? (Select all that apply.) 1- Show a client how to self-administer a small volume enema. 2- Measure the vital signs of a client on contact precautions. 3- Monitor a client whose blood transfusion started 5 minutes ago. 4- Reinforce a pressure injury dressing. 5- Assist a client with poor vision to use the bedside commode.
2,5
The nurse provides care for a client with face, ear, and neck burns. Which is the best position for the client? 1- Prone with a small pillow under the head. 2- Supine with padding on the affected side. 3- Supine without pillows or padding. 4- Prone without extra padding around the head.
3) A supine position minimizes pressure and irritation to the burned areas, but burned areas may stick to pillows or padding. Pillows may cause contractures in clients with neck burns. **NEVER use pillows/padding* --ALWAYS REMEMBER: prone = tummy supine = back
The nurse provides care for an adolescent client who is diagnosed with meningitis but is otherwise previously healthy. The client is prescribed intravenous (IV) and oral fluids. The nurse closely monitors the client's fluid intake. Which serious complication does the nurse monitor this client for based on the current data? 1- Heart failure. 2- Hypovolemic shock. 3- Cerebral edema. 4- Pulmonary edema.
3) Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. **any trauma &/ surgery to brain puts pt @ risk for increased ICP* Hypovolemia (2) occurs as result of FVD, not FVO
The nurse provides care for a client who has a body mass index of 16.2. Which health problem will the nurse identify as being most affected by this assessment finding? 1- Seasonal allergies. 2- Rheumatoid arthritis. 3- Sacral pressure injury. 4- Elevated blood pressure.
3) Being underweight could indicate a lack of protein, vitamins, and calories, which would negatively impact wound healing. --being underweight might be helpful w/ RA & elevated BP
A client experiences a fever, headache, photophobia, and neck stiffness. Which transmission-based precaution will the nurse implement for this client? 1- Contact. 2- Airborne. 3- Droplet. 4- Standard.
3) Droplet **fever, headache, photophobia, and neck stiffness are HALLMARK signs)
The nurse provides care for a client diagnosed with human immunodeficiency virus (HIV) infection. The client receives epoetin alfa for zidovudine-induced anemia. The nurse is most concerned about which of the laboratory test results? 1- Alanine aminotransferase (ALT) 42 units/L (0.7 μkat/L). 2- Aspartate aminotransferase (AST) 36 units/L (0.6 μkat/L). 3- Hemoglobin 12.8 mg/dL (128 g/L). 4- Creatinine level 1.2 mg/dL (106.08 μmol/L).
3) Epoetin should not be administered with a Hgb values of 12 mg/dL (120 g/L) or above because of the increased risk for MI & stroke. --ALT&AST, used to detect liver damage, should monitor if getting epoetin. **NORMAL RANGES** -ALT [7-55] -AST [8-48] -Hgb [12-18] -Creatinine [0.5-1.2]
The nurse assesses jugular vein distention (JVD) in a client experiencing shortness of breath and chest pain. Which health problem will the nurse identify as causing the JVD? 1- Dehydration. 2- Neck tumor. 3- Fluid overload. 4- Electrolyte imbalance.
3) Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the veins to distend, which can be seen most obviously in the neck veins. --other cause of JVD: hypervolemia
The nurse provides care for a client who died from unexplained causes in the hospital. The client has many tubes and drains in place. An autopsy is planned. The nurse prepares for postmortem care of the body. Which action by the nurse is appropriate when managing the tubes prior to the autopsy? 1- Remove all tubes and catheters and send to autopsy with the body. 2- Remove all tubes and catheters and place them in biohazardous waste. 3- Leave all tubes and drains in place in the client's body. 4- Leave intravenous tubes in place but remove drains.
3) If an autopsy is to be performed, any tubes and drains will be left in place to be assessed and cultured and then removed by the medical examiner/ coroner.
A client with injuries from a motor vehicle accident is unconscious from a severe head injury. The client's identity is unknown, but the client needs emergency surgery to stabilize fractures. Which action is the best for the nurse to take when obtaining informed consent for the operative procedure? 1- Ask the emergency services team to sign the informed consent. 2- Obtain an emergency court order for the surgical procedure. 3- Transport the client to the operating room for surgery. 4- Ask the police to identify the client and locate the family.
3) Informed consent of adult generally not needed when emergency is present. -->delaying Tx.-> injury or death
The nurse provides care for a client with type 1 diabetes mellitus who receives insulin. Which laboratory test is important for the nurse to monitor? 1- Serum amylase. 2- Serum calcium 3- Serum potassium 4- Serum sodium.
3) Insulin causes potassium to move into the cells(intravascular) & may cause hypokalemia. **RATIONALES:** --1-is a sensitive test for pancreatitis. However, it is non-specific because other non-pancreatic can cause altered levels. Amylase aids in breakdown of simple carbohydrates in the intestines. --2-test is used to evaluate thyroid issues (parathyroid function) & calcium metabolism. --4-Sodium, the major cation in the extracellular space, determines extracellular osmolarity. Serum sodium levels are a balance between dietary intake and renal excretion.
The nurse provides care for a client diagnosed with a myocardial infarction who is prescribed non-enteric-coated aspirin. Which action does the nurse take in this situation? 1- Give the aspirin with water via a nasogastric (NG) tube. 2- Request a blood type and cross-match for transfusion. 3- Determine if there is a history of peptic ulcer disease. 4- Obtain a 12-lead electrocardiogram (ECG) prior to aspirin administration.
3) PUD is contraindication for non-enteric-coated aspirin-> can cause bleeding **PUD no aspirin & NSAIDs** Enteric-coated aspirin cannot be crushed
The nurse develops a dietary teaching plan for a pregnant client. Which information will the nurse include? 1- Protein requirements will triple. 2- The need for calories will increase by 1200 kcal/day. 3- There is an increased need for iron. 4- Sodium needs will decrease.
3) Pregnant pt requires 27-30 mg/day of iron, which is hard to get w/ just diet. may prescribe iron supplements starting 2nd trimester. (iron SE: #1 black tarry stool #2 constipation) **other recommendations** --added PROTEIN (60g/day) for metabolism and supports growth and repair of maternal and fetal tissues. --additional caloric needs: 2nd trimester(300-340/day) 3rd trimester(462/day) --need for Na+ increases slightly
The nurse provides care for a client experiencing status epilepticus. Which action is most appropriate for the nurse to take? 1- Place a tongue blade in the client's mouth. 2- Prevent the client from flailing the arms. 3- Remove all pillows and raise the bed rails. 4- Maintain the client's head in a midline position.
3) Removing pillows and raising bed rails will help prevent the client from falling out of the bed, smothering, or sustaining additional injuries. Padding should be in place at the head of the bed and on the rails to prevent further injury. Position pt's head so that tongue & secretions can fall forward during seizure activity.
The nurse administers an enema to a client with an impaction. As the nurse begins the procedure, the client's heart rate goes from 70 to 40 beats per minute, and the client reports nausea. Which action does the nurse take first? 1- Remove the tube from the rectum. 2- Slow down the enema rate. 3- Stop the enema. 4- Place the client in a supine position.
3) STOP cause of vagel response --HR<60= bradycardia
The nurse screens a client for sleep apnea. Which question is most important for the nurse to ask the client? 1- Do you have difficulty staying asleep? 2- What time do you wake up in the morning? 3- Has anyone told you that you snore loudly? 4- Do you fall asleep at the wrong times?
3) Snoring is associated with obstructive sleep apnea. --1&2-are r/t insomnia screening --4- is r/t narcolepsy screening
The nurse prepares a school-age client diagnosed with a fractured humerus to be discharged home with the parents. Which observation requires the nurse to make a referral to home health? 1- The child does not play with toys during the hospital stay. 2- One parent is working the night shift. 3- The mother has bruises around the wrists. 4- The father is anxious to leave the hospital.
3) Violence in family is a risk factor for child abuse. Follow-up is needed!
The nurse provides care to a client diagnosed with asthma who suddenly develops wheezing. Which class of medications does the nurse give first? 1- Methylxanthines. 2- Corticosteroids. 3- ß2-adrenergic agonist. 4- Anticholinergics.
3) are known as rescue meds **RATIONALES** --1-is a sustained release --2-takes 1-2 weeks->max effect --4-onset of action is slower than (3)
The nurse provides care to a client with severe hypothermia. Which assessment will the nurse perform first? 1- Determine presence of shivering. 2- Assess the skin for mottling. 3- Examine cardiac monitor for dysrhythmias. 4- Review laboratory values for a low calcium level.
3) b/c risk for ventricular dysrhythmia. --shivering & mottling skin may occur w/ hypothermia, but isnt most important concern--
The nurse provides care for a client who has mild pre-eclampsia. Which evaluation data indicate that the nursing interventions to help control mild pre-eclampsia have been effective? 1- The client's blood pressure is 145/95 mm Hg. 2- Edema is noticed around the client's eyes. 3- The client's patella reflexes are 2+. 4- The client's urine protein is 3+.
3) indications controlled pre-eclampsia, IV is working
The nurse provides for a client who is being evaluated for possible thrombolytic therapy. Which lab value would cause the nurse the most concern? 1- Blood glucose of 160 mg/dL (8.88 mmol/L). 2- International normalized ratio (INR) of 1.2. 3- Platelets of 90,000/mm3 (90 X 109/L). 4- Hemoglobin of 9 g/dL (90 g/L).
3) low platelet count--> higher risk for bleeding **NORMAL RANGES** -blood glucose [70-100] -INR [2-3] -platelets [150,000-400,000] -Hgb [12-18]
The nurse provides care for a client with a nasogastric (NG) tube attached to wall suction. The nurse notes large amounts of gastric secretions in the suction canister. Which arterial blood gas (ABG) result does the nurse expect to observe? 1- PaCO2 50 mmHg, pH 7.20. 2- PaCO2 40 mmHg, pH 7.40. 3- HCO3 28 mEq/L (28 mmol/L), pH 7.50. 4- HCO3 20 mEq/L (20 mmol/L), pH 7.30.
3) metabolic alkalosis --causes include vomiting, gastric suction with loss of hydrogen and chloride ions, longterm diuretic therapy, significant potassium depletion, cystic fibrosis, chronic ingestion of milk and calcium carbonate, and Cushing syndrome. **WHAT THE OTHERS =** --1-resp. acidosis --2-normal results --4-metabolic acidosis
The nurse provides care for a client who had an open-reduction internal fixation (ORIF) for a fractured tibia. The nurse is unable to palpate the client's pedal pulse. Which action should the nurse take next? 1- Assess the client's numeric pain level. 2- Inspect the lower extremity for redness. 3- Check for acute compartment syndrome. 4- Elevate the affected leg above the heart.
3) non-palpable pulse on affected side may indicate acute compartment syndrome
The supervisor observes the nurse delegate a dressing change on a client with a fever, positive blood cultures, and a blood pressure of 86/42 mm Hg to the LPN/LVN. Which action will the supervisor take next? 1- Encourage the LPN/LVN to complete the dressing change as assigned. 2- Assign another LPN/LVN who is more comfortable with dressings to complete the dressing change. 3- Discuss with the nurse that the dressing change should not be delegated to the LPN/LVN. 4- Ensure that the nurse follows up with the LPN/LVN after the dressing change is complete.
3) pt is unstable, nurse should complete dressing change
The nurse observes a student assess an older client with dehydration. Which assessment requires the nurse to intervene? 1- Measures orthostatic blood pressure. 2- Reviews serial daily weight readings. 3- Checks skin turgor on the hand. 4- Reviews serum sodium values.
3)in older pts, skin turgor is best assessed by pinching skin over sternum. -a loss of skin elasticity on hands provides inaccurate assessment. **RATIONALES** (why right) --1-indicates inadequate fluid volume --2-assess hydration --4-provides info about hemoconcentration
A client is scheduled to receive an intravenous antibiotic at 1300 and 2100 hours. The client is prescribed peak and trough blood levels. At which time does the nurse schedule the trough level to be drawn? 1- 1330 2- 1530 3- 1830 4- 2030
4) Trough is drawn 30 minutes before next dose
The nurse reviews medications prescribed for a client with a gastric feeding tube. For which medication will the nurse need to contact the health care provider? 1- Potassium chloride oral solution. 2- Phenytoin oral elixir. 3- Enalapril tablet. 4- Aspirin E.
4) enteric-coated meds cannot be crushed. --1&2- are oral & less likely to block G-tube --3- can be crushed & diluted
The nurse provides care for a client who reports a sexual and physical assault by a friend. Which action should the nurse take first? 1- Place a referral for a psychiatric provider consult. 2- Call the hospital chaplain to offer prayer and support. 3- Clean the client's wounds and provide a clean gown. 4- Stay with the client during the physical examination.
4) nurse provides consistent emotional & physical support, especially during physical exam
Nursing Process: *must know.. its key**
Assessment Diagnosis Plan & Implement Evaluate
S&S for compartment syndrome--
Numbness & tingling Cap refill & peripheral pulses Loss of sensation Skin is warm &/cool --Nurse should preform neurovascular assessments
DRAG & DROP EX. ?...... Pt getting RBC reports sudden pain @ IV site. Nurses notes edema @ site. What are next steps?? (in order)
Stop infusion Aspirate Remove cannula Raise extremity
