Exam 7
depression; second hospitalization in the past year; tranylcypromine sulfate is prescribed because the client did not respond positively to a tricyclic antidepressant; if the clients diet includes foods with tyramine what is the possible reaction
hypertensive crisis
neonate born by cesarean at 42 wks, weighing 4.1 kg (9lb) with Apgar of 8 at 1 min and 9 at 5 min after birth; develops increased respiratory rate and tremors of hands and feet 2 hrs postpartum; priority problem
hypoglycemia
primiparous client who is breastfeeding on how to prevent nipple soreness during feedings; nurse determines that client needs further instruction when states
i should position the baby the same way for each feeding
borderline personality disorder; self inflicted cuts on the arms; risk for suicide; ask first
if the client has a suicide plan
myasthenia gravis receiving anticholinesterase drug therapy; distinguish cholinergic crisis from myasthenic crisis; what symptom not present in cholinergic crisis
improved muscle strength after IV admin for edrophonium chloride
plan of care for client with t-tube; intervention to include
inspect skin around the t-tube daily for irritation
child; sodium level of 118; nursing action priority
instituting seizure precaution
4 month old; what finding needs immediate action
intercostal retractions on inspiration
ischemic stroke, aphasic for 3 hrs and has BP of 220/120; which prescription by HCP should the nurse question
labetalol drip to keep the BP <120/80
initial home visit to new client beginning home IV therapy; group of people begin following and jeering at the nurse; best response
leave the area in the car, if nurse can get to it safely
assessing thoracotomy incisional area from which chest tube exits; feels crackling sensation under fingertips along the entire incision; do next
mark the area with a skin pencil at the outer periphery of the crackling
psych unit; new grad approaches the charge nurse and says "I'm having a hard time taking care of mentally ill people, what can I do to handle this stress?" best response
maybe we could schedule a time to discuss this further
appropriate identifiers to use when providing care or administering meds or treatments
medical record number name band
statement by client who is taking misoprostol indicates therapeutic outcome of therapy
my stomach feels better
finding requires further intervention with mother who is breastfeeding
neonates lips smack
postpartum; assessment should be accomplished first
newly admitted postpartum client receiving mag sulfate at 3 g an hr initiated 10 hrs ago for preeclampsia; infant hasn't eaten in 4 hrs
NA escorts client in early stages of labor to bathroom; nurse detects strange odor coming from bathroom and suspects client has been smoking marijuana; nurse do next
notify physician and security immediately
ped. nurse to work temp in the ICU; never worked in ICU; action should nurse take
notify supervisor that the ped nurse feels unqualified and untrained for the assignment
infant diagnosed with neonatal abstinence syndrome and receiving weaning doses of methadone; measure most needed to ensure safety
obtain independent double check of medication from another nurse
information to include about hypoglycemia; newly diagnosed type 2 diabetes
regular meals and a bedtime snack will decrease the incidence of hypoglycemia symptoms of hypoglycemia can include irritability, hunger, shaking, sweating carbohydrate food source should be available during strenuous exercise alcohol consumption can increase the incidence of hypoglycemia
interpreter to communicate with a mother of child who does not speak english; paged interpreter several times; do next
reschedule the infants appointment for later in the week
visit family 2 days after release from hospital; hears shouting and swearing between mother and father and several loud crashes as she is about to knock on the door; action is appropriate
return to the car and call the police
chronic back pain admitted to floor and is receiving multiple pain meds and antidepressant for pain control; PT for ambulation and strengthening, MRI of lumbar spine, CT of abdomen; how to schedule therapy and tests
schedule MRI of lumbar spine first, then PT consult, then CT scan
evaluating infection control practices performed by spouse on loved one; methicillin resistant staph (MRSA) in right leg wound; actions indicate further teaching
spouse places soiled dressing supplies in the kitchen garbage can sheets with wound drainage are washed in lukewarm water
cranial nerve XII (hypoglossal) assess ability to
stick out tongue and move it rapidly from side to side and in and out
19 yr old with mild concussion after slipping in school parking lot; no loss of consciousness, no neurological deficits, CT scan normal, reports 5/10 headache; acetaminophen PO prescribed when offered acetaminophen the parents tell the nurse that they would like their child to have something stronger; best response
opioids are avoided following a head injury because they may hide a deteriorating condition
24 yr old female; active TB; receiving rifampin 600 mg daily; should avoid because of significant interaction with rifampin
oral contraceptives
voiding sm. amts of urine every 30-60 min; what should the nurse do first
palpate for distended bladder
child admitted to ER with suspected ruptured appendix; what to expect for immediate treatment
prepare child for emergency surgery
chronic renal failure has hemoglobin of 10.2 and hematocrit of 40%; primary assessment
presence of fatigue and weakness
birth plan; specific choices and wishes for the birth of their first baby; why is the nurse asking questions about the plan
recognizing the family as active participants in their care
administer verapamil 0.3 mg/kg IV once a day to a pediatric client who weighs 20 lb (9.07 kg); dose on hand is 5mg/2mL; how many mL?
0.3/5=0.06 x 9.07 = 0.5442 x 2 = 1.0884 = 1.1
cirrhosis; ascites receives 100 mL of 25% serum albumin IV; finding best indicate albumin is having desired effect
reduced ascites
old adult diagnosed with end stage renal disease; fluid volume excess; intervention priority
assess the lung sounds
leukemia who developed thrombocytopenia; assess most common sites for bleeding; which is not a common site
biliary system
nitrazine paper to determine whether pregnant client's membranes have ruptured; if they have the paper will turn what color
blue
circulating nurse for a surgical abortion; nurse has religious objection and wishes to refuse; what should the nurse manager of the OR do
change the assignment without comment
medication administration rights
client dose medication time route
four clients on ortho unit; which should nurse see first
client scheduled for a total hip replacement in 1 hr
triage nurse initial assessment; who to see first
client with uterine contractions who reports they are getting stronger and closer now
admitted with extremely prolonged bleeding time; powerful odor of garlic on the breath, person, clothing; important to assess
client's dietary habits
what time of day should nurse encourage client with parkinson's disease to schedule most demanding physical activities to min effects of hypokinesia
coincide with the peak action of drug therapy
d/c plan for client recovering from total laryngectomy; expected outcome
communicate feelings about body image changes
effectiveness of antipsychotic meds; severe alzheimer's; changes indicate improvement resulting from meds
decrease in verbal and physical aggression
planning care; following repair of an aortic aneurysm; priority assessment
decreased urinary output
type 1 diabetes admitted to ED; respiratory pattern requires immediate action
deep, rapid respirations with long expirations
client on second course of antibiotics to eliminate osteomyelitis; instruct on which aspect of daily care
diet high in protein and nutrients
sub-q injection; after releasing the skin, prior to injecting the med, the needle pulls out of the skin, the nurse should
discard the needle, attach a new need to the syringe and administer the med
cirrhosis; hospice care; nutrition; priority intervention
discuss meals that include low fat, high carb content
end stage heart failure does not want to be resuscitated; HCP written DNR on record; client had cardiac arrest and wife tells the nurse she wants the client to be resuscitated and asks the nurse to do something; what do you do
discuss the DNR prescription with the wife
elderly client; redness in sacral region; small breaks in skin surface; tender and lost skin when NA on previous shift moved client; nurse do first
document the findings
intervention for a child who is receiving chemotherapy and allopurinol
encourage a high fluid diet
ED; right sided dull abdominal and flank pain, nausea, vomiting; temp 101.2, pain 10/10, rebound tenderness; orders VS q 30 min, CBC, morphine 2 mg IM q4h, reg. diet, enemas until clear; what orders should nurse question
enemas until clear regular diet
outbreak of influenza among the nursing staff the hospital is very short staffed; prioritize client needs by which strategy
ensuring that clients receive medications but omitting full bathing when possible
labor and birth area receives telephone call from ED; multigravid in active labor, no prenatal care, "I think the baby is coming...help!"; fetal skull crowning; obtain which information first
estimated date of birth
preop teaching plan for a 14 mo old with undescended testis who is scheduled for surgery; method most appropriate
explain to the parents how the defect will be corrected
prenatal visit; fundal height 19 cm.; indicates that the fetus has reached approx. what gestational age
19 weeks
hypothyroidism; nurse should ask about which s/s
fatigue
labor and birth unit transfers primiparous client and term neonate to mother baby unit 2 hrs after vaginal birth; priority for nurse to report to the nurse receiving the client
firm fundus when gentle massage is used
school-aged child received burns over 60% of body; needs 2,000mL of IV fluid over the next 8 hours. what rate for the pump?
2000/8= 250
child with osteomyelitis is to receive nafcillin IV every 6 hrs; before admin. the nurse calculates appropriate dosage; recommended dosage is 50-100 mg/kg; child weighs 22 lb (10kg); which dosage is acceptable
250 mg every 6 hrs
infant weighs 17.6 lb (8kg) is received ampicillin 25 mg/kg IV q6h; how many mg should the nurse administer per dose
25x8=200
lung cancer being cared for by wife at home; pain increasing in severity; teaching effective when wife uses which pain relief strategies
gives husband long acting or sustained release oral pain medication regularly around the clock uses immediate release medication (oxycodone) for breakthrough pain uses music for distraction; heat and cold in combo with medications has husband use pain rating scale to measure effectiveness at reaching pain goal
NG tube inserted; when inserting the tube the nurse should
have client flex the head when the tube is above the oropharynx
home care nurse; colostomy; changing appliance; next door neighbor wants to visit; intervention by nurse appropriate
have neighbor wait in the next room until the appliance is changed ask the neighbor to come back in 20 min
"I think my baby likes to hear me talk to him"; neonates and stimulation with sound; means to elicit best response
high pitched speech with tonal variations
instruct parents about physical signs to look for in their child suspected of using cocaine; what finding is consistent
his pupils would be large
infant cardiac arrest; resuscitation; team notes critical supplies are missing because the cart was not restocked properly by the nurses; baby sustains brain damage as a result of delays; how does nurse manager address this situation
hold the nurses responsible because hospital procedure was not followed
pulmonary fibrosis; home oxygen therapy; health team member to evaluate knowledge of use
home health nurse
5 yr old; 44lb (20 kg); given penicillin V suspension for a throat culture positive for strep; dose is 40 mg/kg/day, divided into 2 doses; pharm supplies penicillin V in a concentration of 250 mg/5mL; nurse should administer how many mL for each dose
40/250 = 0.16 x 20 = 3.2 x 5 = 16/2 = 8
client instruction about lorazepam; understanding
I can develop a dependency on this medication
correct positioning of the leg and hip following hip replacement surgery; understanding
I should avoid bending over to tie my shoes
teaching female; hx of multiple UTIs about prevention; understands teaching
I should take at least 1,000 mg of vitamin C each day
UAP on how to correctly position client who has had recent total hip replacement; what position to place affected leg when lying on nonoperative side
abduction and extension
elderly couple; relocated; unable to obtain shared room; sexual activity between the couple ceased many years ago; nurse best respond to assertion
actually its not true that older people always stop having sexual activity when they get older
teaching family of older infant; spica cast applied for developmental dysplasia of hip; info when describing abduction stabilizer bar
adds strength to the cast
infection prevention and control program; assessment of infection control practices; client with decreased WBC; most important
adhering diligently to aseptic technique
midazolam 2 mg IV as sedation before bronchoscopy; five minutes after, their respiratory rate drops to 4 breaths/min; most appropriate action
administer flumazenil
client receiving heparin for venous thromboembolism; which finding should concern nurse
after sneezing the client develops a nose bleed
left fractured tibia; how to walk with crutches; instruction
all weight should be on the hands
drugs may be abused because of tolerance and physiologic dependence
alprazolam and phenobarbital
health assessment of client who is a primigravida in prenatal clinic; presumptive signs of pregnancy should the nurse expect to assess
amenorrhea and quickening
two family members visiting father who is experiencing acute delirium; upset their father is disorientated; he knows who we are but that's about it, we don't know what to say to him; nurse tell the family
answer his questions simply, honestly, slowly, clearly occasionally remind him of the time, day, and place when he doesn't remember include him in your conversation instead of talking about him while he's present
cardiac cath; femoral dressing has bright bloody drainage; do first
apply pressure to the site
gestational diabetes during pregnancy has just been admitted in the labor and delivery unit; priority nursing action
ask client about her most recent blood glucose levels
allergic to penicillin has prescription to receive cefazolin; what to do first
ask if client has taken cefazolin before without an adverse response
new nurse on orientation prepares to administer vitamin K to neonate; draws up 1 mg and prepares to administer a sub-q injection in left lateral anterior thigh; action by preceptor is best
stop the nurse and ask that the injection techniques be reevaluated
managing care for client in disaster shelter who broke a femur and has lost her family home in a hurricane; measures should the nurse take
supervise the care provided to the client during crisis act as a client advocate for the client in crisis discuss interdisciplinary team available resources for client obtain accurate ID including name, age, address, contact info, and names of relatives
exacerbation of ulcerative colitis; bedrest with bathroom privileges; indicate that bed rest has had desired outcome
the client has slowed intestinal peristalsis
parkinson disease prescribed fluoxetine for depression; HCP to clarify prescription upon discovering what information
the client is currently prescribed selegiline
client with HIV/AIDS reports to the nurse a loss of 15 lbs in the past month and asks do you think I could use marijuana to help get my appetite back? best response
there are medications in addition to medical marijuana that can stimulate your appetite and help you regain weight
maintain medical record for client; which is a use of the medical record
to investigate the quality of care in the agency
bed rest client after car accident; action to prevent complications of immobility
turning the client every 2 hours and providing a low-air-loss mattress
IV mag sulfate for severe preeclampsia; prioritizes what assessment finding as requiring immediate notification of provider
urine output 20mL/hr
standard precautions when caring for client with HIV; take what action when applying standard precautions
wearing gloves for providing mouth care
IV chemo to client with cancer; precautions necessary when administering chemo
wearing gloves when handling urine disposing of chemo waste as hazardous material wearing long sleeved gown when administering chemo
probe should the nurse use to encourage evaluation of his or her own behavior
what did you do differently with your coworker this time
teaching plan for client who uses a walker; principle to consider
when max support is required, walker should be moved ahead approx. 6 inches (15 cm) while both legs support the clients weight
under which circumstance may a nurse communicate medical info without the clients consent
when treating the client with a STD
treated for DVT in left femoral artery; HCP prescribed 60 mg of enoxaparin sub-q; before admin nurse checks labs; what should nurse do
withhold dose of med and contact HCP
