Final
The nurse is preparing to administer furosemide (Lasix) 20 mg IV to a client with hypertension. The available dose is 40 mg/mL. how many mL will the nurse administer. Enter the numeral only.
0.5
The nurse receives an order to administer hydromorphone (Dilaudid) 1 mg IV for postoperative pain. The available dose is 2 mg/mL. how many mL will the nurse administer? Enter number only.
0.5
The nurse is teaching a client who is receiving information about food choices high in potassium. Which food choices made by the client indicates an understanding of the teaching?
1 large baked potato
the nurse is teaching a client with a calcium level of 7.8 mg/dL about food choices. Which food choice made by the client indicates an understanding of the teaching?
1.5 ounces of cheddar cheese
the physican's order reads 1.5 L 5D1/2S over 12 hours. How many mL/hr will the IV need to run at in order to deliver the solution as ordered?
125 mL/hr
The nurse is preparing to administer vancomycin 2 mg in 250 mL NS IVPB to run over 2 hours. At what rate will the nurse set the infusion pump? Enter the numeral only.
125
The nurse is preparing to administer D5W 500 mL over 8 hours to a client receiving chemotherapy experiencing nausea. The nurse is using a 15 gtt/mL. calculate the flow rate enter only the numeral, round to the nearest whole number.
16
a teenager with a bacterial infection has been prescribed 0.18 g of doxycycline. The dosage strength of the available medication is mg/mL. Calculate the amount of doxycycline oral suspension to be administered per dose to the client in mL
30
The client with CKD is placed on a fluid restriction of 1500 mL per day. On the day shift the client drank an 8 oz cup of coffee, 8 oz of juice, 16 oz of tea and 8 oz of water with medication. What amount of fluid can the night shift nurse give the client?
300
Calculate the following flow rate for 500 mL NS to infuse over 4 hours. Drop factor 15 gtt/mL
31
Order D5W 500 mL IV with Heparin 40,000 units to infuse at 1,500 units/hr. what is the flow rate for the infusion pump
19
the following order was written for a child weighing 66 lbs. order: Morphine 0.2 mg/kg/day po q6h prn pain. How many milligrams should the child receive per day
24
A clients full day oral intake included 5 tsp of gelatin, 7 oz of juice, and 6 Tbs of broth. What is the total intake documented by the nurse in mL? round to the nearest whole number.
325
a client's full day oral intake included 5 tsp of gelatin, 7 oz of juice, and 6 Tbs of broth. What is the total intake documented by the nurse in mL? answer in whole numbers.
325
a clients full day oral intake included 2 tsp of gelatin, 6 oz of juice and 10 Tbs of broth. What is the total intake documented by the nurse in mL?
340
After reviewing an electrocardiogram the nurse determines that an electrical impulse originated in a client's sinoatrial mode. What did the nurse see on the tracking?
A positive P wave before QRS complex
The nurse is caring for a client who has aortic stenosis. During data collection, which of these manifestations should indicate to the nurse that the client is experiencing myocardial oxygen deficiency?
Angina
A female client is prescribed glyburide for control of BG. What precaution does the nurse teach the client about this medication?
Avoid drinking alcohol
A client who is 1 day postoperative thyroidectomy reports feeling numb around the mouth and is experiencing random muscle twitches. Which medication does the nurse anticipate being prescribed by the HCP?
Calcium gluconate
During the postoperative period, the nurse reinforces teaching to a client recovering from a laryngectomy about how to live with a trach, which information will the nurse review?
Be sure to protect your trach from pollutants such as powders, hair, and chemicals.
The nurse is monitoring a client 6 hours after a thyroidectomy for cancer Vital signs are 104 degrees/F, pulse 44, resp 18 and BP 184/108 mm Hg. Which prescription does the nurse anticipate from the HCP?
Beta blockers and a cooling blanket
The nurse auscultates the lung sounds of a client with a pneumothorax every 4 hours. Which finding indicates to the RN that the clients condition is improving?
Bilateral lung sounds are present
The nurse is visited by a teenage neighbor who asks, "I have a friend who thinks she has an STI and she is afraid to ask anyone about it. Can you give me some information for her? Which reply does the nurse make?
Delayed tx can result in serious lifelong complications.
A client is admitted to the hospital with hyperosmolar hyperglycemia. The patient is 40 percent overweight and has a BG value of 987 mg/dL. Which is the priority focus while planning nursing care for the patient?
Hydration status
The physician orders an antimalarial for a client to be taken before meals at the same time on a daily basis. As a part of obtaining a baseline assessment, the physician orders an ophthalmic examination. Which medication has been ordered based on this information?
Hydroxychloroquine sulfate (Plaquenil)
The nurse is teaching a group of clients about risk factors for heart disease. Which does the nurse identify as a modifiable risk factor?
Hypertension
A patient diagnosed with BPH is prescribed the alpha-blocking medication tamsulosin (Flomax) to reduce symptoms. For which side effect does the nurse monitor this patient?
Hypotension
the nurse is caring for a client diagnosed with hypocalcemia. Which of the following signs and symptoms will the nurse expect to see the client exhibiting? Select all that apply.
Hypotension, positive chvostek's sign, tetany
The nurse is teaching a client about allergic rhinitis. Which statement indicated a need for further teaching?
I can take my nasal medication any time my allergies bother me
The nurse is caring for a client with infective endocarditis (IE). Which statement made by the client leads the nurse to suspect the case of the IE?
I have not been to the dentist in 8 years.
The nurse is teaching a class about coronary artery disease and explains atherosclerosis. Which statement made by the client indicates an understanding of the teaching?
I have plaque in my arteries that can cause CAD.
The nurse is providing teaching for a client with thrombocytopenia. Which statement made by the client indicates a need for further teaching?
I need to be sure and floss every day
The nurse has reinforced preoperative teaching with a client about coughing and deep-breathing techniques. Which client statements indicate a correct understanding of the teaching (select all that apply)
I should deep breathe and cough every hour while awake, deep breathing and coughing helps to prevent respiratory problems
The nurse is performing a follow up visit with a client recently diagnosed with GOLD 1 classification of COPD. Which statement by the patient indicates the most important complieance with previous patient teaching?
I successfully completed a smoking-cessation program
The nurse is teaching a group of individuals about HIV prevention. Which statements indicate an understanding of the teaching? (select all that apply).
I wear gloves to protect my hands during genital contact, my sister is pregnant, so she should get tested for HIV
The nurse is reinforcing teaching for a client being discharged home on captopril (capoten). Which statement made by the client indicates an understanding of the teaching?
I will check my BP and HR before taking medication
The nurse is reinforcing teaching about dilated cardiomyopathy. Which statement made by the client indicates a need for further teaching?
I will not have to receive treatment, since it is not useful
The nurse is providing care to the client who has arrived at the clinic to discuss his diagnostic results. The HCP suspects multiple myeloma. Which of the following results may confirm the HCP's suspicions? (select all that apply).
MRI shows diffuse osteroporosis in the bones, blood chemicals reveal an increase in serum calcium, blood and urine studies are positive for M-type globulins.
the nurse is reviewing laboratory results for a group of clients. Which value should be of most concern to the nurse?
Magnesium level 1.0 mEq/L
The nurse is researching the dietary recommendations by the American lung association for clients with lower respiratory tract disease. Which is not supported by the American lung association?
Maintain a diet that is low in fates and high in carbs
The nurse is collecting data on a client recovering from a hysterectomy who is experiencing left calf tenderness. Data include the following: left calf 17.5 inches, right calf 14 inches, left thigh 32 inches; right thigh 28 inches; shiny, warm and reddened left leg. Which actions should the nurse recommend for this clients plan of care?
Maintain bedrest
The nurse is caring for a client recovering from a cardiac catheterization. Which action is a priority for site care by the nurse?
Maintain pressure dressing on the site.
The nurse is collecting data from a female client who is having difficulty conceiving. The nurse notes that the client has increased amounts of body and facial hair, is moderately overweight, and has acne-like lesions on the face. Which medical condition is the nurse likely to suspect?
PCOS
The nurse is reviewing lab values for a client with thrombocytopenia. Which result would concern the nurse the most?
PLATELETS 50,000/mm3
The nurse is teaching a group of clients about stable versus unstable angina. Which should the nurse include in the teaching? (select all that apply).
Pain with stable angina is predictable, unstable angina can lead to MI, Angina is caused by a lack of oxygen to the heart.
The nurse is caring for a patient with peripheral vascular disease. Which S/S should the nurse expect to observe in this client? (select all that apply)
Pain, Paralysis, Paresthesia, Pulselessness
The nurse is caring for a client with stage IV lung cancer who is preparing to undergo surgery. What is most likely the purpose of the surgery?
Palliative
A client receiving large doses of opioids is lethargic and difficult to arouse, with a respiratory rate of 6 per minute and constricted pupils. Which medications should the nurse anticipate being prescribed?
Naloxone (Narcan)
The nurse is caring for a client who must undergo a splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP). Which of the following statements best describes the rationale for the splenectomy?
The spleen is the primary site for platelet destruction.
The licensed practical nurse/licensed vocational nurse (LPN/LVN) is watching a nursing student administer medications to a client with HIV. Which action by the student requires correction by the nurse?
The student recaps the needle and places it in the sharps container
A client with COPD is prescribed methylprednisolone, for what reason should the nurse realize that corticosteroids are used in the tx of this health problem?
To reduce airway inflammation
which of the following would be most appropriate to delegate to a UAP?
Toileting a patient on a bladder training regimen.
a client with hypertension is placed on a low-sodium diet. The nurse recognizes that further teaching is necessary if the client chooses which menu?
Tomato soup, grilled cheese, salad and chocolate chip cookie.
The nurse is providing care for a client diagnosed with type 2 DM. which information will the nurse give the client about the response to the pancrease to hypoglycemia?
Pancreatic alpha cells are stimulated to release glucagon.
List the 10 rights of medication administration
Patient, drug, dose, time, route, documentation, data collection, to refuse, education, order
The nurse is providing care for a client scheduled to receive radioactive iodine as tx for thyroid cancer. Which care intervention for this client is inappropriate?
Pregnant caretakers will wear lead apron w/ pt contact
The nurse is contributing to the plan of care for an adult client diagnosed with GH (growth hormone) deficiency. Which nursing intervention is best for the client?
Promote a caring, supportive relationship
The nurse is providing preoperative care for an 80 y/o patient who is scheduled to have prostate surgery. The patient says, "I know a man who is impotent after this surgery" will it happen to me? Which response by the nurse is most appropriate?
Prostate surgery can cause erectile dysfunction, I'll ask your surgeon to explain the risks to you.
The nurse is caring for a client who is malnourished due to throat cancer. During the hospital stay following a laryngectomy, how does the nurse conclude that the patient's diet is adequate?
The client is tolerating intermittent tube feedings.
The nurse is providing care for a client with type 2 DM who has been treated with an oral hypoglycemic agent. The HCP prescribes for the addition of insulin. Which situation does the nurse recognize as being the least valid reason for giving this client insulin?
The client is unable to effectively follow a diabetic diet
the nurse is teaching a group of nursing students about the chain of infection. Place the order of occurrence, 1-6.
infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host.
A client arrives at the ER and states "I was outside shoveling snow and suddenly started to feel really bad" the patients history indicates tx for hypothyroidism for the past 10 years. Which possible condition causes the nurse the greatest concern?
myxedema coma
he nurse is caring for a client with lung cancer who has been receiving morphine for 2 weeks and reports the medication is no longer effective. Which is the client likely experiencing?
tolerance
The nurse is caring for a client with pernicious anemia. Which deficiency is this client experiencing?
Vitamin B12
The nurse is caring for a client with pneumonia. Which set of lab tests will be most helpful to the nurse to monitor the condition of this patient?
WBC and ABG's
The nurse is taking a medication hx of a client who is to undergo surgery the next morning. Which medication requires immediate notification to the surgeon?
Warfarin (coumadin)
The school nurse is planning to teach a group of school-age children on cough etiquette. What should the nurse emphasize with these students?
Wash hands with soap and water for 20 seconds after blowing the nose.
A client with diabetes has peripheral neuropathy. What should the nurse do to prevent related complications?
Wash, dry and inspect feet daily
a client with uncontrolled diabetes mellitus develops metabolic acidosis. Which assessment finding indicates this finding?
Watery diarrhea
A client with lung cancer develops pleural effusion. Which explanation by the nurse would help the patient understand the problem?
" fluid has collected in the space between your lungs and the sac surrounding the lungs"
The nurse is teaching a client with SLE about avoiding triggers. Which statement by the client indicates a need for further teaching?
" if I get plenty of sunlight, it will help reduce symptoms"
The nurse is preparing a client to undergo a suppression test to verify adrenal cortex dysfunction. Which reply will the nurse make when the client asks about the expected test procedure?
" you will be injected with a steroid hormone that should suppress cortisol release"
. which question should the nurse ask when assessing spirituality?
"Do you have any spiritual practices of which I need to be aware?"
the LPN is reinforcing instructions to a client for the use of an incentive spirometer. Which statement by the client will prompt the LPN to notify the RN that additional teaching is necessary?
"I blow into the mouthpiece 10 times a day just as instructed"
The nurse is teaching a client about mitral valve prolapse and lifestyle modification. Which statement made by the client indicates a need for further teaching?
"I need to avoid physical activity"
The student nurse is preparing to administer ketorolac (Toradol) to a client experiencing pain. The primary nurse knows that the student understands the associated nursing interventions when making with comment?
"I should be aware of and look for the possibility of bleeding"
The nurse is reinforcing teaching to a client who is diagnosed with genetically related hypoparathyroidism. Which comment by the patient indicates that client teaching is successful?
"I will immediately report numbness and tingling of the fingers, tongue, and lips"
The nurse is caring for a client with an abdominal aortic aneurysm. Which statement indicates that the patient understands this condition?
"an outpouching in the wall of an artery"
The nurse is providing discharge teaching for a client with mitral stenosis. What should the nurse include in the teaching?
"because of your heart condition, the blood flow through your heart is slower and blood may tend to pool in certain area's which might allow tiny clots to form"
A client asks the nurse what the doctor meant by the phrase "hypertensive emergency". Which explanation is most appropriate by the nurse?
"it refers to an episode of very high blood pressure"
The nurse is providing care for a client with diabetes who experiences who experiences frequent periods of hyperglycemia. Which comment by the client is included the nurse of a major cause of the imbalance?
"my job is really busy in tax season"
the nurse is caring for a client who states she has been consuming herbal remedies recommended by her healer. Which statement by the nurse is most appropriate?
"please tell me exactly what you are taking so I can make sure they don't interact with your medications.
the primary health-care provider has ordered alprazolam 0.25 mg twice a day for a geriatric client. The pharmacy sends alprazolam which has dosage strength of 2 mg per tablet. How many tablets should the nurse administer to the client each day?
0.25
The nurse is administering methylprednisolone (solu-medrol) 40 mg IM to a client with SLE. The available dose is 80 mg/mL. how many mL will the nurse administer? Round to the nearest tenth.
0.5
The physician orders to give IV penicillin 100,000 units. The penicillin on hand is labels 250,000 units/mL. how much of the drug will you give in mL? (round to the nearest tenth, do not include unit In answer)
0.4
Administer a dose of Vitamin K (aquamephyton) 0.5 mg. available: Vitamin K 1mg/1mL. How many mL would you administer?
0.5
The nurse is preparing to administer morphine 6 mg IV to a client having an MI. available is morphine 10 mg/mL. how many mL will the nurse administer? Enter number only.
0.6
The HCP prescribes enoxaparin (Lovenox) 1 mg/kg to a client who weighs 80 kg. the available dose is 80 mg/0.8 mL. How many mL will the nurse administer? Numeral only.
0.8
the nurse is told to administer IV fluid the same osmolarity as blood. Which fluid can the nurse expect to administer?
0.9% normal saline
The nurse is preparing to administer a cyanocobalamin (B12) injection 1000 mcg IM to a patient with B12 deficiency. Available vials are 1000 mcg/mL. how many mL will the nurse administer?
1
The nurse is preparing to administer epoetin alfa (Procrit) to a patient with anemia. The prescribed dose is 50 units/kg to a patient who weighs 60 kg. the available dose is 3,000 units/mL. how many mL will the nurse administer? Enter the numeral only. Round to the nearest whole number.
1
The nurse is preparing to administer midazolam (versed) 1 mg IV. The available dose is midazolam(versed) 1mg/1mL. How many mL will the nurse administer? Enter the numeral only. Round to the nearest whole number.
1
The nurse is assisting in the surgical holding area. When should the nurse administer a prophylactic antibiotic to a client?
1 hour prior to surgery
the nurse is caring for a group of clients. Prioritize from 1 to 4 with one being the highest priority, resu
1- a 47 y/o client who reports two loose stools and feels nauseated. 2 - a 52 y/o client with fluid volume excess and 2+ pedal edema 3 - a 60 y/o client with a potassium level of 2.6 mEq/L and heart palpitations 4 - a 71 y/o client with a calcium level of 10 mg/dL and negative Trousseau sign.
A client with prostate cancer asks the nurse the meaning of his high prostate-specific antigen (PSA) level. Which response by the nurse is correct?
1. "PSA is a tumor marker that is elevated in clients with prostate cancer"
A family member is concerned that a client near the end of life is not eating or drinking and asks the nurse how the family can help the client increase oral intake. Which response by the nurse is most appropriate?
1. "as a family member becomes dehydrated from not eating or drinking, natural endorphins will be released, which increase comfort near the end of life."
A client has been on opioids for 3 months to control pain caused by injuries from a motor vehicle crash. The client asks about the risk of withdrawl symptoms when the drugs are no longer needed. How should the nurse respond to the client?
1. "as long as you taper the drug dose down slowly, you should not experience withdrawl symptoms"
A client is receiving a transfusion of packed RBC's. Ten minutes after the infusion begins, the client reports back pain and a headache. Place the actions in order, from 1-5, of importance of performance.
1. 1.Stop the blood transfusion 3 obtain V/S and assess client 2. Notify the physician STAT 5. Prepare a new 0.9% NS infusion 4. Start the new 0.9% NS infusion
A client asks what a DNR order means. What should the nurse explain to the client?
1. A DNR order means you will not be resuscitated if your heart stops. You can specify whether you still want treatment to prolong your life or only care that keeps you comfortable.
The nurse is caring for a group of clients. Which client should the nurse see first?
1. A client receiving a blood transfusion who is reporting chills and low back pain
The nurse is caring for a group of clients. Which client is experiencing chronic pain?
1. A client who fell off a ladder 6 months ago and injured his back.
The nurse is contributing to a group of clients care plan. Which client should the nurse identify as being at risk for developing serum sickness?
1. A client who receives IV PCN for infection
The nurse is caring for a group of clients with HIV. Which client is at highest risk for developing CMW?
1. A client who works in a day care
A client asks the nurse to explain a durable power of attorney. Which statement by the nurse is most accurate?
1. A durable power of attorney is a person you choose to speak for you when you cannot make decisions
The nurse is providing information on breast self-exam to a female patient. Which palpitation pattern does the nurse instruct the patient to use when performing this examination?
1. Any pattern that is consistent and thorough
The nurse is reinforcing teaching for a client who has chronic kidney disease. Which statement made by the client indicates the need for further teaching.
1. As long as I don't eat protein, I'll be ok
The nurse is providing care for residents in an extended-care facility. An oriented, older adult female states to the nurse, "I think my boyfriend made me sick. My private parts itch and hurt. Which action by the nurse is appropriate?
1. Ask permission for the RN to do a physical examination
The nurse is reinforcing teaching on how to care for a new fistula in the left arm for dialysis. Which of these client statements include understanding? Select all that apply.
1. Avoid carrying heavy things with my left arm, wear loose clothing on my left arm, do not allow BP to be taken in the left arm, do not sleep on the left arm.
A client who has HIV asks a nurse why blood work has to be done so frequently. Which response should the nurse make to the patient?
1. CD4+ lymphocytes counts are monitored to determine the progression of the disease.
The nurse is educating a client who is newly diagnosed with stage 3 ESRD. The client asks the nurse, what exactly are the functions of the kidney? What is the best response from the nurse? Select all that apply.
1. Controls fluid balance, removes waste and toxins from the body by making urine, controls blood pressure, make erythropoietin, produces renin.
The nurse is monitoring a client with CKD. Which of the following findings would indicate fluid overload? Select all that apply.
1. Crackles in lungs, periorbital edema, increased BP
The nurse is collecting information from an older adult client in the HCP's office. The patient reports frequent urination. Which is an effect of aging does the nurse recognize?
1. Decrease bladder size and muscle tone.
As the nurse prepares to administer abacavir (ziagen), which of the following would indicate the medication is effective?
1. Decreased viral load and increased CD4 cell count
The nurse is inserting an indwelling catheter into a male elderly client. Which intervention should the nurse implement first?
1. Determine if the client has any betadine allergies.
When inspecting the IV site of a client receiving a vesicant chemotherapy agent, the LPN notes a small area of swelling. What should the LPN do first?
1. Discontinue the infusion and notify the RN
The nurse is collecting data for a client who has a graft in the right arm for dialysis. Which of the following actions would be most appropriate for the nurse to take? Select all that apply.
1. Do not use affected arm for BP, auscultate for a bruit over the site, palpate for a thrill over the site.
An adult client has been hospitalized with pyelonephritis. The nurse reviews the client's I/O records and finds that the client has been consuming between 3L and 3.5L of oral fluid each day since admission. What is the best action by the nurse?
1. Encourage the client to continue this pattern of fluid intake.
A nurse is assessing a client with a UTI who takes lisinopril. The nurse reviews the client's UA results pH 6.8, RBC 3 per high power field, color-yellow, specific gravity-1.032. what is the best action by the nurse?
1. Encourage the client to increase fluid intake.
The nurse is planning care for a client with leukopenia caused by chemotherapy. Which nursing intervention is most important for the nurse to include for this client's plan of care?
1. Ensure that staff members practice good hand washing.
A 19 y/o client reports flank pain and very little urination. The nurse notices periorbiltal edema, increased BP and the UA reveals elevated WBC, RBC, albumin and casts. What question would be most important for the nurse to include in the data collection?
1. Have you had an upper respiratory infection?
The nurse is providing care for a patient who presents with redness, itching, pain and burning of the vulva and vagina. Which additional manifestation will support the nurse's suspicion of vulvovaginitis?
1. History of treatment for multiple STI's
The nurse is caring for a client who was diagnosed with trichomoniasis. The client was prescribed metronidazole (flagyl). Which of the following statements by the client indicates education about this medication was successful?
1. I need to make sure my partner gets treated also.
The nurse is teaching the family of a child who is allergic to peanuts about important topics regarding the allergy. Which statements made by the patient indicates an understanding of the teaching? (select all that apply
1. I will make sure my child wears a medical alert bracelet at all times, I need to notify my childs school of the peanut allergy, I am going to ensure my child carries an EpiPen at all times
The nurse is teaching a group of older adults about prevention of HIV. Which statement made by the client indicates an understanding of the teaching?
1. I will use a condom with each sexual contact.
The nurse reviews orders from the HCP for a patient recovering from a TURP. The patient is prescribed for bladder irrigation, antispasmodic medication, and IV antibiotics q6h. which potential complications are these orders specifically addressing? (select all that apply)
1. Infection, bladder spasms, blood clots
A client with ESRD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage cloudy. What is the most appropriate action by the nurse?
1. Inform the physician and assess the client for signs of infection.
The nurse is caring for clients on the renal unit. Which task is most appropriate for the LPN to delegate to the UAP?
1. Instruct the UAP to calculate the client's urinary intake and output
The nurse has been asked to participate in a healthy living workshop. While teaching about women's health, which guidelines should the nurse provide to the audience?
1. It's recommended that you get a mammogram each year after you turn 40
A client with CKD is taking lisinopril. The client's potassium is 5.8. the nurse understands that which of the following is causing the potassium to increase?
1. Lisinopril causes alderstrone to decrease, which causes potassium to increase.
The nurse is developing a plan of care for a client who is admitted with congestive heart failure exacerbation. The client has a glomular filtration rate (GFR) of 12, bilateral 2+ pitting edema in the lower extremities, extreme dyspnea on exertion, and crackles in the right and left lower bases of the lungs. The client is prescribed furosemide 40 mg IVP BID. Which of the following interventions will the nurse include for this client? Select all that apply.
1. Monitor potassium levels, weigh client every morning, monitor clients v/s, strictly monitor I/O daily, educate the client about the importance of asking for help before ambulating.
The nurse is caring for an elderly client who has an indwelling catheter. The client has a change in mental status. What is the nurse's most appropriate intervention?
1. Notify the HCP
A client with chronic pain is on a sustained-release opioid that is ordered every 12 hours. After 12 hours. After 6 hours, the client complains of increasing pain. Which intervention by the nurse is appropriate?
1. Obtain an order for an immediate-release opioid for breakthrough pain.
The nurse is caring for a client with rheumatoid arthritis who takes celecoxib (Celebrex). The client is on a pureed diet, and the nurse from the previous shift reported some difficulty with oral pills. Which of the following actions by the nurse is best?
1. Open the capsule and sprinkle granules on applesauce.
A client with cancer is scheduled for palliative surgery. Which explanation should the nurse use to describe the purpose of this surgery?
1. Pallative surgery is done to increase the client's comfort when cure is not possible
The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions would the nurse implement? Select all that apply.
1. Place the client's urine in an appropriate specimen container for 24 hours, post signs on the client's door alerting staff to save all urine output
The nurse is reviewing the chart of a client to determine if he is appropriate for hospice. Which qualification supports hospice care?
1. Prognosis of 6 months or less.
The nurse is preparing to care for a client who is HIV positive. Which action should the nurse take when following standard precautions for protection from HIV exposure?
1. Put on gloves before touching body fluids
A client who has just returned from abdominal surgery states, "I learned relaxation exercises, so I won't need any drugs." Which statement about relaxation therapy should the nurse use to guide care for this client?
1. Relaxation therapy is an excellent adjunct treatment for pain when used with analgesics
A 70 y/o male arrives in the emergency department and says "I haven't urinated in 24 hours. I feel like I have to go, but I can't", which care does the nurse anticipate providing first?
1. STAT insertion of indwelling catheter.
The nurse is caring for a client who has CKD and is very weak due to low hemoglobin. Which of the following does the nurse understand is the best explanation for the anemia?
1. Secretion of erythropoietin by the diseased kidney is reduced.
A client is receiving a transfusion of packed RBC's. ten minutes after the infusion begins, the client reports low back pain and a headache. What action should the nurse take first?
1. Stop the infusion
A client who has been diagnosed with calculi reports that the pain is intermittent and has moved locations. Which of the following nursing actions is most important at this time?
1. Strain the urine carefully.
Which interventions will the nurse delegate to the UAP when caring for a client who is 2 days postoperative from kidney surgery? Select all that apply.
1. Take and record the client's V/S and pulse ox reading, empty the client's indwelling catheter at the end of the shift, assist the client to ambulate in the hallway 3-4 times a day.
A physician writes an order to give a saline flush to a client who has been requesting frequent meperdine (Demerol) shots. Which initial response by the LPN is best?
1. Tell the physician about feeling uncomfortable administering saline if the client thinks its Demerol.
The nurse is caring for a client with CKD who has a left forearm graft. Which action by the UAP requires immediate intervention by the nurse?
1. The UAP takes the clients BP in the clients left arm.
The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is best?
1. The irrigation is needed to keep the catheter from being occluded by blood clots.
A client with acute urinary retention associated with BPH is admitted to the emergency department. The client has had no urine output for 16 hours, and the lab work shows a BUN level of 50 mg/dl and the creatinine of 3.0 mg/dl.
1. The nurse will anticipate a HCP to order which of the following? Insert an indwelling catheter
The nurse is reinforcing teaching to a class on breast health to a group of ladies at the senior center. Which is the most important risk factor to emphasize to this group?
1. The older a women gets, the greater the chance of developing breast cancer.
The nurse is providing care for older adult clients in an extended care facility. Which patient will the nurse monitor most closely from symptoms of urosepsis?
1. The patient who has an indwelling catheter for a UTI
The nurse is discussing menstruation with a patient who is present for her yearly physical. The patient is 11 years old and states "I have not had a period yet and I hear so much at school it is confusing. Which detail about the function is unnecessary at this point?
1. The process is related to fluctuating estrogen and progesterone hormones.
The LPN is providing instructions on testicular self-exam. Which statements do the nurse include in this teaching? Select all that apply.
1. The testicle should be examined monthly while in the shower, the left side of the scrotum usually hangs a little lower than the right, if you notice any lumps or unusual changes, you should call your doctor.
The nurse is caring for a client who is complaining of pain in the back from nephrolithiasis. Where should the nurse assess for pain at the right costovertebral angle?
1. Top left 353,518 and bottom right coordinates 470,629
The nurse is caring for an 86 year old female client. The client is asking what changes to expect due to getting older. The nurse explains that the following changes will be seen in the renal and urinary system. Select all that apply.
1. Urine retention, dysuria, urinary frequency
The nurse is teaching a client about nonpharmacological therapies. Which topics should the nurse include in the teaching? (select all that apply).
1. Use of guided imagery, watching TV for distraction, biofeedback techniques, application of heat
A client is diagnosed with an AKI, has azotemia and is septic. Which of the following orders written by the HCP would the nurse question?
1. Vancomycin 2 g IV BID
A client is to receive a transfusion of packed RBC's. before administering the transfusion, which action should the nurse take?
1. Verify blood type of the client and donor
The nurse is reinforcing teaching about to a female client who has acute cystitis and is starting therapy with phenazopyridine (Pyridum) which of the following information should the nurse give to the client?
1. Wear a protective pad under your clothing to prevent staining of your clothing
The nurse is preparing an oral chemotherapeutic medication for a client's cancer treatment. What should the nurse do to ensure personal safety preparing this medication?
1. Wear gloves while preparing
The nurse contributed to the teaching plan for a client with a history of allergies to pollen. Which client action indicates an understanding of how to control this disease?
1. Wearing a mask when mowing the lawn.
The nurse is caring for a client who has congestive heart failure exacerbation and ESRD. The client has a bilateral 2+ pitting edema in the lower extremities, extreme dyspnea upon exertion, and crackles in the right and lower bases of the lungs. The client is prescribed furosemide 40 mg IVP BID. Which of the following nursing interventions would the nurse expect for this client? Select all that apply.
1. Weight client every morning, monitor client's v/s, strictly monitor I/O daily, educate the client about the importance of asking for help before ambulating
Nitroglycerin 125 mg IV in 500 mL D5W is infused at 42 mcg/min. Determine the flow rate in mL/hr. (round to the nearest whole, do not include unit in answer?
10
The nurse is administering clindamycin (cleocin) 300 mg in 100 mL of NS IV to run over 1 hour to a client with an infection. At what rate will the nurse set the infusion pump? Enter the numeral only. Round to the nearest whole number.
100
The nurse is preparing to administer metronidazole (Flagyl) 500 mg in 100 mL of NS to run over 1 hour IV to a patient with an infection. At what rate will the nurse set the infusion pump? Enter number only.
100
the doctor orders 750 mL bag of IV NS to infuse at a rate of 65 mL/hr. how long will it take for the IV bag to completely infuse?
11 hr 32 min
Ordered is misoprostol (Cytotec)200 mcg PO to be given Q4H for 24 hours. On hand is 100 mcg tablets. How many tablets would you administer per day? (round to nearest whole) (do not include your units in answer
12
6 y/o weighing 25 kg has a staph infection and the provider has ordered penicillin. The recommended dose of penicillin for children is 25-20 mg/kg/day po in equally divided doses administered q6h. what is the maximum recommended range of milligrams of medication for this child per day?
1250
A pediatrician orders Demerol 1 mg/kg/day PO divided Q4H for a child weighing 33 lbs. How many mg of Demerol should the child receive daily?
15
The nurse is caring for a client with HF receiving enalapril (Vasotec) 5 mL PO daily. The available dose is 2.5 mg tablets. How many tablets will the nurse administer?
2
The nurse is preparing to administer Heparin 5,000 units SQ to a client to prevent DVT. The available dose is Heparin 2,500 units/mL. how many mL will the nurse administer? Enter number only.
2
The nurse is preparing to administer bumetanide (Bumex) 0.50 mg IV. The available dose is 0.25 mg/mL. how many mL will the nurse administer: enter the numeral only.
2
The nurse is preparing to administer diphenhydramine (Benadryl) 50 mg IV to a client with severe allergies. Available is diphenhydramine 25 mg/1mL. how many mL will the nurse administer?
2
order: cefepime (maxipime) 0.75 g Available: a vial of cefepime powder. Directions: add 2.6 mL of sterile water to yield 200 mg/mL for a total volume of 3 mL after reconstitution. How much diluent will be added to the powder for reconstitution?
2.6
The nurse is preparing to administer cefazolin (ancef) 1 g in 100 mL of NS to run over 30 minutes IV to a patient as a surgical prophylactic medication. At what rate with the nurse set the infusion pump? Enter the number only.
200
The nurse is preparing to administer fluconazole (Diflucan) 50 mg in 100 mL of NS to run over 30 minutes IV. At what rate should the nurse set the infusion pump?
200
The nurse is calculating the intake of a patient who underwent surgery. The patient consumed two 240-mL juice box, 800 mL of water, 120 mL of gelatin and 2 40 mL cups of soda. The patient also received 1 L of LR IV. Calculate the patient's total intake (in mL) enter number only.
2480
Doctor orders 400 mL NS to infuse over 4 hours. Drip factor 15 gtt/mL. what is the correct flow rate to administer the infusion?
25
as IV I ordered to infuse at 150 mL/hr. the nurse has an IV infusion set with a drop factor of 10 gtt/mL. what is the flow rate for the gravity infusion?
25 gtt/min
A client is receiving ciproflaxin to treat a UTI. The physician has ordered Ciproflaxin 400 mg IV to be given over 2 hours. The premixed solution in a 500 mL bag of NS. What will the nurse set the IV pump to run at?
250
A pediatrician has ordered ampicillin 50 mg/kg/day PO to be divided Q6H for a child who weighs 44 lbs. How many mg should the child receive per dose?
250
a pediatrician has ordered ampicillian 50 mg/kg/day po q6h for a child who weighs 44 lbs. how many milligrams will the child receive per dose?
250
The client has following for lunch. 8 oz of apple juice, 3 TBS of chicken broth and 1 tsp of beef broth. How many mL has the client consumed?
290
The physician orders 1200 mg of renagel to be given q6h. the nurse has 400 mg tablets available. How many tablets will the nurse administer?
3
A nurse is reinforcing teaching for a client who is on four injections of regular insulin daily. About how many hours after each injection of insulin does the nurse teach the client to be alert for symptoms of hypoglycemia?
3 hours
The client with ESRD is placed on a fluid restriction of 1500 mL per day. On the day shift the client drank 2-8 oz cups of coffee, 8 oz of ice chips, 16 oz of water and 3 TBS of chicken broth. Whtat amount of fluid can the night shift give the patient
375
Dopamine 800 mg in 500 mL NS IV at 15 mcg/kg/min. weight is 70 kg. calculated the flow rate for the infusion pump. (round to nearest tenth. Do not include unit in answer)
39.4
A client has an IV administration of NS running continuously at 35 mL/hr. for dinner at 1800, the client had an 8 oz bowl of chicken broth, 4 oz jello, 120 mL of sweet tea. The client had a bladder irrigation with a solution amount of 550 mL with an output of 725 mL. the client also experienced watery diarrhea of 150 mL at 1000, emesis of 85 mL at 1300, and wound drainage of 60 mL collected at 0600 this morning. What is the total output in mL for this patient between the hours of 0700 and 1900?
410
A client has an IV administration of NS running continuously at 35 mL/hr. for dinner at 1800, the client had an 8 oz bowl of chicken broth, 4 oz jello, and 120 mL of sweet tea. The client had a bladder irrigation with a solution amount of 550 mL with an output of 725 mL. the client also experienced watery diarrhea of 150 mL at 1000, emesis of 85 mL at 1300, and wound drainage of 60 mL collected at 0600 this morning. What is the total output in mL for this patient between 0700 and 1900?
410
1000 mL D5W to infuse in 8 hours drop factor is 20 gtt/mL (round to nearest whole, do not include unit)
42
The nurse is calculating the intake for a client who received 50 mL of an antibiotic, 120 mL of juice, 60 mL of water and 240 mL of green tea. How much intake is measured?
470
the nurse is receiving a client who is a roofer and became confused and disoriented while on the roof during the heat of the day. The nurse anticipates that which isotonic IV fluid may be included in the treatment plan?
5% dextrose in water (D5W)
The nurse is administering fluconazole (Diflucan) 100 mg in 50 mL of normal saline to run over 30 minutes using a 30 gtt/mL drop factor. Calculate the flow rate. Round to the nearest whole number. Enter the numeral only.
50
The nurse reviews an order to administer LR 1000 mL to run over 2 hours IV to a patient in the recovery room. At what rate will the nurse set the infusion pump?
500
The nurse is preparing to administer acyclovir (zovirax) to a client with HIV who also has a diagnosis of herpes zoster. The prescribed dose is 10 mg/kg BID to a client who weighs 60 kg. available are 200 mg tablets how many tablets will the nurse administer daily?
6
the order is for oral morphine solution 30 mg q3h around the clock. Oral morphine solution is available in 20 mg/5 mL. how many mL will the patient receive per day?
60
6 y./o weighing 25 kg has a staph infection and the provider has ordered penicillin. The recommended dose of Penicillin for children is 25 to 50 mg/kg/day po in equally divided doses administered q6h. what is the minimum recommended range of milligrams of medication for this child per day?
625
The nurse is preparing to infuse a liter of NS over 4 hours IV to a pt who experienced a hemolytic reaction to blood. The drop factor is 15 gtt/mL. calculate the drip factor. Enter the number only. Round to nearest whole number.
63
calculate the IV flow rate for 100 mL NS to infuse over 30 minutes. Drop factor is 20 gtt/min?
67
A client with an AKI is placed on a fluid restriction of 1750 mL per day. On the day shift the client consumed 10 tsp of vegetable broth, 3-8 oz of water, 16 oz ice chips. What amount of fluid can the night shift nurse give the client?
740
The nurse is providing a blood transfusion and sets the infusion pump to run at 300 mL/hr for 15 min. what is the amount of blood that will be transfused at the time (in mL)?
75
The nurse is teaching a group of clients about hypertension. Which client is highest risk for developing hypertension?
A 60 y/o African American female who is 5 foot 7, weighing 275 lbs.
The nurse is caring for a group of clients. Which client does the nurse identify at the highest risk for developing an infection?
A 60-year old who lives in a long-term care facility
The nurse is reviewing the CD4 count results of a client with AIDS. What can the nurse expect to find?
A CD4 count of 100/
the charge nurse on a medical surgical floor is assigning clients to 1 LPN and 1 RN. Which of the following clients would be assigned to the RN?
A 34 y/o patient with potassium of 5.9 mEq/L
in which situation should the nurse assess vital signs instead of delegating it to a UAP? Select all that apply.
A client is being administered IV medication that may affect the V/S, a client is being admitted to the facility, a client has pale, cold and clammy skin., a client is in an unstable postoperative condition.
The nurse is caring for a client with folic acid deficiency anemia. Which client is at risk for this condition?
A client who drinks alcohol daily
The nurse is reviewing laboratory results for a group of clients and notes a CD4 count of 120 cells. For which client would the nurse expect to see the result?
A client with HIV
The nurse is caring for a group of clients. Which patient should the nurse see first?
A client with a BP of 180/120 mm Hg reporting a nosebleed
The nurse is caring for a group of clients. Which client should the nurse see first?
A client with a WBC of 2,000 cells.
the nurse is caring for a group of clients. Which patient most warrants a phone call to the health care provider?
A client with abdominal cramping and hyperactive deep tendon reflexes.
The nurse is caring for a group of clients. Which client should the nurse see first?
A client with an aneurysm reporting sudden back pain.
The nurse is caring for a group of clients on the telemetry unit. Which client should the nurse see first?
A client with atrial fibrillation reporting dyspnea.
The nurse is working on a medical-surgical nursing unit and is caring for several clients with CKD. Which client does the nurse expect will be given the option for peritoneal dialysis as a treatment.
A client with severe heart failure.
A client is identified with a thyroid disorder resulting in hormone deficiency. The HCP prescribes a stimulation test. Which process does the for the test?
A substance will be injected into the client.
The LPN/LVN is monitoring a client with a goiter who is scheduled for surgery. Physical inspection reveals only slight swelling in the anterior base of the neck. Which manifestation will prompt the LPN/LVN to notify the RN?
A whistling sound is heard when breathing
The nurse is providing care to a client with a hematological disorder. Which of the following would be a manifestation of disseminated intravascular coagulation (DIC)?
Absent peripheral pulses
the nurse is caring for a client with AKI that is scheduled to go for a CT scan with contrast. The nurse expects to see which medication ordered to protect the kidneys from the contrast dye?
Acetylcysteine
The nurse is assisting in the development of a care plan for a client with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?
Activity intolerance related to tissue hypoxia
A client is being treated for the AIDS-related condition of herpes zoster. Which medication will likely be prescribed by the physician?
Acyclovir (Zovirax)
the mother of a 6 y/o Vietnamese child, admitted with pneumonia, is rubbing a coin on the child's back. The coin leaves red marks. Which action by the nurse is best regarding this observation?
Add a statement to the care plan that the family practices coining.
The nurse is caring for a client who underwent an amputation of the left arm. The client reports level 9 on the 0-10 pain scale. Which action should the nurse take?
Administer 4 mg of morphine IV as prescribed
The nurse is caring for a client with serum sickness. Which intervention should the nurse implement?
Administer Tylenol as ordered
the nurse is preparing to administer furoseminde (Lasix), kayexalate and insulin to a client with a potassium level of 6.8 mEq/L. which action should the nurse take?
Administer as ordered
The nurse is providing education to a client with mild hemophilia on how to avoid bleeding episodes. Which one of the following would be most appropriate to include in the teaching plan?
Administer desmopressin intranasally prior to any dental procedure or sport.
The nurse is working in a clinic when a client presents with shortness of breath, wheezing, and hives. The nurse should plan to implement which one first?
Administer epinephrine IV
The nurse is assisting in developing a plan of care for the client with hemophilia who is experiencing severe acute pain. Which of the following is the most appropriate intervention based on the nursing diagnosis acute pain related to bleeding into tissues?
Administer opioids as prescribed, avoiding IM injections.
The nurse is preparing to administer furosemide (Lasix) to a client with hypertension. The nurse reviews the client's potassium and notes a level of 4.6 mEq/L. which action should the nurse take?
Administer the medication as prescribed.
A summer camp worker reports SOB and audible wheezing to the camp nurse. Which inhaled medication will the nurse administer?
Albuterol
The nurse notices that the ST segment is depressed on a client reporting chest pain. What action should the nurse take?
Alert the supervising RN and client's physician immediately.
There are limited amounts of influenza vaccine currently available in the clinic. Which individual should the nurse identify as having the highest priority to receive vaccination at the time?
An 88 y/0 who lives in an apartment for senior citizens.
the nurse is assessing a group of clients. Which client does the nurse identify at highest risk for stroke?
An African American male
The nurse is reviewing lab values for a female client and notes a hgb of 8.2 and hct of 21% . these levels are found in clients with which condition?
Anemia
The nurse is reviewing the medications prescribed by the HCP for a client with COPD. Which prescription will cause the nurse to verify the ordered medication?
Antitussive
The nurse is caring for a client with chronic episodes of hypoxia secondary to chronic obstructive pulmonary disease. The nurse will monitor the patient's laboratory results for increased RBC's due to the low oxygen levels. Which of the following blood disorders will the nurse expect to find?
Aplastic anemia
After positioning a patient with epistaxis, which action will the nurse take next?
Apply ice to nose/eyes
a male nurse was assigned a female muslim client. Which of the following actions by the nurse is best?
Ask a female colleague take the client
the nurse is caring for a client with liver failure who is unconscious. The client's girlfriend of 12 years has been making health care decisions. The client is still legally married and his wife whom he has not seen in 20 years shows up and wants to take over in making decisions. Which of the following actions by the nurse is best?
Ask for an ethics committee consult.
The nurse is caring for a client with idiopathic autoimmune hemolytic anemia. Which action should the nurse include in the plan of care for this client?
Assist with ambulation
The nurse is following the care plan risk for ineffective peripheral perfusion related to sickled cells and infarction. Which is most appropriate intervention?
Avoid restrictive clothing and raising the knee gatch in the bed.
the nurse reviews a client's electrolyte levels on a laboratory report and notes the client has hyponatremia. Which symptoms will the nurse expect to find during assessment?
BP of 100/58
pedal pulse The nurse is reinforcThe nurse is calculating the intake for a client who received 50 mL of an antibiotic, 120 mL of juice, 60 mL of water and 240 mL of green tea. How much intake is measured?ing discharge teaching to a client with IE. Which topics will the nurse include in the teaching? (select all that apply)
Brushing teeth with a soft-bristle toothbrush, avoid biting nails, report fever or chills to HCP, instruction on proper handwashing.
The nurse finds a client gasping for breath and looking very anxious. Based on the clients history, the nurse believes the patient may be experiencing a PE. Which action should be taken first?
Call for help and start oxygen
The nurse is contributing to the plan of care for a client who has CKD. The client asks the nurse what are possible effects of this conditions? What is the best response from the nurse? Select all that apply.
Cardiac dysrhythmias, anorexia, n/v, anemia
Management of asthma involves avoidance of triggers. Which environmental triggers will the nurse suggest the client eliminate?
Carpet and drapes in bedroom, exposure to secondhand smoke, pets and foods that cause symptoms
the IV infusion pump for a client receiving IV therapy begins to alarm and displays an 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.
A client has a bone marrow aspiration from the posterior iliac crest. Before the procedure, the client's vital signs were blood pressure ?????, pulse 88 bpm. One hour after the procedure, the blood pressure is 108/70, pulse is 96 bmp. Which assessment is important for the client at this time?
Check the clients most recent CBC report
The nurse is planning to review information with a client diagnosed with diabetes. Which information does the nurse include regarding an increased risk for and treatment of infection?
Circulation may not be adequate to heal a wound or fight infection.
For which client would the nurse was her hands with soap and water instead of using an alcohol-based hand rub?
Cleaning stool off a client with C-Diff
A health care worker is exposed to blood from a client who has HIV. What action should the worker take after the exposure?
Cleanse with soap and water
The nurse is assessing a client who underwent an epidural block for a procedure 6 hours ago. Which findings should the nurse report to the RN? Select all that apply.
Clear fluid leaking from puncture site, headache, dizziness, nausea, visual disturbances
The nurse is collecting data for a client with cystitis. Which of the following would indicate a normal UA finding? Select all that apply.
Clear to amber color, pH of 5.5, specific gravity 1.010
The nurse is reviewing orders for a client with suspected cancer. The nurse notes an order for a carcinoembryonic antigen (CEA). For which cancer does this test?
Colon cancer
During a visit to the home of a client with HF and Diabetes, the nurse learns that the client "feels strange". Data collected includes blood pressure 172/94, HR 112 beat/min, respirations 22/min, heart rhythm regular, and coarse crackles in the lower lung bases. What action should the nurse take?
Consult the RN
The nurse is contributing to the teaching plan for a client who is allergic to dust. Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms?
Covering heating ducts with filters
The nurse is auscultating the lungs of a client with HF. Which can the nurse expect to document?
Crackles
The nurse is collecting data for a client with kidney disease. Which adventitious lung sound is the nurse most likely to note from fluid overload?
Crackles
. the nurse is caring for a client who is receiving vancomycin multiple times a day and a continuous infusion of normal saline at 50 mL/hr. the nurse notes which of the following signs of symptoms of fluid overload when assessing the client? Select all that apply.
Crackles in lungs, peripheral edema, SOB , full bounding pulses
The nurse instructs a client with renal failure, who is receiving hemodialysis, about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?
Cream of wheat, blueberries, coffee
The nurse is caring for a client who scheduled for a cardiac angiogram. The nurse knows to notify the physician regarding which of the following pre-procedure lab values?
Creatinine 3.0
The nurse is caring for a client with a suspected PE. Which diagnostic tests or procedures should the nurse expect to be prescribed for this client? Select all that apply.
D-dimer,angiogram, ventilation-perfusion lung scan,
The nurse is caring for a client who has CLL when the client suddenly develops petechiae, nausea, and severe back pain. The nurse recognizes the life-threatening event as which of the following?
DIC
The nurse is caring for a client with CKD who is fluid overloaded. What is the important information for the nurse to collect based on the diagnosis for this client?
Daily Weight
a nurse manager has to make a decision about scheduling and asks the nurses on the unit before making a decision. This demonstrates which style of leadership?
Democratic
The nurse is caring for a client receiving treatment for a hemolytic anemia due to a reaction from a mismatched blood transfusion. The nurse understands that hemolytic anemia is a definition of what type of anemia?
Destruction of RBC's
years. The nurse is collecting data from a client. Which approach should the nurse use to determine the presence of a Homans sign?
Dorsiflexing the clients foot sharply and asking if calf pain occurs.
The nurse is preparing to provide an opioid medication for a client's postoperative pain. Which action should the nurse take first?
Determine the respiratory rate
Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause?
Do you sleep well at night?
A client is scheduled for diagnostic test for hypothyroidism. Which symptoms does the nurse expect to observe in a client with this disorder?
Dry skin and slowed heart rate
The nurse is collecting information from a female patient who is 55 years old. The patient is postmenopausal for 8 years. The patient is also small boned, Caucasian, and has never been pregnant. Which type of bone testing does the nurse suggest to the patient?
Dual energy x-ray
The nurse is reviewing compensatory mechanisms with a client in heart failure. What should the nurse include when providing this teaching? (select all that apply)
EPI and NONEPI are released, kidneys activate the renin-angiotensin-aldosterone system.
The nurse is contributing to a teaching plan. What should the nurse emphasize as being the most effective method known to control the spread of HIV infection?
Education about preventive behaviors
The nurse is monitoring a client admitted for testing of DI. Which observation by the nurse is unexpected?
Elevated blood glucose levels
the nurse is caring for a client admitted with fluid volume deficit. Which diagnostic test results does the nurse identify as supporting the client's diagnosis? Select all that apply.
Elevated urine specific gravity, elevated BUN, high hematocrit level
The nurse is assisting a health care provider with subcutaneous immunotherapy (SCIT). Which is a priority to have readily a available?
Emergency equipment
The nurse is caring for a client who has developed an increased temperature during the first 24 hours postoperatively. Which action should the nurse take?
Encourage coughing and deep breathing
The nurse is caring for the client who underwent emergency treatment for DIC. The client voices concern over how to explain the tubes and extensive bruising to his family members. Which of the following would be an appropriate nursing intervention for disturbed body image related to physical evidence of aggressive treatment procedures?
Enlist the aid of other members of the health care team to support the family.
the nurse is caring for a client who values time. Which demonstrates respect for the cultural phenomenon?
Ensure 0900 medications are administered at 0900 and not 0920.
a client who is Jehovah's witness has severe gastrointestinal bleeding and a dangerously low hemoglobin level. The client is fully alert and competent and refuses to accept the blood transfusion ordered by the physician. Which action by the nurse is most appropriate?
Ensure the patient understands possible consequences and then respect the patient's wishes.
A client recovering from surgery denies postoperative pain, however, vital signs indicate an elevated pulse and blood pressure. The client refuses to move in bed. Which nursing action would best ensure comfort and timely discharge?
Explain that the pain medicine will help prevent complication.
the nurse suspects the client has developed septicemia as a complication of peripheral IV therapy. Which clinical manifestation supports the nurse's suspicion?
Fever and chills
before leaving a client's room, the nurse says that pain medication will be provided in 15 minutes. The nurse returns in 10 minutes with the pain medication. Which ethical principle did the nurse demonstrate?
Fidelity
A young adult is admitted with manifestations associated with cystic fibrosis. What should the nurse expect to find when collecting data from this client? Select all that apply
Finger clubbing, thick sputum production, body mass index 16, complaints of frequent foul-smelling stool
the nurse is collecting data on a client who experienced a sports injury to the lower back area. Which finding will cause the nurse greatest concern?
Flank edema and bloody urine.
while receiving lab results, the nurse notes that one of the clients has a low blood urea nitrogen (BUN) level. Which cause is most likely related to the result?
Fluid volume excess
A client is prescribed to receive 2 units of PRBC's. what approach should the nurse use to ensure that the correct blood be provided to the patient?
Follow the organization's verification process
1. The nurse is concerned that a client has a short time left to live. Which criterion is the nurse using that indicates a prognosis of 6 months or less to live? (select all that apply)
Functional decline, recurrent infections, frequent hospitalizations, weight loss of 10% or more
. the nurse is caring for a client with fluid volume excess. Which medication can the nurse expect to administer?
Furosemide (Lasix)
The nurse is researching info for a client newly diagnosed with DM. the RN wants to present the responses by hormones other than insulin. Which information does the nurse avoid?
GH and GH inhibiting hormone (GHIH) are secreted to maintain BG levels and metabolism rates are normal
The nurse is caring for a client with stage IV Hodgkins disease. Where should the nurse expect to find enlarged lymph nodes during the assessment?
Generalized throughout the body within multiple organs
The nurse is assessing the client diagnosed with chronic myelogenous leukemia (CML). What of the following indicates a positive diagnosis for CML?
Genetic analysis of bone marrow reveals Philadelphia chromosome.
A client recovering from hernia repair surgery reports pain level of 4 on a 0-10 scale. The client's orders include ibuprofen (motrin) 400 mg orally every 6 hours pm (as needed) for pain. Which action should the nurse take?
Give the ibuprofen as ordered for pain.
The nurse is reviewing lab values for a client who will undergo surgery. Which value requires notification of the surgeon?
Glucose of 383 mg/dL
The nurse is monitoring lab BG levels for a client diagnosed with type 2 DM. which test result does the nurse use to evaluate the client's compliance with tx?
Glycohemoglobin test (HbA1c)
A client with type 1 DM expresses concern about developing retinopathy due to a chronic disease. Which information does the nurse explain to the patient the best reassurance?
Good control of BG and blood pressure can reduce the risk
a client having a severe anxiety attack has an arterial blood gas result showing respiratory alkalosis. Which nursing action should the nurse take first?
Have the client rebreathe air from a paper bag
the nurse is caring for a client from korea who does not speak or understand English. The patient's 8 y/o son offers to interpret medical information. Which are reasons to be cautious of allowing him to interpret? Select all that apply.
He may not be mature enough to handle information being conveyed, using the son to interpret violates the patients right to privacy, the son may intentionally omit information being conveyed.
While collecting data, a client expectorates pink, frothy sputum. Which health problem should the nurse consider is occurring in this client?
Heart Failure
The nurse is reviewing complications of hypertension with a client. Which should the nurse include in the teaching? (select all that apply)
Heart failure, stroke, MI, Kidney failure
The nurse is caring for a client in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this client?
Heat increases circulation by preventing vasoconstriction
A client recovering from an abdominal hysterectomy is experiencing abdominal gas pain. Which action should the nurse take?
Help the client ambulate
The nurse is caring for the client with iron deficiency anemia, who has been taking oral iron supplements. Which of the following laboratory tests would determine the effectiveness of this intervention?
Hemoglobin and hematocrit
The nurse is caring for a client with herpes simplex. Which statement related to disease transmission should the nurse include in the client's discharge teaching?
Herpes simplex is transmitted through direct transmission.
The nurse is caring for a client who is stung by a wasp. Which manifestation should the nurse expect if an allergic reaction develops?
Hives
The nurse is assisting during surgery when a client develops malignant hyperthermia. Which protocol should the nurse prepare to assist with as directed?
Immediately cease anesthesia and surgery. Cool client, and administer dantrolene sodium.
A client is admitted to a respiratory unit with a diagnosis of pneumonia. Assessment data reveal the patient to be febrile and congested-sounding cough, with moist crackles through the lungs fields. Based on the data provided, the nurse will focus care.
Inability to clear the airway
The nurse is providing education to a client newly diagnosed with iron deficiency anemia. Which of the following would be a component of the education?
Include citrus fruits while taking the medication for this disorder.
A client is prescribed a dose of epinephrine. Which effects does the nurse expect the client to exhibit after receiving the medication? Select all that apply.
Increase HR and force of contractions, stimulates vasoconstriction in skin and moist viscera, decreases peristalsis, stimulates liver to convert glycogen to glucose
The nurse is caring for a client receiving chemotherapy who is in the nadir period. For which complication is the nurse at risk?
Infection
The nurse is caring for a client who reports enlarged, painful, and moveable preauricular lymph nodes, and cerv. Nodes. Which does the nurse infer from these findings?
Infection
the nurse who is caring for a client with an infusion of D5 1/2NS 1,000 mL with 20 mEq KCL at 100 mL/hr notes that there is slight swelling at the insertion site and no blood return when aspirating at the injection port closest to the IV site. Which of the following problems does the nurse suspect?
Infiltraton
The nurse is caring for a client with iron deficiency anemia, which of the following would be the most appropriate nursing intervention for this client?
Instruct the client to notify the HCP of nausea or constipation.
The nurse is aware that the pancreas is the only gland that is both endocrine and exocrine. Which secretion is related to the endocrine of the pancreas?
Insulin
The nurse is providing care for a client diagnosed with complications related to cushing syndrome. Which situation indicates a need for a change in nursing intervention?
Insulin for high BG is administered by the nurse.
the nurse is teaching a client about taking oral potassium supplements. Which topics should the nurse cover in the teaching? Select all that apply.
Keep appointments for lab tests to check potassium level, do not crush extended-release potassium tablets.
which statements are true regarding delegation of duties to unlicensed assistive personnel by a licensed nurse? Select all that apply.
LPN must be familiar with the job descriptions of UAP's, the LPN in charge must be familiar with the competency of staff, the LPN must be familiar with the job description of UAP's.
The nurse is gathering information from a client in a HCP's office. The client reports difficulty speaking and swallowing and, recently, frequent headaches. Which additional manifestion does the nurse observe that indicates a possible glandular dysfunction?
Large fleshy hands
The nurse is collecting data from a client who has chronic venous insufficiency of the lower extremities. Which finding should the nurse expect?
Leathery, brown skin
The nurse is caring for a client who had a cardiac cath using the left femoral site for entry. Which data is most Important for the nurse to monitor?
Left pedal pulse
The nurse is caring for the client who underwent emergency treatment for DIC. The client voices concern over how to explain the tubes and extensive bruising to his family members. Which of the following would be appropriate nursing intervention for disturbed body image related to physical evidence of aggressive treatment procedures?
Limit the number of visitors to two at a time for short intervals.
A client being treated with rosiglitazone for type 2 DM is receiving a routine follow-up assessment. In addition to HbA1c and a fasting plasma glucose test, which other lab test should the nurse expect to be monitored in this client?
Liver function test
which action by the nurse best demonstrates adherence to the HIPPA?
Logging out of the computer after documenting patient care.
The nurse is caring for a client who reports feeling several enlarged lymph nosed. The nurse should plan to prepare the client for which test?
Lymphangiography
The nurse is providing care for a patient who is on fluid restrictions due to renal failure. The patient's I/O's should be carefully measured. Which substance does the nurse exclude from the intake total?
Mashed potatoes and creamed corn
The nurse is caring for the client who is 1day post splenectomy. The client complains of pain with breathing especially with inspiration. What would be the most appropriate nursing intervention for this client?
Medicate with opioids for pain and assist the client to deep breathe, cough and ambulate.
The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which additional diagnosis does the nurse need to identify as a contributor to the patient's disorder?
Mental health disorder
the nurse is providing care for a client whose ABG results are pH 7.48, CO2 44, NaHCO3 29. Which conclusion about the client's condition will the nurse draw from the test results.
Metabolic alkalosis
which topic should the nurse include in a health promotion course for a Pacific Islander?
Methods of preventing HIV
The nurse is reviewing a plan of care for a client who is having an IVP done to diagnose possible bladder cancer. Which intervention will the nurse perform for the client after the procedure?
Monitor creatinine level
The nurse is caring for a client with a platelet count of <20,000/mm. which of the following precautions should the nurse take in providing care for this client? (select all that apply).
Monitor for black tarry stools, avoid blood draws when possible, ,use soft toothbrush to clean the teeth.
The nurse is caring for a client with angioedema. Which nursing action should have the highest priority?
Monitor for restlessness
the nurse is providing care for a client admitted with fluid volume overload. Which nursing care will the nurse implement for this client? Select all that apply.
Monitor the effects of diuretic therapy, obtain a daily weight on the same scale, assess intake and output results for imbalance and teach about foods naturally high in sodium.
The nurse is caring for a client who underwent a bone marrow biopsy. What is the role of the LPN/LVN in this client's care?
Monitor the site for bleeding and infection
The nurse is assessing a client and notes a prolonged, very loud swishing sound. The nurse knows this describes which of the following?
Murmur
The nurse is reviewing laboratory values for a client and notes a potassium level of 6.4 mEq/L. which clinical manifestation can the nurse expect the client to report?
Muscle cramps
an older adult client has an IV infusion of 0.45% normal saline infusing at 150 mL/hr. which assessment finding should cause the nurse to be most concerned about?
Newly noted crackles in lungs
The nurse is providing care for a client diagnosed with posterior pituitary tumor resulting in oversecretion of hormones. Which disorder will the nurse expect?
Notable increase in blood pressure
The nurse is caring for a client who underwent a colostomy yesterday morning. The nurse removed the catheter 1 hour after the surgery and the client has not voided. Which action should the nurse take?
Notify HCP
The nurse is caring for a client and notes the client is coughing up pink, frothy sputum. Which action should the nurse take?
Notify the HCP
The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. The client has a temp of 99.8, urine output of 70 mL in 3 hours, absent bowel sounds and complains of a pain level of 6/10 20 min post receiving oral pain meds. What is the appropriate intervention by the nurse?
Notify the HCP about the urine output
A healthy postoperative client who has been on bedrest for 3 days suddenly develops dyspnea, tachypnea, restlessness, and chest pain. The client says "I feel as if something is going to happen to me" which action should the nurse take?
Notify the HCP immediately
The nurse assesses a client's pain level to be an 8 on 1-10 scale. The nurse notes the client has a order for morphine 4 mg IV as needed for pain. The clients BP is 80/54 mm Hg, respirations 10 breaths per minute and pulse of 64 beats/min. what action should the nurse take?
Notify the RN
The LPN?LVN is reviewing lab results for a client with COPD. Which action does the LPN/LVN take if the ABG analysis shows a PaCO2 of 62 mm Hg?
Notify the RN of the high lab results.
the nurse is caring for a client receiving a continuous IV infusion who develops sudden dyspnea, chest pain, and change in mental status. Which interventions should the nurse implement? Select all that apply.
Notify the health care provider, administer oxygen as ordered, monitor V/S
The nurse is caring for a client who is about to undergo a mastectomy. The nurse notes that the client has not signed the consent. 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 client has not signed the form and does not understand the surgery.
The LPN is taking a hx on a client who is scheduled for surgery in which he was to remain NPO after midnight. The nurse asks the client when he had something to eat or drink last, to which the client replies "about 2 hours ago." Which action should the nurse take?
Notify the surgeon immediately
The nurse has been discussing actions to prevent AIDS-related wasting syndrome with a client being treated for AIDS. Which client statement indicates an understanding of this teaching? Select all that apply.
Numb painful oral sores with ice or popsicles, eat three high-calorie, high-protein meals a day, plus snacks, eat low-residue diet
The LPN/LVN is assisting with the physical examination of a client in the HCP's office, which physical examination does the LPN/LVN perform?
Observes for abnormal physical characteristics.
A client with heart failure is prescribed bedrest, but becomes angry and walks to the bathroom independently to use the commode. How should the nurse handle this situation?
Obtain a bedside commode.
The HCP prescribes a 24 hour urine specimen for cortisol. The client is incontinent. Which method will the nurse use to collect the specimen?
Obtain an order for indwelling catheter during test.
The nurse is planning care for a patient diagnosed with chronic renal failure. The nurse notes that the patient's output is 620 mL for the past 24 hours. The patient has periorbital edema and crackles in all lung fields upon auscultation. Which intervention is most important for the nurse to implement during care of this patient?
Obtain daily weight
The nurse is providing information to a client recently diagnosed with type 2 DM. The HCP prescribes an oral hypoglycemic medication for BG control. Which information is the best comparison the nurse can give the client between insulin and an oral hypoglycemic?
Oral hypoglycemic agents stimulate a partially working pancreas
The nurse is caring for the client with hemoglobin less than 6 g/dL. Which of the following clinical manifestations would the nurse expect the client to present?
Orthopnea, blurred vision and pruritus.
The nurse is caring for a client with pericarditis who develops hypotension, confusion, tachycardia, tachypnea, and JVD. For which procedure should the nurse prepare the patient?
Pericardiocentesis
the nurse is caring for a client with an IV. The client begins to have redness and swelling at the IV site. The client also complains of burning and tenderness at the IV site. Which does the nurse suspect?
Phlebitis
The nurse is taking a healthy history for a client who is ill. The client states that no one in his family is sick nor has he been around any sick individuals. The nurse suspects the client likely contracted the illness by indirect transmission. Which is an example of this type of transmission?
Picking up a toy a sick child has played with.
A client with TB who is in respiratory isolation must go to the x-ray department. Which action will the nurse take?
Place a mask on the client's nose and mouth
while assessing an older adult client with fluid excess, the nurse notes the following T=98.6, P = 92, R = 18, BP = 166/88 mm Hg bilateral crackles, oxygen saturation = 95%. Which action should the nurse take first?
Place pt in high fowlers position
The nurse is triaging several clients in an urgent care center. One client states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which action by the nurse is most appropriate at this time?
Place the client in an examination room immediately and notify the physician of a potential bleeding crisis.
the LPN/LVN is assessing a client receiving IV therapy and notes crackles upon auscultation of lung sounds and puffy eyelids. Which action should the nurse take first?
Place the client in semi-fowler position.
The nurse is teaching a class for older adults regarding the importance of vaccinations. Which vaccination should the nurse suggest for this age group?
Pneumococcal vaccine
The nurse is collecting data from a client experiencing an MI. which finding should the nurse expect.
Profuse diaphoresis
The nurse is caring for a client who is receiving morphine via PCA. Which finding would be of most concern to the nurse?
Respirations 10 beats/min
A client is diagnosed with respiratory failure. Which acid based abnormality should the nurse expect the patient to demonstrate?
Respiratory acidosis
the nurse is caring for a client with a longstanding diagnosis of generalized anxiety disorder presents to the ER. The nurse is aware that hyperventilation is the most common cause of which acid-based imbalance?
Respiratory alkalosis
The nurse is caring for a client who has possible kidney damage from high blood pressure. Which action should the nurse take first?
Review creatinine level
The home care nurse is providing teaching to the family of a client with multiple myeloma. Which nursing diagnosis should guide the nurse for this teaching?
Rick for injury related to compromised bone integrity
Place in order, from 1-5, the sequence for normal electrical impulse movement through the cardiac conduction system.
SA Node, Left/Right Bundle Branches, Bundle of His, AV Node, Purkinje fibers.
The nurse is caring for a client with aortic regurgitation. Which intervention is most important for the nurse to implement?
Schedule activities with periods of rest
The nurse is caring for a client with pulmonary edema. The nurse should place the client in which position?
Semi or High Fowler's
the nurse is collecting data on a patient with chlamydia. Which assessment finding should be reported immediately to the RN or physician?
Sharp pain at the base of the ribs
a nurse delegates activities of daily living to a CAN. ADL's that can be delegated to a CAN include which of the following? Select all that apply.
Showering patient, assisting a patient dressing, shaving a patient.
The nurse is reinforcing teaching for a client with hypertension. If a patient states, "I understand that if I do not eat or cook with salt, my hypertension will go away" what is the nurses best response?
Some patients blood pressure may not respond to salt restriction alone.
A patient develops a hospital-acquired surgical wound infection. Which organism should the nurse recognize as being the most likely cause of this infection?
Staphylococcus aureus
The nurse is sitting at the desk watching the telemetry monitors and notes a client's rhythm suddenly shows asystole. Which action should the nurse take first?
Start CPR
The nurse is caring for a patient who received a blood transfusion and experienced a hemolytic reaction. Place in order, from 1-5, the steps the nurse should take.
Stay with the patient, stop the infusion, have another nurse contact HCP, administer IV fluid, call the blood bank.
the nurse is caring for a Hispanic client and calls a local catholic priest to come visit with the client without asking religious preference what has the nurse demonstrated?
Stereotyping
What should the the nurse is providing IV push Meperidine (Demerol) through a free-flowing IV line and notes a hazy appearance in the tubing. nurse do first?
Stop the infusion
The nurse is providing care to the client with Hodgkin disease who has cervical lymph node enlargement. Which of the following symptoms should the nurse attend to first?
Stridor
The nurse is caring for a client who is unconscious and begins to make a gurgling sound, or death rattle. Which action should the nurse take?
Suction the client
The nurse is caring for a client with lung cancer who reports chest pain, dyspnea, facial redness, and swollen neck veins. Which oncological emergency does the nurse suspect this client is experiencing?
Superior vena cava syndrome (SVCS)
The nurse is preparing a client with type 2 DM for surgery. The client expresses concern about the use of insulin at this time. Which reason does the nurse understand that insulin therapy is appropriate in regard to surgery.
Surgery is a stressor causing counter-regulatory hormones to increase BG.
the nurse is counseling a young female client who is a long-distance runner. Which factor does the nurse recognize as the greatest risk for this client to develop dehydration?
Sweating and hard breathing will cause fluid loss.
the nurse receives report that the client is experiencing "third spacing" which manifestation will the nurse expect to see?
Swelling in the extremities
The nurse is discussing a terminal diagnosis with a client. Which is most appropriate for the nurse to include?
Tell me what you know about your diagnosis
The nurse is contributing to the teaching plan for a client who is taking nitroglycerin. Which action should be included if chest pain occurs?
Take one tablet every 5 min for 3 doses until pain is relieved.
a client with malnutrition refuses to ingest animal protein products, because it is against religious teachings. What should the nurse do to support this clients needs?
Talk with a dietician to accommodate patient.
the nurse is using Chvostek sign to assess for hypocalcemia. Which statement correctly describes this test?
Tap the face just below and in front of the ear
the nurse is caring for a European American client who is jewish. For which illness should the nurse suggest screening for before becoming pregnant?
Tay-Sachs disease
A client learns that a serum antibody test is positive. What should the nurse explain to the client about this test result?
The body has been exposed to an antigen.
The nurse is providing care to the client with suspected aplastic anemia. The HCP has completed a bone marrow biopsy. Which of the following would be a description of the bone marrow that would signify a positive diagnosis of aplastic anemia?
The bone marrow is pale, fatty and fibrous.
the nurse is providing care for a patient who had a mastectomy for breast cancer 2 days ago and is now developing pulmonary congestion. For which reason is the mastectomy patient at risk for pulmonary complications?
The chest incision makes a patient hesitant to deep-breath and cough
the nurse suspects a client is a victim of human trafficking. Which characteristic supports this suspicion?
The client has a man with her who answers all questions for her and will not leave her alone.
The nurse is caring for a client who is admitted with pneumonia. The nurse notes a BUN of 32 mg/dL and creatinine of 0.8 mg/dL. What is the most probable explanation for this finding?
The client is dehydrated.
The nurse is providing education to the client with the nursing diagnosis of impaired oral membrane integrity related to chemotherapy and pancytopenia. The nurse is aware that the patient understands the teaching by which of the following actions?
The client keeps her dentures in at all times except for cleaning.
The nurse caring for a client with chronic leukemia in an acute care setting the client asks the nurse to observe the client's last bowel movement as it is very dark. The nurse immediately contacts the primary HCP. What would explain the nurse's action?
The client may have a GI bleed
A client returns to the observation area after outpatient septoplasty for a deviated septum. Which observation will most concern the nurse?
The client swallows frequently
A client with type 1 diabetes has frequent episodes of hypoglycemia, even with multiple daily BG self-monitoring throughout the day. Which method of self-monitoring does the nurse recognize as being more effective for this patient?
The client will benefit from continuous monitoring
The nurse is caring for clients on the surgical unit. Which client should the nurse assess first after shift report?
The client with acute pyelonephritis who has N/V and is dehydrated.
A client with an arteriovenous fistula (AVF) in the left arm, who is undergoing hemodialysis, is at risk for infection. Which should the nurse formulate as the best outcome goal for this client's problem?
The client's WBC remains within 5000-1000 cells/mcL
The client with chronic renal failure is on hemodialysis. Which of the following indicate improvement of the client's condition due to hemodialysis? Check all that apply.
The clients BP is 130/80, the clients serum sodium is 140 mEq/L, the client's serum potassium is 4.8 mEq/L
a nursing student is listing the features of the 24 hour military time clock. Which feature listed by the nursing student indicates a need for further training?
The colon is used to separate the hours and minutes.
A client who underwent lymphanglography the day before asks the LPN, why does my urine look blue? What should the LPN respond to the concern?
The dye used in the procedure may cause bluish skin and urine for 2 days.
A client is diagnosed with adrenal gland dysfunction and is schedule for a 24 hour urine test. Which action by the nurse in regard to the test is incorrect?
The first morning urine sample is retained for test
The nurse is assessing a client in a family practice clinic. The client had extensive testing to rule out Hodgkin disease. Which of the following characteristics would indicate Hodgkin disease? Select all that apply.
The lab results show presence of reed-sternberg cells, the client has painless swelling of the cervical and axillary nodes.
The nurse is assisting with discharge of a client with addison's disease following an adrenal crisis. Which instruction is most important for the nurse to reinforce?
The importance of taking steroid replacements as prescribed
which of the following is the nurse aware of when delegating to an unlicensed assistive personnel? Select all that apply.
The nurse is responsible for overall client care, the nurse is responsible to communicate expectations to the UAP
The nurse is employed at a clinic for client diagnosed with diabetes. Which client does the nurse identify as being at great risk for?????
The older adult with type 2 diabetes, unstable BG, and hypertension
The nurse is attending to clients in an assisted living center. For which reason is the nurse aware that the recognition of hyperthyroidism in older patients?
The presenting symptoms tend to mimic cardiac concerns
A client with lung cancer who is expected to die within a few days is being given a blood transfusion. Family members, who realize death is imminent ask, "why are you giving a blood transfusion when we all know death is just around the corner?" which response by the nurse to the family is most appropriate?
The transfusion will help increase the client's oxygen levels. It will no prolong life, but will increase comfort.
The nurse is preparing to provide therapeutic treatment to the client with an exacerbation of polycythemia vera (PV). Which of the following is the expected treatment for this client?
Therapeutic phlebotomy
The nurse notes that a client's lower legs are brown and the feet are blue when they are in the dependent position. For which health problem should the nurse collect additional data?
Venous blood flow problems
The nurse is caring for a client admitted with chest pain and suspected MI. which lab value should the nurse to see elevated?
Troponin
a client who is being treated for pneumonia starts complaining of sudden SOB. An ABG is drawn. The ABG has the following values pH 7.21, PaCO2 64 mm Hg, HCO3 24 mm Hg. What does the ABG reflect?
Uncompensated respiratory acidosis
A client had surgery to remove a kidney stone. Which of the following lab assessment data warrants intervention by the nurse?
Urinalysis showing blood in the urine.
The LPN/LVN is assisting in the care of a 51 y/o client recovering from a hypop????, which observation should the nurse identify as needing immediate intervention?
Urinary output of 800 mL in 4 hours
The nurse determines that treatment has been effective for a client with DI. Which lab value did the nurse use to come to this conclusion?
Urine Specific gravity
A male patient reports that manifestions of BPH have been occurring for several years. On which problem related to this condition does the nurse focus when collecting health information? Select all that apply.
Urosepsis, renal insufficiency, evidence of hydronephrosis, recurrent UTI's
The nurse is assisting with the development of an educational program to reduce the incidence of infectious diseases in a community. What topics should the nurse suggest be included in the program? Select all that apply.
Use a cough etiquette, performance of hand hygiene, safe food handling technique, importance of receiving immunizations
The nurse is preparing a client for a thyroid scan to rule out thyroid cancer. Which instruction does the nurse give the client prior to the test?
Use the bathroom before the scanning part of the test is performed
The nurse is caring for clients on the cardiac unit reviews the standards related to DVT prophylaxis. Which approach should the nurse recognize as being the most effective to prevent the development of DVT?
Using a combination of pharmacological and compression interventions.
The nurse is caring for a client who develops red man syndrome. Which medications does the nurse suspect this client is receiving?
Vancomycin (vancocin hydrochloride)
A client is stabilized after having an allergic reaction. Which preventative instructions should the nurse reinforce with the client?
Wear medical alert identification
The nurse is monitoring the effects of a water deprevation test on a client suspected of DI related to pituitary dysfunction. Which test results supports the diagnosis?
Weight loss occurs due to the large amounts of urine voided
The nurse is assessing a client who underwent valve replacement surgery. Which finding should concern the nurse the most?
Wet lung sounds
The nurse is assessing a client with a MI who may receive tissue plasminogen activator [t-PA]. which question is most important for a nurse to ask.
What time did the chest pain begin?
The nurse is witnessing a adult clients surgical consent. What should the nurse confirm before witnessing the surgical consent? Select all that apply.
Whether the client is informed about the surgery, the last time a sedative was administered.
The RN is providing care for a marathon runner who is recently diagnosed with DM. which explanation regarding exercise is best for the nurse to provide?
You always need to take some emergency glucose with you when you are running
The nurse is caring for a client with thrombophlebitis of the left leg. Which interventions should the nurse implement? (select all that apply)
administer acetaminophen as ordered, elevate the feet above heart level, apply compressions stocking per order.
the nurse is caring for a client receiving morphine who states the morphine is no longer working. The nurse notifies the health care provider and requests that an increase in dosage or a different medication be given. Which of these is the nurse demonstrating?
advocacy
The nurse is caring for a postoperative client at risk for DVT. Which actions should the nurse recommend be included in the client's plan of care? (select all that apply)
assist with early ambulation, apply anti-embolic stockings, perform leg exercises 10 times hourly while awake
A client with type O blood is scheduled to undergo open heart surgery. Which blood type would this client receive?
o
The nurse is preparing a client for a blood transfusion. The client has type O blood. Which type can this client receive?
o
The nurse is assessing a client with pernicious anemia. Thich clinical manifestation can the nurse expect to document? (select all that apply)
pallor, weakness, glossitis, periphereal neuropathy
The nurse is reinforcing teaching for a client who is to wear a Holter monitor. Which of the following should the nurse include? (Select all that apply)
push the event button when symptoms occur, keep an accurate diary of symptoms and activities, avoid showers or baths while wearing the monitor.
While receiving a unit of PRBC's , the client begins to experience hives around the neck and upper chest. What actions should the nurse perform because of this reaction? (select all that apply)
stop transfusion, notify HCP, administer prescribed antihistamine, restart the infusion and carefully monitor.
