final

Which is the best resource for the nurse who has a question about the process and implementation of intravenous therapy for a specific patient?

Institution policy

The nurse is caring for a patient with gastritis. Which intervention should the nurse implement for a patient with acute gastritis?

Monitor patient for bloody diarrhea

The nurse is caring for a patient who is about to undergo a mastectomy. The nurse notes that the patient has not signed the consent. The patient tells the nurse, "The doctor didn't explain the risks of the surgery to me." Which action should the nurse take?

Notify the surgeon and inform him or her the patient has not signed the form and does not understand the surgery.

A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important?

Put on gloves prior to collecting the sample.

The nurse is monitoring a patient and finds a bulging area in the patients groin. Which additional finding should cause the nurse the most concern?

The patient develops pain at the site and vomiting.

The nurse is preparing to administer a hypertonic solution to a patient with hypovolemia. Which fluids are considered to be hypertonic? (Select all that apply)

-Albumin -5% dextrose in 0.9% sodium chloride (D5NS)

The nurse has reinforced preoperative teaching with a patient about coughing and deep-breathing techniques. Which patient statements indicate a correct understanding of the teaching? (Select all that apply.)

-Coughing and deep breathing helps prevent respiratory problems -I should cough and deep breath 10 times every hour while awake

The nurse is caring for a patient with a nontunneled central venous access device who is receiving a continuous IV infusion and develops sudden dyspnea, chest pain, and change in mental status. Which actions should the nurse take? (Select all that apply.)

-Montior vital signs -Administer oxygen as ordered -Notify the health care provider (HCP

The LPN/LVN has a patient receiving a medication IV push. What should the licensed practical nurse do prior to administering the medication? (Select all that apply.)

-Observe the patient for desired or adverse effects of the medication after administration -Inform the RN of the medication administration

A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B?

A 20-year-old college student who has had several sexual partners

Which patient would benefit most from hypodermoclysis?

A 5-year-old patient with poor venous access receiving normal saline

The nurse is preparing to provide care for a client diagnosed with peptic ulcer disease. Which pathophysiological characteristic will the nurse correctly associate with the patient's diagnosis?

A common cause is an infection from Helicobacter pylori.

For which patient would a port be most beneficial?

A patient receiving chemotherapy

An older client has gastric cancer and is scheduled to have a partial gastrectomy. The family does not want the client told about her diagnosis. What action by the nurse is best?

Assess family concerns and fear.

The nurse is reviewing laboratory values for a patient who will undergo surgery. Which value requires notification of the surgeon?

Glucose of 383 mg/dL

Identify the surgical intervention:

Billroth II

The nurse is providing care for a patient who reports nausea following chemotherapy. Which nursing intervention is unlikely to effectively manage the patient's nausea?

Bring the patient a small, bland meal to ease any hunger.

The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?

Check for kinking of the tubing or a closed clamp

The nurse is caring for a patient who is receiving parenteral nutrition (PN). The patient develops increased thirst, blurred vision, and a headache. Which action should the nurse take?

Check the patient's glucose level

A patient recovering from an abdominal hysterectomy is experiencing abdominal gas pain. Which action should the nurse take?

Help the patient ambulate

The nurse is preparing to give discharge education to a patient who was recently admitted for an asthma attack. Which of the following topics should the nurse plan to discuss first ?

Determine the patients perception of the disease and what may have triggered the current attack

The licensed practical nurse/licensed vocational nurse (LPN/LVN) is assessing a patient receiving IV therapy and notes crackles upon auscultation of lung sounds and puffy eyelids. Which action should the nurse take?

Stop IV infusion and notify the registered nurse (RN) immediately

Upon entering a patient's room, the licensed practical nurse (LPN) notes a white precipitate forming in the IV tubing at the site of a piggybacked antibiotic. What should the nurse do first?

Stop the infusion

The nurse is caring for a patient after ambulatory surgery. Which oxygen saturation level should the nurse use as evidence that the patient is ready for discharge?

above 90%

during the postoperative period, the nurse reinforces to a patient recovering from a laryngectomy about how to live with a tracheostomy. which information will the nurse review?

be sure to protect your tracheotomy from pollutants such as powders, hairs and chemicals.

The nurse provides care to older adult residents in an extended-care facility. One resident is experiencing diarrhea. The resident reports loss of appetite, weakness, and drowsiness. Which body system is most important for the nurse examine?

cardio vascular

a nurse is assessing a client who has obstructive sleep apnea (OSA). which of the following findings should the nurse expect?

decreased energy

A patient is preparing to undergo an appendectomy for a ruptured appendix. Which level of urgency is this surgery?

emergency

The nurse is caring for a patient who has developed an increased temperature during the first 24 hours postoperatively. Which action should the nurse take?

encourage coughing and deep breathing

an early sign of cancer of the larynx is halitosis

false

Which procedure involves removal of an organ?

gastrectomy

The nurse assesses a patient's pain level to be an 8 on a 0-to-10 scale. The nurse notes the patient has an order for morphine 4 mg IV as needed for pain. The patient's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 67 beats/min. Which action should the nurse take?

notify the RN

the nurse is proving education to an older adult about common complications of influenza. LPN knows that a common complication is:

pneumonia

the nurse is providing care for a patient immediately after a tonsillectomy. which action by the nurse should be avoided?

provide the patient with warm tea sweetened with honey

the nurse is taking care of a patient with pharyngitis cause by beta hemolytic streptococci. LPN knows that if untreated the infection can lead to

rheumatic fever

the nurse is providing education to an adult after the rhinoplasty. which of the following actions is NOT appropriate after this procedure?

sneezing with mouth closed

the nurse is providing care for a patient diagnosed with influenza. the patient has fever, chills, sore throat and a cough. breath sounds include crackle and wheezes. for which reason will the nurse contact the physician

the breath sounds indicate development of pneumonia

a patient returns to the observation area after outpatient septoplasty for a deviated septum. which observation will most concern the nurse?

the patient swallows frequently

an obsese patient is being evaluated by the HCP for sleep apnea. which recommendations by the HCP does the nurse find unexpected?

using a sedative before sleeping

The LP/LVN is taking a history on a patient who is scheduled for surgery in which he was to remain NPO after midnight. The nurse asks the patient when he last Wad something to eat, to which the patient replies, "About 2 hours ago." Which action should the nurse take?

•Notify the surgeon immediately.

The nurse is asking about the type of bariatric surgery the patient had. The patient states, "They folded my stomach inward and sutured the folds in place." Which surgery description does the nurse expect?

Gastric plication

The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). What statements by the client indicate good understanding of the teaching? (Select all that apply).

- "I will eat three small meals and three small snacks a day." - "I sure hate to give up my coffee, but I guess I have to." - "Sitting upright and not lying down after meals will help." - "I just joined a gym, so I hope that helps me lose weight."

The nurse is caring for a postoperative patient at risk for deep vein thrombosis. Which actions should the nurse recommend be included in the patient's plan of care?

- Ambulate the patient tid Apply anti-embolic stockings Perform leg exercises 10 times hourly while awake

A client is scheduled to have a fundoplication. What statement by the client indicates a need for further preoperative teaching?

After the operation I can eat anything I want.

A client has a large oral tumor. What assessment by the nurse takes priority?

Airway

The nurse is providing care for a patient who is diagnosed with Mallory Weiss tear (MWT). Which treatment for the condition is the nurse expecting?

An injection of epinephrine

The nurse is teaching a patient with gastroesophageal reflux related to a hiatal hernia about body position for management of the disease process. Which patient statement indicates that teaching has been effective?

I elevate the head of the bed 4 to 6 inches on blocks.

a patient is discharged from the emergency department after treatment for epistaxis. the physician orders that all home medication be continued. which medication will the nurse question?

Ibuprofen

The nurse is assisting during surgery when a patient develops malignant hyperthermia. Which protocol should the nurse prepare to assist with as directes?

Immediately cease anesthesia and surgery, cool patient, and administer dantrolene sodium.

The nurse mistakenly assesses the blood pressure of the patient on the arm an IV is transfusing. What can this cause?

Increase in venous pressure

The nurse instructs a patient with a nosebleed to sit up and lean slightly forward. For which reason does the nurse teach the patient to maintain this posture

To avoid unseen blood from being swallowed or aspirated

The nurse is taking a medication history of a patient who is to undergo surgery the next morning. Which medication requires immediate notification of the surgeon?

Warfarin (Coumadin)

a nurse is caring for a client who has active pulmonary tuberculosis (TB) and a prescription for a chest x-ray. which of the following actions should the nurse plan to take?

instruct the client to wear a mask while outside the room

the nurse is providing care for an adult patient with a diagnosis of viral rhinitis. the HCP orders acetaminophen and a decongestant. comfort measures include rest and an increased in vitamin C and oral fluids. which patient health information will cause the nurse to question of the treatments

history of hypertension

The nurse is providing care to a patient three days after a Bill Roth 1 procedure. About which observation should the nurse be most concerned?

Reports of abdominal cramping shortly after eating.

Upon entering a patient's room, the licensed practical nurse/licensed vocational nurse (LPN/LVN) notes coolness of the skin at the IV site and a sluggish infusion rate. What should the nurse do first?

Stop the infusion

a nurse is caring for a client who develops a pulmonary embolism. which of the following interventions is the priority for the nurse to take ?

imitate oxygen therapy

The nurse is planning care for a patient admitted for gastric bleeding, which is presently controlled. If the patient experiences a reoccurrence of bleeding, which manifestation will indicate to the nurse that the patient is experiencing hypovolemic shock?

Tachycardia and tachypnea

A client has returned to the nursing unit after an open Nissen fundoplication. The client has an indwelling urinary catheter, a nasogastric (NG) tube to low continuous suction, and two IVs. The nurse notes bright red blood in the NG tube. What action should the nurse take first?

Take a full set of vitals

The nurse suspects the patient has developed septicemia as a complication of peripheral IV therapy. Which signs and symptoms support the nurse's suspicion?

Fever and chills

The nurse is gathering information from a patient who reports anal pain. Which finding upon physical examination supports the presence of an anal abscess?

Fever and drainage

The nurse is collecting health information from a patient. Which patient statement will cause the nurse the most concern

Lately, I've had two or three loose, sticky, black stools every day.

The nurse is providing care for a patient who underwent A billroth 1 surgery for stomach cancer. Which nursing care is most important during the post operative. For this patient?

Medicating for pain to promote coughing and deep breathing.

The nurse is caring for a patient who underwent a colostomy yesterday morning. The nurse removed the catheter 1 hour after surgery, and the patient has not vet voided. Which action should the nurse take?

Notify the HCP

A patient who is NPO (nothing by mouth) for scheduled surgery has been on long-term oral steroid therapy and should receive a dose of Prednisone 10 mg by mouth at 0600. Which action should the nurse take?

Notify the RN

A patient who had extensive gastric surgery for stomach cancer reports feeling sick and diaphoretic with abdominal cramping about 20 minutes after eating. The nurse is providing information about dumping syndrome. Which information is correct? (Select all that apply.)

- The patient is experiencing one of the most common complications. - Food enters the jejunum without adequate amounts of digestive juices. - High concentrations of electrolytes and sugar draws fluid into the bowel. - The patient will need to eat some candy or drink juice containing sugar.

A nurse is preparing to hang a gravity infusion for a patient who is dehydrated. At what level should the solution be placed for the best results?

3 feet above the level of the heart

The nurse is caring for a group of patients about to undergo surgery. Which patientis at highest risk for surgical complications?

A 65-year-old who smokes a pack of cigarettes per day

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?

It's a good thing I love orange and cherry gelatin.

a nurse on a medical surgical unit is assisting with the care of a patient who has a possible closed pneumothorax following a motor vehicle crash. the patient reports severe chest pain on inspiration. which of the following findings does the nurse expect during auscultation of the patients lung sound?

absent breath sounds

A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse taketo decrease the presence of ascites?

Provide a low-sodium diet.

The nurse is observing a patient's peripheral IV with hypotonic fluid by gravity that has stopped dripping despite an open roller clamp. The IV site is not swollen, red, or painful. The nurse suspects ________ and should __________

-a thrombosis -attempt to flush

a nurse is caring for a client who has hypertension and experiences acute epistaxis. which of the following actions should the nurse take?

-apply ice to bridge of the nose -apply pressure to the nasal bridge -lean the client forward

the nurse is providing education to an older adult about preventive measures for influenza. the LPN knows that important preventive measures are

-hand hygiene and avoidance of people with influenza

a patient reports having a cold to the nurse in a HCPs office. which symptoms does the patient report that causes the nurse to suspect influenza instead

-sore throat - severe muscle aches -persistant cough -suddent onset of symptoms

A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take?

Encourage the client to verbalize feelings about the diagnosis.

The nurse is teaching a patient about following a high-protein diet before and after surgery to promote healing. Which food choice made by the patient indicates an understanding of the teaching?

One small grilled chicken breast with one small egg

The licensed practical nurse/licensed vocational nurse (LP/LVN) is working in the postoperative care unit. Which assessment finding should be reported to the RN?

Oxygen saturation of 82%

The nurse is caring for a patient with stage IV lung cancer who is preparing to underga surgery. What is most likely the purpose of the surgery?

Palliative

The nurse is reinforcing teaching with a patient who had a large portion of the stomach surgically removed. For which condition related to the surgery will the patient need to receive vitamin B12 for life

Pernicious anemia

The nurse answers a patient's call light and finds the patient sitting up in bed with a wound evisceration. What action should the nurse take first?

Place the patient in low Fowler position.

The nurse is providing care for a patient who is receiving chemotherapy and radiation as treatment for esophageal cancer. Which factor in the care of this patient is the nurse's least concern?

The ability to speak

The nurse is preparing to start an IV on a newly admitted patient. Which action by the nurse places the patient at risk for infection?

The nurse blows on the area cleansed with alcohol

For which patient would a port be most beneficial?

A patient receiving long-term antibiotics

The nurse is providing care for a patient who is experiencing nausea and vomiting. Which pathological manifestation is unlikely to occur with prolonged vomiting?

Anemia

Which patient would benefit most from a subcutaneous infusion?

An older adult patient with poor venous access receiving normal saline