PRepU test 2

A nurse is taking care of two clients who have a prescription to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50 mm Hg. The second client is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their IV lines and vital signs, what should the nurse do next?

Call for and hang the first client's blood transfusion.

A client who is 1 day postoperative is using a morphine patient-controlled analgesia (PCA) pump. The client is confused and disoriented. What is the priority intervention by the nurse

Check respiratory rate and depth as well as oxygen saturation levels.

The nurse is administering a medication to a client with myeloid leukemia and does not know the use, dose, or side effects. To obtain the most up-to-date information about this drug, what should the nurse do?

Consult the drug guide provided by the clinical agency.

An adolescent in the early stages of labor is admitted to the labor and delivery unit. The nurse notes lymphadenopathy and a macular rash on the palmar surfaces of the hands and plantar surfaces of the feet. Admission laboratory testing reveals trace ketones in the urine, white blood cell count [10,000/μl (10 x 10 9th /L), hemoglobin 14.5 g/dl (145 mmol/L), hematocrit 40% (0.40), and the nontreponemal antibody test is positive. The nurse notifies the physician of the laboratory results. Which action by the nurse takes priority?

Consulting with the infection control nurse.

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action?

Contact the physician and obtain necessary orders.

The assessment of a client on the first day after thoracotomy shows a temperature of 100°F (37.8°C); heart rate, 96 beats/minute; blood pressure, 136/86 mm Hg; and shallow respirations at 24 breaths/minute, with rhonchi at the bases. The client states incisional pain. Which nursing action has priority?

Correct response: Medicate the client for pain.

What is the most common cause of medication errors among noninstitutionalized elderly clients?

Deficient knowledge

With shorter lengths of stay becoming the norm, which statement is true of the stages of the nurse-client relationship?

Different phases of the relationship involve emphasizing different processes and goals related to client needs.

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?

Instruct the client to breathe into a paper bag.

When caring for the neonate of a mother with gestational diabetes, which finding is most indicative of a hypoglycemic episode?

Jitteriness

A registered nurse (RN) instructs the unlicensed assistive personnel (UAP) to check the urine intake and output (I&O;) on clients on the oncology unit at the end of the 8-hour shift. It is important for the nurse to instruct the UAP to do what?

Report back to the nurse immediately if any client has an output less than 240 mL.

A client is transferred to a rehabilitation center after being treated in the hospital for a stroke. Because the client has a history of Cushing's syndrome (hypercortisolism) and chronic obstructive pulmonary disease, the nurse formulates a nursing diagnosis of:

Risk for impaired skin integrity related to tissue catabolism secondary to cortisol hypersecretion.

A client with chronic back pain is admitted to the medical-surgical floor and is receiving multiple pain medications and an antidepressant for pain control. The physician's orders include a physical therapy consult for ambulation and back strengthening, magnetic resonance imaging (MRI) of the lumbar spine, and a computed tomography (CT) scan of the abdomen. How should the nurse schedule therapy and diagnostic tests?

Schedule the MRI of the lumbar spine first, then the physical therapy consult, and then the CT scan.

A client has been hospitalized with a diagnosis of myasthenia gravis. A friend is visiting the client during lunch. The nurse enters the room after the client recovered from choking on lunch. What should the nurse do next?

Tell the client to swallow when her chin is tipped down on her chest.

To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard?

The client receives a complete bed bath each morning.

A client experiencing acute alcohol withdrawal is upset about going through detoxification. Which goal should be the priority for the nurse?

The client will work with the nurse to remain safe.

The nurse notes that a placebo has been prescribed when a client requests pain medication. Which statement is most accurate about the use of placebos in the client's plan of care?

The use of placebos violates the client's right to ethical care.

Following the formation of an ileal conduit, the nurse notes that the client's urinary drainage appliance contains pale yellow urine with large amounts of mucus. How should the nurse interpret these data?

These findings are normal for a client with an ileal conduit.

A multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm, completely effaced (100%), and at 0 station. Based on these findings, the nurse should recognize that the client is in which phase of labor?

Transitional phase

Which laboratory study is most relevant to treating a client who has sustained a pelvic fracture?

Type and crossmatch

The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment?

a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling

A client on a psychiatric care unit has muscle spasms in the neck, stiffness in other muscles, and the eyes are rolling upward. The client had two PRN doses of haloperidol in the last 6 hours. Of the drugs that have been prescribed for the client as needed (see chart), the nurse should administer:

benztropine.

A toddler hospitalized with nephrotic syndrome has marked dependent edema and hypoalbuminemia. His urine is frothy. When assessing the child's vital signs, the nurse should report which finding to the primary care provider?

body temperature of 102.8° F (39.3° C)

A client is undergoing fertility testing, and it has been determined that she is oligo-ovulatory. Which drug would be used to stimulate ovulation in this type of menstrual cycle?

clomiphene

The nurse teaches the client with type 1 diabetes mellitus about the importance of maintaining stable blood glucose levels. The nurse should suggest the client include which type of food to minimize the rise in blood glucose level after meals?

dietary fiber

The nurse assesses a 7-month-old infant's growth and development. Which behavior should the nurse consider unusual?

drinking from a cup and spilling little of the liquid

Which lifestyle modification should the nurse encourage the client with a hiatal hernia to include in activities of daily living?

eliminating smoking and alcohol use

The nurse should instruct the client with low back pain to avoid:

exceeding the prescribed exercise program.

The couple with the lowest risk of having a child with sickle cell anemia disease is the one in which the:

father is HbA and the mother is HbS.

While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to opiate use during pregnancy, which finding would alert the nurse to possible opiate withdrawal?

high-pitched cry

If a manual end-of-shift count of controlled substances isn't correct, the nurse's best action is to:

immediately report the discrepancy to the nurse-manager, nursing supervisor, and pharmacy.

A nurse writes a note in a client's chart that says: "The physician is incompetent because he ordered the incorrect drug dosage." This statement may lead to a charge of:

libel.

A nurse caring for a client with a fecal impaction should watch for:

liquid or semiliquid stools.

Following surgery to set a fractured mandible, the client has swelling at the surgery site. The priority for nursing care is to:

maintain a patent airway.

When planning care for a client with osteoarthritis, the nurse should instruct the client to use:

orthotic devices to support involved joints.

The nurse is evaluating the pin insertion site of a client's skeletal traction. Which finding indicates a complication?

pin moves slightly at insertion site

An adolescent who is immobilized in a cast to stabilize a recently fractured femur suddenly develops chest pain, dyspnea, diaphoresis, and tachycardia. The nurse should further assess the client for:

pulmonary emboli.

When percussing a client's chest, the nurse should expect to hear

resonance.

Which is the most appropriate diet for a client during the acute phase of myocardial infarction?

small, easily digested meals

A newly pregnant woman tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to telling the client how important taking the vitamins are, the nurse should advise her to:

take the vitamin on a full stomach.

When a nurse is assessing a client for pain, what finding is most significant? The client:

tells the nurse about experiencing pain.

A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation?

urine output of 30 mL/h

An obese client, age 65, is diagnosed with type 2 diabetes. When educating this client about his diagnosis, the nurse knows that the client will need more education when he says which of the following? Select all that apply.

• "If I follow my diet and exercise, I won't have diabetes any more." • "I can never eat a hot fudge sundae again." • "I guess I will need to stop meeting my friends at the coffee shop."

The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which statement indicates that the client still has a knowledge deficit?

"Heat-producing liniments can be used with other heat devices."

The client with a spinal cord injury asks the nurse why the dietitian has recommended to decrease the total daily intake of calcium. Which response by the nurse would provide the most accurate information?

"Lack of weight bearing causes demineralization of the long bones."

The client diagnosed with conversion disorder has a paralyzed arm. A staff member states, "I would just tell the client her arm is paralyzed because she had an affair and neglected her baby's care to the point where the baby had to be hospitalized for dehydration." Which response by the nurse is best?

"Pushing insight will increase the client's anxiety and the need for physical symptoms."

Which comment indicates that a client understands the nurse's teaching about sertraline?

"This medicine can cause delayed ejaculations."

When administering atropine sulfate preoperatively to a client scheduled for lung surgery, the nurse should tell the client?

"This medicine will make your mouth feel dry."

A client diagnosed with acquired immunodeficiency syndrome (AIDS) is experiencing end-stage Kaposi's sarcoma. Concerned that the health care team is investing too much energy in keeping him alive, he asks that they not attempt any more interventions. How should a nurse respond to this client?

"We have to make sure you've signed an advance directive."

A 24-year old client who has diabetes mellitus accidentally cut herself while preparing dinner and has sustained a large laceration on her left wrist. After the laceration is sutured, the client asks the nurse, "How long will it take for my scars to disappear?" Which statement is the nurse's best response?

"With your history and the type and location of your injury, it's hard to say."

The mother of a 4-year-old child with juvenile idiopathic arthritis (JIA) is worried that her child will have to stop attending preschool because of the illness. Which response by the nurse would be most appropriate?

"Your child should be encouraged to attend school, but he will need extra time to work out early morning stiffness."

After receiving an oral dose of codeine for an intractable cough, a client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond?

30 minutes

A primigravid client with severe preeclampsia exhibits hyperactive, very brisk patellar reflexes with two beats of ankle clonus present. How does the nurse document the patellar reflexes?

4+

A child with suspected rheumatic fever is admitted to the pediatric unit. When obtaining the child's history, the nurse considers which information to be most important?

A recent episode of pharyngitis

A client is recovering in the labor and delivery area after giving birth to a 6-lb, 3-oz (2,813 g) boy. On assessment, the nurse finds that the client's fundus is firm and located two fingerbreadths below the umbilicus. Although she didn't have an episiotomy, her perineal pad reveals a steady trickle of blood. What is the probable cause of these assessment findings?

A vaginal laceration

A new nurse working on a mental health unit observes a senior nurse administer a parenteral dose of haloperidol to a client against the client's wishes. What should the new nurse do in response to this observation?

Advise the nurse that he/she can be accused of battery.

Parents of an infant infected with human immunodeficiency virus (HIV) tell the nurse that they aren't going to inform the day-care providers about their son's infection. How should the nurse respond to the parents' plan?

Agree that the parents have the legal right to confidentiality.

A nurse has completed 4 hours of his 8-hour shift on a medical-surgical unit when he receives a phone call from the nursing supervisor. The nursing supervisor informs the nurse that he needs to give report to the other two nurses on the medical-surgical unit and immediately report to the telemetry unit to assist with staff needs on that unit. The nurse informs the supervisor that he has been busy with his client assignment and feels this will overwhelm the nurses on the medical-surgical unit. The supervisor informs the nurse that the need is greater on the telemetry unit. This is an example of which type of ethical problem?

Allocation of scarce nursing resources.

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?

An isolation room three doors from the nurses' station

A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which information should the nurse include in client teaching?

Apply deodorant only under the left arm.

Which nursing intervention would most likely promote self-care behaviors in the client with a hiatal hernia?

Ask the client to identify other situations in which the client changed health care habits.

A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process?

"Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels."

After instructing a multigravid client at 10 weeks' gestation diagnosed with chronic hypertension about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client makes which statement?

"I need close monitoring because I may have a small-for-gestational-age infant."

A client with schizophrenia tells a nurse preparing him for discharge that he has no home or family and has been living on the street. Which action is most appropriate?

Asking the physician to refer the client to social services for further evaluation

A nurse records a client's finger stick blood glucose level and gives 2 units of regular insulin as ordered. At the next scheduled blood glucose assessment, the nurse realizes that he/she previously tested and administered the insulin to the wrong client. What is the nurse's priority action related to this incident?

Assess both clients and call the appropriate physicians to notify them of the errors.

Which is the highest priority performed by the nurse prior to completing this nursing action?

Assess stomach residual

A client in the emergency department has symptoms of anxiety, a 'racing heart,' and dyspnea. The cardiac monitor shows sinus tachycardia with a heart rate of 122. What is the appropriate action of the nurse?

Assess the client's vital signs and oxygen saturation.

The client with peripheral vascular disease and a history of hypertension is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which should be the nurse's first step in planning the dietary instructions?

Assess the family's food preferences.

A client in the second stage of labor is fully dilated. Which nursing action is appropriate for this stage of labor?

Assessing vital signs every 15 minutes

A nurse is coordinating care for a client admitted to the psychiatric unit after his/her fiancé was killed accidentally at his work site. Several weeks after the accident, the client is unable to sleep, eat, or work. Which of the following interventions would be most therapeutic for the client?

Assign the same staff as often as possible.

While undergoing treatment with a caustic chemotherapeutic agent, a client experiences extravasation. Indicate how the nurse should respond to extravasation by placing the following nursing interventions in chronological order. Use all the options.

Discontinue the intravenous infusion. Follow facility policy for dealing with extravasation. Notify the physician. Document all signs and symptoms thoroughly. Monitor the client throughout the shift and give a

A client with dementia is eating off of other clients' meal trays. After the client with dementia is asked to stop, which of the following actions should be taken?

Distract the client

During a visit to the clinic, a pregnant 25-year-old woman who began prenatal care at 10 weeks' gestation and is now in her third trimester reports frequent constipation. Which suggestion by the nurse would be most helpful?

Eat at least four pieces of fruit daily.

The nurse is evaluating the test results of a client undergoing testing for depression. Which of the following results of from a dexamethasone suppression test (DST) would the nurse interpret as indicative of depression?

Elevated afternoon serum cortisol

A nurse who is teaching a group of parents about Reye's syndrome presents the following scenario: A 6-year-old child with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. For which assessment findings should the nurse instruct the parents to seek immediate medical attention?

Fever, lethargy, and vomiting

During periods of extreme stress a client may experience elevated blood pressure, dilated pupils, and increased respirations. These unconscious responses originate in which part of the brain?

Hypothalamus

A client with Rh isoimmunization gives birth to a neonate with an enlarged heart and severe, generalized edema. The neonate is immediately transferred to the neonatal intensive care unit. Which nursing diagnosis is most appropriate for the client?

Impaired parenting related to the neonate's transfer to the intensive care unit

The nurse is caring for a laboring client fluent in English, but the client defers to her mother-in-law when asked to sign the hospital consent forms. Which of the following factors contributes to the challenges the nurse faces in obtaining consent?

Influence of the extended family

A nurse is reviewing instructions for a low-residue diet with a client who has an acute exacerbation of colitis. To evaluate the client's understanding of the diet, the nurse asks the client to plan a menu. Which of the following food selections by the client indicates an understanding of a low-residue diet?

Lean roast beef, white rice, and tea with sugar

Clients with cancer who receive multiple blood transfusions are at risk for forming antibodies against the blood. What precautions should the nurse take when administering blood to a client with a history of multiple transfusions?

Make sure that leukocyte-reduced blood products are ordered.

While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan?

Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.

A client is in an acute manic phase of bipolar disorder, pacing the halls and talking in a loud voice. The client frequently threatens and disrupts others on the unit. Which of the following interventions by the nurse would be a priority?

Monitoring blood lithium levels

The parents of a neonate with a cleft lip are shocked when they see their child for the first time. Which nursing action should the nurse include in the neonate's plan of care to help the parents accept their newborn's anomaly?

Show them pictures of babies before and after corrective surgery.

A nurse is caring for another nurse's clients while that nurse is on break. While making rounds of the other nurse's clients, the nurse found medications left at a client's bedside stand. How should the nurse best address this problem?

Speak to the coworker when she returns to the unit.

Which recommendation would be most helpful to suggest to a primigravid client at 37 weeks' gestation who has leg cramps?

Straighten the knee and flex the toes toward the chin.

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which conditions?

Tachycardia, weight loss, and mood swings

During the first hour postpartum, assessment of a multiparous client who gave cesarean birth to a neonate weighing 10 lb, 2 oz (4,593 g) reveals a soft fundus with excessive lochia rubra. The nurse should include which interventions in the client's plan of care?

administration of intravenous oxytocin

A client develops atrial fibrillation following an acute myocardial infarction. The physician orders digoxin, 0.125 mg I.M. daily. The nurse clarifies the order with the physician because I.M. administration of digoxin leads to:

an increased serum creatine kinase (CK) level.

A client with unstable angina is scheduled to have a cardiac catheterization. The nurse explains to the client that this procedure is being used to:

assess the extent of arterial blockage.

A client who was involved in a motor vehicle accident has a fractured femur. The nurse caring for the client documents "acute pain" as a nursing diagnosis in the care plan. Which nursing interventions are appropriate? Select all that apply.

• Ask the client about the methods used previously to alleviate pain. • Assess the client's perception of pain.

A client is admitted to the emergency department after complaining of acute chest pain radiating down his left arm. Which laboratory studies would be indicated? Select all that apply.

• Creatinine phosphokinase (CPK) • Myoglobin • Troponin T and troponin I

A client's breathing stops after receiving the wrong medication. The nurse initiates the code protocol, and the client is emergently intubated. As soon as the client's condition stabilizes, the nurse completes an incident report. What should the nurse do next? Select all that apply.

• Do not document in the nursing notes about an incident report being completed. • Notify the nursing supervisor and or medical director. • Prepare for remediation on medication adminis

A neonatal nurse is assessing a 2-week-old's pain level following open heart surgery. To assess the pain level using an age appropriate scale, which scales would be appropriate? Select all that apply.

• FLACC scale • NIPS scale

The nurse is caring for a postpartum client and suspects that the client has developed a postpartum adjustment reaction with depressed mood, also known as the "baby blues." Which of the following client findings support the nurse's assessment? Select all that apply.

• Is tearful without an identifiable reason • Expresses anxiety about caring for the newborn after discharge • Presence of fatigue and physical discomfort Correct

A primigravid client is seen for her first visit in the antenatal clinic and tells the nurse that her brother was born with cystic fibrosis (CF). When teaching the client about this disorder, the nurse should include which information? Select all that apply.

• To inherit CF, each parent must carry a recessive trait for the disease. • Chorionic villi sampling (CVS) can identify prenatally if their child carries the trait or has the disease. • If both parents carry the trait, each offspring has a 25% chance of inheriting the disease. Correct