Question Trainer 6 Incorrects
pt admitted to hospital with dry mucus membranes and decreased skin turgor. pt's vitals are 120/70BP, temp 101, HR 88, RR 14. labs indicate sodium is 150 and hct 48%. nurse expects HCP to order what IV fluids? - d5NS - 0.45% NaCl - 0.9 NaCl - LR
0.45 NaCl rationale: hypotonic solution- shifts fluid into intracellular space to correct dehydration / d5NS = hypertonic and shouldn't be used in dehydration / LR and 0.9NaCl = isotonics - to replace electros and not best with dehydration
nurse teaches pt diagnosed with MS prior to discharge. it is important for nurse to include which instructions? SATA - ambulate as tolerated every day - avoid overexposure to heat - perform stretching and strengthening exercises - participate in social activities - use cold packs on joints
ambulate as tolerated every day avoid overexposure to heat perform stretch/strength exercises participate in social activities rationale: overexposure to heat or cold may cause damage related to changes in sensation
nurse instructs parents of child diagnosed with celiac disease. nurse determines teaching is effective when parents make which statement? SATA - child's diet will include fruits and veggies - i will make sure i serve child foods high in protein - i will serve cereal and milk only twice per week - i will pack pudding for snack every day - i will use wheat bread for sandwiches
diet with fruits and veggies foods high in protein rationale: intolerance of gluten = celiac, fruits/veggies are good source of proper nutrition that doesn't contain gluten, protein is a good choice for them, cereals/puddings/breads contain fluten
24 yo pt at 30wks gestation is seen in outpatient clinic for routine visit. nurse is most concerned if pt makes which statement? - during the day i seem to get hot flashes and chills - i am having some trouble with constipation and hemorrhoids - at the end of the day, i have leg cramps - when i put my hand on my abdomen, i can feel it tense and relax
during the day i seem to get hot flashes and chills rationale: report to HCP, constipation/hemorrohoids form growing baby, leg cramps from compressed nerve supply, braxton hicks are common
nurse prepares the pt for lumbar puncture. it is important nurse makes which statement? SATA - don't worry because a general anesthetic will be used - you can't drink fluids for 8 hrs before test - you will remain flat in bed for 8 hrs after test - compression bandage will be in place for 10hr after test - you may feel discomfort in leg when needle is inserted - you can have analgesic after procedure if you have a headache
flat in bed for 8hrs after test discomfort in leg when needle insert analgesics if you have headache rationale: flat in bed and analgesics to prevent post lumbar puncture headache, nerve endings may be touched when performing procedure / fluids aren't restricted before test
pt who had a bowel resection returns to med surg unit from postanesthesia care unit at 1100. at 1200 pt reports pain. HCP prescribes fentanyl 100mcg IV q3 to 4 hrs. record indicates pt was given fentanyl 100mcg IV at 0915. action by nurse? - ask HCP to increase dose - give pt med 50mcg IV now - inform pt hte next dose of fentanyl will be given at 1300 - give pt fentanyl 100mcg IV in 15 mins
give in 15 mins rationale: nurse should give pt med as prescribed, which would be at 1215
nurse obtains nursing history from teen pt. pt says : i drink lots of fluids and still feel thirsty" it is most important for the nurse to ask what question? - has your weight changed recently? - what meds do you take? - do you have any allergies to food or med? - how often do you menstruate?
has your weight changed recently? rationale: excess thirst and weight loss could be indicative of t1dm
nurse prepares discharge plans for pt being treated for syphilis. which is most important to include? - have sexual activity with only one partner - how to practice safe sex - info about health clinics - signs of secondary infection
how to practice safe sex rationale: practice of safe sex is primary prevention for transmission of STIs, the rest are as effective ways to prevent transmission of STIs
adult admitted to acute locked psych unit on month prior to the election. pt requests opportunity to vote in upcoming election. best response by nurse? - you aren't eligible to vote because you are a psych pt - i'll make the appropriate arrangements for you to vote - you may vote only if you are discharged by election day - i'll contact the election board to see if you are registered to vote
i'll make the appropriate arrangements for you to vote rationale: pt can vote via absentee ballot
nurse cares for pt diagnosed with hyperthyroidism. which nursing action is best? - provide pt with extra blankets - instill artificial tears PRN - offer the pt reading material - offer frequent low calorie snacks
instill artificial tears PRN rationale: pts with hyperthyroidism frequently exhibits exophthalmos, which requires opthalmic drops on regular basis, frequent snacks should be high calorie, want calm/restful environment with low stimulation, sensitive to heat so don't give blankets / protecting the eyes from injury is a priority
the home health nurse makes a follow up visit to elderly pt receiving isoniazid 200mg every day for 6mth. nurse is most concerned if the pt makes which statement? - i have blurred vision at times - my legs and knees hurt - my hands and feet tingle - i think i had a migraine yesterday
my hands and feet tingle rationale: may cause peripheral neuropathy indicated by tingling, may also cause nausea.
pt is scheduled for cardiac cath at 0800. pt's lab work was completed 5 days ago, results include k+ 3.0, na 148, BG 178. pt reports muscle weakness and cramps, which action is best? - administer 0700 dose of spironolactone - encourage eating bananas for breakfast - obtain stat K level - call for 12 lead ECG
obtain stat K level rationale: s/s are indicative of hypokalemia, stat K level is needed to confirm K level prior to going for cardiac cath
nurse caring for pt diagnosed with perforated bowel secondary to bowel obstruction. at the time of diagnosis, which is the priority action in nursing care plan? - maintain pt in supine position - notify pt's next of kin - prepare pt for emergency surgery - remove NG tube
prepare pt for emergency surgery rationale: when bowel perforates as a result of increased pressure within the gut, intestinal contents will be released into peritoneum = peritonitis = surgery needed ASAP, would also want to keep in semi-fowler's position
which finding indicates to nurse the pt's NG tube is functioning effectively? - fluctuation of fluid level in the water seal chamber - active bubbling in the suction bottle - presence of a hissing sound from blue lumen tube - pressure of 25mmHg in esophageal balloon
presence of a hissing sound from blue lumen tube rationale: hissing = air freely exiting airway; purpose to provide continuous steady suction without pulling gastric mucosa
nurse reviews medical records. which is a properly recorded client chief complaint in nursing health history? - "client reports midepigastric discomfort with flatus after meals" - "area above umbilicus appears to be painful and tender to palpate" - "pt states, 'my stomach hurts after dinner every night'" - "rebound tenderness present in mid to upper abdominal area"
pt states "my stomach hurts after dinner every night" rationale: chief complaints should be the pt's own words
nurse returns to the nurse's station after making pt rounds and finds 4 phone messages. which message does nurse return first? - pt with hep a who says "my arms and legs are itching" - the pt with a cast on the right leg who states "i have a funny feeling in my right leg" - the pt with osteomyelitis of the spine who states 'i a so nauseated i can't eat" - the pt with arthritis who says "i am having trouble sleeping at night
pt with cast on the right leg who states "i have a funny feeling in my right leg" rationale: may indicate neurovascular compromise, needs immediate assessment
pt diagnosed with necrotizing spider bite is to change dressing at home. nurse determine which pt statement indicates correct understanding of aspectic technique? SATA - i need to buy sterile gloves to redress this wound - i should wash my hands before redressing my wound - i should keep wound covered at all times - i should only use whatever my HCP orders for dressing change - i should make sure someone looks at my wound every dressing change - i will throw dressing away in kitchen garbage bag wrapped in glove
wash before redressing only use what is prescribed make sure someone looks at it throw dressing away wraped in glove rationale: no sterile gloves, need to wash hands, can't keep wound covered at all times, only used prescribed meds, observe for changes, discard dressing after wrapped in nonsterile glove
nurse conducts pre-op teaching with family of pt scheduled for total laryngectomy. which families statement indicates a need for further teaching? SATA - we will need to learn other ways to communicate with each other - my spouse will require a feeding tube for several months - my parent will require a special kind of tube in the neck for the airway - my parent may develop some difficulty with taste and smell after the surgery - my parent is looking forward to learning how to laugh using tracheosophageal puncture - we will encourage our parent to cough and deep breathe after surgery
- my spouse will require a feeding tube for several months - my parent is looking forward to learning how to laugh using trachesophageal puncture rationale: need nutrition support for 10 days until wounds heal then gradually resume oral intake, won't be able to sing/whistle/laugh using laryngeal communication, communicate in writing initially then by artificial larynx/esophageal speech, need laryngectomy tube to prevent scar tissue contracture
pt has a 25yr history of alcohol abuse. pt is being treated for chronic cirrhosis. which s/s suggest pt is in early stages of hepatic encephalopathy? SATA - pt has a distended abdomen and protruding umbilicus - pt has difficulty describing what is done at work - pt states difficulty sleeping thru the night - pt exhibits asterixis when hands are assessed - pt sleeps 10-12 hrs thru day - pt's spouse notes a change in pt's handwriting
- pt has difficulty describing what is done at work - pt states difficulty sleeping thru the night - pt's spouse notes a change in pt's handwriting rationale: writing/hand tremors, insomnia/sleep disturbances, impaired thought processes are early signs
charge nurse cares for pt with internal radiation. nurse intervenes if which actions are noted? - visitor limited to 5 hrs per day with pt - male caregiver is assigned to all care - time in room limited for all care providers - lead lined apron is worn for all care delievery - verbal exchanges with pt are made from doorway - frequent rest periods are incorporated into pt care
- visitors limited to 5 hrs/day - male caregiver assigned to all care - lead lined apron is worn for all care rationale: 3hr/day limit, shouldn't have one person assigned to all care, lead apron isn't appropriate for routine care
nurse cares for pt currently hospitalized with CKD. pt has 3+ pitting edema of lowers. which nursing observations indicate a therapeutic response to therapy for the edema? SATA - K of 4.0 - BG 140 - increased USG - weight loss of 5 lb over last two days - decrease in calf circumference by 2cm
- weight loss of 5lbs over last 2 days - decrease in calf circumference by 2cm rationale: edema is result of sodium and fluid retention; weight loss should occur if therapy is effective; decrease in peripheral circumference should occur if therapy is effective / potassium has no relation to edema
pt comes to nurse's station for prescribed antipsychotic med. nurse notes pt has torticollis, arched back, rapid eye movement. which action does nurse take first? - determines what other meds pt is taking - perform neuro assessment - administer haloperidol IM STAT - administers PRN trihemyphenidyl IM immediately
administers ORM trihexyphenidyl IM immediately rationale: administer benzotropine or trihemyphenidyl, haloperidol is antipsychoitc so will exacerbate
nurse cares for elderly pt recovering from fractured pelvis. activity order reads "ambulate with walker bid" after nurse implements the order, which documentation is best? - pt ambulated well with walker. states no stiffness or pain, didn't appear fatigued - ambulated without difficulty for 20 mins. VS remained stable, color good - walked full length of hall with walker, no difficulty with balance, using walker correctly - pt ambulated 6ft independently with walker, gait steady, RR 14 unlabored
ambulated 60ft independently with walker, gait steady, RR 14 unlabored rationale: objective information, others are subjective/judgement/incomplete
multipara pt comes to prenatal clinic during 5th month of pregnancy. pt reports breasts are sensitive and sore. which suggestions by nurse are effective? SATA - apply warm compresses to your breasts - massage breasts with lotion in downward motion - apply cool compresses to sides of your breasts - take herbal diuretic once a day - wear a well fitting supportive bra
apply cool compresses to sides of your breasts wear well fitting supportive bra rationale: cool packs decrease discomfort, support helps decrease pain / during pregnancy can use ice
clinic nurse receives call from parents of 12yo getting albuterol. child is irritable and parent states, "i can feel my child's heart pounding" which response by nurse is most appropriate? - instruct parent to decrease external stimuli in child's room - ask the parent to administer ordered analgesic - ask parent how long child has been taking med - explain to parent this is expected
ask parent how long the child has been taking the med rationale: adverse effects may diminish child taking the med a week or longer, may be expected but doesn't take action to resolve problem
nurse cares for pt with VTE. pt receives heparin via continuous IV infusion. the activated partial thromboplastin time (aPTT) is 1.5 greater than normal. which action by nurse is most appropraite? - discontinue heparin infusion - check INR - check PT results - continue to monitor the pt
continue to monitor the pt rationale: expected result of heparin therapy is a prolonged aPTT of 1.5 times the control without signs of hemorrhage. INR and PT is used with warfarin therapy
pt had surgery 2 days ago. nurse assesses the incision and a shiny, pink, open area is noted with underlying bowel visible. which action does nurse take 1st? - covers open area with sterile gauze soaked in NS - reapplies a sterile dressing after cleaning the incision with hydrogen peroxide - packs opened area wit h sterile 0.75 in gauze soaked in NS - applies antibiotic ointment and covers incision with a waterproof transparent dressing
covers open area with sterile gauze soaked in NS rationale: evisceration is treated immediately by applying sterile gauze soaked in sterile NS, followed by notification of HCP
nurse cares for pt with sengstaken-blakemore tube in place. nurse enters room and finds pt in resp distress. which action does nurse take first? - notify HCP immediately to remove tube - elevate HOB, administer oxygen - cut balloon ports, removes tube - calls code, begins resucue breathing
cut balloon ports and removes tube rationale: tube is used to stop/slow bleeding form esophagus and stomach that is usually caused by varices that obstruct blood flow, scissors should always be secured at bedside, remove tube if observing sign of resp distress or airway obstruction from upward displacement of esophageal balloon
during the nursing history interview, the preschooler's parent reports the child has frequent bouts of gastroenteritis. which question is most important for the nurse to ask? - are there other children in the family? - does the child attend a day care center? - does the child play with neighborhood children? - is the child current on the immunizations?
does the child attend a day care center? rationale: environments with increased numbers of children (day care centers) are more likely to promote infection due to close conditions and increased likelihood of disease transmission, immunizations doesn't impact gastroenteritis
what plan is best for nurse to use for 10yo who is about to undergo a cardiac cath? - videotape about cardiac cath, one specifically prepared for kids - provide with pamplet about it, encourage them to read it - draw picture of heart, explain where tube will go, what the HCP will see - present puppet show about anatomy and physiology of heart
draw picture of heart, explain where tube will go, what HCP will see rationale: explains in simple terms and allows choices when possible, video isn't best method for school aged child
post-op pt returns in assigned room from the surgical recovery area. pt is sleeping, and nurse notes the pt is disoriented when aroused. which nursing action is best? - place call bell within pt's reach - stay with pt until pt is totally oriented - restrain all 4 extremities until pt is oriented - elevate side rails until the pt is fully awake
elevate the side rails until the pt is fully awake rationale: side rails should always be elevated for any disoriented pt, don't need to stay with pt esp when sleeping
pt diagnosed with a fracture of the left femur is placed in skin traction (buck) with 7lb weight. nurse notes pt keeps sliding down in bed. what action? - elevate pt's left thigh on two pillows - elevated HOB and tilt mattress, as in a slight trendelenburg - raise knee gatch on bed 30 degrees - instruct pt to remain in the middle of the bed
elevates HOB and tilts mattress, as in a slight trendelenburg position rationale: trendelenburg and raising HOB will keep leg straight, prevent slide down and counter the weight pull
nurse performs physical exam on newborn. which assessment should be reported to HCP? SATA - head circumference of 40cm - chest circumference of 32cm - circumoral cyanosis - HR 160 - RR 80 - scalp edema
head circumference of 40cm circumoral cyanosis RR 80 rationale: newborn head circumference is 32-36cm, circumoral cyanosis = blue color around mouth = cold stress or hypoxia, normal RR for newborn is 30-60, scalp edema = normal from delievery
7 yo child weighs 50.25lbs an dis 48in tall. child has gained 2.5 lbs and grown 3 in in the past year. which response by nurse is best? - height and weight are within normal limits - height is normal, but some weight needs to be gained - height in normal, but some weight needs to be lost - weight is normal, but child is shorter than normal
height and weight are normal rationale: 6-12 yo grow about 2 in/year and gain 4.5-6.5lbs/year
nurse cares for pt diagnosed with hyperparathyroidism. which symptom is most important for nurse to report to next shift? - abdominal discomfort - hematuria - muscle weakness - diaphoresis
hematuria rationale: hematuria is a sign of urinary tract calculi- 55% of hyperparathyroid pts have urinary tract calculi / the rest are signs but don't require reporting
nurse cares for elderly pt following right total hip replacement. nurse notes indicate pt has become disoriented and confused at night since surgery. one evening as nurse prepares pt for sleep they glance to the left and say "oh you think so ?" and starts laughing. which response by nurse is best? - do you hear voices talking to you? - tell me why you are laughing so i can laugh too - what is that you find amusing? - i notice you're laughing
i notice you're laughing rationale: reflect what behavior nurse is observing and offer pt opportunity to communicate back
nurse prepares the older pt for discharge after treatment for dehydration. which solution indicates the nurse needs to provide further teaching? - i should weigh myself daily - i should drink fluids thru out day - i can use a measuring cup to find out how much i drink during the day - i should let my HCP know if i get dizzy when i change positions
i should weight myself daily rationale: only indicates overhydration, not response to dehydration / fluid increase up to 3000ml, measuring cup helps total intake indication, postural hypotension from volume deficit is expected
pt develop DI following craniotomy. nurse provides discharge instructions for pt and spouse. what indicates further teaching needed? - i should keep daily record of my fluid intake and how much i go to bathroom - i should call my HCP if i seem thirsty a lot and my USG is less than 1.005 - i should weigh myself everyday and drink less fluid if i gain over 5lb in a week - i will need to take the nose spray med for rest of my life
i should weight myself every day and drink less fluid if i gain more than 5lb over a week rationale: weight gain should be reported to HCP, may need med adjusted / desmopression nose spray for rest of life
pt admitted with abdominal pain and nausea. HCP orders stool for guaiac times three days. nurse asks NAP to obtain stool specimen. which statement by NAP requires RN intervention? - i'll remind the pt use the bedpan instead of the bathroom toilet - i'll use a tongue blade to collect a small amount of stool in a clean container - i'll get a couple of specimens this afternoon because the pt is having loose stools - i'll ask the pt if any red meat has been ingested recently
i'll get a couple of specimens this afternoon because the pt is having loose stools rationale: ordered to be collected over 3 day period, don't need to put it in a sterile container, re meat may cause false positive reading, bedpan is easier to get specimen in rather than toilet
home care nurse visits pt receiving levothyroxine sodium 0.1mg PO daily. which finding indicates the pt is getting favorable results from the med? - decreased BP - increased UO - decreased HR - increased RR
increased urine output rationale: med increases metabolic processes of body, including GFR; edema will decrease as water is excreted
staff informs nurse that their 6yo has head lice. it is important for nurse to take what action? - inspect the staff member's head for live and nits - inform staff that care can't be given to pts until further notice - request staff member contact the HCP - instruct staff about how to use gamma benzene hexachloride shampoo
inspect staff member's head for live and nits rationale: observe and treat with gamma benzene hexachloride, want to confirm presence of them before excluding from duty - should exclude from care until treatment received and shown to effective
nurse instructs the pt with newly diagnosed t1dm about proper foot care. which pt statement indicates that further teaching is needed? SATA - i should cut my toenails straight across - i love to go barefoot - i should inspect my feet once a week - i should bathe my feel daily in warm water - i can keep using my heating pad on my feet - i am going to buy some warm socks
love to go barefoot inspect feet once per week keep using heating pad on feet rationale: feet need to be protected by footwear, inspect feet daily, extreme temps dangerous for diabetic foot
nurse performs routine IV tubing change on pt with a central line. 15 mins later, nurse re-enters the pt's room to find pt cyanotic, SOB, reporting pain. pt's VS are BP 84/62, HR 112, RR 18. which is first action the nurse takes? - calls HCP to report pt's symptoms - lowers head of bed and places pt on left side - places pt in high fowler's - start oxygen at 4l/min via NC
lowers head of bed and places pt on left side rationale: air will rise to right atrium, minimizes chance of air bubbles entering pulmonary circulation
nurse counsels pt who has been abusing alcohol and other drugs for 6 yrs. nursing diagnosis of ineffective individual coping. which action takes priority during working stage of nurse/pt relationship? - observe pt every half hour to determine extent of drug seeking behavior - monitor fluid, meals, snack intake to ensure adequate nutrition - help pt obtain sponsor thru 12 step group in the pt's local area - meet individually with pt to discuss consequences of drug using behavior and examine other options
meet individually with pt to discuss consequences of drug using behavior and examine other options rationale: describes work of interpersonal relationship with a chemically dependent pt - want to get pt to recognize problems the chemicals have caused and learn new methods of solving problems
nurse discharging group of pts. which pts need referral for home care? SATA - post op appendectomy reporting incisional pain - newly diagnosed diabetic with vision impairment - postop cholecystectomy requires steps to get into apartment - pt with HF who underwent diuresis in hospital - elderly pt with new right hip replacement who lives with adult child
newly diagnosed diabetic with vision HR with diuresis elderly with new hip replacement rationale: diabetic needs follow up med administration and ability for self care, HR needs more assessment at home, hip replacement needs self care at home
pt reports dysuria, urinary frequency, discomfort in suprapubic area. RN obtains UA. after evaluating results, nurse orders repeat UA based on ? - negative glucose - RBCs present - no WBCs or RBCs present - USG 1.018
no WBCs or RBCs reported rationale: with symptoms, WBCs and RBCs should be present, WBCs are response to inflammation process and irritation of urethra, RBCs are increased when bladder mucosa is irritated and bleeding
nurse cares for pt following cardiac cath. two hours after the procedure, nurse checks pt's insertion site in the AC space. pt reports hand is numb. nurse takes which action? - change position of hand - checks pt's grip strength in both hands - notify HCP - instructs pt to exercise fingers
notifies HCP rationale: absent/weak pulse or numbness could indicate circulation problem, anticoagulant or vasodilator will be ordered
pt at 39 weeks gestation in active labor screams "i have to push, i have to push". nurse notes pt is 8 cm dilated. nurse takes what action? - instructs pt to take deep breath and bear down - applies gentle but firm pressure to pt's abdomen - coach pt in relaxation techniques - tell pt to pant with pursed lips
pant with pursed lips rationale: transition phase of labor so breathing techniques will allow pt to control pain and urge to push and promote adequate oxygenation of fetus, pushing shouldn't be encouraged until 2nd stage of labor, pressure to abdomen increases discomfort, relaxation teaching is inappropriate at this time
nurse cares for pt in ED. before administering calcium gluconate 10% 500mg IV STAT, which assessment does nurse complete first? - stability of the respiratory system - adequacy of urine output - patency of the vein - availability of mag sulfate injection
patency of the vein rationale: if injected into extravascular tissues = severe chemical burn
adult with NG has order for acetaminophen 650mg PRN for temp greater than 101. nurse takes which action when administering this med? - tablets should be swallowed carefully with sips of water - the med should be withheld until NG tube is removed - placement of NG tube should be checked prior to giving this med - powdered med should be used and mixed with water to form solution
placement of NG tube should be checked prior to giving the med rationale: placement needs to be checked, liquid acetaminophen may be given via NG, placemnet checked before anything
nurse care for young adult pt. pt is scheduled for 1st debriedment of deep partial thickness burn of left arm. it is most important for nurse to take which action? - assemble all necessary supplies and meds - plan adequate time for dressing change and provide emotional support - prepare pt and family for the pain and the pt will experience during and after procedure - limit visitation prior to procedure to reduce stress
plan adequate time for dressing change and provide emotional support rationale: planning for wound treatment should include organizing and planning to spend time not only on mechanics of procedure but also on providing emotional support to pt
during physical assessment, nurse determine the need to perform the bulge test. which statement is best? - please lie down and extend your legs - please bend over and touch your toes - please hold both hands behind your back - please bend your elbow
please lie down and extend your legs rationale: bulge test confirms presence of fluid in the knee; pt's leg should be extended and supported on the bed
nurse answers phone on psych unit. caller identifies self as spouse of pt and inquires about pt's condition. which response by nurse is best ? - i can't discuss any pt's condition who is in the hospital - please provide HIPAA password for the pt - i can't give info over phone. if you come in, we can discuss spouse's condition - i will have to ask pt if that info may be given out
please provide the HIPAA password for the pt rationale: HIPAA password requirement requires 8 character password in order for info to be shared via phone, can't just tell over the phone
nurse assesses infant after cleft lip and palate repair. infant has upper airway congestion and slightly labored respirations. which nursing action is most appropriate? - elevate HOB - suction mouth and nose - position infant on one side - administer oxygen until breathing is easier
position infant on one side rationale: will facilitate drainage of mucus from upper airway and promote adjustment to breathing thru nose / elevating HOB won't promote adequate drainage from upper airways and poor head control makes position unstable / oxygen won't relieve congestion
pt diagnosed iwth lung cancer undergoes pneumonectomy in immediate post op period, which assessment is most important? - presence of breath sounds bilaterally - position of trachea in sternal notch - amount/consistency of sputum - increase in pulse pressure
position of trachea in the sternal notch rationale: position of trachea should be evaluated, with tracheal shift an increase in pressure should occur on operative side and could cause pressure against mediastinal area / on surgical side breath sounds will be absent
adult multipara pt is seen in prenatal clinic. nurse notes the pt is in the 5th month of pregnancy and has a weight gain so far of 14lbs. the history indicates the pt was of average height and weight prenatally. nurse knows which statement is most likely true? - pt has gained too much weight, and diet should be re-evaluated - pt hasn't gained enough weight, diet should be re-evaluated - weight gain is appropriate, present diet should be continued - weight gain indicates possible difficulties may occur later in the pregnancy
the weight gain is appropriate, and present diet should be continued rationale: weight gain of 2-5lb in 1st trimester, 0.66-1.1lb WEEKLY in 2nd and 3rd trimester
pt recieves digoxin 0.25mg PO once daily and furosemide PO bid. reports mild diarrhea. bismuth subsalicylate 60mg prescribed after each bowel movement for two days. pt asks nurse if med schedule should be changed. nurse instructs pt to take which action? - continue med schedule - wait 1 hr before taking the scheduled meds if bismuth is taken - hold scheduled meds until diarrhea subsides - take digoxin but hold furosemide if pt takes bismuth subsalicylate
wait 1 hr before taking scheduled meds if bismuth is taken rationale: bismuth absorbs PO meds, separate administration of other meds , PO meds should be absorbed by bismuth not stomach
visiting nurse evaluates progress of pt recently diagnosed with t1dm. as part of the treatment plan, the pt receives intermediate acting insulin 32 units and short acting insulin 8 units each morning. which pt actions while preparing the morning insulin require nurse intervention? SATA - after drawing up 8 units of short acting, pt adds intermediate to syringe for total of 40 units - pt draws up 32 units intermediate first - pt injects air into intermediate vial then draws up 32 units - pt injects air into each bottle of insulin equal to amount of insulin to be withdrawn - after drawing up the intermediate, the pt injects air into short insulin vial - pt cleans the vials with a new alcohol wipe
- draws up 32 of intermediate first - inject air into intermediate insulin vial then draws up 32 units - after drawing up intermediate acting, pt injects air into short acting vial
nurse cares for pts on surgical unit and has just received report from previous shift. in which order dies nurse assess pts? - collapsed lung due to accident, no drainage noted from chest tube - abdominal perineal resection 3 days ago, reports chills - admitted 3 hrs ago with gunshot, 2mm area of dark drainage on dressing - mastectomy 2 days ago, 23 ml serosanguinous fluid in jackson pratt drain
1. abdominal perineal resection 3 days ago, reports chills 2. collapsed lung due to accident, no drainage noted form chest tube 3. admitted 3 hrs ago with gunshot wound, 2mm area of dark drainage on dressing 4. mastectomy 2 days ago, 23 ml serosanginuos fluid in jackson-pratt drain
nurse admits pt from postop recovery area after abdominal exploratory surgery. in which order does nurse perform these actions? - position pt on left side - check med record for surgical notes - assess RR - determine pulse - check dressing for evidence of bleeding - monitor for purulent drainage at incision site
1. assess RR 2. determine pulse 3. check dressing for bleeding evidence 4. position pt on left side 5. check medical record for surgical notes 6. monitor incision site for purulent drainage
nurse observes graduate nurse perform a moist to dry dressing change on a pt's 2in incision. in which order does the student perform? - moisten prescribed number of gauze with prescribed amount of solution - gently remove dressing - apply moist gauze as a single layer - cover with dry dressings - dry skin surrounding the wound
1. gently remove dressing 2. dry skin around wound 3. moisten prescribed number of gauze with prescribed amount of solution 4. apply moist gauze as a single layer 5. cover with dry dressings
nurse cares for pts in diabetic clinic. in which order does nurse see pts? - pt with sunken eyeballs and fruity breath - pt who reports pain in calves when exercising - pt states "i am drinking liquids often and am always hungry" - pt who says " i am having difficulty sleeping and cry frequently"
1. sunken eyes and fruity breath 2. drinking liquids often and always hungry 3. reports pain in calves when exercising 4. difficulty sleeping and cry frequently
nurse cares for pt in PACU. what order does nurse assess pts? - unresponsive to verbal stimuli with oral airway out of place - chest tube reporting SOB - responsive with moderate amount of clear fluid from NG tube - new tracheostomy with small amount of serosanguineous drainage
1. unresponsive to verbal with oral airway out of place 2. chest tube reports SOB 3. new trach with small amount of serosangineous drainage 4. responsive with moderate amount of clear fluid from NG tube
pt admitted with metastatic cancer has received chemo for 3 months. rbc 3.8, WBC 3, hgb 9.3, plt 50,000. which symptoms does nurse expect pt to exhibit? - 120/70 bp, 100HR, 22RR - ankle edema, ascites - flushed face, light colored stools - nausea, anorexia, vomiting
120/70 bp, 100 HR, 22 RR rationale: increased HR and RR from decreased oxygenation of tissues, would be pale from anemia not flushed
RN cares for 4yo diagnosed with epiglottitis. which observation indicates child is experiencing an early complication of hypoxemia? SATA - HR 148 - bluish skin discoloration bluish discoloration around mouth - throwing toys and kicking bed - difficulty swallowing - nasal flaring with activity
HR 148 throwing toys and kicking bed nasal flaring with activity rationale: HR is high which correlates with hypoxemia and is an early finding of this, cyanosis (bluish color) is a late sign of hypoxemia, irritability and nasal flaring also early sign
nurse cares for pneumonia pt. which observation indicates therapeutic response to treatment? - oral temp of 101, increased chest pain with nonproductive cough - cough, productive of thick, green sputum, reports feeling tired - RR at 20 with moderate amount of thin, white sputum, denies dyspnea - WBC 10000, UO 40ml/hr, decreasing about of sputum
RR at 20 with moderate amount of thin, white sputum, denies dyspnea rationale: sputum characteristics indicate a decrease in pneumonia; supported by resp status
The neonatal nurse instructs the family of a newborn about an apnea monitor. The nurse is MOST concerned if a family member makes which of the following statements? 1. "We will be able to leave our baby for brief periods of time." 2. "We plan to sleep by our baby's crib." 3. "We can remove the monitor during our baby's bath." 4. "A family member will closely watch the monitor all the time."
a family member will closely watch the monitor all the time rationale: this would indicate a feeling that the monitor may not let them know if their baby stops breathing / apnea monitor = monitor's baby HR and RR, apnea is when breathing slows down or stops - this would trigger an alarm to go off, it is small and portable
nurse cares for pt diagnosed with bipolar disorder. the pt will not stop swinging a mop to threaten other pts and staff. which information is most important for the nurse to consider before administering a PRM IM dose of lorazepam? - pt is harmful to self - pt is psychotic - less restrictive intervention failed - pt is harmful to others
a less restrictive intervention failed rationale: use least restrictive interventions in ascending order, want to try those less restrictive interventions first before considering self or others harm
nurse cares for pt after delievery of 7lb 10oz baby. pt has decided to bottle feed. nurse encourage pt to take which action related to breast milk production?SATA - use acetaminophen PO as directed - apply cool packs around outside of each breast - massage the breasts - wear a well supported bra 24 hrs a day - use manual breast pump to relieve pressure - be patient, milk will resolve in 5-7 days
acetaminophen cool packs on outsides well supportive bra be patient, resolve 5-7 days
nurse administers sublingual nitro to pt reporting chest pain. which observation is most important for nurse to report to next shift? - pt indicates need to use bathroom - bp has decreased from 140/80 to 90/60 - RR has increased form 16 to 24 - indicates chest pain has subsided
bp decreased from 140/80 to 90/60 rationale: hypotension is adverse effect of nitro, bp should be monitored closely to ensure it doesn't continue to decrease
pt who attends outpatient clinic is taking chlorpromazine hydrochloride 100mg tid. pt reports sleeping through the day. which action by nurse is most appropriate? - contact HCP to change dose to 100mg bid - change time of med to 100mg in morning, 100 mg after dinner, 100mg at hs - instruct man to take frequent naps during the day - encourage man to be more active during the day
change time of med to 100mg in morning, 100mg after dinner, 100mg at hs rationale: will reduce daytime sedation
HCP writes an order for piperacillin 3g IV q6h for adult pt. before administering this med the nurse takes which action appropriate to this med? SATA - checks for known allergies to meds - obtains specimen for culture and sensitivity - administers dexamethasone sodium phosphate 2mg IV stat - obtains pt's current creatinine clearance results - ensure pt's RR is over 12 - checks pt BP both sitting and standing
check for known allergies to meds obtain specimens for c/s obtain pt's current creat clearance rationale: penicillins allergies need to be checked for, assessment before starting antibi9otic, creat to determine appropriate dosage ordered / don't need to assess RR or BP with this med specifically
nurse cares for pt with marked depression of t cells. nurse takes which action? - keeps a linen hamper immediately outside the room - restricts eating utensils to spoon made of plastic - provides masks for anyone entering the room - removes any standing water left in containers or equipment
removes any standing water left in containers or equipment rationale: water should be allowed to stand in containers (like resp or suction equipment) - could culture medium / no maks unless active pulmonary infection
child received morphine 1 hr ago for abdominal pain. nurse knows which assessment finding best identifies pain relief? - child states pain has gone away - child's HR has changed from 80 to 95 - child sleeps except when receiving nursing care - results from incentive spirometer have improved
results from incentive spirometer have improved rationale: when pain is decreased child will be better able to breathe deeply and improve outcome of IS use / some children will deny pain so they don't get another injection or something painful
nurse cares for 8mth old pt. which observations tell nurse the pt is in pain? SATA - HR decreasecu - fluid intake increase - RR decreases - rubs body part and cries - closes eye tightly - pushes away nurse's hands
rubs body part and cries closes eyes tightly rationale: pushing the hand away isn't something an infant would do at 8mth
nurse instructs prenatal pt about importance of prenatal vitamins. it is most important for nurse to include what instructions? - take prenatals with orange juice at bedtime - take prenatals at breakfast with coffee - take prenatal with milk at lunch - take prenatal with water at dinner
take with orange juice at bedtime rationale: taking with something acidic increases absorption of iron; taking with food at bed decreases possibility of nausea as pt will be asleep
nurse makes home visit to pt with abdominal wound. when irrigating draining wound with sterile saline solution, which sequence is most appropriate? - pour solution, wash hands, remove soiled dressing - wash hands, remove soiled dressing, wash hands, then prepare the sterile field - prepare sterile field, put on sterile gloves, remove soiled dressing - remove soiled dressing, flush wound, then wash hands
wash hands, remove soiled dressing, wash hands, then prepare the sterile field rationale: wash hands before irrigating wound, don't use sterile gloves to remove dressing
3yo pt has delays on denver development screening test (DDST). parent asks nurse, "does this mean my child is going to be slow?" which response by nurse is best? - maybe it is just a bad day. i'm sure your child will do much better next time - the test indicated a delay, and we will have to investigate to learn more. - what are your thoughts about how your child performed on the test? - the results may not be accurate. let's set up a time to retest your child.
what are your thoughts about how your child performed on the test? rationale: open ended, encourages discussion
pt comes to outpatient clinic reporting dizziness and palpitations. physical and lab results are normal. pt reports family owned company is on the verge of bankrupty. best response? - when did you first notice these symptoms? - have you shared this info with anyone? - are you concerned about your financial difficulties? - would you like to discuss your situation iwth me?
when did you first notice these symptoms? rationale: open ended, encourages pt to discuss when problems occurred
pt reports chronic constipation to nurse. nurse in HC clinic advises the pt to take which actions? SATA - reduce intake of highly seasoned foods/fats - drink 1L of fluids daily - increase intake of cereals, fresh fruits, vegetables - ask HCP to prescribe bisacodyl enteric coated tabs daily - plan day to be home around the usual time of defecation - establish a daily exercise pattern
- increase cereals, fresh fruits, veg - plan day to be home around usual time of defecation - establish daily exercise pattern rationale: seasoned foods/fats have no effect on constipation, normal fluids per day 1500-2000, particular time in home helps establish bowel routine decreasing constipation, exercise helps bowel function
pt is seen in the clinic reporting back pain. nurse discusses and demonstrates how to perform activities of daily living to decrease the incidence of back pain. which pt actions indicate to nurse that further teaching needed? SATA - pt bends over to put on and tie tennis shoes - pt stands on toes to place box on top shelf of closet - pt sits in recliner with feet elevated to watch TV - pt stands with feet close together and shifts the weight between feet - pt squats to pick up a spoon on the floor - pt places right lef on top to the left while reading
- pt bends over to tie shoes - pt stands on toes to put box on top shelf - stands with feet close together and shifts weight between feet - places right lefe on top of left while reading rationale: bending and tip toes = back stress, want feet wide apart for solid base of support, right leg on top of left turns back = stress
nurse cares for pt after a vaginal delievery. which action is implemented first? - check pt's lochial flow - palpate pt's fundus - monitor pt's pain - assess the pt's LOC
check pt's lochial flow rationale: complications of hemorrhage assessed by observing lochia flow
RN talks with parents of 6mth old. discussing ways to minimize adverse effects of dtap vaccine. which action is important to discuss? SATA - give child alcohol bath for elevated temp - administer acetaminophen for discomfort - place cool cloth on injection site for 15 mins - check temp every 4 hrs for 3 days - wrap and comfort child for signs of irritability - administer salicylate med for fever
acetaminophen for discomfort cool cloth in injection site wrap and comfort if irritable rationale: salicylates aren't recommended for kids
HCP writes order for HIV positive infant to receive IPV immunization. which nursing action is most appropriate? - wear gloves and gown when administering immunization - administer the immunization - contact HCP for order clarification - determine if infant has history of seizures
administer immunization rationale: IPV (inactivated polio) contradictions include anaphylactic reaction to neomycin, streptomycin, polymyxin B, need standard precautions
pt admitted with failure to thrive has just had a positive sweat test. nurse anticipates which changes in child's plan of care? SATA - administration of replacement enzymes - immediate ABG - salt restricted diet - limited activity with PT - social service referral - unrestricted fat diet
administer replacement enzymes social service referral unrestricted fat diet rationale: sweat test is positive finding for CF - need enzymes, need multi-disciplinary care and unrestricted fat diet due to malabsorption of fat
nurse cares for pt receiving amphotericin B 1mg in 250 ml of d5w IV over 2 hour period. nurse is most concerned if which is observed? - BUN 7.2, creat 0.9 - BP 90/60, reports fever and chills - reports of burning on urination, thirst, dizzy - AST 12, ALT 14, total bili 0.4
bp 90/60 with fever and chills rationale: monitor VS every 30 mins, causes renal toxicity so normal, check liver function studies weekly
nurse cares for pt with RA. nurse prepares for pt to be discharged. nurse understands that for the pt to manage at home along the pt needs to be able to perform which activities? SATA - climb up stairs - lace shoes - comb hair - walk without assistance - brush teeth - eat independently
comb hair brush teeth eat independently rationale: stairs can be eliminated, slip on shoes instead of ties, walker/wheelchair can be used to help walk
nurse cares for pt reporting moderate pain. which action is most important to provide pt with effective pain relief? - teach pt about pain - establish trusting relationship with the pt - determine how various relaxation techniques affect the pain - provide alternative measures to relieve pain
establish a trusting relationship with the pt rationale: need to help work with pt to identify interventions to relief pain
RN cares for pt just admitted after sustaining deep partial thickness thermal injury to right arm. observation is most important to report to HCP? - pain around periphery of injury - gastric ph less than 5.0 - increased right arm edema - elevated hct
gastric ph of less than 5.0 rationale: pt at risk for curling's ulcer which may develop 24 hrs after severe burn injury, gastric ph acidic at 1-5
nurse instructs pt how to use glucose monitor to self monitor BG. which action indicates further teaching is needed? - pt dangles hand before sticking finger - pt sticks finger on side of the distal phalanx - pt touches strip with large drop of blood hanging on fingertip - pt milks finger after sticking it
pt milks finger after sticking it rationale: forces interstitial fluid to mix with capillary blood and dilutes blood, want to take it from side of finger = less painful
pt placed on cephalexin prophylactically after surgery. nurse encourages pt to eat which foods? - bran cereals - egg whites - yogurt - fish - acidophilus milk
yogurt acidophilus milk rationale: these dairy foods will help maintain normal intestinal flora, which would be altered by cephalexin
home care nurse visits the elderly pt with osteoarthritis. which instruction is most important for nurse to include? - swimming is the only helpful exercise for osteoarthritis - you should do warm up exercises prior to exercising - you should do exercises routinely, even if you have severe joint pain - isometric exercises are most helpful to prevent contractures
you should do warm up exercises prior to exercising rationale: warms up and stretching should always be done to begin and end exercising, don't exercise if joints severely painful
nurse cares for pt in outpatient clinic. pt seen for treatment of hypertension. pt expresses concern to nurse that spouse has been unemployed for more than 6 mths. pt is afraid that soon they will be unable to pay their rent. which response is best? - these things always have a way of working themselves out - it's important for your health that you don't worry too much - you're worried that you won't be able to pay the rent? - a social worker might be able to help you with this problem
your worried you won't be able to pay the rent? rationale: reflective response, encourage discussion of feelings and concerns
