KPREP: C a t 1
The nurse assesses a client being considered for thrombolytic therapy. Which question is most appropriate for the nurse to ask? (Select all that apply.)
"Can you tell me the exact time your chest pain began?" Establishing the exact time of onset of chest pain is essential in thrombolytic therapy screening because the medicine is ideally given within 6 hours of a coronary event. "Are you taking any medications to thin your blood?" Concurrent use of anticoagulants such as warfarin is a relative contraindication for thrombolytic therapy.
A client who received ascorbic acid for the treatment of scurvy asks the nurse, "How does ascorbic acid treat my symptoms?" Which response by the nurse is appropriate?
"It is responsible for collagen synthesis." Ascorbic acid (vitamin C) is responsible for collagen synthesis and helps prevent scurvy (joint pain, weakness), infant anemia, and oxalate hypersensitivity.
The nurse notes that a client is prescribed alendronate. Which instruction will the nurse include when teaching about this medication?
"Take the medication with a full glass of water." Alendronate must be taken with a full glass of water to prevent acid reflux. Alendronate is to be taken on an empty stomach. Remain upright 30 minutes after taking alendronate to prevent esophagitis.
The nurse provides care for a client diagnosed with a duodenal ulcer. The client asks how a stomach infection can cause a duodenal ulcer. Which response by the nurse is best?
"The bacteria enters the lining of the intestines and changes the protective layer." With Helicobacter pylori (H. pylori), the bacteria penetrate the intestinal mucosa, altering the function and consistency leading to ulcerations.
The nurse provides care for a client who is status post for a cardiac catheterization. The client is also diagnosed with type 2 diabetes mellitus (DM) and renal insufficiency. Which statement is most important for the nurse to include in discharge teaching?
"You should not take your metformin for the next 48 hours." Post cardiac catheterization, best practice includes withholding the metformin for 48 hours to prevent lactic acidosis. Metformin is excreted via the kidney. A client diagnosed with renal insufficiency has an increased risk for lactic acidosis.
The nurse prepares discharge instructions for a client with active tuberculosis who has been on a medication regimen for 14 days. Which statement by the client does the nurse recognize as the need for additional education?
1) This response is accurate. Family members living with the client with active TB will be treated prophylactically with isoniazid (INH). 2) CORRECT- The client will be on four medications: INH, rifampin, ethambutol, and pyrazinamide. There are some combination drugs that include two of the four medications. However, they cost more and are used most often only when medication adherence is a concern. 3) This response is accurate. The client is considered infectious for 2 to 3 weeks after treatment is initiated. The risk of exposing others is greatest if the client is contagious.
The nurse provides care to four clients. For which client illness will the nurse use an N95 disposable respirator?
Active chicken pox, or varicella, requires airborne transmission precautions, including a fit-tested N95 respirator, until the lesions are dried or crusted.
The nurse works with an LPN/LVN on a team nursing unit. Which task is most appropriate for the nurse to delegate to the LPN/LVN? (Select all that apply.)
Administering an intramuscular injection. Administering oral medications. Obtaining a capillary blood glucose.
The nurse develops a teaching plan for a client diagnosed with heart failure. Which information does the nurse include?
Advise the client to have flu and pneumococcal immunizations. Flu and pneumonia create a greater hemodynamic burden and lead to higher mortality. The Centers for Disease Control and Prevention (CDC) recommends flu and pneumonia immunizations for clients with heart failure and all chronic diseases.
The nurse provides care to clients on a progressive care unit. Which client does the nurse see first?
After a TIPS procedure the client is at risk for bleeding. This client's clotting factors are likely to be altered due to liver dysfunction. The procedure shunts blood away from esophageal varices and requires an assessment by the nurse.
The nurse is providing care to a client diagnosed with measles. Which transmission-based precaution does the nurse implement when caring for this client?
Airborne precautions are implemented when providing care for clients with measles for up to 4 days after the onset of rash. Droplet precautions are used for clients with diphtheria, rubella, streptococcal pharyngitis, pertussis, and mumps, among other conditions. Contact precautions are used for clients diagnosed with multidrug resistant infections and Clostridium difficile. Neutropenic precautions are used specifically for clients with very low white blood cell counts.
The nurse performs diet teaching for a client with a total serum calcium level of 8.0 mg/dL and ionized calcium level of 4.1 mg/dL. Which menu selection indicates to the nurse that teaching was effective?
Almonds. Almonds are high in calcium. A client's normal total serum calcium level should be 8.6 to 10.2 mg/dL and normal ionized calcium level should be 4.5 to 5.1 mg/dL.
The nurse provides care to a client who reports "ringing in the ears" and dizziness. Which medication in the client's history will the nurse suspect as causing this client's symptoms?
Amikacin - an aminoglycoside that can cause ototoxicity. Manifestations of ototoxicity include tinnitus and vertigo.
The nurse receives a report of an elevated vancomycin trough level. The client has a glomerular filtration rate (GFR) of 58 mL per minute. Which action does the nurse take?
An elevated vancomycin trough level with an inadequate GFR requires immediate attention by HCP. The client's antibiotic level is toxic and the kidneys are not filtering correctly. Red man syndrome is due to rapid infusion of vancomycin.
The nurse provides care for a client diagnosed with a stage 2 sacral pressure injury. The nurse educates the client's family members about proper positioning. Which statement by the family members indicates a need for further teaching?
Any type of ring cushion should not be used because it can lead to additional or worsening pressure injuries.
The nurse develops a plan of care for the client who had epidural anesthesia. Which assessment does the nurse include in the client's plan of care?
Assess for hypotension. Maternal hypotension with possible reduction in placental perfusion is most likely to occur within the first 15 minutes after initiating an epidural or the injection of intermittent bolus doses to maintain pain relief
A client takes a statin as prescribed. Which action does the nurse implement to identify if the client is experiencing any side effects of the medication?
Assess for muscle tenderness. Myalgia or muscle tenderness may indicate the development of rhabdomyolysis, which is an adverse reaction to statin medication.
The nurse provides care for a client recovering from an above the knee amputation. Which is the best intervention for the nurse to include in this client's plan of care?
Assist the client into the prone position for 30 minutes, three or four times a day. Lying prone for 30 minutes, three or four times a day, prevents the development of hip contractures.
The nurse provides care for a client who reports mid-back discomfort. Which technique does the nurse use to determine if the pain is coming from the kidneys?
Blunt percussion used over the costovertebral angle to assess for kidney tenderness
While administering a cleansing enema to a client, the nurse notes the client is restless with a rigid and distended abdomen. The nurse recognizes this client is experiencing which type of complication?
Bowel perforation.
The nurse receives a prescription to start an IV dopamine infusion for a client with hypotension. Which action does the nurse take next?
Check to see if the client received volume replacement. Adequate fluid volume must be achieved before vasopressors are given because this vasoconstrictor results in further reduction in tissue perfusion without volume.
The nurse assesses a yellow-brown coating on a client's tongue. Which assessment data will the nurse consider as the reason for this finding?
Client smokes cigarettes.
The nurse provides care for a client diagnosed with diabetic ketoacidosis (DKA). The nurse receives a prescription to transition the client from a regular insulin infusion to insulin glargine. Which action does the nurse take first?
Continue the insulin infusion for 1 to 2 hours after the glargine is started. Discontinuing the regular insulin infusion before the long-acting insulin glargine can take effect will lead to hyperglycemia. Insulin glargine has an onset of 1 to 1.5 hours.
Which assessment findings does the nurse tell the client to expect in the latent phase of the first stage of labor?
Contractions occur at 5- to 30-minute intervals, lasting 10 to 30 seconds. Contractions occurring at 2- to 4-minute intervals and lasting 50 to 60 seconds are seen in the active phase of labor. Contractions occurring at regular intervals and lasting 1 to 2 minutes are seen in the transition phase.
The nurse prepares a client, diagnosed with diabetes mellitus, for a cardiac catheterization. Which lab result would cause the nurse to notify the health care provider (HCP)?
Creatinine clearance of 41 mL/min (41 mL/min). Creatinine clearance of 41 mL/min signals poor kidney function (normal creatinine clearance is 75 to 125 mL per minute). Since the contrast used in cardiac catheterization is potentially nephrotoxic, the nurse will notify the HCP.
The nurse provides care to a client with an internal radiation implant. Which intervention will the nurse include in the plan of care? (Select all that apply.)
Donning gloves when emptying the client's bedpan. A private room with a private bathroom is essential to prevent the exposure of others to radiation. Wearing a lead apron when providing direct care to the client. Keeping all linens in the room until the implant is removed. Visitors are limited, not restricted, for the client with an internal radiation implant.
The nurse uses a paper-based documentation system to write a client care note. The previous nurse's documentation appears incomplete. Which action should the nurse take next?
Draw a line through any empty space and continue documenting. Empty spaces should not be left because it allows others to document in that space in an incorrect manner.
The health care provider prescribes an external urinary catheter for a client with urinary incontinence. Which action does the nurse take after the catheter is rolled onto the penis?
Ensure there is 1 to 2 inches of space at the end of the catheter.
The nurse provides care for a client diagnosed with type 2 diabetes. The health care provider has ordered exenatide for the client. When will the nurse administer this medication?
Exenatide stimulates the pancreas to secrete insulin when blood sugar levels are high. It should be administered twice a day within 1 hour before the morning and evening meals.
The nurse provides discharge instructions for an older adult client with osteoporosis. Which point about exercise is most important for the nurse to include in the teaching?
Exercise must include weight bearing activities because the bone adapts by building and becoming stronger.
The nurse provides care to a client receiving lactulose as treatment for hepatic encephalopathy. For which reason will the nurse withhold the next scheduled dose of the medication?
Experienced five watery stools today. Two to three soft bowel movements is desireable when taking lactulose. Watery stools indicate lactulose overdose.
The nurse teaches a client about the effects of intensity-modulated radiation therapy (IMRT) prescribed to treat throat cancer. Which side effect should the nurse include in this teaching session? (Select all that apply.)
Fatigue. Esophagitis. Raspy voice.
The nurse reviews a client's prenatal record. Which factor is associated with risk for fetal macrosomia? (Select all that apply.)
Gestational diabetes. Maternal obesity - twice as great in an obese mother.
The nurse prepares to administer prescribed amoxicillin to four clients. Which client condition causes the nurse to question the health care provider's prescription for this medication?
Hay fever is not caused by bacteria; therefore, is not treated with amoxicillin. Hay fever is managed with antihistamines and removal of known allergens.
The nurse assesses a client recovering from an acute myocardial infarction (MI). Which assessment finding indicates to the nurse that the client is developing cardiogenic shock?
Hypotension with a narrow pulse pressure is a clinical manifestation associated with cardiogenic shock.
A client diagnosed with thrombocytopenia calls the clinic nurse. The client states, "I just cut my skin while shaving; the bleeding won't stop even though I placed a bandage over the cut." Which response by the nurse is best?
If the client holds pressure for a significant amount of time but continues to bleed, a visit to the emergency department might be appropriate. However, this is not the best response from the nurse at this time.
The magnetic resonance imaging report for a comatose client with a traumatic brain injury (TBI) states that forces disrupted the structure of neurons and nearby blood vessels. Which type of TBI will the nurse suspect this client experienced?
In a diffuse axonal injury, axons in the cerebral hemispheres, corpus callosum, and brain stem are damaged. This typically results from high-speed acceleration, deceleration, or a rotational injury from a motor vehicle crash. Bleeding may or may not be present, but global cerebral edema is present.
The nurse provides care for a client experiencing a sickle cell crisis. Which nursing diagnosis is the priority for the nurse to include in the plan of care?
Ineffective peripheral tissue perfusion.
The nurse learns that a client with a seizure disorder has a serum phenytoin level of 35 mcg/ml. Which action does the nurse take first?
Inform the health care provider and expect a change in the phenytoin order. A serum phenytoin level above 25 mcg/ml is toxic. The priority is to inform the health care provider.
The nurse provides care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which finding indicates to the nurse that the client is experiencing cor pulmonale?
Jugular vein distension indicates cor pulmonale (right-sided heart failure).
The nurse provides care for a client who reports fatigue, has dry skin, and a poorly healing wound. Which health problem will the nurse consider the client to be experiencing?
Malnutrition. Manifestations of malnutrition include fatigue from a lack of adequate caloric intake, dry skin from a deficiency in protein and vitamins, and poor wound healing from a lack of adequate protein and vitamins needed for skin repair.
Which understanding will the nurse have about Medicare before planning care for this client?
Medicare uses a fixed reimbursement amount based on assigned diagnosis-related group, regardless of a patient's length of stay or use of services. Diagnosis-related group reimbursement is based on case severity, rural/ urban/ regional costs, and teaching costs, not national averages.
The nurse teaches a group of nursing students about informed consent for medical treatment. The nurse includes teaching about informed consent involving minors. Which statement is correct for the nurse to include in the teaching?
Minors who are in active military service are considered to be emancipated minors. This legal status allows them to consent to medical treatment on their own accord. In an emergency, consent is not necessary and may not be obtainable quickly enough. Being an orphan does not prevent an emancipated minor from consenting to medical treatment. Cognitively impaired persons of any age cannot sign their own consent forms.
The nurse provides care for a client who has undergone detoxification of long-term opioid use. The nurse plans discharge teaching for the client. Which medication does the nurse include in the discharge teaching?
Naltrexone. The client can take naltrexone, an opioid antagonist, during detoxification and continue to take this medication as maintenance therapy to eliminate craving.
The nurse notes that a client with a traumatic brain injury has an intracranial pressure reading of 25 mm Hg. Which action will the nurse take first?
Neutral alignment helps reduce intracranial pressure.
The nurse teaches a client who had a radical retropubic prostatectomy about potential complications of the surgery. Which client statement indicates the teaching was successful?
Pelvic floor exercises (Kegel) prevent or reduce the severity of urinary incontinence after a radical retropubic prostatectomy.
The nurse examines the medical record of a client with type 1 diabetes mellitus (DM). Which health problem causes the nurse the most concern?
Pneumonia. The most common precipitating factor in the development of diabetic ketoacidosis is infection.
The nurse notes that at 2200, a client is scheduled to receive 10 units of insulin glargine. The client also has a "now" prescription of 7 units of regular insulin. Which approach will the nurse use to administer these medications?
Prepare two separate injections. Insulin glargine should not be mixed with any other insulin
The nurse provides care for a client diagnosed with intractable pain. The client is prescribed magnesium sulfate 2 mg intravenous push (IVP) now and every 4 to 6 hours, PRN for pain. Which action should the nurse take first?
Question the prescribed medication. Magnesium sulfate is used as an electrolyte replacement or anticonvulsant. It is not used for pain management. The nurse will question this prescription.
The nurse prepares for the admission of a child diagnosed with rubeola. Which isolation precaution does the nurse plan for the child?
Respiratory. Rubeola is transmitted by airborne particles or direct contact with infectious droplets, so respiratory isolation is required.
The nurse plans to delegate a simple dressing change to nursing assistive personnel (NAP). The nurse checks with the charge nurse before delegating the task. Which right of delegation does the nurse follow in this situation?
Right task. The nurse needs to determine first if the task is in the NAP's scope of practice before delegating.
The nurse provides care for a client diagnosed with diabetic ketoacidosis (DKA). Which intervention does the nurse expect the health care provider to prescribe? (Select all that apply.)
Short acting intravenous (IV) insulin. Isotonic intravenous (IV) fluids. Hourly intake and output. Hourly blood glucose check is indicated.
Which substance is included on the list of potential sources of infection as outlined by the Centers for Disease Control and Prevention (CDCP)? (Select all that apply.)
Sweat is the only bodily secretion that is not considered infectious as outlined by the CDCP.
he nurse observes a nursing assistive personnel (NAP) prepare to provide mouth care to a client who is comatose. Which action made by the NAP requires the nurse to intervene?
The NAP raises the head of the bed thirty degrees. The client who is comatose is placed in a side-lying position with the bed flat. In this position, saliva automatically runs out of the mouth by gravity instead of being aspirated into the lungs
The nurse delegates vital sign measurement to the nursing assistive personnel (NAP). Which statement provides the best information for the nurse to give when delegating this task?
The NAP should not perform pain assessments. "Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Let me know if anyone's systolic blood pressure is <100 or >160, heart rate <60 or >100, respiratory rate <12 or >20, temperature >100.50F (40.60C), or pulse oximetry <95%."
The nurse is assessing a newly admitted client. Which observation leads the nurse to suspect that the client has a respiratory health problem?
The client appears to be whistling during activity. Pursing the lips as if preparing to whistle is a breathing technique called pursed-lip breathing. This technique helps to slow respirations in the person with a respiratory disorder.
The nurse provides care for a hospitalized client receiving ethambutol, isoniazid, pyrazinamide, and rifampin for active tuberculosis (TB)
The client can be discharged after antibiotics are initiated. The client remains on antibiotics for 6 to 9 months. The client with active tuberculosis must wear a mask around everyone, not just around sick people. Client remains in isolation for 2 to 4 weeks, or until the client has had three negative sputum cultures.
The nurse provides care for a client who had epidural morphine following a cesarean birth. Which intervention does the nurse include in the client's plan of care for the first 24 hours after the delivery?
The client can prevent constipation by increasing fluid intake, and fiber intake also should be increased when possible
The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp, face, and trunk. Which transmission-based precaution does the nurse implement for this child?
The client demonstrates signs of a varicella infection. Airborne and contact precautions are needed and should be maintained for at least 5 days after the onset of the rash and until the vesicular lesions are gone
The nurse receives report for a group of adult clients. Which client will the nurse see first?
The client diagnosed with failure to thrive lying supine with a nasogastric tube feeding infusing. The client diagnosed with failure to thrive and receiving a nasogastric tube feeding in the supine positions is at risk for aspiration. The head of the bed needs to be elevated 30 to 45 degrees during the tube feeding to reduce the risk of reflux and pulmonary aspiration. The position should be maintained for at least 1 hour post intermittent tube feeding and at all times for continuous tube feedings.
The nurse provides care for a client who is confused and reports a headache. The client's vital signs are as follows: temperature 101.0°F (38.3°C), BP 150/64 mm Hg, pulse 58 beats/min, and irregular respirations of 12 breaths/min. Which action does the nurse take next?
The client is demonstrating signs of increased intracranial pressure (ICP) and Cushing triad. A head CT scan is indicated.
The nurse instructs a client being discharged about home oxygen therapy. Which client statement indicates that further teaching is needed? (Select all that apply.)
The client should not adjust the flow rate on the oxygen concentrator. Oxygen is a medication and only the health care provider can adjust the rate. Smoking is not allowed anywhere in the home of a client receiving home oxygen. Gas stoves or heaters are a fire hazard in the home of a client receiving oxygen.
The nurse provides care for a client who is experiencing withdrawal from long-term alcohol use. The nurse prepares to administer medications to the client. Which medication does the nurse administer first?
The client who has acute alcohol withdrawal is at greatest risk for seizures; therefore, the first medication the nurse should give is chlordiazepoxide to prevent seizures, brain injury, and delirium tremors.
The nurse provides care to clients on a progressive care unit. Which client does the nurse see first?
The client with a blood pressure of 86/44 mm Hg receiving intravenous antibiotics for urosepsis. The client with urosepsis has low blood pressure, which could indicate poor organ perfusion. This client should be seen first by the nurse.
A client with a history of intravenous drug abuse experiences a low-grade fever, cough, night sweats, fatigue, weight loss, and a productive cough with mucopurulent sputum. Which transmission-based precaution will the nurse use for this client?
The client's history and signs suggest pulmonary tuberculosis, which is spread by airborne pathogens (M. tuberculosis). Airborne transmission-based precautions should be initiated immediately.
A client reports having chest irradiation as a child for non-Hodgkin lymphoma (NHL). On which potential adulthood complication will the nurse focus when assessing this client?
The development of secondary cancers in adults is a long-term complication of childhood cancer treatment. These cancers can be site specific, such as lung cancer or leukemia.
The nurse teaches a community education class about preventing lead poisoning for parents of young children. At which age will the nurse instruct that screening for lead poisoning begins?
The nurse will start screening a child for lead poisoning at age 12 months for low-risk clients and perform a repeat screening at 24 months of age. High-risk infant clients should have initial lead poisoning screening at 6 months of age.
The nurse observes a client sign a surgical consent form. The nurse signs the form as a witness. What does the nurse's signature on the surgical consent form indicate?
The nurse's signature only states that the client signing the form was the person listed as having the procedure.
An adolescent client is brought to the hospital with a head injury requiring emergency surgery. The client's parents are out of the country. The client is staying with the paternal grandparents. The nurse identifies which source as legal consent for surgery?
The paternal grandparents. Any grandparent can give consent for a minor grandchild in an emergency, if the parents are not present. If no family members are available and the client's condition is life-threatening, the surgeon can perform surgery with assumed consent.
Which example indicates the best quality improvement process?
The quality improvement process begins at the staff level, where problems are defined by the staff. Quality improvement is not identified by another department. Not identified by the health care providers.
The nurse auscultates heart sounds in a school-age client. Where does the nurse place the stethoscope to listen to the aortic area of the heart?
The second right intercostal space is the location for auscultating the aortic area
The nurse provides care for a client diagnosed with idiopathic thrombocytopenic purpura (ITP). The client asks the nurse why the health care provider (HCP) is not performing a splenectomy since the spleen is causing the thrombocytopenia. Which response by the nurse is best?
The spleen is a protective organ, and the overall chance of getting infections, especially pneumococcal, meningococcal, and Haemophilus influenza, become very high if the spleen is removed. A splenectomy increases the risk for morbidity and mortality substantially.
The nurse provides care for a newborn who is recovering from necrotizing enterocolitis (NEC). Which intervention does the nurse include in the newborn's plan of care?
The use of fresh breast milk is the preference for the newborn who is recovering from NEC. It is the preferred enteral nutrient because it confers some passive immunity (IgA), macrophages, and lysozymes. Also, breast milk is more easily digested than formula.
The nurse plans to teach a local community group about chronic obstructive pulmonary disease (COPD). Which information does the nurse include? (Select all that apply.)
Uncontrolled COPD can lead to cardiac disease. Right-sided heart failure results from uncontrolled COPD. Cigarette smoking is the leading COPD risk factor. Co-existing illness may cause COPD exacerbation. Heart failure, gastroesophageal reflux disease (GERD), and pneumonia may lead to COPD exacerbation.
The nurse provides care for a client diagnosed with diabetes mellitus who is hospitalized with acute pyelonephritis. Which collaborative problem is a priority for the team to address?
Urosepsis. Acute pyelonephritis is an upper urinary tract infection that can rapidly lead to urosepsis and septic shock. This is a priority. There is a high mortality rate if not caught early.
The nurse receives a prescription to place a client on 40% oxygen. Which oxygen delivery method does the nurse use?
Venturi mask provides a precise amount of high flow oxygen; therefore, this is the delivery method the nurse uses to implement this prescription. A partial rebreather mask delivers between a 60% and 90% oxygen concentration. A non-rebreather mask delivers a 60% and 90% oxygen concentration. A simple face mask does not provide precise percentage of oxygen
The nurse teaches nursing students about the Institute of Medicine (IOM) competencies for nursing knowledge, skills, and attitudes.
Working in interdisciplinary teams is one of the five competencies identified by the IOM Using evidence-based practice is one of the five competencies identified by the IOM. Applying quality improvement is one of the five competencies identified by the IOM
The newly-licensed nurse states to the nurse preceptor, "I am so frustrated. I take so long to pass medications, and I make administration errors nearly every day. Because I am so slow, I have to stop to get my other tasks done. " Which advice by the preceptor best addresses the nurse's concerns?
"Interruptions can cause errors, so let's talk about how to stay focused."
The nurse provides care for a client diagnosed with multiple myeloma. The client's new pain management regimen includes timed-release oxycodone and immediate-release oxycodone. The client asks the nurse how to schedule these new medications. Which response by the nurse is best?
"Schedule both medications so that your pain is relieved all day." The client needs to schedule the medications so that around the clock stable analgesic control is achieved.
The nurse administers carisoprodol to the incorrect client. Which strategy should the nurse use to reduce the risk of malpractice litigation? (Select all that apply.)
2) CORRECT — The health care provider must be notified of any medication error so that corrective action or monitoring can be instituted immediately. 3) CORRECT — The manager will follow up with the client immediately to explain the incident and to monitor for additional needs
The nurse provides care for several assigned clients. Which situation requires an immediate follow-up by the nurse?
A client receiving a liter of intravenous fluid at 120 mL/hr has 460 mL remaining after 2 hours. A complication of intravenous therapy is fluid overload from a too-rapid infusion. This is the priority as heart failure can result from fluid overload.
The nurse provides care for a client diagnosed with cervical cancer and spinal metastasis. The client is prescribed dexamethasone three times daily. Which client statement would indicate to the nurse that treatment has been effective?
"The pain in my pelvic area is less." Palliative reduction of pain is the goal of steroid therapy in metastatic cancer.
The nurse notes that a client has 3+ pitting edema of both feet and ankles. Which additional assessment does the nurse make before contacting the health care provider (HCP)? (Select all that apply.)
1) CORRECT - Pitting edema indicates fluid overload. An increase in body fluid can cause a full, rapid, and bounding pulse. 2) CORRECT - Body weight is the most reliable indicator of fluid balance. Since pitting edema is present, body weight should be measured and compared with previous weights. 3) CORRECT - Excess body fluid can back up in the peripheral vasculature and cause fluid to pool in the lungs. Lung sounds should be assessed. 4) Body temperature is not affected by fluid volume. 5) CORRECT - Excess body fluid affects heart function, causing an increase in blood pressure. The blood pressure should be assessed.
The nurse observes a wrench taped to the head of the bed of a client who is currently in surgery. Which device does the nurse expect this client to have when returning to the care area?
A wrench is needed to open the halo vest in the event the client needs cardiopulmonary resuscitation.
The parent of a 5-year-old client reports to the nurse that the child has difficulty settling down at bedtime. Which intervention should the nurse recommend to the parent?
Allow the child to select a stuffed animal to sleep with. Allowing children choices and finding items that allow them to feel more comfortable going to bed can increase comfort.
The nurse auscultates the heart of a client experiencing increasing shortness of breath. Which finding causes the nurse the most concern?
An S3 heart sound, a significant finding in older adult clients, suggests heart failure. It is heard in early diastole during the period of rapid ventricular filling as blood flows from the atrium into a noncompliant ventricle. An S4 heart sound occurs immediately before the S1 heart sound. It is considered a normal finding in older adult clients.
An unemancipated 15-year-old single parent of an infant brings the child to the clinic. The infant is diagnosed with an umbilical hernia and requires surgery. From whom does the nurse obtain surgical consent for the infant?
An unemancipated minor may sign the consent for medical treatment for the client's own custodial child.
A client may be developing side effects from an anticholinergic medication. Which question does the nurse ask the client to further assess for side effects to this medication? (Select all that apply.)
Anticholinergics cause dilatation of pupils and vision may be blurred. Cause xerostomia or dryness of mouth. Cause urinary hesitancy and retention. Reduce bowel tone and motility and constipation may occur.
The nurse admits several clients during the day shift. Which room assignment is most appropriate for the nurse to make?
Assign the client who is returning from a total knee replacement to a room with a client diagnosed with pancreatitis. Neither client is infected. Pancreatitis is an inflammatory process of the pancreas and not an infectious disease.
The nurse develops a teaching plan to promote optimal cardiac output during pregnancy. Which information is most important for the nurse include?
Avoid resting or sleeping in the supine position. Particularly in second half of pregnancy, the weight of the pregnant uterus compresses the vena cava (which can lead to maternal hypotension syndrome) and aorta (which can lead to fetal hypoxia). It is a priority to prevent compression of these major vessels
The nurse makes assignments for the health care team that includes two licensed practical nurses/licensed vocational nurses (LPNs/LVNs) and a nursing assistive personnel (NAP). Which client is most appropriate to assign to the LPN/LVN? (Select all that apply.)
Client with a chest tube who is ambulating in the hall. Client with a colostomy who requires assistance with colostomy irrigation. This is a stable client and a LPN/LVN can appropriately provide care.
The nurse reviews the daily lab results of four clients. Which client does the nurse delegate to the LPN/LVN to provide care?
Client with an erythrocyte sedimentation rate of 10 mm/h. Normal value: < 30
The nurse is assessing a neonate born at 44 weeks' gestation. Which finding does the nurse document as consistent with the newborn's gestational age?
Cracked, peeling skin. A post-term neonate has dry, cracked (desquamating) skin at birth. No vernix is on the body of a post-term newborn Post-term neonates have deep plantar creases
The nurse provides care to a school-age child suspected of being sexually abused. Which assessment data best supports this suspicion?
Difficulty walking. This finding, along with bloody or stained underclothes and pain, itching, or swelling in the genital area, are indicators of sexual abuse.
The nurse notes that a client's T-tube has drained 425 mL of dark green thick fluid. Which action does the nurse take next?
Document the amount on the output sheet. This is an expected amount of T-tube drainage. The volume should be documented on the client's output record.
The nurse provides care for a school-age child who has a peanut allergy. Which early manifestation of the allergy should the nurse expect the child to exhibit? (Select all that apply.)
Dyspnea, Urticaria, and wheezing are early symptom of peanut allergy.
The nurse provides care to a client at risk for hypercalcemia. Which action is most appropriate for the nurse to take?
Encourage oral fluids. Dehydration contributes to and exacerbates hypercalcemia. Fluids containing sodium should be administered, unless contraindicated, because sodium assists with calcium excretion. About 3L of fluids per day or more are encouraged.
The health care provider prescribes a unit of packed red blood cells for a client admitted with lower gastrointestinal bleeding. Which step will the nurse take when administering the blood product? (Select all that apply.)
Ensure adequate infusion access is present before obtaining the blood from the blood bank. The infusion should be started within 30 minutes of removing the blood from the blood bank refrigerator. Two-person verification in the presence of the client is done to make sure that the blood product matches the health care provider's prescription and the blood product is properly identified to the client to prevent a blood incompatibility error. The client should be closely monitored for the first 15 to 30 minutes of the transfusion. The blood administration time should not exceed 3 to 4 hours to reduce the risk for bacterial growth.
A client receiving 50 mL/hr of continuous bladder irrigation fluid has a total output of 500 mL over 8 hours. Which action does the nurse take?
The client received 400 mL of bladder irrigation fluid over 8 hours with an output of 500 mL. The urine output for this time frame is 100 mL (12.5 mL/hr). Normal urine output is at least 30 mL/hr; therefore, the nurse notifies the health care provider
The nurse conducts a staff development workshop about organ donations. Which statement by a staff member indicates a correct understanding of the Uniform Anatomical Gift Act?
Family members can consent to organ donation after the client's death, even if the clients had not expressed a desire to have organs donated.
The nurse teaches the parents of a newborn how to care for a circumcised penis. Which instruction does the nurse include? (Select all that apply.)
Fasten the diaper loosely to prevent rubbing or pressure on the incision site. Signs of infection and are to be reported to the health care provider. Squeeze warm water from a clean washcloth over the penis to wash it. Avoid alcohol wipes.
The nurse provides care for a client diagnosed with type 2 diabetes mellitus. The nurse anticipates that the client will be prescribed a second-generation sulfonylurea. Which medication in the hospital formulary belongs to this class of drugs?
Glipizide, a second-generation sulfonylurea, controls blood glucose levels in type 2 diabetes by stimulating pancreatic beta cells to secrete insulin
The nurse provides care for a 9-month-old infant who weighs 9 pounds. The infant was taken from the parent's home for neglect. The infant cannot roll over or sit up independently. Which nursing diagnosis does the nurse assign as highest priority?
Imbalanced nutrition; less than body requirements. The infant weighs far less than a 9-month-old infant should weigh. Because of the lack of nutrients, the infant cannot perform milestones that would be normal at this age. Therefore, imbalanced nutrition is the highest priority
The nurse provides care for a client with the following arterial blood gas (ABG) results: pH 7.29, pCO2 31 mmHg, and HCO3 19 mEq/L. Which electrolyte alteration does the nurse monitor for based on this client data?
Hyperkalemia Serum potassium levels are often high in metabolic acidosis. As the pH drops, excess hydrogen ions enter the red blood cells, causing potassium to leave the cells, resulting in hyperkalemia.
After receiving a unit of red blood cells, a child reports tingling in the ears, nose, fingers, and toes. Which electrolyte imbalance does the nurse suspect the client is experiencing?
Hypocalcemia. Hypocalcemia results from blood transfusions containing citrate. Citrate causes increased cell membrane permeability, leading to increased neuromuscular excitability, which may result in numbness or tingling of the ears, nose, fingers, and toes. If severe, laryngospasm, seizures, and cardiac arrest may occur. Hypercalcemia causes decreased neuromuscular excitability. Signs of this imbalance include fatigue, hypoactive deep tendon reflexes, decreased muscle tone and strength, bone pain, and decreased gastrointestinal motility
The nurse observes that a client's peripheral intravenous (IV) dressing has loosened. Which action does the nurse take next?
Immediately change the IV dressing. The nurse should immediately change the dressing if it becomes loosened, dampened, or soiled to reduce the risk for an intravascular catheter-associated bloodstream infection
The nurse provides care to a client with a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Which action will the nurse take first?
Initiate seizure precautions. The client is at risk for seizures because hypocalcemia increases irritability of the central nervous system and peripheral nerves.
The nurse provides care for a client experiencing supraventricular tachycardia (SVT). Which action by the nurse is appropriate when giving adenosine?
Inject over 1 to 3 seconds, followed by a normal saline flush. To maximize efficacy, inject over 1 to 3 seconds, followed with a 20 mL NS flush
The nurse provides care for a client who takes digoxin for heart failure. Which finding is a priority for the nurse to communicate to the health care provider (HCP)?
Intermittent nausea and loss of appetite. Nausea, anorexia, and vomiting are early signs of digitalis toxicity. It is a priority to communicate this data to the HCP
The nurse receives reports on several clients. Which client will the nurse assess first?
The client with a sore throat, sitting upright, refusing to swallow, and drooling could indicate epiglottitis, which causes severe edema in the epiglottis. Epiglottitis can cause loss of airway if the child is stressed, coughs, or cries. This client should be seen first.
The nurse provides care for a client experiencing the final stage of chronic kidney disease. Which lab value does the nurse anticipate for this client when providing care?
Phosphate of 5 mg/dL (2 mmol/L). The nurse anticipates hyperphosphatemia for this client, caused by a decreased excretion of phosphate and increased stimulation of parathyroid glands. This causes a release of phosphate from bones. The normal serum phosphate range is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The final stage of chronic kidney disease is associated with hypocalcemia. The normal serum calcium range is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L).
The nurse provides care to a client in hypovolemic shock. Which intravenous solution will the nurse recognize as being an isotonic crystalloid solution? (Select all that apply.)
Normal saline. Lactated ringer.
During an assessment the nurse suspects that an injured child is a victim of physical abuse. Which action is the nurse's primary legal responsibility in this situation?
Nurses are obligated to report suspected child abuse to local authorities.
The nurse provides care to a client of Asian descent having surgery later in the day. Which action will be most appropriate for the nurse to take when assessing this client?
Observe the client's use of eye contact.
Which areas will the nurse include in complete and accurate documentation? (Select all that apply.)
Only objective nursing observations belong in documentation. An explanation of any incident does not belong in a client record, but in an incident report. The nurse would document medications and treatments given.
The nurse provides care to a client with pneumonia, anorexia, and chronic pain. Which laboratory result does the nurse report to the health care provider immediately?
PaCO2 of 50 mm Hg The PaC02 is significantly higher than the normal range of 35 to 45 mm Hg. This finding suggests compromised alveolar exchange with a potential for respiratory acidosis
A client recovering from total hip replacement surgery reports increased pain with movement. Which nursing diagnosis is the most appropriate for this client?
Pain is a priority problem for a client recovering from total hip replacement surgery
The nurse uses research findings to improve client care. Which technique of care is the nurse using?
Performance improvement. Performance improvement typically involves clinical projects conceived in response to identified clinical problems and designed to use research findings to improve clinical practice
The nurse directs the nursing assistive personnel (NAP) to provide a back massage to a client. Which action does the nurse emphasize when giving these directions?
Place the bed in the lowest position after the massage. The NAP raises the bed to facilitate ease of performing the back massage and provide good body mechanics for the NAP. Afterward, the bed is placed in the lowest position for safety of the client.
The nurse prepares a client for a contraction stress test using nipple stimulation. Which measure does the nurse include in the plan of care?
Placing the client in a reclining chair with a slight lateral tilt optimizes uterine perfusion and avoids supine hypotension.
The nurse provides care for a newborn in the delivery room. Which nursing intervention will the nurse use to prevent the newborn from experiencing conductive heat loss?
Putting the unclothed newborn against the mother's skin. 1) Drying the newborn's skin immediately after birth helps prevent convective heat loss. 2) CORRECT - Placing the unclothed newborn against the mother's helps prevent conductive heat loss. 3) Keeping the incubator away from windows helps prevent radiant heat loss. 4) Placing the newborn under a radiant warmer can increase heat loss from evaporation
The nurse reviews how and when to collect a client's sputum specimen before delegating the task to nursing assistive personnel (NAP). Which right of delegation does the nurse follow in this situation?
Right communication. The nurse communicates with the NAP and provides information to correctly complete the task. This is an example of right communication.
The nurse provides care for a client in the final stage of chronic kidney disease. The client's serum calcium level is 7.5 mg/dL (1.8 mmol/L) and the phosphate level is 6.0 mg/dL (1.9 mmol/L). Which priority nursing diagnosis does the nurse use to plan care for this client?
Risk for injury. This client is experiencing both hypocalcemia and hyperphosphatemia. Normal range for serum calcium is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L), while the normal range for phosphate is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client in the final stage of chronic kidney disease is at risk for osteodystrophy due to bone mineral loss leading to an increased risk for fractures or osteoporosis. Due to this condition, the client is at risk for serious injuries during a fall.
The nurse plans to teach a group of nursing assistive personnel (NAP) about measures to prevent catheter-associated urinary tract infections. Which measure does the nurse include? (Select all that apply.)
Secure the catheter to prevent movement. Maintain a closed drainage system. Perform hand hygiene before and after contact with the client. Encourage the client to drink 8 to 10 glasses of fluid daily, if permitted.
A client relieves severe abdominal pain that radiates to the back by sitting forward with the knees bent. Which laboratory test will the nurse expect to be prescribed for this client?
Serum amylase. Amylase is a digestive enzyme secreted by the pancreas. Since the client is demonstrating signs of acute pancreatitis, the nurse should expect a serum amylase level to be prescribed
A client with a chronic kidney injury takes sevelamer as prescribed. Which finding indicates to the nurse that the medication is effective?
Sevelamer is used to manage hyperphosphatemia in clients with chronic kidney injury. It binds phosphate in the bowels to facilitate excretion in the stool. Effective treatment with sevelamer results in a serum phosphate value within the normal range of 2.4 to 4.4 mg/dL (0.78 to 1.42 mmol/L). Effective treatment with sevelamer results in a normal calcium level.
The nurse provides care to a client who is prescribed oxycodone for pain every 6 hours. The nurse notes that the client's serum potassium level is 2.4 mEq/L (2.4 mmol/L). Which finding indicates to the nurse that the client is experiencing an adverse reaction to the prescribed oxycodone?
Severe hypokalemia and use of oxycodone may cause paralytic ileus resulting in absent bowel sounds. This finding indicates the client is experiencing an adverse reaction to the prescribed medication.
The nurse reviews prescriptions from a health care provider for a client's care. Which prescription will the nurse question before implementing?
Start heparin infusion by 0800 hours. The heparin infusion is missing a dose or amount of heparin to be infused. This prescription should be questioned before implementing.
The nurse provides care for a client taking warfarin for a mechanical prosthetic heart valve. The client has an international normalized ratio (INR) of 3.1. Which is the correct interpretation by the nurse of this finding?
The desired goal for warfarin therapy is an INR of 2.5 to 3.5.
The nurse assess a pregnant client at 10 weeks gestation. Which finding is consistent with the gestational age of the fetus?
The fetal heartbeat may be detected as early as 10 weeks using a Doppler device.
The nurse delegates a task to an LPN/LVN. Which action will the nurse make that indicates delegation was appropriate?
The nurse follows up with the LPN/LVN to make sure the task was completed. Following up with the LPN/LVN indicates appropriate supervision in a timely manner.
The charge nurse reviews the medical records of several clients. Which documentation from a staff nurse requires the charge nurse to follow-up?
The nurse should not document that an occurrence report or incident report was completed. This documentation requires follow-up.
The visiting nurse notes that a client diagnosed with asthma is in the "red zone" of the peak flow meter system. Which action does the nurse take first?
The red zone (50% or below peak flow) of the peak flow meter system signals an emergent situation.
The nurse performs a pelvic exam on a client admitted in labor to determine the station of the presenting part. The client asks the nurse, "What does the term station mean?" Which explanation does the nurse give to the client?
The relationship of the presenting fetal parts to the ischial spines.
The nurse observes a student nurse provide a client with a subcutaneous injection of heparin. For which student action will the nurse intervene? (Select all that apply.)
The skin should be pinched and needle inserted at a 90 degree angle when giving a subcutaneous injection. The injection should be at least 2 inches away from umbilicus. Heparin injections are not aspirated. Massaging is not indicated after a subcutaneous injection.
The nurse teaches a client about prescribed vaginal suppositories for use at home. Which client statement indicates a need for further instructions?
The suppository should be inserted a minimum of 2 inches for the medication to be effective
The nurse provides care for a client newly diagnosed with a benign brain tumor. The nurse teaches the client about the diagnosis. Which property of benign tumors should the nurse include in the teaching?
They can cause tissue destruction.
The nurse provides care for a client diagnosed with trigeminal neuralgia. The client reports severe burning and shooting pain. Which understanding does the nurse have about managing this type of pain?
Treatment will include the use of adjuvant analgesics. Neuropathic pain is not well controlled by opioid analgesics alone and often requires the addition of tricyclic antidepressants or anti-seizure drugs to help prevent pain transmission.
The nurse provides care for an adolescent client experiencing a migraine headache. Which finding causes the nurse to be most concerned?
Urinary incontinence. Incontinence of bowel or bladder could signal seizure activity or a stroke, which is an uncommon, but serious, migraine complication.
The nurse provides care for a client with rhabdomyolysis. Which finding will the nurse determine is most appropriate for the client?
Urinary output >60 mL per hour This is an appropriate outcome for rhabdomyolysis. Muscle breakdown can lead to myoglobinuria, which can put the kidneys at risk for acute renal injury. Keep the client hydrated and a urine output of 200 to 300 ml per hour.
A preschool-age client experiences a sudden cardiac arrest. Which action will the nurse take when performing cardiopulmonary resuscitation (CPR)?
Use the heel of one hand for sternal compressions.
The nurse provides care to a client who experienced prolonged cold exposure. For which complication does the nurse closely monitor this client?
Ventricular fibrillation. Cold-induced myocardial irritability may cause cardiac arrhythmias, especially ventricular fibrillation
The nurse applies the prescribed medication to an adult client diagnosed with scabies. Which body area should the nurse avoid when applying the scabicide?
When treating an adult client diagnosed with scabies, the scabicide is applied from the neck down
The nurse is providing care for a client who is prescribed amoxicillin-clavulanate for 14 days. Which finding indicates to the nurse that the client has developed a superinfection?
Whitish plaque in mouth indicates an oral fungal infection, a sign of superinfection
A nurse who is in Generation X, works the night shift and requests more time off than other staff nurses. Which statement best explains a characteristic of this generation?
Individuals in this generation have a tendency to want work-life balance
The nurse is teaching the client about the warning signs and symptoms of lung cancer. Which statement is appropriate for the nurse to include in the teaching?
"Symptoms of lung cancer are vague and often present late in the disease." Lung cancer is often diagnosed in late stages because the symptoms are vague and often attributed to other causes.
The nurse prepares teaching for a client prescribed alendronate sodium. Which information will the nurse include in this teaching? (Select all that apply.)
"Take this medication with at least 8 ounces of water." (Bisphosphonate alendronate sodium is given as treatment for osteoporosis. The medication should be taken with at least 8 ounces of water.) "Sit upright for at least 30 minutes after taking the medication." (Alendronate sodium can cause esophageal irritation and erosion. Because of this, the client should be instructed to sit upright for at least 30 minutes after taking.) "Take this medication 30 minutes before food or other medications." (Alendronate sodium is to be taken on an empty stomach. Once taken, the client should wait 30 minutes before eating so as not to interrupt the absorption of the medication from the gastrointestinal tract)
The nurse provides care for a client with severe urinary retention caused by an enlarged prostate. Which type of catheter does the nurse use to relieve the urinary retention?
1) CORRECT - The curved tip on the Coude catheter allows the catheter to pass by the prostate more easily. 2) A three-way catheter is used after a transurethral resection of the prostate. It is not used for an enlarged prostate. 3) A suprapubic catheter is often used after trauma or surgery. It is not the first choice for an enlarged prostate. 4) A condom catheter does not address the problem of urinary retention.
The nurse is assisting in the care of a client with ventricular fibrillation. The "code" leader called to shock the client uses a biphasic defibrillator. The nurse sets the defibrillator at which energy level?
120 to 200 Joules.
The nurse provides care for a post-operative client. Which conditions does early ambulation after surgery help prevent? (Select all that apply.)
2) CORRECT - Ambulation reduces the risk of thromboembolism by increasing venous blood flow. 3) CORRECT - Ambulation reduces the risk of atelectasis by increasing the mobilization and expectoration of mucus. 4) CORRECT - Ambulation reduces the risk of paralytic ileus and promotes peristalsis. 5) CORRECT - Ambulation reduces the risk of pressure decubiti by reducing the time in bed and relieving pressure on bony prominences
The nurse delegates tasks to nursing assistive personnel (NAP). Which statement will the nurse make that indicates adherence to the rights of delegation? (Select all that apply).
1) It is beyond the scope of practice for NAP to evaluate the effectiveness of medication. 2) It is beyond the scope of practice for NAP to evaluate the effectiveness of nursing interventions. 3) CORRECT - The nurse is delegating an appropriate task and asking NAP to report the amount of urine output to the nurse. 4) CORRECT - The nurse is delegating an appropriate task and asking NAP to report the client's ability to ambulate with a walker to the nurse. 5) CORRECT - The nurse is following up on a task of temperature assessment that was delegated to ensure it was completed by NAP.
The nurse assists with a cardiac arrest for a client in ventricular fibrillation. Cardiopulmonary resuscitation is in progress and 1 mg of epinephrine was just given. The nurse is likely to give which medication next?
1) Magnesium IV is given in torsades de pointes, not in v-fib. 2) CORRECT - Give amiodarone, an antiarrhythmic, after epinephrine in v-fib and v-tach.
The nurse mentors a nursing student. The student asks which organization requires all clients to be assessed for pain. Which response by the nurse is correct?
1) The NCSBN asserts that the scope of nursing includes a comprehensive assessment, but does not specifically identify pain. 2) The ANA developed standards for clinical practice, including those for assessment, but not specifically for pain. 3) CORRECT -The Joint Commission developed assessment standards, including that all clients be assessed for pain. 4) The NLN promotes valid, reliable guidelines and standards for clinical practice, but not specifically for pain.
The nurse provides care for a very low birth weight (VLBW) preterm newborn receiving oxygen therapy. The nurse assesses the infant for which complication of oxygen therapy?
1) The primary means by which newborns generate heat is via nonshivering thermogenesis. In an underdeveloped and premature central nervous system, this type of heat production may be inadequate, but the act of thermogenesis is not a complication. 2) Hyperbilirubinemia is a common complication in the VLBW infant, but this is not a complication of oxygen therapy. 3) Anemia is more common in preterm infants than polycythemia. 4) CORRECT - Visual impairment or blindness in preterm infants, especially VLBW, due to injury of developing retinal blood vessels is sometimes precipitated by high levels of oxygen.
The nurse provides care for a client with a brain natriuretic peptide (BNP) level of 899 pg/mL. Which priority nursing diagnosis does this finding substantiate?
A BNP level of 899 pg/mL indicates acute congestive heart failure. There is excess fluid volume related to increased venous pressure and decreased renal perfusion secondary to acute congestive heart failure. This is the priority nursing diagnosis. Normal BNP finding of <100 pg/mL. The finding indicates acute congestive heart failure
The nurse plans care for an older adult client. Which intervention does the nurse implement to reduce this client's risk for falls?
A bedside commodes reduces the risk of rushing when needing to go to the bathroom
The nurse provides cares for a client with a wound. The client's wound culture is positive for vancomycin-resistant Staphylococcus aureus (VRSA). Which personal protective equipment (PPE) does the nurse don before entering the client's room? (Select all that apply.)
A client diagnosed with VRSA, a resistant organism, requires contact precautions (in addition to standard precautions) to prevent the spread of infection. Contact precautions require the use of gloves and a gown when entering the client's room to protect against contamination with the resistant organism
The nurse uses a tape measure to ensure that a client receives the correct size of knee-high antiembolism stockings. Which measurement does the nurse use for these stockings?
Achilles tendon to the popliteal fold.
The nurse evaluates care provided to a client diagnosed with anorexia nervosa. Which laboratory result indicates to the nurse that further treatment is needed?
Arterial bicarbonate 19 mEq/L. A bicarbonate level of 19 mEq/L is low and indicates metabolic acidosis that, in this client's case, is caused by starvation.
The nurse provides care for an adolescent client who is diagnosed with meningitis but is otherwise previously healthy. The client is prescribed intravenous (IV) and oral fluids. The nurse closely monitors the client's fluid intake. Which serious complication does the nurse monitor this client for based on the current data?
Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure.
The nurse cares for a client scheduled for surgical repair of a hiatal hernia next month. Which intervention should the nurse suggest that the client implement? (Select all that apply.)
Carbonation, chocolate, caffeine, and greasy or spicy foods can all increase symptoms associated with a hiatal hernia. These symptoms are commonly associated with gastroesophageal reflux. The client should not recline for a period after eating a meal because the contents tend to reflux or cause increased pressure on the lower esophageal sphincter increasing symptoms. This position can cause the hernia to slide and worsen. Elevating the head of the bed decreases the motion of the hernia which will decrease symptoms
The nurse provides care for a client in the second trimester of pregnancy. Which finding does the nurse attribute to the normal increase in blood volume during pregnancy?
Cardiac output increases as more blood is pumped from the heart with each contraction and the pulse increases by 10 to 15 bpm.
The nurse prepares to administer fondaparinux to a client. Which laboratory test result will the nurse monitor in the client receiving this medication?
Creatinine level. Fondaparinux is excreted by the kidneys; creatinine level should be monitored periodically, and the drug stopped in clients who develop unstable kidney function or severe renal impairment Fondaparinux, an anticoagulant that inhibits factor Xa, has no effect on routine coagulation tests
The nurse provides care for a client with an oral temperature of 90 °F (32 °C). Which nursing diagnosis will the nurse use first to guide this client's care?
Severe hypothermia can lead to cardiac arrest
The nurse provides care for a client receiving chemotherapy and radiation who has several bruises. Which nursing intervention will be part of the care plan to prevent further injury? (Select all that apply.)
Shave with an electric razor. Avoid enemas and suppositories. Administer stool softeners.
The nurse notes that a toddler-age client has burn marks in various stages of healing and is fearful of male health care professionals. Which action will the nurse take next?
Talk to the nursing supervisor. The nurse should involve the nursing supervisor if abuse is suspected. Each health care facility has a policy on how to address the suspected abuse
The family sits at the bedside of a client nearing the end-of-life. Which action is appropriate for the nurse to implement? (Select all that apply.)
Teach family members about physical signs of impending death. Encourage the management of adverse signs and symptoms. Assess family coping mechanisms to handle impending loss.
The nurse provides care to a client requiring a sterile dressing change. Which action will the nurse take when preparing the sterile field?
The outer 2.5 cm (1 in.) of the sterile field is not considered to be sterile. Therefore, the nurse should place all sterile items within 2.5 cm (1 in.) of the edge of the sterile field to ensure all items remain sterile.
The nurse provides care for a toddler who is a ward of the state. The toddler requires surgery. Who is authorized to give written, informed consent for the procedure?
When children are minors, aren't emancipated, and the parents do not have custody, the designated legal guardians are responsible for providing consent for medical procedures. For this child, the legal guardians are the foster parents.
