Pn3 final

Intravenous heparin therapy is prescribed for a client . While implementing this prescription . The nurse ensures which medications is available on the nursing unit ?

Protamine Sulfate

The nurse suspects a client is experiencing an exacerbation of COPD when which of the following is assessed SATA )

Decrease oxygen saturation . Sputum production Cough Dyspnea on exertion

Which teaching intervention is most appropriate for the client with Parkinson's disease

Fall precautions

32. The client with heart failure has been prescribed intravenous nitroglycerin and furosemide for pulmonary edema . Which is the priority nursing intervention ?

Monitor the client's blood pressure

The nurse assesses a client who has myasthenia gravis . Which clinical manifestation does the nurse expect to observe in this client ?

Muscle weakness that worsens with use and improves with rest

The nurse is assessing a client admitted to the cardiac unit . What statement made by the client alerts the nurse to the priority of right - sided heart failure ?

My shoes fit tight lately

The nurse is concerned that a client with a gastrostomy feeding tube is developing a complication Which of the following are considered complications associated with this type of feeding tube ? ( Select all that apply . )

Nausea. Vomiting Abdominal distention Aspiration

The nurse is discharging home a client at risk for venous thromboembolism on enoxaparin sodium . What instruction is a priority for the nurse to provide to this client ?

Notify your health care provider if your stools appear tarry . "

A client is receiving TPN . Which of the following routes is not appropriate for the type of nutrition administration ?

PERCUTANEOUS ENDOSCOPIC GASTRONOMY ( PEG tube

A nurse is caring for a client who reports difficulty breathing and tingling in both hands . His respiration rate is 36 and he appears very restless . The nurse anticipates which of the following values to be outside the expected reference range if the client is experiencing respiratory alkalosis .

PaCO2

98. A nurse is assessing a male client who has a new diagnosis of peripheral artery occlusion . Which of the following findings should the nurse expect to find on the affected extremity ? ( Select all that apply )

Pallor Paralysis pulseless Paresthesia

27. A nurse is planning care for a client who has acute dysphagia . Which of the following nursing interventions should be included in the plan of care ?

Placing the client in at least Semi - Fowlers position during meals

80. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes . The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations specific to hyperglycemia

Polydipsia Polyuria ,

The nurse assesses for which clinical manifestations in a client with suspected diabetic ketoacidosis ?

Increased rate and depth of respirations

4. A nurse is caring for a client with a bowel obstruction with a nasogastric tube in place to low intermittent suctioning . The nurse would assess for which of the following conditions ?

Metabolic alkalosis

The nurse is teaching a client who is newly diagnosed with epilepsy . Which statement by the client indicates a need for further teaching concerning the drug regimen

D. I can skip a couple of pills if they make me ill

Arrange the nursing statements in order as they would be communicated using the SBAR method

. 4 , 2 , 1 , 5 , 3 ,

A client diagnosed with type 1 diabetes mellitus administers a dose of NPH insulin at 7:00 am . At which of the following times would this client most likely exhibit hypoglycemia

1400

The nurse is caring for a client who is administering insulin for diabetes for the first time . The nurse is instructing the client on mixing Humulin N and Humulio R in one syringe . Arrange the instructions in order . Gently roll both insulins between your hands Wipe w / alcohol and inject air in Humulin N Wipe and inject air into Humulin R Withdraw Humulio R Withdraw Humulio N Double check total

4 , 2 , 3 , 6 , 1,5

Which client is at greatest risk for atherosclerosis

A 65 - year - old client who is obese with LDL of 188 .

The nurse is caring for four clients with asthma . Which client does the nurse assess first ?

A client whose heart rate is 120 beats / min

The nurse is assigned to care for a group of clients . Upon reviewing the clients records the nurse determines which client is most likely at risk for a fluid volume deficit

A client with ileostomy

Phenazopyridine is prescribed for symptomatic relief of pain resulting from a lower urinary tract infection . The nurse should provide the client with information regarding this medication

A reddish orange discoloration of the urine may occur

A client is having a sudden and sever anaphylactic reaction to a medication . The nurse immediately stops the medication and calls a rapid response . The clients blood pressure is 80/52 , HR 120 BPM and oxygen saturation 87 % . Audible wheezing is noted , along with facial redness and swelling . Which initial treatment should administered first ?

A.M epinephrine

A client appears dyspneic ; but the oxygen saturation is 97 % . What action by the nurse is best ?

Assess for other manifestations of hypoxia

A client comes into the emergency department with an acute shortness of breath and a cough that produces pink , frothy sputum admission assessment reveals crackles and wheezes . A blood pressure of 85/46 mm Hg , and heart rate of 122 bpm and a respiratory rate of 38 breaths per minute . The client's medical history included diabetes ( DM ) hypertension HTN and heart failure . Which of following disorders should the nurse suspect ?

Pulmonary edema

A client is admitted with a possible deep vein thrombosis . Nursing interventions should be implements for which of the following complications ?

Pulmonary embolism

63. A client with Alzheimer's disease is admitted to the hospital . Which psychosocial assessment is most important to the nurse to complete ?

Reaction to a change of environment

90. A client receiving a dose of red blood cells begins to report chest pain and lower back pain . Which action does the nurse take first ?

Stop the transfusion .

The nurse is performing an assessment on a client diagnosed of left - sided heart failure . Which assessment component would elicit specific information regarding the left sided heart condition ?

organomegaly Listen to lung sounds

Which arterial blood gas ( ABG ) values are expected with hyperventilation ?

pH , 7.55 ; PaCO₂ , 32 mm Hg

A client is admitted with a diagnosis of Diabetic Ketoacidosis ( DKA ) . Which arterial blood gas ( ABG ) lab value would the nurse expect to see with this client ?

pH 7.29 ; PaCO2 32 ; HCO3

A nurse is teaching a group of nursing students about dissecting abdominal aortic aneurysm . Which of the following statements should the nurse include in the teaching ?

. It is a medical emergency requiring immediate treatment

A client with macular degeneration would like to watch television Where does the nurse place the television for best visualization of the screen ?

In the client's peripheral view

The home care nurse is about to administer intravenous medication to the client and reads in the chart that the peripherally inserted central catheter ( PICC ) line in the client's arm has been in place for four weeks . The PICC line is patent with a good blood return . The site is clean and free from manifestations of infiltration , irritation , and infection . What is the nurse's best action ?

Administer the prescribed medication

Which action by the nurse is most effective to prevent becoming exposed to the Human Immunodeficiency

Always use Standard Precautions with all clients in the workplace

9. A nurse is planning care for a client who has quadriplegia . Which of the following actions should the nurse take to prevent a DVT ( deep vein thrombosis ) ? ( Select all that apply . )

Assess legs for redness or swelling . Turn patient every 2 hours Administer ordered subcutaneous Heparin . Massage the calves every day

The nurse assesses a client with pneumonia and notes no audible lung sounds on the left side and decreased lung expansion . What is the nurse's initial action ?

Assess oxygen saturation and notify the health care provider

A nurse is assessing a client with mechanical bowel obstruction who reports intermittent abdominal pain . An hour later , the client reports constant abdominal pain . Which is the nurse's priority action ?

Assess the client's bowel sounds

The nurse is caring for a client who was started on TPN two days previously . The client reports increased thirst , dry mouth , and voiding frequently . Which is the nurses most appropriate action ?

Assess the clients blood sugar-

A client being treated for a spinal cord injury needs immediate ventilator support . The nurse realizes that this client's level of injury is most likely

C3

A client receiving care for a spinal cord injury complains of a pounding headache , flushed skin , cardiac dysrhythmias and has a blood pressure of 220/125 mmHg . What is the first action the nurse should take ?

Check the bladder for distention

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily . The client refused breakfast and is complaining of nausea and weakness . Which of the following actions should the nurse take first ?

Check the client's vital signs .

The nurse is changing the central line of a client receiving TPN and notes that the catheter insertion site appears reddened The nurse should next assess what item ?

Clients temperature

The nurse has completed an assessment on a client with decreased cardiac output . Which findings should be the highest priority ?

Confusion , urine output 15 mL over the last 2 hours , orthopnea

To delay the onset of microvascular and macrovascular complications in the diabetic client the nurse stresses what action ?

Controlling hyperglycemia

A client has the following ABG 7.30 , HCO 22 PaC02 86. Which intervention by the nurse takes priority ?

D. Assess the airway

71. A client who is experiencing an exacerbation of Crohn's disease should be monitored for which complication

Dehydration

A client is worried about contracting influenza . What is the nurse's best response to the client ?

Did you receive a flu vaccine this year

Which of the following would the nurse most likely assess in a client diagnosed with right sided heart failure

Distended neck veins

A client is suspected of having an abdominal aortic aneurysm . Which question is the highest priority for the nurse to ask first ?

Do you have any abdominal or back pain ?

A client has hypokalemia . What question be the nurse obtains the most information on a possible cause ?

Do you use diuretics or laxatives ?

A client with diabetes melites is prescribed to take insulin glargine once daily and regular insulin four times daily . How will the nurse teach the client to take these two medications when the first dose of regular insulin should be given at the same time of day as the insulin glargine dose

Draw up and inject the insulin glargine fist and then draw up and inject the dose of regular insulin in a separate syringe

The nurse is assessing a client with anemia . Which clinical manifestation does the nurse expect to see in this client

Dyspnea with activity

A nurse is assessing a client who has systemic lupus systemic erythematosus . Which of the following should the nurse expect ? ( SATA

Elevated temperature during exacerbation Elevated Creatinine Butterfly rash Joint Inflammation

A client returned to the nursing unit after a prostatectomy Which activities does the nurse delegate to unlicensed assistive personnel ? ( SATA )

Encourage the client to get out of bed and use the chair Demonstrate how to use incentive spirometer Measuring and recording output from the indwelling catheter

A client with diabetes mellitus has hot dry skin ; rapid and deep respirations ; and fruity odor to his breath . The charge nurse observes a newly graduated registered nurse performing all the following tasks Which action requires that the charge nurse intervene immediately ?

Encouraging the client to drink 4 ounces of orange juice

The nurse is caring for a client post spinal cord injury . What interventions will the nurse provide to minimize the risk of autonomic dysreflexia ?

Ensure strict adherence to a bowel retraining program

The nurse is caring for a client who is experiencing a seizure that is continuing after 5 minutes What is nurse's priority action ?

Establish airway

A nurse is documenting the plan of care for a client who has type 1 diabetes mellitus that has remained unstable despite conventional insulin therapy . The provider has explained to the client that the new plane will incorporate a long - acting insulin preparation . The nurse anticipates seeing a prescription for the addition of which of the following insulin preparations ?

Glargine

A nurse is instructing a client diagnosed with type 2 diabetes mellitus on diagnostic tests used to evaluate how well the control disorders has been managed . The nurse should instruct the client on which of the following diagnostic tests that will provide this intervention ?

Glycosylated hemoglobin

A client presented to ER with decrease level of consciousness polydipsia hyperthermia , dry mucous membranes . Blood glucose result was critical high of 600 mg / dl and serum Na = 155 , K = 6 , and no serum ketones . The nurse determines the physician will diagnosis this client with which of the following conditions ? .

Hyperglycemic Hyperosmolar State ( HHS / HHNK )

A client diagnosed with heart failure is prescribed furosemide . Which of the following should this client be monitored for because of this medication ? SATA

Hyponatremia Dehydration

A nurse admitting a client who has a leg ulcer and a history of diabetes mellitus . The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous status ulcer ?

Inquire about the presence or absence of claudication

Which action should the nurse take when caring for a newly admitted client receiving a blood transfusion ?

Instruct the client to report any itching , chest pain , or dyspnea

A client with benign prostate hyperplasia asks why his enlarged prostate is causing difficulty with urination Which is the nurses most accurate response

It compresses the urethra , blocking the flow of urine

A nurse suspects anaphylaxis when caring for a client following the initial administration of an intravenous infusion of an antibiotic . Which of the following would the nurse likely assess in this client ? ( Select all that apply ) .

Itchiness Edema / swelling Hypotension Tachycardia

Which medication will the nurse prepare to administer to the client who is experiencing status epilepticus

Lorazepam

A client is experiencing a loss of central vision nut not a loss of peripheral vision . The nurse realizes the client should be evaluated for condition ?

Macular degeneration

The nurse is caring for a client with Parkinson's disease . Which intervention does the nurse implement to prevent aspiration related respiratory complications in the client ? .

Maintain the head of the bed at least 30 degrees or greater

The nurse is discussing an elderly client's diet and nutritional status with the hospital dietician . The nurse knows this client is at risk for which complication ?

Malnutrition

8. A 75 - year - old diabetic client presents to the ER after collapsing in a local department store . The client has been fasting for days and testing had found ketones in the urine . Which acid base imbalance would the nurse expect assess in the client ?

Metabolic acidosis

The nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia . The nursing instructor determines that the student is unprepared for this procedure if the student states that which action is part of the plan or preparation and administration of the potassium ?

Prepare the medication for bolus administration

A client brought to the emergency department states that he has accidentally been taking two times has prescribed dose of warfarin for the past week . After noting that the client has no evidence of obvious bleeding , the nurse plans to take which action

Prepare to draw a sample for of PT / INR

The nurse assess a client who has Guillain - Barre syndrome . Which clinical manifestation does the nurse expect to find in this client ?

Progressive ascending weakness and paresthesia

7. A client is admitted to the emergency room with a respiratory rate of 6 / min . Arterial blood gasses ( ABGs ) have been drawn and reveal to following values : pH 7.22 , PaCO2 68 , HCO3 26 , PaO2 74. Which of the following is an appropriate analysis of these ABGs ?

Respiratory acidosis

The nurse reviews the ABG results of a client and notes the following : pH 7.45 , PaCO2 30 , HCO3 20. The nurse analyzes these results as indicating which condition ?

Respiratory alkalosis Fully compensated

92. The nurse writes the nursing problem of " fluid volume excess " Which intervention should the nurse include in the plan of care ?

Restrict the client's sodium in the diet

72. A client with renal failure who has been taking aluminum hydroxide / magnesium hydroxide suspension at home for indigestion is drowsy and has decreased deep tendon reflexes . Which action should the nurse take first

Review magnesium level on client's chart

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis . Which of the following actions is the highest priority for the nurse to take ?

Review the client's electrolyte values .

The nurse conducts a physical assessment for a client with abdominal pain . Which finding leads the nurse to suspect appendicitis

Severe , steady right lower quadrant pain -

A client with chronic obstructive pulmonary disease ( COPD ) is admitted to the hospital . How can the nurse best participate the client to improve gas exchange ?

Sitting up at the bedside or in the chair and leaning slightly forward

18. A client receiving continuous tube feedings develops restlessness , agitation , and weakness . Which laboratory result is most important to report to the health care provider ?

Sodium 154

A nurse is reviewing the labs for a newly admitted heart failure client and notes a serum potassium level of 5.8 . Upon reviewing the clients ' meds , the nurse realizes which of the following medications most likely contributed to this electrolyte imbalance ?

Spironolactone

The nurse is caring for a client who is about to have immunotherapy initiated due to severe allergies . Knowing that this patient is being exposed to a known allergen , what intervention does the nurse implement to provide for client safety this allergy treatment ?

Stay with the client and ensure that emergency equipment is in the room .

An older adult client who has mature cataract in the right eye states " Now I have lost the sight in my right eye because I waited too long for treatment " . How does the nurse best respond to the client ?

Surgery can still save the sight in your eye with removal of the cataract

Which assessment data obtained by the home care nurse suggests that an older client may be dehydrated

The client states he feels lightheaded when he gets out of bed or stands up

19. The laboratory values of a client who has diabetes mellitus include a fasting blood glucose level of 196mg / dl and hemoglobin AIC of 6.8 . What are the nurses interpretations of these findings ?

The client's glucose control for the past 24 hours has been poor but the overall control is good

A client is diagnosed with glaucoma and is prescribed medication to treat it . The nurse knows that which of the following best explains the purpose of the medication ?

This medication lowers intraocular pressure

Which of the following conditions should the nurse recognize as a type Il hypersensitivity reaction

Transfusion with the improper blood type

Which of the following assessment techniques can the nurse us to determine if a client is experiencing hypocalcemia SATA )

Trousseau's Sign chvostek sign Check the chart to evaluate recent lab values

A nurse is caring for a client and observes that the client's urine is cloudy and has an unpleasant odor . The nurse should recognize that these findings are associated with which of the following ?

Urinary tract infection

6. A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days . The provider prescribes warfarin PO without discontinuing the heparin . The client asks the nurse why both anticoagulants are necessary . Which of the following statements should the nurse make ?

Warfain Take several days to work so the IV heparin will be used until the warfarin reaches a therapeutic level

24. A client asks the nurse why it is important to be weighed every day if he has right - sided heart failure . What is the nurse's best response

Weight is one of the best indications that you are gaining or losing fluid .