Final

The medication order reads: heparin (HIGH ALERT) IV at 1400 units/hr. The pharmacy sends a bag of heparin containing 25,000 units in 250 ml D5W. What infusion rate should the RN set the IV pump? Answer with a number only. _____ ml/hr

14 ml/hr

A client with bacterial pneumonia is to start IV antibiotics. The nurse should verify which diagnostic test before administration? 1.urinalysis 2.sputum cultures 3.chest radiograph 4.RBC count

2

For the client who is experiencing expressive aphasia, which nursing iNtervention in promoting communication is most effective: 1, speaking loudly and slew 2. using a "picture board" fs the client to point to pictures 2. writing directions so the client can read them 4. speaking in short sentences

2

43. Following a stroke, a client has dysphagia mad left-sided facial paralysis. Which feeding tech- ique will be most helpful at this time? 1. Encourage sipping diluted liquid meal supplements from a straw. 2. Position the client with the bed at a 30-degree angle. 3. Offer solid foods from the unaffected side of the mouth. 4. Feed the client a soft diet from a spoon intothe left side of the mouth.

3

48. A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign? 1. pulse 2. respirations 3. blood pressure 4. temperature

3

the nurse is caring for a client with bacterial pneumonia. The effectiveness of the clients oxygen therapy is best determined by? 1.absence of cyanosis 2.clients RR 3.ABG value 4.clients LOC

3

47. A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activa- tor (t-PA)? 1. Ask what medications the client is taking. 2. Complete a history and health assessment. 3. Identify the time of onset of the stroke. 4. Determine if the client is scheduled for any surgical procedures.

3. Tpa 4.5 hours

A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identity as the primary safety precaution to use? - 1. Wear a patch over one eye. - 2. Place personal items on the sighted side. -3. Lie in bed with the unaffected side toward the door. - 4. Turn the head from side to side when walking.

4

A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm? A Normal sinus rhythm B Sinus tachycardia C Sinus bradycardia D Sinus arrhythmia

A. Normal sinus rhythm Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.04 to 0.10 seconds. P and QRS waves are consistent in shape.

What is Kernig's sign?

After flexing the hip and knee at 90 degree angles, pain and resistance are noted.

A 19-year-old student comes to the student health center at the end of the semester complaining that, My heart is skipping beats. An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next? a. Start supplemental O2 at 2 to 3 L/min via nasal cannula. b. Ask the patient about current stress level and caffeine use. c. Ask the patient about any history of coronary artery disease. d. Have the patient taken to the hospital emergency department (ED).

B

A client with glomerulonephritis is at risk of developing acute renal failure. The nurse monitors the client for which sign of this complication? a) bradycardia b) hypertension c) decreased cardiac output d) decreased central venous pressure

B

The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia? a. BP 146/88 b. Respirations 28 shallow c. Weight gain of 10 pounds in 6 months d. Pink complexion

B increased O2 demand

A patient is diagnosed with an infection caused by the hepatitis A virus. Which statement, if made by the patient, would indicate the patient needs further teaching about the infection? A "I will wash raw fruits and vegetables thoroughly before I eat them." B"Before I take any over-the-counter medicines I should call the clinic." C"I might get liver cancer someday because I have this infection." D"It's important for me to remember to wash my hands after I use the bathroom."

C

A patient with heart failure is taking Losartan and Spironolactone. The patient is having EKG changes that presents with tall peaked T-waves and flat p-waves. Which of the following lab results confirms these findings? A. Na+ 135 B. BNP 560 C. K+ 8.0 D. K+ 1.5

C. tall t waves = hyperkalemia

During your morning assessment of a patient with heart failure, the patient complains of sudden vision changes that include seeing yellowish-green halos around the lights. Which of the following medications do you suspect is causing this issue? A. Lisinopril B. Losartan C. Lasix D. Digoxin

D

While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Whichaction should the nurse take next? a. Document this finding in the patients record. b. Obtain vital signs, including oxygen saturation. c. Have the patient perform the Valsalva maneuver. d. Observe for JVD with the patient upright at 45 degrees

D

A 22 month old child is admitted with second degree burns to his arms and legs due to a kitchen accident involving boiling water. While the RN tries to assess his vital signs he cries, clings to his blanket and continuously points to the door. When the child's grandmother, his primary caregiver at home, finally arrives the child begins crying even louder and tries to physically escape the RN's arms into the arms of the grandma. The nurse assesses this behavior as A. indicative of pain and the need for pharmacologic intervention. B. likely from the abusive situation that led to the burns; contact CPS. C. possibly the result of regression back to the stage of trust vs. mistrust. D. evidence of the need for an early intervention program with the social worker. E. none of the above.

E. normal behavior bonded with grandma

What is worn for droplet precautions?

Glove, gown, and mask

A client is about to have a blood transfusion and asks the nurse which type of hepatitis is most frequently transmitted through food. Which type of hepatitis should the nurse teach the client about being most associated with food? Hepatitis.... A B C D

Hepatitis A

What is a patient at risk for after parathyroidectomy?

Hypocalcemia

What is Cyclosporine used for?

Immunosuppressive agent. Patients that receive organ transplants will need to take them for the rest of their lives

A patient with CKD has a low erythropoietin (EPO) level. The patient is at risk for? A. Hypercalcemia B. Anemia C. Blood clots D. Hyperkalemia

The answer is B. EPO (erythropoietin) helps create red blood cells in the bone marrow. The kidneys produce EPO and when the kidneys are damaged in CKD they can decrease in the production of EPO. Therefore, the patient is at risk for anemia.

A 6 month old infant is sleeping. The RN notes a heart rate of 140 beats per minute on the hard wired monitor. What is the RN's best action? A. Chart the normal pulse. B. Recheck after arousing the infant. C. Report the abnormal pulse immediately. D. Retake the pulse apically in 15 minutes.

a

You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining? A. Check for kinks in the outflow tubing B. Raise the drainage bag above the level of the abdomen C. Place the patient in a reverse Trendelenburg position D. Ask the patient to cough

a

A patient has a history of heart failure. Which of the following statements by the patient indicates the patient may be experiencing heart failure exacerbation?SATA A. "I've noticed that I've gain 6 lbs in one week." B. "While I sleep I have to prop myself up with a pillow so I can breathe." C. "I haven't noticed any swelling in my feet or hands lately."

a,b

The healthcare provider is teaching a patient diagnosed with hepatitis C about the disease. Which of these statements made by the patient indicate that the patient has an understanding of the teaching?Choose all answers that apply: A"I should get vaccinated for hepatitis A and hepatitis B." B"It's important for me to use barrier protection when I have sex." C"I should not drink any wine, beer or other alcoholic beverages." D"I'll plan to do all my activities in the morning when I'm most rested." E"I should avoid sharing drinking cups and eating utensils with my family." F"Acetaminophen is the best medication for me if I have a headache."

a,b,c

The RN is caring for a patient whose cultural background is different from the RN's own. Which actions are appropriate for the RN to take? Select all that apply. A. Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures. B. Explain the RN's beliefs so that the patient will understand the differences. C. Respect the patient's cultural beliefs. D. Ask the patient about cultural or religious requirements that should be considered for nursing care. E. Understand that most cultures experience and respond to pain the same way.

a,c,d

Which of the following patients are MOST at risk for developing heart failure? Select-all-that-apply: A.A 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction. B. A 55 year old female with a health history of asthma and hypoparathyroidism. C. A 30 year old male with a history of endocarditis and has severe mitral stenosis. D. A 45 year old female with lung cancer stage 2. E. A 58 year old female with uncontrolled hypertension and is being treated for influenza.

a,c,e

A member of the clinic housekeeping staff experiences a needlestick by a contaminated needle. Which of the following should be administered by the healthcare provider to provide the patient with passive immunity against the hepatitis B virus? A. Antiviral medication B Hepatitis B immune globulin (HBIG) C Hepatitis B vaccine d. Antibiotics

b

An 8-month-old infant is sitting quietly on the mother's lap, chewing on a toy. When preparing to perform a routine assessment of this infant the RN should plan to do which action first? A. Measure head circumference. B. Auscultate heart and lung sounds. C. Perform a neuro check. D. Obtain a body weight.

b

The RN is planning care for a four year old child admitted with viral gastroenteritis. The child who is NPO, has been vomiting and has a urine specific gravity of 1.020 over the last 24 hours. Which client problem is the highest priority? A. Imbalanced nutrition B. Fluid volume deficit C. Risk for infection D. Altered urinary elimination

b

When auscultating the heart, the RN identifies the S1 component as the closing of which valves? A. Mitral and aortic valves B. Mitral and tricuspid valves C. Tricuspid and pulmonic valves D. Tricuspid and aortic valves

b

Which items are part of the neuro check, but are not an assessment of LOC? A. Vision and hearing ability. B. Pupillary size and reaction to light. C. Alertness and verbal response. D. Best motor response.

b

During the patient's hospital stay, the patient states, "I told my wife that I was going to start exercising and I think I will join a fitness club." What stage of Prochaska's Transtheoretical model of Health Behavior change is the patient exhibiting? a Action b Preparation c Precontemplation d Maintenance

b preparation

Which nursing actions are considered tertiary health promotion? Select all that apply. a. A nurse runs an immunization clinic in the inner city. b. A nurse teaches a patient with an amputation how to care for the residual limb. c. A nurse provides range-of-motion exercises for a paralyzed patient. d. A nurse teaches parents of toddlers how to childproof their homes. e. A school nurse provides screening for scoliosis for the students .f. A nurse teaches new parents how to choose and use an infant car seat.

b,c

A patient diagnosed with chronic hepatitis has developed hepatic encephalopathy. When assessing the patient, the healthcare provider looks for which of the following clinical manifestations characteristic of this condition Choose all answers that apply: ARetroperitoneal bleeding BInvoluntary hand tremoe CBloody emesis DShortened attention span EHypersomnia FSlurred speech

b,d,e,f

A patient diagnosed with hepatitis is undergoing a liver biopsy. When caring for the patient, which of these actions would be essential for the healthcare provider to take? Choose all answers that apply: A Review the patient's baseline liver function tests B Ensure the patient's clotting profile is within normal limits C Provide a mechanical soft diet for before the procedure D Ensure the patient has an empty bladder before the procedure E Help the patient assume a left lateral position after the procedure F Monitor the patient's vital signs after the procedure

b,d,f

Which of the following are NOT typical signs and symptoms of right-sided heart failure? Select-all-that-apply: A. Jugular venous distention B. Persistent cough C. Weight gain D. Crackles E. Nocturia F. Orthopnea

b,d,f

A 9 month old infant is hospitalized after a three day history of nausea and vomiting. Which urine specific gravity indicates achievement of an expected outcome related to rehydration? 1.001 1.007 1.018 1.025

b. 1.007

The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear? a. Stridor b. Crackles c. Wheezes d. Friction rubs

b. Crackles LHF

What is a D-Dimer test used for/indicative of?

blood test that can be used to help rule out the presence of a serious blood clot. DVT

A 3.12 kg baby is ordered to have a medication via IV piggyback every six hours. Which type of delivery device should the RN use to administer this medication? a Standard IV tubing since there is nothing in the stem to indicate otherwise. b There is no way to answer this question without more information. c Syringe tubing for such a small child. d Call the primary health care provider or pharmacist for advice. e IV push method would work best.

c

A client has developed HELLP syndrome and the last liver function tests suggest acute liver failure is beginning. The nurse should prepare for which intervention?I a. Insertion of a intrahepatic shunt B Administration of penicillin G c Delivery by cesarean section d Administration of acyclovir

c

The 2.96 kg baby is ordered to have Ampicillin 155 mg. IVPB. every six hours. Which type of delivery device should the RN choose to administer this medication? A.Standard IV tubing; there is nothing in the stem to indicate otherwise. B.The syringe will be enough; for such a small baby and small dose, IV Push would work best. C.Syringe tubing is small bore; given this child's age and weight a 4 ml flush is the best choice .D.Without knowing the underlying morbidity, i.e. cardiac and renal status, there is no way to answer this question. E.Call the doctor or pharmacist for advice.

c

When completing discharge teaching for the mother of a toddler, which activity should the RN recommend to help the child meet the major developmental task for this age group? a Feed the child favorite foods at mealtime. b Read the child bedtime stories. c Allow the child to pull a small wagon. d Have the child watch "Sesame Street".

c

When caring for a patient diagnosed with viral hepatitis, the healthcare provider experiences a needlestick with a contaminated needle. Which of the following actions should the healthcare provider do first? A. Make an appointment with the infection control department B. Put the needle in a biohazard bag for testing C Wash the area thoroughly with soap and water D Report to the emergency department

c wash then notify

A client has acute liver failure. The nurse would assess for which skin changes? Select all that apply. a Poor wound healing b Dark-brownish discolorations on the chest c Pale mucous membranes d Presence of pruritus e Presence of petechiae

c,d,e

A patient with early evidence of obstructive airway disease states, "My smoking has already damaged my lung. Why stop now?" On what information should the RN base the response? a Encouraging patients to stop smoking is rarely effective. b Smoking cessation rates are low, even with drug therapy. c Avoiding environmental irritants can minimize the effect of smoking. d If smoking cessation occurs in time, the changes may be reversible.

d

Considering the developmental tasks of toddlers, which approach would best enhance communication between the RN and the child? A. respect the child's need for privacy; close the door when providing care. B. Prepare the child several days in advance for painful or invasive procedures. C. Use appropriate medical terminology; allow the child to ask questions. D. Integrate dolls, storytelling and picture books into conversations.

d

Erythropoietin sometimes is administered subcutaneously to treat which of the following? (Select all that apply.) a. Clients with marrow suppression b. Clients with chronic liver disease c. Clients with Hodgkin's disease and non-Hodgkin's lymphoma d. Clients with anemia and fatigue related to non-myeloid cancers

d

The pediatric surgery team arrives to perform an unscheduled, potentially painful procedure on a 3 year old child. What is the RN's best action? A. Encourage the mom to hold the child in the bed while the RN sets up supplies. B. Assign the child life specialist to distract the child with a toy. C. Demonstrate the procedure using a teddy bear first. D. Facilitate the set up for the procedure in the treatment room.

d

You're providing diet discharge teaching to a patient with a history of heart failure. Which of the following statements made by the patient represents they understood the diet teaching? A. "I will limit my sodium intake to 5-6 grams a day." B. "I will be sure to incorporate canned vegetables and fish into my diet." C. "I'm glad I can still eat sandwiches because I love bologna and cheese sandwiches." D. "I will limit my consumption of frozen meals."

d