Fall Week 11 Clinical ADN 2

A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

"Do you have difficulty staying awake when you are driving?"

A nurse is caring for a client is who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)

24

A nurse is assessing a client who has carpal tunnel syndrome. The nurse should expect which of the following findings?

Positive Phalen's sign

A nurse is teaching a client about the uses of aloe vera. Which of the following information should the nurse include in the teaching?

"Aloe vera can act as a laxative."

A nurse is preparing to administer hydrocortisone sodium succinate 250 mg via IV bolus every 6 hr. Available is hydrocortisone sodium succinate 1000 mg/8 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2

A nurse is caring for a client who has diabetes and a new prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe?

42 units

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

Administer antibiotics to the client.

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?

Apply hydrating lotions.

A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess?

Aspartate aminotransferase (AST)

A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

Auscultate bowel sounds.

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?

Barrel

A nurse is caring for a client who is breastfeeding and states that her nipples are sore. Which of the following interventions should the nurse suggest?

Change the newborn's position on the nipples with each feeding.

A nurse is assessing for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

Decrease in systolic pressure by more than 10 mm Hg during inspiration

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)

Difficulty relaxing Rule-conscious behavior Perfectionist behavior

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?

Difficulty starting the flow of urine

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

Difficulty swallowing

A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.)

Don a mask, gloves, and gown. Restrict visitors who have active infections. Instruct the client to eat cooked foods only.

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?

Exercise

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Hypotension Absence of bowel sounds Weakened gag reflex

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

Increase dietary intake of raw vegetables.

A charge nurse is teaching a group of nurses about clients who report using garlic, ginger, and ginkgo biloba. The charge nurse should identify which of the following as an adverse effect of these supplements?

Increased effects of oral anticoagulants

A nurse is caring for a client who has just begun therapy with alprazolam to treat anxiety. The nurse should monitor the client for which of the following adverse effects of this medication?

Insomnia

A nurse is educating a client who is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages should the nurse recommend?

Lemon-lime soda

A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take?

Notify the provider of the situation.

A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse's priority?

Notify the surgeon.

A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestation should the nurse expect?

Pain worsens with activity

A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?

Pale pink

A nurse is assessing a client 15 min after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

Respiratory rate 8/min

A nurse in the emergency department is assessing a client who has experienced intimate partner abuse. The nurse should monitor the client for which of the following behavioral findings?

Self-esteem disturbance

While assessing a client's dressing, a nurse notes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous

A nurse is reviewing a client's admission record. The nurse notes that there are prescriptions for several medications. Which of the following factors should the nurse recognize is of primary consideration when determining the schedule of administration?

Specific characteristics of the medications

A nurse is planning care for a client who is postoperative following a liver transplant and weighs 65 kg. Which of the following actions should the nurse plan to take?

Stress the importance of safe food-handling practices.

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?

The client will walk for 30 min 5 days a week.

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet?

"I eat two eggs for breakfast each morning."

A nurse is providing teaching to a client who has gout and a new prescription for allopurinol. Which of the following statements by the client indicates an understanding of the teaching?

"I need to increase my fluid intake while taking this medication."

A nurse is teaching a client who has vulvodynia about self-care measures to alleviate symptoms. Which statement by the client indicates an understanding of the teaching?

"I should avoid the use of any lubricants."

A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?

"I should expect dark, tarry stools."

A nurse is evaluating teaching with a client who is receiving continuous subcutaneous insulin via an external insulin pump. Which of the following statements by the client indicates a need for further teaching?

"I will use insulin glargine in my insulin pump."

A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next day, the nurse explains the situation and one of the parents says, "She never wets the bed at home. I am so embarrassed." Which of the following responses should the nurse make?

"It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better."

A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse?

"The teacher says my child has to squint to see the board."

A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the following replies by the nurse requires intervention?

"There is no gate for me to open."

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?

"Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."

A nurse is providing discharge teaching to a client following an abdominal hysterectomy. Which of the following information should the nurse include in the teaching?

"You should refrain from sexual intercourse for at least 4 weeks."

A nurse is preparing to administer heparin 3,000 units by IV bolus. Available is heparin injection 5,000 units/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.6

A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

300

A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients?

A child who has a new diagnosis of type 1 diabetes mellitus

A nurse is assessing a client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should identify which of the following as a cutaneous manifestation of SLE?

Butterfly rash on face

A nurse is assessing a client who has diabetes mellitus. Which of the following findings is a manifestation of hypoglycemia?

Cool, clammy skin

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

Repeat the order back to the provider. Question any part of the order that is unclear or inappropriate. Transcribe the order into the client's health record.

A nurse manager is observing an AP applying wrist restraints for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure?

The padding of the restraints is against the client's bony prominences.