Nurselogic: Testing & Remediation

A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam (Ativan) preoperatively. Which of the following statements by the client indicates the med has been effective? "I am wide awake now." "My mouth is very dry." "I feel very relaxed." "My heart is racing."

"I feel very relaxed"

A nurse is preparing to administer an IM injection to an adult who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle? 1/2 inch 5/8 inch 1 inch 1 1/2 inch

1 1/2 inch 1 inch for pts with low BMI

5 percussion sounds

1. Flatness 2. Dullness 3. Resonance 4. Resonance 5. Tympany

A nurse is reinforcing teaching to a client who has a fractured ankle and is learning to walk up stairs. Identify the sequence of actions the client should be taught when using a modified 3-point crutch gait.

1st- to stand and bear weight on the unaffected leg 2nd- transfer body weight to the crutches 3rd- advance the unaffected leg between the crutches 4th- shift weight from the crutches to the unaffected leg 5th- align crutches on the stair

2) A nurse in a provider's office is reinforcing teaching to the parents of a child who has allergies and is prescribed Benadryl 25 mg every 6hrs as needed. Available is Benadryl 12.5mg/5mL. How many teaspoons of Benadryl does the nurse instruct the parents to administer per dose?

2 tsp To answer this calculation fill in the blank question, the nurse should be able to convert 10 mL of medication into a household measurement (teaspoon). The child needs to receive 10 mL of diphenhydramine. There is 5 mL in one teaspoon, so 10 mL = (10 / 5) = 2 tsp. Therefore, you should enter the numeral 2 in the box without any units or spacing devices. STEP 1: What is the dose needed? Dose needed = Desired; 25 mg STEP 2: What is the dose available? Dose available = Have; 12.5 mg STEP 3: Do the units of measurement need to be converted? No (mg = mg) STEP 4: What is the quantity of the dose available? 5 mL STEP 5: Set up an equation and solve: Desired x Quantity / Have = Amount to be given; 25 mg x 5 mL / 12.5 = x mL; 25 x 5 / 12.5 = 125 ÷ 12.5 = 10 mL. Convert to tsp: Equivalents: 1 tsp = 5 mL; 5 mL / 1 tsp = 10 mL / x; 5x = 10; x = 2 tsp.

Wheezing

Abnormal breath sounds that are produces because of a narrowing passageway Common in pts with asthma

Crackles

Abnormal breath sounds that result from air passing through fluid

Auscultation

Auscultation should be the second technique used while conducting an abdominal assessment on a client to determine the frequency and intensity of bowel sounds. Normal bowel sounds occur 5 to 35 times per min. Auscultation also detects vascular sounds or bruits.

A nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking if the results don't come back positive for cancer." This statement indicated the client is in which of the following stages of grief?

Bargaining

8) A nurse is performing a respiratory examination on a client whio has pneumonia. Which of the following sounds should be elicted over areas of consolidation during percussion? A. Dullness B. Hyper-resonance C. Resonance D. Tympany

Dullness Percussion over dense tissue or a fluid-filled body cavity produces a thud-like sound, which is described as dullness. This is the sound that will be elicited during percussion over areas of consolidation.

3) A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the client's diet? (select all that apply) Cooked oatmeal Grape juice Applesauce Ice cream Smooth peanut butter

Grape juice, Ice cream

A nurse is caring for a client who is receiving Vancomycin for a beta-hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor?

Hearing loss

19) A nurse us collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first? a) Inspection b) Percussion c) Palpation d) Auscultation

Inspection

A nurse is preparing to auscultate a client's heart. Which of the following positions is best for detecting low-pitch diastolic murmur?

Left lateral

5) A nurse in a provider's office is caring for a client who has depression and is taking St. John's Wort. The herbal supplement is thought to improve which of the following? a. Mood b. Immunity c. Memory d. Vitality

Mood

Palpation

Palpation should be the fourth technique used during examination of the abdomen to identify abdominal tenderness, masses, or distention. Both light and deep palpation techniques should be performed to identify unexpected masses or organ size outside the expected parameters.

6) A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer? a. Partial thickness skin loss b. Visible subcutaneous fat c. Nonblanchable redness d. Exposed muscle

Partial-thickness skin loss Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage II pressure ulcer involves partial thickness skin loss and typically presents as an abrasion or blister.

Percussion

Percussion is the third technique used while conducting an abdominal assessment on a client to discern the presence of tympany and dullness. It is performed to evaluate for the presence of gas in the intestines or fluid and masses in the abdominal cavity.

Tympany

Percussion over an air-filled stomach produces a drum-like sound, which is described as tympany

Hyper-resonance

Percussion over emphysematous lungs produces a booming sound, which is described as hyper-resonance

Resonance

Percussion over healthy lung tissue produces a hollow sound, which is described as resonance.

4) A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client? Lithotomy Dorsal recumbent Prone Sims'

Sim's

A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury? Lock knees. Stand close to the client. Keep feet close together. Move client by twisting at the waist.

Stand close to patient

7) A nurse on a Peds unit is caring for an infant who is diagnosed w/laryngotracheobronchitis. While performing a respiratory exam, the nurse hears the sound in the provided audio clip. Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds? A. rhonchi B. Stridor C. Wheezes D. Crackles

Stridor Stridor is a harsh high-pitched sound heard on inhalation or expiration. It is caused by turbulent air flow secondary to a narrowing or blockage in the upper airway and is a common clinical manifestation of acute laryngotracheobronchitis.

Dorsal recumbent position

The dorsal recumbent position places the client prone with knees flexed. This position allows for relaxation of the abdominal muscles and facilitates assessment of the abdomen

9) A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading?

Using a cuff that is too wide

1) A nurse is reinforcing to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Which of the following nutritional selections by the client indicates a need for further testing? a. 1/2 cup of white rice b. 1 slice of wheat bread c. 1 cup of 2% milk d. 3/4 cup of canned tomato juice

¾ cup of canned tomato juice

Subcutaneous injection needle size

1/2" needle 5/8" needle

A nurse is reinforcing teaching to a client who is newly diagnosed w/Lyme disease. The nurses should include that the disease is transmitted in which of the following ways? a. Vector b. Airborne c. Vehicle d. Bloodborne

Vectors - arthropods - carry and transmit certain illnesses - ex of illnesses transmitted by vectors - malaria which is transmitted by mosquitos - Rocky mountain spotted fever which is transmitted by ticks - Lyme disease is transmitted by ixodid or deer ticks

Sim's position

a side-lying position with the lowermost arm behind the body and the uppermost leg flexed left side-lying, or Sims' position, places the client on the side with the knee flexed. This position allows the enema to flow along the curve of the sigmoid colon and rectum naturally, which improves retention of the solution.

Rhonchi

course rattling sounds that are similar to snoring

Stage IV pressure ulcer

full thickness tissue loss and exposed bone, tendon, or muscle Slough or eschar

Stage 1 pressure ulcer

intact skin with localized area of non-blanching redness

Stage III pressure ulcer

involves full thickness skin loss and can have visible subcutaneous fat

Prone position

lying on abdomen, facing downward (head may be turned to one side) prone position places the client on the abdomen and is only used to determine extension of the hip joint, and examining skin and the buttocks.

Lithotomy position

lying on back with legs raised and feet in stirrups lithotomy position facilitates insertion of a vaginal speculum to examine the female genitalia and genital tract.

A nurse on a rehab unit is caring for a client who was admitted 3 days ago. Upon review of the client's med record, which of the following actions should the nurse take? HGB 15.4, BUN 8, Glucose 72 Increased urinary output Crackles a. Request prescription for iron supplement. b. Administer 4 oz of orange juice. c. Restrict fluid intake. d. Encourage bed rest.

restrict fluid intake

Echniacea

sometimes taken to reduce manifestations and duration of colds and flu like illness -- used for immunity

Ginkgo biloba

taken to increase cognitive functions in older adults to delay progression of Alzhemier's disease used to improve memory

Ginseng

to improve overall energy and vitality Particularly during times of fatigue or stress