RN Comprehensive online practice 2019 A with NGN-tap

A.) Obtain the client's blood pressure before the nurse administers medication

A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A.) Obtain the client's blood pressure before the nurse administers medication B.) Initiate a referral with a dietician for the client C.) Inform the client about adverse effects of the medication D.) Recommend a salt substitute to the client

D.) An assistive personnel (AP) who is assisting a client to return to bed.

A nurse is caring for a client who is 12 hours postoperative is receiving PCA for pain control, and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information? A.) An RN who is monitoring a client who started receiving a blood transfusion 5 min ago B.) An assistive personnel (AP) who just began performing a bed bath. C.) a Licensed practical nurse (LPN) who is reinforcing discharge instructions with a client D.) An assistive personnel (AP) who is assisting a client to return to bed.

D.) provide dextrose 10% in water solution using manual drip tubing at 60mL/hr.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by continuous IV infusion at 60mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for the new infusion pump? A.) Administer the TPN solution at the same rate using manual drip tubing. B.) Offer the client oral fluids in place of the TPN solution C.) Infuse 0.9% sodium chloride solution using manual drip tubing at 30mL/hr D.) provide dextrose 10% in water solution using manual drip tubing at 60mL/hr.

medication B.) Check the insulin dose with another licensed nurse

A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? A.) Teach the client reportable adverse effects from the medication B.) Check the insulin dose with another licensed nurse C.) Administer the insulin at a 90 degree angel D.) Clean the insertion site.

0.6mL

A nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a toddler who weighs 22lb and is experiencing a grand mal seizure. Available is diazepamn solution for injection 5mg/mL. How many mL should the nurse administer? (Round to nearest tenth)

C.) platelet count E.) hemoglobin

A nurse is caring for a newly admitted client. Nurses' Notes: 1200: 50 year old client diagnosed with acute myeloid leukemia (AML) one month ago. Client continues to have nausea and vomiting 1 week after completion of first round of chemotherapy. Reports dyspnea on exertion, fatigue, and poor appetite for 1 week. 1230: Client ambulated to bathroom. Urine output 400mL dark yellow urine. Reports feeling short of breath while walking. Assessment: 1200: skin warm, dry, and pale with petechiae and bruising. Mucous membranes pale and dry. Vital signs: 1200: Temp: 37.8 C (100.0 F); HR: 100; RR: 24; BP: 140/92; O2 Sat: 96 on room air 1230: RR: 22; O2 Sat: 96 on room air Diagnostic Results: 1300: WBC count: 1,000 (5,000-10,000); Neutrophils: 90 (2500-8000); Hgb: 6.8 (10-15.5); Platelet count: 8,000 (150,000-400,000); Na: 136 (136-145); K+: 5.0 (3.5-5); Phosphate: 5.5 (3-4.5); Calcium: 8 (9-10.5); Uric acid: 9.3 (2.7-8.5) Select the 2 findings that require immediate follow-up: A.) pallor B.) WBC count C.) platelet count D.) mucous membranes E.) hemoglobin

A.) Measure the client's vital signs

A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first? A.) Measure the client's vital signs B.) reposition the client C.) encourage the client to use the incentive spirometer D.) Administer pain medications

C.) grandiose delusions

A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect? A.) hypersensitivity to criticism B.) fears of abandonment C.) grandiose delusions D.) reclusive behavior

A.) Encourage the parents to bring toys from home

A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care? A.) Encourage the parents to bring toys from home B.) Use a visual analog scale to rate the toddler's pain C.) Inform the toddler about the procedure 1 week before hospitalization D.) Stress to the parents the need for maintaining the hospital's daily routine

A.) Educate the client on new prescription for sulfamethoxazole/trimethoprim B.) Collect urine specimen for urine culture C.) Educate client on new prescription for phenazopyradine D.) Collect urine specimen for urinalysis

A nurse in a provider's office is caring for a client. Nurses' Notes: Day 1 0900: Client is a. 65-year-old who reports pain and burning on urination. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented x3. Bilateral breath sounds clear. Respirations even and unlabored. S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2. Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. Vital Signs: 0900: Temperature 37.2 C (99F). HR: 88; BP: 142/88; RR: 20; O2 Sat: 92 on room air Which of the following provider prescriptions should the nurse anticipate for this client? Select the 4 prescriptions the nurse should anticipate. A.) Educate the client on new prescription for sulfamethoxazole/trimethoprim B.) Collect urine specimen for urine culture C.) Educate client on new prescription for phenazopyradine D.) Collect urine specimen for urinalysis E.) Initiate home oxygen therapy F.) Educate client on new prescription for furosemide.

The client is at highest risk for developing __C.) pyelonephritis_____ As evidenced by the client's ___A.) urinalysis results_______

A nurse in a provider's office is caring for a client. Provider Prescriptions: Day 1: 0930: Collect urine specimen for urinalysis and urine culture and sensitivity. Trimethoprim/sulfamethoxazole 160/800 mg PO bid x10 Phenazopyridine 200mg PO q6h x2 Laboratory Results Day 1: 1100: Urinalysis: Color: amber (amber yellow); appearance: cloudy (clear); specific gravity: 1.04 (1.005-1.03); pH: 9 (4.6-8); Glucose: None (None); Ketones: None (none); bilirubin: None (none); Blood: trace (none); Nitrite: Positive (negative); Leukocyte esterase: positive (negative); RBC: 18 (less than 2); WBC: 30 (0-4) Urine culture: pending Nurses' Notes: Day 1 0900: Client is a. 65-year-old who reports pain and burning on urination. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented x3. Bilateral breath sounds clear. Respirations even and unlabored. S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2. Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. Vital Signs: 0900: Temperature 37.2 C (99F). HR: 88; BP: 142/88; RR: 20; O2 Sat: 92 on room air Complete the following sentence by using the list of options: The client is at highest risk for developing _______ A.) urolithiasis B.) kidney failure C.) pyelonephritis As evidenced by the client's __________ A.) urinalysis results B.) history of COPD C.) temperature

Flow sheet: A.) Temperature 36.4° C (97.5° F) D.) Weight 2,545 g (5 lb 9 oz); 12% weight loss Nurses Notes: A.) Mild tremors noted when awake. D.) Breastfeeding every 3 to 5 hr for 5 to 10 min. E.) Client reports nipple discomfort throughout the feeding.

A nurse is assessing a newborn who is 3 days old. History and Physical Newborn was delivered at 37 weeks of gestation via cesarean section for fetal distress.Apgar scores: 8 at 1 min and 9 at 5 min.Birth weight: 2,892 g (6 lb 6 oz)Birthing parent plans to breastfeed. Day 2 of Life 0900: Temperature 36.7° C (98.1° F)Heart rate 140/minRespiratory rate 48/minWeight 2,718 g (6 lb); 6% weight loss Day 3 of Life 0800: Temperature 36.4° C (97.5° F) Heart rate 140/min Respiratory rate 48/min Weight 2,545 g (5 lb 9 oz); 12% weight loss Nurses' Notes Day 3 of Life 0800: Skin color consistent with newborn's genetic background. Respirations easy and unlabored. Abdomen soft with active bowel sounds. Mild tremors noted when awake. Anterior fontanel level and soft. Large ecchymotic caput succedaneum noted on posterior scalp. Small amount of bloody mucus discharge noted from vagina. Breastfeeding every 3 to 5 hr for 5 to 10 min. Client reports nipple discomfort throughout the feeding. Select the findings that Require a followup: Flow Sheet: Day 3 of Life: 0800: Day 3 of Life 0800: A.) Temperature 36.4° C (97.5° F) B.) Heart rate 140/min C.) Respiratory rate 48/min D.) Weight 2,545 g (5 lb 9 oz); 12% of weight loss Nurses' Notes Day 3 of Life 0800: Skin color consistent with newborn's genetic background. Respirations easy and unlabored. Abdomen soft with active bowel sounds. A.) Mild tremors noted when awake. Anterior fontanel level and soft. B.) Large ecchymotic caput succedaneum noted on posterior scalp. C.) Small amount of bloody mucus discharge noted from vagina. D.) Breastfeeding every 3 to 5 hr for 5 to 10 min. E.) Client reports nipple discomfort throughout the feeding.% weight loss Nurses' Notes Day 3 of Life 0800: Skin color consistent with newborn's genetic background. Respirations easy and unlabored. Abd

The child is at risk for developing _A.) an infection_______ and ____B.) skin breakdown_____

A nurse is caring for a 3-year-old child who has a gastrostomy tube. Nurses' Notes Day 1 0700: Child sleeping in bed. Gastrostomy tube site clean. Parents at bedside. 0900: Child consumed water with no difficulties. Parents at bedside. Day 2 0900: Child alert. Completed bolus feeding. Flushed site with 100 mL of tap water before and after feeding. Child tolerated feeding well with no vomiting, reflux, or abdominal pain noted. 1100: Called to child's bedside by parent. Parent reports child had episode of diarrhea. Perineal care provided. 1115: Nurse inspects gastrostomy tube and observes clear drainage around the tube site. Site cleansed with soap and water. 2000: Child alert. Completed bolus feeding. Flushed site with 100 mL of tap water before and after feeding. Child tolerated feeding well with no vomiting, reflux, or abdominal pain noted.Redness and clear drainage noted to gastrostomy tube site. Vital Signs Day 1 0800: Temperature 36.7° C (98.1° F)Heart rate 90/minRespiratory rate 22/minBlood pressure 92/52 mm HgOxygen saturation 100% on room air 1200: Temperature 37.2° C (99.0° F)Heart rate 96/minRespiratory rate 23/minBlood pressure 90/54 mm HgOxygen saturation 100% on room air Day 2 0800: Temperature 37.8° C (100.0° F)Heart rate 100/minRespiratory rate 24/minBlood pressure 96/52 mm HgOxygen saturation 100% on room air 1200: Temperature 38.1° C (100.6° F)Heart rate 112/minRespiratory rate 22/minBlood pressure 96/53 mm HgOxygen saturation 100% on room air The child is at risk for developing ________ and _________ A.) an infection B.) skin breakdown C.) dehydration D.) aspiration E.) delayed bowel training

1.) Action to take 1- d.) request a rx for IV abx 2.) Action to take 2- e.) initiate droplet precautions 3.) Condition most likely experiencing- a.) epiglottitis 4.) parameter to monitor 1-b.) breath sounds 5.) parameter to monitor 2- c.)temp

A nurse is caring for a 5-year-old child. Nurses' Notes 1500: Child accompanied to emergency department by caregiver. Caregiver states child has a sore throat and reports the child has "pain on swallowing" and denies cough. Child is agitated and leaning forward with drooling noted. Physical Examination 1510: Upon visual inspection, throat is inflamed, tonsils appear pink, reddened and epiglottis is edematous and cherry red in appearance. Skin appears pale. Stridor noted upon inspiration with diminished bilateral lung sounds. Vital Signs 1505: Axillary temperature 38.8° C (102° F)Heart rate 130/minRespiratory rate 28/minBlood pressure 99/58 mm HgOxygen saturation 90% on room air Medical History Family history of asthma Child seen 6 months ago for tonsillitis and treated with antibiotic therapy 1.) Action to take 1 2.) Action to take 2 a.) suction secretions prn b.) teach the caregiver and child about allergens c.) have the child gargle with warm saltwater d.) request a rx for IV abx e.) initiate droplet precautions 3.) Condition most likely experiencing a.) epiglottitis b.) pneumonia c.)retropharyngeal abscess d.) asthma 4.) parameter to monitor 1 5.) parameter to monitor 2 a.) chest xray b.) breath sounds c.)temp d.) neck swelling e.) peak flow rate

1.) Action 1- b.) monitor the client's physical manifestations 2.) Action 2- C.) assess the client for a secondary gain from illness 3.)conditions most likely- c.)somatic symptom disorder 4.) Parameter 1 to monitor- b.) pain 5.) parameter 2 to monitor- e.) vital signs

A nurse is caring for a Client Nurses' Notes 1100: Client arrives at the clinic with palpitations, difficulty breathing, and reports feeling faint. Client also reports constipation and joint pain for the past 2 days. After asking about the client's history, the client states they experienced physical abuse as a child. Client had a disturbing childhood, as parents were not emotionally attached to the client. Client reports nervousness and that they only leave home when necessary. Their medical record indicates frequent hospital visits due to headaches and gastrointestinal distress. Vital Signs 1100: Temperature 37.6° C (99.7° F)Heart rate 105/minRespiratory rate 20/minBlood pressure 118/70 mm HgOxygen saturation 95% on room air Plan of Care ​ • Encourage the client to talk about their feelings through therapeutic communication. • Encourage the client to identify support systems. • Educate the client to focus on other activities in leisure time. • Encourage client to be independent when performing daily activities. Client Education Benefits of individual and group therapyTechniques to identify and manage anxiety Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse must take address to that condition, and 2 parameters the nurse should monitor to assess the client's progress. 1.) Action 1 2.) Action 2 a.) assess the client for a preoccupation with illness b.) monitor the client's physical manifestations C.) assess the client for a secondary gain from illness d.) encourage the client to participate in physical therapy e.) explain boundaries to the client | 3.)conditions most likely experiencing a.)factitious disorder b.)illness anxiety disorder c.)somatic symptom disorder d.) conversion disorder | 4.) Parameter 1 to

B.) Perform a clinical institute withdrawal assessment for alcohol (CIWA-Ar) C.) Initiate seizure precautions D.) chlordiazepoxide E.) maintain a low-stimulation environment

A nurse is caring for a client in the emergency department (ED). Nurses' Notes 0600: Client presents with acute altered mental status. Client has a history of frequent ED visits for alcohol intoxication. Client states that they had an episode of binge drinking yesterday afternoon. Client awoke this morning on the living room floor trembling and flushed; remembers having intense dreams and was afraid they had a seizure so they called a family member to bring them to the ED.Client reports their average alcohol intake has been "two or three beers" after work each day and "more on the weekends" for the past 6 months.Client reports headache, nausea, agitation, and is noted to be diaphoretic. 0800: Client states "I've got bugs crawling on me. Get them off me!" Client tremulous and diaphoretic. History and Physical Alcohol use disorderDelirium tremensNicotine use disorderHypertension, diet and exercise controlled. Vital Signs 0600: Temperature 37° C (98.6° F)Heart rate 110/minRespiratory rate 20/minBlood pressure 140/90 mg HgOxygen saturation 98% on room air 0800: Temperature 37° C (98.6° F)Heart rate 114/minRespiratory rate 20/minBlood pressure 180/100 mg HgOxygen saturation 98% on room air Laboratory Results 0600: Blood alcohol concentration 80 mg/dL (0 to 50 mg/dL) The nurse is planning care for the client. Select the 5 actions the nurse should plan to take. A.) administer thiamine B.) Perform a clinical institute withdrawal assessment for alcohol (CIWA-Ar) C.) Initiate seizure precautions D.) Administer chlordiazepoxide E.) maintain a low-stimulation environment F.) Administer disulfiram

A.) ensure the client is assigned a private room C.) Assess the client's method of lethality D.) Observe the client swallow all prescribed medications E.) Ensure that the client does not have access to sharp objects G.) Provide one- to- one observation

A nurse is caring for a client in the inpatient psychiatric unit. Admission Assessment An adult client is admitted to the inpatient psychiatric unit for evaluation, monitoring, and treatment of major depressive disorder. Client has been treated in the outpatient setting, but depressive symptoms have worsened. Client has significant insomnia (only sleeping 1 to 2 hr each night), has been unable to concentrate long enough to complete daily tasks, such as paying the bills, and developed a markedly diminished interest in any activities, including meeting ADL tasks and hygiene needs. Nurses' Notes 0800: Client is resting quietly in room. States they do not want to come to the dining area for breakfast. "Maybe I will come out in a little while." 0900: Client is sitting on the side of their bed staring blankly at the wall. 1000: Client has not moved from previous location. Client is still staring blankly at the wall. Asked the client how they are feeling. They state, "I just can't do it anymore. I am going to end my life." Based on the assessment findings, which of the following actions should the nurse take? Select all that apply. A.) ensure the client is assigned a private room B.) Remind the client that everything is going to be fine C.) Assess the client's method of lethality D.) Observe the client swallow all prescribed medications E.) Ensure that the client does not have access to sharp objects F.) Discuss with the client that things are not as bad as they seem. G.) Provide one- to- one observation

D.) The client's heel is reddened and tender

A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority? A.) the client reports leg itching under the cast around the mid-upper thigh area B.) The client reports increased pain when the leg is lowered below the level of the heart C.) The client's cast became wet during a sponge bath D.) The client's heel is reddened and tender

The nurse should first address the client's _______ C.) electrolyte imbalance Followed by the client's __________ C.) fear of weight gain

A nurse is caring for a client who has a new diagnosis of anorexia nervosa. Laboratory Results Day 12030:Sodium 146 mEq/L (136 to 145 mEq/L) Potassium 3.3 mEq/L (3.5 to 5.0 mEq/L) Chloride 110 mEq/L (98 to 106 mEq/L) BUN 21 mg/dL (10 to 20 mg/dL ) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Phosphate 2.8 mg/dL (3.0 to 4.5 mg/dL) Glucose (casual) 75 mg/dL (74 to 106 mg/dL) Total protein 5.8 g/dL (6.4 to 8.3 g/dL) Albumin 3.0 g/dL (3.5 to 5.0 g/dL) Day 20530:Sodium 150 mEq/L (136 to 145 mEq/L)Potassium 3.1 mEq/L (3.5 to 5.0 mEq/L) Chloride 110 mEq/L (98 to 106 mEq/L) BUN 25 mg/dL (10 to 20 mg/dL) Magnesium 1.0 mEq/L (1.3 to 2.1 mEq/L) Phosphate 2.8 mg/dL (3.0 to 4.5 mg/dL) Fasting blood glucose 65 mg/dL (74 to 106 mg/dL) Total protein 5.5 g/dL (6.4 to 8.3 g/dL) Albumin 2.7 g/dL (3.5 to 5.0 g/dL) Nurses' Notes Day 1 2005: Client alert and oriented with flat affect. Client states, "I cannot gain any more weight. My legs are already too big." Lanugo noted over face, skin cool to touch. 2+ nonpitting edema to lower extremities. Client reports last bowel movement was 4 days ago. Bowel sounds hypoactive. Vital Signs Day 1 2005: Temperature 35.3° C (95.5° F)Heart rate 60/minRespiratory rate 23/minBlood pressure 90/55 mm HgOxygen saturation 98% on room air Day 2 0800: Temperature 36.1° C (97° F)Heart rate 65/minRespiratory rate 20/minBlood pressure 88/57 mm HgOxygen saturation 98% on room air Graphic Record Day 1 2005: Weight 37.5 kg (82.7 lb)Height 162.56 cm (64 in)BMI 14.2 Day 2 0800: Weight 37.4 kg (82.5 lb)BMI 14.1 Complete the following sentence by using the list of options: The nurse should first address the client's _______ A.) cool skin B.) temperature C.) electrolyte imbalance Followed by the client's __________ A.) lanugo B.) heart rate C.) fear of weight gain

F.) Client has involuntary tongue movement and foot tremor. G.) Client reports an increase in urination and had one episode of incontinence. H.) Family noticed increased agitation and delusions.

A nurse is caring for a client who has schizophrenia in an inpatient facility. Medication Administration Record Day 1 0730: Clozapine 100 mg PO daily Aripiprazole 5 mg PO daily Multivitamin PO daily Laboratory Results Day 1 0730: Sodium 125 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 90 mEq/L (98 to 106 mEq/L) BUN 8 mg/dL (10 to 20 mg/dL) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Vital Signs Day 1 1230: Temperature 37.6° C (99.7° F)Heart rate 98/minRespiratory rate 20/minBlood pressure 142/92 mm HgOxygen saturation 100% on room air 1500: Temperature 37.1° C (98.8° F)Heart rate 104/minRespiratory rate 24/minBlood pressure 150/90 mm HgOxygen saturation 100% on room air Nurses' Notes Day 1 0730: Client sleeping. Lungs clear to auscultation bilaterally. Hyperactive bowel sounds noted x 4. Abdomen soft and nontender. Small bruise noted on right hand. Family at bedside. Family states client is diagnosed with schizophrenia, and last doctor's appointment was 6 months ago. 1500: Client alert and oriented to person and place. Agitated. Speech disorganized. Client has involuntary tongue movement and foot tremor. Lungs clear to auscultation bilaterally. Hyperactive bowel sounds noted x 4. Abdomen soft and nontender. Small bruise noted on right hand. Client reports an increase in urination and had one episode of incontinence. Family noticed increased agitation and delusions. Select the findings that require immediate follow-up. Day 1 0730: Client sleeping. Lungs clear to auscultation bilaterally. A.)Hyperactive bowel sounds noted x 4. Abdomen soft and nontender. Small bruise noted on right hand. Family at bedside. Family states client is diagnosed with schizophrenia, B.) and last doctor's appointment was 6 months ago. 1500: C.) Client alert and oriented to person and place. D.)Agitated. E.)

D.) The enlarged uterus compresses the intestines and causes constipation

A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make? A.) Estrogen levels decrease during pregnancy causing stool to become hardened B.) decreased water absorption in the intestine during pregnancy causes constipation C.) The intestine absorbs iron less efficiently during pregnancy leading to constipation D.) The enlarged uterus compresses the intestines and causes constipation

The client is at risk for _____C.) Thrombocytopenia ________ Due to ____C.) Petechiae _______

A nurse is caring for a client who is on 24-hour observation. Laboratory Results: Day 1 0600: Sodium 150 (136-145); Potassium: 5.5 (3.5-5); Chloride: 105 ( 98-106); BUN: 17 (7-30); Magnesium: 1.2 (1.3-2.1); Total Calcium: 10 (9-10.5); Phosphate: 4 (3-4.5); Glucose: 135 (74-106); Platelet: 99,500 (150,000-400,000); WBC: 9500 (5,000-10,000); total protein: 4 (6.4 to 8.3); Albumin: 1.5 (3.5-5); blood alcohol content: 200 (0-50) History and Physical: 0600: Client admitted for 24 hour observation for alcohol intoxication. History of alcohol use disorder per family. Client alert and oriented to person. Client appears lethargic. Diminished lung sounds auscultated in bilateral lower lobes. Heart is tachycardic. Nausea and vomiting for last 2 days. Bowel sounds hypoactive in all 4 quadrants. Abdomen is distended and nontender. Client unable to verbalize last alcohol ingestion. Petechiae noted on forearms bilaterally. Client is diaphoretic. Medication Administration Record: Day 1 0700: 0.9% sodium chloride IV fluids at 150mL/hr Vital Signs: Day 1: 0600: Temp 38.4 C (101.1 F) HR: 84; RR: 18; BP: 132/68; O2Sat: 98 0645: Temp: 37.7 (99.9 F); HR: 90; RR: 20; BP: 142/58; O2 Sat: 95 0800: Temp: 35.9 C (96.6 F); HR: 110; RR: 20; BP: 110/76; O2 Sat: 92 0910: Temp: 37.6 C (99.7 F); HR: 116; RR: 22; BP: 105/62; O2: 90 on room air Nurse's Notes: Day 1: 0700: Client is sleeping. No change in previous condition. 0810: Client awake. Lethargic. Bleeding noted from left nostril. Applied pressure to left nostril with cotton gauze. Provider notified. 0903: Client alert to person and place. Verbalized last drink was "last night". Does not recall events from previous night. Bleeding increased. Provider notified The client is at risk for _____________ A.) Dehydration B.) Malnutrition C.) Thrombocytopenia Due to _________ A.) Fever

The nurse should first address the client's __A.) Respiratory Rate______ Followed by the client's __C.) Level of consciousness ___

A nurse is caring for a client who is pregnant in the acute care setting. Nurse's Notes: 1400: Client reports a constant low dull backache and painless abdominal tightening for the past 3 hours. Denies any changes in vaginal discharge. External fetal monitor applied. 1430: Contraction pattern: contractions every 4 to 5 min , lasting 30 to 45 seconds, palpate mild in intensity. Fetal HR: 150-155 bpm, moderate variability, adequate accelerations present, no decelerations noted. Provider in to see client. Specimen obtained for fetal fibronectin. 1800: Client sleepy. Difficult to arouse. Respirations slow and shallow, Contraction pattern: Contractions every 10 min, lasting 30 to 45 seconds, palpate mild in intensity. Fetal HR: 140 bpm, moderate variability, no accelerations noted, no decelerations noted. Vital Signs: 1400: Temp: 37 C (98.6 F); HR: 72; RR: 20; BP: 115/75; O2 Sat: 98 on room air 1800: HR: 65; RR: 10; BP: 100/60; O2 sat: 88 on room air Medication Administration Record: 1445: Administered magnesium sulfate 4g IV bolus over 20min. Initiated lactated Ringer's continuous infusion at 75mL/hr. 1450: Administered betamethasone 12mg IM. 1505: Initiated magnesium sulfate continuous infusion at 2g/hr History and Physical: Gravida 2 Para 1; 30 weeks gestation. Previously uncomplicated pregnancy. Reported the onset of back pain and contractions 3 hr ago. Vaginal examination: 3cm dilated and 50% effaced. Amniotic membranes intact. Diagnosis: Preterm labor Plan: Administer tocolytics and glucocorticoids The nurse reviews the assessment data at 1800. Which of the following actions should the nurse plan to take? The nurse should first address the client's ________ A.) Respiratory Rate B.) Contraction Pattern C.) Fetal heart rate variability Followed by the client's _____ A.) Blood pressure B.) absent acc

A.) Back pain B.) headache C.) anxiety

A nurse is caring for a client who is receiving a transfusion of packed red blood cells (RBCs) Vital Signs: 0900: Temp 36.9 C (98.5 F) HR: 74; RR: 16; BP: 112/68; Pulse ox: 98 0915: Temp: 36.9 C (98.5 F); HR: 76; RR: 16; BP: 120/68; Pulse Ox: 98 0930: Temp: 36.9 C (98.5 F); HR: 90; RR: 18; BP: 116/70; Pulse Ox: 98 Diagnostic Results: 0800: Hgb 5.6 (12-16); Platelets: 18000 (150,000-400,000) Nurse's Notes: 0900: platelet count and hgb unchanged from post-transfusion results yesterday. Infusion of 1 unit of packed RBCs started as ordered. Client alert and oriented to person, place, and time. 0930: Client requests pain medication for headache and reports level of 5 on a scale of 0-10. Client reports "arthritis must be acting up because my back and knees and ankles hurt" Asked if nurse can assist in placing pillows behind back for low back pain. Reports back and joint pain as a 4 on a scale of 0 to 10. States they did not have any concerns yesterday during transfusions but "starting to feel a little anxious about it now. I'm not really sure why I need this". Alert and oriented to person and place. Skin pale, cool, and dry to touch. Mucous membranes pink and moist. Urine output 150mL of clear, yellow urine in urinal. The nurse should suspect a transfusion reaction based on which of the following assessment findings? Select all that apply: A.) Back pain B.) headache C.) anxiety D.) urine output E.) skin F.) vital signs

A.) Place the BP cuff in a labeled bag and send it for decontamination

A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take? A.) Place the BP cuff in a labeled bag and send it for decontamination B.) Immediately rinse the BP cuff in hot running water. C.) Dispose of the contaminated BP cuff in the bag lining of a trash can. D.) Clean the BP cuff with chlorine bleach solution

A.) A client's IV pump delivers an inadequate dose of medication

A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report? A) A client's IV pump delivers an inadequate dose of medication B.) A nurse follows a client's advance directives and discontinues enteral feedings C.) A nurse discards unused, expired bags of IV fluids D.) A client refuses an IV bolus of pain medication

The nurse should plan to first assess the newborn's _______C.) Respiratory rate Followed by the newborn's _________C.) Heart rate

A nurse is caring for a newborn. History and Physical: 41 weeks of gestation. Spontaneous vaginal delivery with meconium-stained amniotic fluid at 1350Apgar 7 at 1 min and 9 at 5 minBirth weight 2,500 g (5 lb 8 oz)Birthing parent urine toxicology positive for marijuana use during pregnancyBirthing parent blood type A, Rh negativeGroup B streptococcus β-hemolytic: positive (negative)Birthing parent received 3 doses of intravenous antibiotics while in labor. Nurses' Notes 1400:Newborn placed skin-to-skin on parent's chest with light blanket over top. Lusty cry. Acrocyanosis noted. Newborn rooting and attempting to latch onto the breast.1430:Newborn lying quietly on parent's chest. No latch achieved. Acrocyanosis noted. Expiratory grunting and nasal flaring present. Skin loose and dry. Scant amount of green stained vernix caseosa noted in skin folds. Complete the following sentence by using the list of options: The nurse should plan to first assess the newborn's _______ A.) neonatal abstinence score B.) blood glucose level C.) Respiratory rate D.) Temperature Followed by the newborn's _________ A.) new Ballard score B.) blood pressure C.) Heart rate D.) transcutaneous bilirubin level

A.)Skin assessment B.) Temperature E.) WBC count H.) Casual Blood Glucose I.) Potassium

A nurse is caring for an adolescent in the emergency department (ED). Nurse's Notes: 0700: Adolescent admitted to ED. Adolescent's parents are concerned about left leg injury that appears to be getting worse. Parents report adolescent had fever, decreased appetite, and decreased energy within the past 2 days. Adolescent reports leg injury occurred while playing soccer. 0715: Adolescent is alert and oriented to person, place, time, and situation. Adolescent reports lower leg pain as a 4 on a scale of 0-10. HR regular. Capillary refill less than 3 seconds. Respirations even, unlabored. Lungs clear anterior/posterior. Abdomen soft, non-distended. Bowel sounds hyperactive in all 4 quadrants. Pedal pulses +2 bilaterally. Medial lateral aspect of left lower leg: 3 x 3 cm2 area of redness with small pustules present. Tenderness and warmth noted to the area. Vital signs: 0700: Temp 38.7 C (101.7 F); Pulse: 100; RR: 18; BP: 110/60 Lab Results: 0730: Sodium 132 (136-145); Potassium 5 (3.4-4.7); BUN: 16 (5-18); WBC: 13,000 (5,000-10,000); Hgb 9.5 (10-15.5); Hct: 30 (32-44); Casual blood glucose: 250 (less than 200) History and Physical: Type 1 diabetes mellitus The nurse is reviewing the adolescent's electronic medical record (EMR). Which of the following findings requires immediate follow-up by the nurse? Select which findings require immediate follow-up. A.)Skin assessment B.) Temperature C.) Pulse D.) Blood pressure E.) WBC count F.) Abdominal Assessment G.) Pain H.) Casual Blood Glucose I.) Potassium

B.) Withhold administering the varicella vaccine to the child

A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. which of the following interventions should the nurse include in the plan? A.) Encourage friends and family to visit the child B.) Withhold administering the varicella vaccine to the child C.) collect a daily urine specimen from the child to check for proteinuria D.) Provide a low-protein diet for the child

D.) Determine the client's perception of the personal impact of the crisis

A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first? A.) Assist the client with contacting individuals from the client's support system B.) Give the client information about available community resources for shelter C.) Suggest the client obtain mental health counseling D.) Determine the client's perception of the personal impact of the crisis

D.) Elevate the affected leg

A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care? A.) Maintain the client on bed rest B.) restrict the client to 1L of fluid per day C.) Place cool compress on the edematous area D.) Elevate the affected leg

A.) inject 20 units of air into the NPH insulin vial

A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. which of the following actions should the nurse plan to take? A.) inject 20 units of air into the NPH insulin vial B.) Shake the NPH insulin vial vigorously to mix the insulin C.) Use a new needle to draw up the insulin from the second vial D.) Draw the longer-acting insulin into the syringe first.

D.) Straight urinary catheter

A nurse is preparing to perform an intermittent urinary catheterization for a client who has urinary retention. Which of the following images indicates the catheter the nurse should use? A.) indwelling catheter B.) three-way urinary catheter C.)Specimen catheter D.) straight urinary catheter

A.) Refer the client to a community-based social worker B.) Initiate a consult with a home health care provider E.) Give the client information about local support groups

A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover ostomy supplies." Which of the following actions should the nurse take? Select all that apply. A.) Refer the client to a community-based social worker B.) Initiate a consult with a home health care provider C.) Provide the client with information about the American Red Cross D.) Postpone the discharge until someone can stay with the client E.) Give the client information about local support groups

D.) "Secure the retainer clip at the level of your baby's armpits"

A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching? A.) "Place your baby's car seat at a 30 degree angle" B.) "Your baby's car seat should be rear-facing until he is 6 months old" C.) "Swaddle your baby in a tight blanket before placing him in the car seat" D.) "Secure the retainer clip at the level of your baby's armpits"

A.) "A speech pathologist will performing a swallowing study for you" B.) "You should rest before eating a meal" E.) "Thicken your beverages before drinking"

A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? (Select all that apply) A.) "A speech pathologist will performing a swallowing study for you" B.) "You should rest before eating a meal" C.) "You should restrict foods that are high in Vitamin D" D.) "reduce your intake of dietary fiber" E.) "Thicken your beverages before drinking"

A.) "Set your hot water heater temperature at or below 120 degrees F"

A nurse is providing teaching to a client about newborn safety. Which of the following statements should the nurse include in the teaching? A.) "Set your hot water heater temperature at or below 120 degrees F B.) "Cover your baby with a light blanket while sleeping" C.) "Make sure your slats on the baby's crib are no more than 3 inches apart" D.) "Place your baby's car seat rear-facing until the age of 1 year old"

B.) "We should read a story together every night before bedtime"

A nurse is teaching the parents of a preschooler about sleep promotion. The parents report that their child is demonstrating reluctance in going to bed at night and states, "I am not tired." Which of the following statements by the parents indicates an understanding of the teaching? A.) "We will let our child watch a favorite video before bed" B.) "We should read a story together every night before bedtime" C.) "We can let our child fall asleep in our room, and then move to her to her own bed" D.) "We should change the bedtime to be an hour later"

D.) Tells the hospital chaplain a client's diagnosis

A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene? A.) informs the provider about the client's suicide plan B.) Notifies the health department of a client's diagnosis of chlamydia C.) Reports suspected child maltreatment to social services D.) Tells the hospital chaplain a client's diagnosis

D.) Notify the incident commander

A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan? A.) contact the triage officer B.) Implement the client tracking system C.) Ask the communications officer to release a press statement D.) Notify the incident commander

A.) Provide information about scheduling issues to the staff.

A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first? A.) Provide information about scheduling issues to the staff. B.) Ask staff members to participate in a trial of the new scheduling system. C.) Encourage staff to offer alternate scheduling solutions. D.) Develop goals to implement the new scheduling system.

D.) Ask the nurse about their knowledge of the procedure

A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes? A.) Refer the nurse to the procedure manual B.) Use a diagram to explain the procedure to the nurse C.) Demonstrate the procedure to the nurse D.) Ask the nurse about their knowledge of the procedure

A.) identify health-related issues within the community

A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse plan to take first? A.) identify health-related issues within the community B.) develop measurable health goals for community residents C.) Create safety education classes for the program D.) Enlist volunteers from the rural community to promote the program

D.) Keep the head of the bed elevated to 45 degrees for 1 hour after feedings

A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A.) Instill 100mL of air into the NG tube after checking for residual B.) flushes the NG tube with 0.9% sodium chloride irrigation every 2 hours C.) Adds 20mL of blue dye to each feeding to help detect aspiration D.) Keep the head of the bed elevated to 45 degrees for 1 hour after feedings

B.) Flumazenil

A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44. Which of the following medications should the nurse anticipate administering? A.) Nalozone B.) Flumazenil C.) Acetylcysteine D.) Atropine

A.) Ask the client to rate their pain level

A client who is 24 hours postoperative abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? A.) Ask the client to rate their pain level B.) Assist the client in changing positions C.) Administer a PRN analgesic medication D.) Explain the importance of early ambulation

D.) "I have not vomited as much recently"

A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following statements by the client indicates that this therapy is having the desired effect? A.) "I have not had any food cravings" B.) "The spotting I was having has stopped" C.) "I don't feel depressed anymore" D.) "I have not vomited as much recently"

B.) An adolescent client who has foodbourne botulism

A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a nationally notifiable infectious condition? A.) a client who is pregnant and has cytomegalovirus (CMV) B.) An adolescent client who has foodbourne botulism C.) A child who has erythema infectiosum D.) A young adult client who has herpes simplex virus type 1 (HSV-1)

A.) mark the edges of stairs for contrast

A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plan of care to prevent injury in the home? A.) mark the edges of stairs for contrast B.) Cover exposed extension cords with throw rugs C.) Use 40-watt bulbs in lighting fixtures D.) Instruct the client to obtain vision testing once every other year

A.) Use hydrogen peroxide to clean kitchen surfaces

A home health nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include? A.) Use hydrogen peroxide to clean kitchen surfaces B.) Seal nonwashable items in a plastic bag for 2 weeks C.) Wear a surgical mask in public D.) Limit family visits to 30min periods

A.) document the client's refusal of the medication

A nurse on a mental health unit is caring for a client who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. Which of the following actions should the nurse take? A.) document the client's refusal of the medication B.) administer the medication that the provider prescribed C.) Request consent from the client's family to administer the medication D.) Administer an oral dose of the medication

A.) Ask the Caller for verification of their identity

A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themself as the client's parent. Which of the following actins should the nurse take? A.)Ask the caller for verification of their identity B.) Give the caller limited information about the client C.) transfer the phone call to the client's room D.) Inform the caller that they should obtain permission from the client's provider

D.) Insertion of a nasogastric tube

An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN? A.) Collection of a stool specimen B.) Preparation of a client's postoperative bed C.) preparation of a teaching plan about pneumonia D.) Insertion of a nasogastric tube

B.) Neurologic status

Graphic Record: O2 sat 94%; Insertion site pain level of 6 on a scale of 0-10; Urinary output 70mL/2hr Nurse's Notes: 0900 Neurological check: Responds verbal to stimuli; speech slurred; hand grasps weak an unequal Diagnostic Results: Lab: Hemoglobin 15; Hematocrit: 45% Cardiac Catheterization Report: Stenosis of the right coronary artery A nurse is assessing a client who is 2 hours postoperative following a cardiac catheterization. Which of the following information should the nurse report to the provider? A.) Pain level B.) Neurologic status C.) Laboratory results D.) Urinary output

Voiding pattern- expected Temp- unexpected Urine color- expected O2 sat- expected Bowel elimination- unexpected BP- expected Skin- unexpected

Nurses' Notes: Day 1 0900: Client is a. 65-year-old who reports pain and burning on urination. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented x3. Bilateral breath sounds clear. Respirations even and unlabored. S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2. Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. 3 Days Later: 0900: Client returns to office due to orange-colored urine and diarrhea Client reports drinking a minimum of 3L of fluids daily as instructed and states, "I'm still going to the bathroom a lot, and I noticed that I am bruising more easily." Vital Signs: 0900: Temperature 37.2 C (99F). HR: 88; BP: 142/88; RR: 20; O2 Sat: 92 on room air 3 days later: 0900: Temp: 37.7 C (100.9 F); HR: 87; BP: 144/90; RR: 22; O2 Sat: 93 on room air Provider Prescriptions: Day 1: 0930: Collect urine specimen for urinalysis and urine culture and sensitivity. Trimethoprim/sulfamethoxazole 160/800 mg PO bid x10 Phenazopyridine 200mg PO q6h x2 Laboratory Results Day 1: 1100: Urinalysis: Color: amber (amber yellow); appearance: cloudy (clear); specific gravity: 1.04 (1.005-1.03); pH: 9 (4.6-8); Glucose: None (None); Ketones: None (none); bilirubin: None (none); Blood: trace (none); Nitrite: Positive (negative); Leukocyte esterase: positive (negative); RBC: 18 (less than 2); WBC: 30 (0-4) Urine culture: pending Which of the following assessment findings should the nurse report to the provider as unexpected? For each assessment finding, click to specify if the finding is expected or unexpected. BP- Expected or Unexpected? Skin- Expected or Unexpected? Bowel Elimination- Expected or Unexpected? Temp-

A.) specific gravity B.) pH D.) WBC

Nurses' Notes: Day 1 0900: Client is a. 65-year-old who reports pain and burning on urination. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented x3. Bilateral breath sounds clear. Respirations even and unlabored. S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2. Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. 3 Days Later: 0900: Client returns to office due to orange-colored urine and diarrhea Client reports drinking a minimum of 3L of fluids daily as instructed and states, "I'm still going to the bathroom a lot, and I noticed that I am bruising more easily." Vital Signs: 0900: Temperature 37.2 C (99F). HR: 88; BP: 142/88; RR: 20; O2 Sat: 92 on room air 3 days later: 0900: Temp: 37.7 C (100.9 F); HR: 87; BP: 144/90; RR: 22; O2 Sat: 93 on room air Provider Prescriptions: Day 1: 0930: Collect urine specimen for urinalysis and urine culture and sensitivity. Trimethoprim/sulfamethoxazole 160/800 mg PO bid x10 Phenazopyridine 200mg PO q6h x2 Laboratory Results Day 1: 1100: Urinalysis: Color: amber (amber yellow); appearance: cloudy (clear); specific gravity: 1.04 (1.005-1.03); pH: 9 (4.6-8); Glucose: None (None); Ketones: None (none); bilirubin: None (none); Blood: trace (none); Nitrite: Positive (negative); Leukocyte esterase: positive (negative); RBC: 18 (less than 2); WBC: 30 (0-4) Urine culture: pending 3 Days Later 1100: Urinalysis Color: orange (amber yellow); appearance: clear (clear); specific gravity: 1.005 (1.0050-1.03); pH: 4.6 (4.6-8); Glucose: trace (none); ketones: none (none); bilirubin: none (none); blood: none (none); nitrite: negative (negative); leukocyte esterase: negative (nega

The client is most likely experience manifestations of _B.) Autonomic dysreflexia ______ and ____E.) Pneumonia _____

The nurse is caring for a client who is on the spinal cord injury (SCI) unit. Nurse's Notes: Day 3: 1700: Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale, and dry to touch. Respirations easy and unlabored. Lung sounds diminished in lower lobes. Abdomen soft and non-distended with active bowel sounds. Client passed a small amount of hard formed stool this AM. Indwelling urinary catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+, triceps 1+, patella 0, and ankle 0 bilaterally. Client reports pain of 0 on a 0 to 10 scale. Day 4: 0600: Client reports increased coughing and shortness of breath. Crackles auscultated in lower lobes bilaterally. Face and neck flushed. Skin warm and moist. Client reports blurred vision and a headache as an 8 on a 0 to 10 pain scale. Abdomen soft and mildly distended. Hypoactive bowel sounds present. Urinary output 300mL over last 8 hours. Vital Signs Day 3: 1700: Temp 38.2 C (100.8 F) HR: 74 RR: 20 BP: 108/60 and O2 sat: 96 on room air Day 4: 0600: temp: 38.4 (101.2 F) HR: 54; RR: 26; BP: 142/90; O2 sat: 91 on room air The client is most likely experience manifestations of _______ and _________ Choose words from these words: A.) Paralytic ileus B.) Autonomic dysreflexia C.) peritonitis D.) urinary tract infection E.) Pneumonia

C.) Blowing bubbles with liquid soap to "blow the hurt away"

When caring for a child, a nurse plans to use non-pharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? A.) Coloring with crayons in a coloring book B.) Deep breathing and "going limp as a rag doll" C.) Blowing bubbles with liquid soap to "blow the hurt away" D.) Taking a warm bath and playing with a bath toy

D.) "I will walk for short distances throughout the day"

A home health nurse is providing teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? A.) "I will leave my drinking water out of my refrigerator for at least 1 hour so it will be room temperature" B.) "I will clean my toothbrush in my dishwasher once each month" C.) "I will take my temperature once each week and let my doctor know if it is high" D.) "I will walk for short distances throughout the day"

2.) Remove the Inner Cannula 4.) Remove soiled dressing 1.) Clean the stoma with 0.9% sodium chloride irrigation 3.) Change the tracheostomy collar

A m nurse is providing Teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. Steps: 1.) clean the stoma with 0.9% sodium chloride irrigation 2.) remove the inner cannula 3.)change the tracheostomy collar 4.) remove soiled dressing

C.) Explain to the client why this information will be shared

A nurse is caring for a client who has an STI that must be reported to the state health department. Which of the following actions should the nurse take? A.) Tell the client to self report to the state health department B.) Require that the client speak with the public health nurse C.) Explain to the client why this information will be shared D.) Refer the client to a social worker for counseling

B.) Place the child in a side-lying position

A nurse is caring for a child who is experiencing a tonic-clonic seizure. Which of the following action should the nurse take? A.) Insert a padded tongue blade into the child's mouth B.) Place the child in a side-lying position C.) Administer rescue breathes until the seizures subsides D.) Obtain an ECG during the seizure

B.) Nausea

A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching? A.) Constipation B.) Nausea C.) Wheezing D.) Muscle rigidity

C.) "Sedation is a common adverse effect of this medication"

A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching? A.) "If you suspect you are pregnant, stop taking this medication" B.) "You cannot become physically dependent on this medication" C.) "Sedation is a common adverse effect of this medication" D.) "If you forgot a dose, you can double your next dose"

D.) guided imagery

a nurse in an outpatient mental health clinic is working with a client who has post-traumatic stress disorder (PTSD) and asks the nurse to recommend a non-pharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? A.) spinal manipulation B.) acupuncture C.) therapeutic touch D.) guided imagery

B.) WBC: 2,800

A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the following findings should the nurse identify as a contraindication for the client to receive clozapine? A.) BP: 150/87 B.) WBC: 2,800 c.) auditory hallucinations D.) nausea

C.) Pulsus paradoxus

A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? A.) Carotid bruit B.) tracheal deviation C.) Pulsus paradoxus D.) Heart murmur

D.) Mannitol

A nurse is caring for a client who has a closed-head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce intracranial pressure? A.) propranolol B.) phenytoin C.) lorazepam D.) mannitol

C.) Upper chest petechia ** sign of a fat embolism; fat enters the blood stream and obstructs blood vessels; petechia on upper torso is a common sign**

A nurse is assessing a client who has a skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority? A.) muscle spasms of the affected extremity B.) A pain rating of 6 on a scale from 0 to 10 C.) Upper chest petechia D.) Ecchymosis over the fractured area

B.) Confusion **early sign of lithium toxicity**

A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following findings should the nurse identify as the priority? A.) Lethargy B.) Confusion C.) Polyuria D.) Fine hand tremors

C.) Rapid speech

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? A.) Projecting blame B.) Excessive clinging C.) Rapid speech D.) social awkwardness

C.) Hypertension

A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor? A.) weight loss B.) urinary retention C.) hypertension D.) hypoglycemia

A.) Temp 39.4 C (102.9 F)

A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report to the provider? A.) Temp 39.4 C (102.9 F) B.) headache C.) constipation D.) Dry mouth

B.) hematuria **vaso-occlusion of the kidneys**

A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis? A.) diminished reflexes B.) hematuria C.) hyperglycemia D.) hearing loss

B.) Facial Flushing D.) Nasal Congestion e.) Headache

A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? (Select all that apply) A.) Nystagmus B.) facial flushing C.) diplopia D.) Nasal congestion E.) Headache

B.) troponin T

A nurse is reviewing the laboratory findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following laboratory values indicates cellular injury of myocardial tissue. A.) amylase B.) troponin T C.) Low-density lipoprotein (LDL) D.) homocysteine

D.) Provide a staff member to stay with the client continuously

A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan? A.)Remove the client's restraints while sleeping B.) Document the client's status every 60 minutes C.) Check for a new prescription every 6 hours D.) Provide a staff member to stay with the client continuously

D.) Gather more information about the staff nurse's actions

A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first? A.) Ensure that the staff nurse changes the dressing B.) notify the nurse manager C.) Complete an incident report D.) Gather more information about the staff nurse's actions

A.) Flush the client's gastrostomy tube with 30mL of water before administering the medication

A nurse is administering medications to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube? A.) Flush the client's gastrostomy tube with 30mL of water before administering the medication B.) Crush the client's medications and mix them in with the tube feeding formula prior to administration C.) Change the client's feeding bag every 72 hours D.) Administer multiple prescribed medications at the same time

C.) boggy uterus

A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? A.) intermittent cramping B.) moderate lochia rubra C.) boggy uterus D.) perineal edema

B.) Complete a serum pregnancy test before taking the medication

A nurse is teaching a client who is to start taking misoprostol and currently is on long-term therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following information? A.) Increase intake of fluids and fiber to prevent constipation B.) Complete a serum pregnancy test before taking the medication C.) This medication coats stomach ulcers so that they can heal D.) Take a magnesium-containing antacid along with this medication

C.) Places a pillow under the client's right arm

An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? A.) uses a draw sheet to move the client to the left side of the bed B.) Raises the total height of the bed to waist level C.) places a pillow under the client's right arm D.) Lowers the side rails on the left side of the bed

D.) Maintain regular notes about the nurse's time management skills

A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills? A.) Compare the nurse's time management skills to the skills of coworkers B.) Review client satisfaction reports about the nurse's performance C.) Ask another staff nurse to evaluate the nurse's time management skills D.) Maintain regular notes about the nurse's time management skills

B.) Develop a safety plan with the client

A nurse in an emergency department is preparing to discharge a client who has experienced intimate partner violence. Which of the following actions should the nurse take first? A.) Offer a referral to the client for social services B.) Develop a safety plan with the client C.) Encourage the client to reach out to family and friends D.) Provide the client with a list of support groups

C.) massage the uterus to expel clots

A nurse is caring for a client who is 4 hours postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first? A.) administer oxygen B.) initiate an infusion of oxytocin C.) massage the uterus to expel clots D.) obtain a CBC

D.) sublimation

A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out". The nurse should recognize the client is demonstrating which of the following defense mechanisms? A.) Displacement B.) Regression C.) Suppression D.) sublimation

A.) Investigate environmental factors that might be contributing to client injury during these hours

A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis? A.) Investigate environmental factors that might be contributing to client injury during these hours B.) Review the performance evaluations of nurses who work during these hours. C.) Implement a plan to transition from team nursing to primary care nursing during these hours D.) Discuss a plan with the providers to reduce the use of barbiturate sedatives prior to these hours

C.) place ice packs on the breasts for 15min several times per day

A nurse is providing client education to a postpartum client who has decided to bottle feed the newborn. which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement? A.) allow the newborn to breastfeed temporarily B.) relieve pressure by expressing milk daily C.) place ice packs on the breasts for 15min several times per day D.) Sleep with a loose-fitting bra to prevent nipple stimulation

C.) place the skin barrier over the stoma and hold it for 30 seconds

A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? A.) cleanse the skin at the stoma site with povidone-iodine for 15 seconds B.) dampen the skin before applying the skin barrier and ostomy pouch C.) place the skin barrier over the stoma and hold it for 30 seconds D.) cut the skin barrier opening 0.6cm (0.25in) larger than the stoma

C.) Use 0.9% sodium chloride for irrigation of the NG tube

A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. Which of the following actions should the nurse take? A.) Instill chilled lavage solution into the client's NG tube B.) Attach the client's NG tube to low intermittent suction C.) Use 0.9% sodium chloride for irrigation of the NG tube D.) Instill the lavage solution into the client's NG tubes in volumes of 500mL at a time

A.) the client needs assistance when transferring from the bed to the wheelchair

A night shift nurse is giving change-of-shift report to the day shift nurse on a client who is reading for discharge which of the following information is the priority for the nurse to communicate to the oncoming nurse? A.) the client needs assistance when transferring from the bed to the wheelchair B.) the client will have a visit by a home health nurse tomorrow C.) the client's partner will bring clothes for the client to change into prior to discharge D.) the client often needs encouragement to engage in personal hygiene activities

A.) bleeding

A nurse is caring for a newborn whose parents ask why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following? A.) bleeding b.) potassium deficiency C.) infection D.) hyperbilirubinemia

D.) decreased lung expansion

A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging? A.) Decreased BP B.) increased CO C.) increased oral temperature D.) decreased lung expansion

The infant is at highest risk of developing A.) dehydration As evidenced by C.) vomiting

Nurse's Notes: 1500: Infant is admitted to the pediatric unit. Parent reports infant has been irritable and has vomited after each feeding within the last 3 days. Infant alert, not crying. S1 and S2 noted without murmurs. Lungs clear to auscultation anterior/posterior. Respirations even, unlabored. Abdomen firm. Bowel sounds hypoactive x4 quadrants. Small 1x1 cm2 mass palpated near umbilicus. Skin warm and dry, turgor with tenting. 1600: Called to room by a parent. Parent attempted breastfeeding. Infant projectile vomited No bile noted in vomit. Some blood-tinged vomitus noted. Instructed parent to keep child NPO. 1800: Infant crying. Soothed with Pacifier. Diagnostic Results: 1545: Hgb: 20g/dL (14-24) ; Potassium: 5.8mEq/L (3.9-5.9); Na: 132mEq/L (134-150); Chloride: 110 (96-106); WBC: 16,000 (6,200-17,000); BUN: 20 (5-18); Creatinine: 0.2 (0.1-0.4) 1730: Abdominal ultrasound: Narrowing of pyloric canal. Thickening of pylorus. Consistent with hypertrophic pyloric stenosis. Vital Signs: 1500: Temp: 37.1 (98.8 F); HR: 120; RR: 30; Weight: 3.62 (8lbs) History and Physical: Birthweight: 3,492.7g (7.7lbs(); parent is breastfeeding. Newborn birthed vaginally at 38 weeks of gestation. The infant is at highest risk for_____________ A.) dehydration B.) anemia C.) hyperkalemia As evidenced by the infant's __________ A.)potassium level B.) hemoglobin C.) vomiting

Clang association

A nurse is assessing a client who has schizophrenia. What speech is on the audio?

B.) Hemoptysis 275mL/24hour

A nurse is assessing a school-aged child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider? A.) decreased activity B.) Hemoptysis 275mL/24hour C.) fever D.) weight loss 2.3kg (5lb)

A.) stroke the infant's cheek

A nurse is assessing a 2-month-old infant during a well-baby examination. Which of the following actions should the nurse take to assess the infant's rooting reflex? A.) stroke the infant's cheek B.) depress the infant's tongue C.) Turn the infant's head to one side D.) Tap on the bridge of the infant's nose

stomach

A nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should use to administer the injection.

A.) Lack of remorse

A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? A.) Lack of remorse B.) sensitivity to rejection C.) extreme mood swings D.) self-mutilating behavior

A.) A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis

A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference? A.) A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis B.) A client who has alcohol use disorder and has decided to start attending Alcoholics Anonymous meetings C.) A client who was admitted for dehydration and is receiving a continuous IV infusion D.) A client who has a history of two prior miscarriages and has ruptured membranes at 38 weeks of gestation.

B.)The newly licensed nurse writes detailed notes while performing the head-to-toe assessment.

A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene? A.) While performing a breast examination, the newly licensed nurse discusses techniques of breast self-examination with the client. B.)The newly licensed nurse writes detailed notes while performing the head-to-toe assessment. C.) The newly licensed nurse uses a penlight to assess for changes in the contour of the body. D.) The newly licensed nurse uses the dorsal surface of the hand to assess skin temperature.

A.) Dry the newborn

A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first? A.) Dry the newborn B.) Assign the first APGAR score to the newborn C.) place an identification bracelet on the newborn D.) Obtain the newborn's weight

B.) the family can have the child in an open casket without fearing that the organ donation might disfigure the child's body

A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include? A.) Choosing to donate organs can delay the timing of the child's funeral B.) the family can have the child in an open casket without fearing that the organ donation might disfigure the child's body C.) the family should understand that an autopsy is mandatory prior to organ donation D.) the nurse should introduce the option of organ donation to the parents when first discussing the child's impending death

D.) Inform the nurse manager of the issue

A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff. Which of the following actions should the charge nurse take first? A.) Document the actual time of medication administration B.) Notify the risk manager C.) Complete an incident report D.) Inform the nurse manager of the issue

B.) The cervix transitions to an anterior position.

A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching? A.) Contractions will be felt primarily in the upper abdomen. B.) The cervix transitions to an anterior position. C.) Contraction intensity decreases with ambulation. D.) The cervix progressively thickens.

C.) Tell the nurses to stop the discussion

A charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take? A.) Apologize to the client for the nurses' actions B.) Advise the nurses that they are being insubordinate C.) Tell the nurses to stop the discussion D.) document the incident in the client's medical record

C.) maintain hydration with liberal fluid intake

A nurse is administering cyclophosphamide orally to a school-age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication? A.) Give an antiemetic 30min after medication administration B.) Monitor glucose levels C.) maintain hydration with liberal fluid intake D.) Monitor for tumor lysis syndrome

A.) Performing a rapid needs assessment

A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? A.) Performing a rapid needs assessment B.) Organizing an immunization campaign C.) Identifying the specific roles of disaster workers D.) Conducting home visits to identify health hazards

B.) A client who has significant head trauma and agonal respirations

A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag? A.) A client who is alert and has a 2.5 cm (1 in) laceration on the forehead B.) A client who has significant head trauma and agonal respirations C.) A client who has an open fracture of the right forearm D.) A client who is unconscious and has a rapid, thready radial pulse

B.) the newborn has 6-8 wet diapers per day

A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8lbs) and is being breastfed. Which of the following findings indicates effective breastfeeding? A.) the newborn nurses q4h during the day and sleeps through the night B.) the newborn has 6-8 wet diapers per day C.) The newborn's current weight is 3.18kg (7lb) D.) The newborn has sticky, greenish stools

The client is at risk for developing ___b.) delayed wound healing__ due to __a.) glucose level___

A nurse in a provider's office is caring for a client who has a new diagnosis of type 2 diabetes mellitus Nurses' Notes 0800: Client has a 2 cm x 3 cm (0.79 in x 1.18 in) vascular ulcer noted on right ankle. Site cleaned with 0.9% sodium chloride and dressing covered with hydrogel foam. Capillary refill greater than 5 seconds bilaterally. Dorsalis pedis pulses 1+ bilaterally. Education provided to the client about wound care and diet to control glucose levels. Laboratory Results 0830: Glucose 175 mg/dL (74 to 106 mg/dL)HbA1c 9% (less than 7%)WBC count 9,500/mm3 (5,000 to 10,000/mm3)Hct 44% (42% to 52%)Hgb 15 g/dL (14 to 18 g/dL) Potassium 3.6 mEq/L (3.5 to 5.0 mEq/L) The client is at risk for developing _____ a.) dysrhythmias b.) delayed wound healing c.) anemia due to _____ a.glucose level b. potassium level c. hematocrit level

B.) diaphoresis

A nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should he nurse expect? A.) Lethargy B.) diaphoresis C.) bradycardia D.) Cough

C.) hemoglobin level D.) allergies E.) family history

A nurse is assessing a client who is scheduled for surgery. Vital Signs 0630: Temperature 36.9° C (98.4° F)Heart rate 74/minRespiratory rate 20/minBlood pressure 122/76 mm HgOxygen saturation 96% on room air 0730: Temperature 36.9° C (98.4° F)Heart rate 76/minRespiratory rate 20/minBlood pressure 128/78 mm HgOxygen saturation 95% on room air Nurses Notes 0630: Client reports restlessness and inability to sleep more than 3 to 4 hr per night for the last week.Client reports pain in the right upper quadrant as 2 on a 0 to 10 pain scale, constant for 2 weeks and increases after meals. Diagnostic Results 0730: Creatinine 0.9 mg/dL (0.5 to 1.1 mg/dL)Hct 43% (42 to 52%)Hgb 12 g/dL (14 to 18 g/dL) Medical History 0630: Client is 68 years old, diagnosed with cholelithiasis 2 weeks ago after reports of right upper quadrant pain rated as an 8 on a 0 to 10 scale after meals.Family history of coronary artery disease and malignant hyperthermia.Reports allergy to avocados and bananas.No known allergies to medications. Physical Examination 0700: Lung sounds clear bilaterally.Apical pulse 74/min and regular.Skin warm and dry. Click which assessment findings that the nurse should notify the provider about prior to the procedure. A.) O2 sat B.) creatinine level C.) hemoglobin level D.) allergies E.) family history F.) insomnia G.) pain level

b.) Assess the client for functional limitations.

A nurse is caring for a client who had a recent stroke. Prior to transferring the client to the. bedside commode, which of the following actions should the nurse take first? a.) Ask for help with a two-person assist transfer. b.) Assess the client for functional limitations. c.) Request a mechanical lift device. d.) Medicate the client for pain.

1.) Client's risk from bloodborne transmission- Hepatitis B Hepatitis C 2.) Physical examination findings - Hepatitis A,B,C 3.) Laboratory results- Hepatitis A,B, C 4.) Client's risk from fecal-oral transmission- Hepatitis A 5.) Antiviral treatment- Hepatitis B and C

A nurse is caring for a client who has abdominal pain. Nurses' Notes 0900: Client reports loss of appetite, weight loss, and fatigue for 1 week. Reports abdominal pain, 6 on a scale from 0 to 10, for 2 days.Client is a perioperative nurse, returned 1 week ago from a 2-week mission trip to an underdeveloped country. 1200: Results of antibody studies obtained. Provider prescription for antiviral medication pending. Physical Examination 0930: Lung sounds clear bilaterally.Skin warm to touch and jaundiced. Dry skin noted on extremities. Sclera yellow bilaterally.Bowel sounds normoactive in four quadrants. Client reports right upper quadrant pain upon palpation.Urine specimen obtained for urinalysis, dark yellow in color. Vital Signs 0900: Temperature 36.9° C (98.5° F)Heart rate 84/minRespiratory rate 18/minBlood pressure 118/78 mm HgOxygen saturation 98% on room air Diagnostic Results 1100: Aspartate aminotransferase (AST) 375 units/L (0 to 35 units/L)Alanine aminotransferase (ALT) 100 international units/L (4 to 36 international units/L)Alkaline phosphatase (ALP) 60 units/L (30 to 120 units/L) For each condition, specify if the characteristic is consistent with an acute infection of hepatitis A, Hepatitis B, or hepatitis C. 1.) Client's risk from bloodborne transmission 2.) Physical examination findings 3.) Laboratory results 4.) Client's risk from fecal-oral transmission 5.) Antiviral treatment

B.) Move the client to a quiet place away from others

A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? A.) Provide an opportunity for the client to express their feelings B.) Move the client to a quiet place away from others C.) State expectations that set limits on the client's behavior D.) Administer a PRN dose of haloperidol to calm the client

C.)Contact

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. Which of the following precautions should the nurse implement. A.)Airborne B.)Droplet C.)Contact D.) Protective environment

A.) "I should report a change in the color of my stools"

A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as an indication that the client understands the teaching? A.) "I should report a change in the color of my stools" B.) "I can take acetaminophen to treat a headache" C.) "I will take a calcium supplement while taking this medication" D.) "I will return in a month to have my blood tested"

D.) Involve the client in selection of a physical therapy provider

A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take? A.) Initiate the referral at the time of discharge B.) Have the client contact a physcial therapist when feeling ready to begin therapy C.) Verify that insurance will pay for outpatient physical therapy D.) Involve the client in selection of a physical therapy provider

A.) contact

A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate? A.) contact B.) droplet C.) airborne D.) protective environment

C.) "Maybe this is better for our child because we don't want any suffering through chemotherapy treatments."

A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization? A.) "Our child wouldn't have this terminal diagnosis if the doctor had diagnosed the cancer sooner" B.) "Let's go on that family vacation we've got planned. We will deal with this when we return." C.) "Maybe this is better for our child because we don't want any suffering through chemotherapy treatments." D.) "This isn't possible. Just last week the doctor said that the cancer was responding well to treatment."

1.) pain- bacterial meningitis, encephalitis, 2.) rash- bacterial meningitis 3.) temperature- bacterial meningitis, encephalitis 4.) hepatic function- reye syndrome 5.) photophobia- bacterial meningitis, 6.) mental status - bacterial meningitis, encephalitis, reye syndrome

A nurse is caring for an adolescent in the emergency department (ED). Nurses' Notes Day 1 0830: Adolescent presents to the ED with vomiting and irritability. Adolescent reports neck pain and headache as 6 on a 0 to 10 scale. 0930: Adolescent prepped for CSF biopsy and examination. Tolerated procedure well. No redness, excessive bleeding, or drainage noted from site. Resting in bed with lights off. 1000: Called to bedside by parent. Petechial rash noted on adolescent's arms bilaterally. Provider notified. Laboratory Results Sodium 140 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5 to 5 mEq/L) Chloride 103 mEq/L (98 to 106 mEq/L) BUN 15 mg/dL (10 to 20 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9.5 mg/dL (9 to 10.5 mg/dL) Phosphate 3.7 mg/dL (3 to 4.5 mg/dL) Glucose 80 mg/dL (74 to 106 mg/dL) Total protein 7 g/dL (6.4 to 8.3 g/dL) Albumin 4.5 g/dL (3.5 to 5 g/dL) WBC count 19,500/mm3 (5,000 to 10,000/mm3) AST 30 units/L (10 to 40 units/L) ALT 20 units/L (4 to 36 units/L) Diagnostic Results Cerebrospinal fluid examinationPressure: 35 cm H2O (less than 20 cm H2O) Color: Cloudy (clear and colorless) Blood: None RBC: 0 (0 cells) WBC total: 120 cells/µL (0 to 10 cells/µL) Protein: 90 mg/dL (15 to 45 mg/dL) Glucose: 20 mg/dL (50 to 75 mg/dL) Medication Administration Record Day 1 0830: Acetaminophen 325 mg PO 0930: Midazolam 2.5 mg IV Cefotaxime 2 g IV Vital Signs 0830: Temperature 39.2° C (102.6° F)Weight 51.4 kg (113.3 lb) For each assessment finding, select either bacterial meningitis, encephalitis, or reye syndrome that is consistent. It can be more than 1. 1.) pain 2.) rash 3.) temperature 4.) hepatic function 5.) photophobia 6.) mental status

D.) A client who is confused and has been attempting to get out of bed

A nurse is caring for four clients at the beginning of a shift. After receiving change-of- shift report, which of the following clients should the nurse attend to first? A.) A client who has a temperature of 38.2 C (100.8 F) and requests a cup of ice chips B.) A client who is postoperative and reports a pain level of 5 on a scale of 0 to 10. C.) A client who has voided and is ready for a bladder scan D.) A client who is confused and has been attempting to get out of bed

A.) A client who has Alzheimer's disease and is demonstrating aphasia

A nurse is caring for four clients. Which of the following clients should the nurse assign to an assistive personnel (AP) to assist with meals? A.) A client who has Alzheimer's disease and is demonstrating aphasia B.) A client who has asthma and an increased respiratory rate C.) A client who had a stroke and is to start oral intake D.) A client who had diabetic ketoacidosis and is difficult to rouse

B.) Request a referral for the client to receive physical therapy

A nurse is initiating discharge planning for a client who had a stroke and is experiencing right-sided weakness right-sided weakness. Which of the following actions should the nurse take first? A.) Ask a social worker to identify the client's insurance eligibility for rehabilitation services B.) Request a referral for the client to receive physical therapy C.) Arrange for the delivery of prescribed medications to the client's home D.) Provide the client with a list of community resources

C.) Clear objects from the client's walking area

A nurse is planning care for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan to take? A.) keep the client resting in bed B.) ask the client to restate directions C.) Clear objects from the client's walking area D.) evaluate the client's ability to swallow

B.) Auscultate the affected extremity for a bruit

A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care? A.) Notify the provider if a thrill is palpated at the fistula B.) Auscultate the affected extremity for a bruit C.) Discourage range-of-motion exercises in the affected extremity D.) Perform venipuncture in the affected extremity

b.) oranges

A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following foods should the nurse include in the teaching? A.) liver b.) oranges C.) chicken D.) red wine

D.) set the catheter tray on the overbed table at waist height

A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the following techniques should the nurse use to maintain surgical aseptic technique? A.) Open the top outer flap of the package toward the body B.) Clean the penis with the nondominant hand C.) don sterile gloves after opening the lubricant packet D.) set the catheter tray on the overbed table at waist height

0.5mL

A nurse is preparing to administer heparine 5,000 units subcutaneously. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose? Round to the nearest tenth.

C.)Latex allergy

A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure? A.) Ketonuria B.)Fecal impaction C.)Latex allergy D.)Tachycardia

C.)"I will bend at my knees when picking an object up off the floor."

A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching? A.)"I can resume my daily aspirin therapy." B.)"I will contact my provider if my eye feels itchy." C.)"I will bend at my knees when picking an object up off the floor." D.) "It's okay for me to pick up my grandchild who weighs 20 pounds."

B.) "You should keep the catheter clamped when not in use"

A nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter without a pressure-sensitive valve. Which of the following information should the nurse include in the teaching? A.) "You should flush the catheter with 0.9% sodium chloride solution daily when not using it regularly" B.) "You should keep the catheter clamped when not in use" C.) "You should swim twice weekly to prevent tissue from adhering to the cuff" D.) "You should change your dressing every 10 days"

A.) 1 medium raw carrot

A nurse is teaching a client about foods in vitamin A. Which of the following foods should the nurse recommend as having the highest amount of vitamin A? A.) 1 medium raw carrot B.) 1/2 cup cooked spinach C.) 1/2 cup cooked butternut squash D.) 1 cup sliced cantaloupe

B.) Headaches

A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? A.)Hypotension B.) Headaches C.) Bruising D.) Oliguria

B.)"I should have my child avoid sun exposure between 10 am and 2 pm."

A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? A.)"I will make sure my 4-year-old child wears a helmet when using a skateboard." B.)"I should have my child avoid sun exposure between 10 am and 2 pm." C.)"I can give my 2-year-old child a whole hotdog on a bun." D.)"When my infant is in the carrier, I will place it on a raised, flat surface whenever possible."

D.) "You should complete advance directives in the even you cannot express your own wishes"

A nurse is teaching a newly admitted client who has heart failure about advance directives. Which of the following statements should the nurse make? A.) "You don't need advance directives now because you are competent and can make decisions for yourself" B.) "You must wait for a period of 6 months after your diagnosis before initiating advance directives" C.) "You will have to speak to an expert who works in the social service department" D.) "You should complete advance directives in the even you cannot express your own wishes"

B.) "You will receive fingersticks for blood glucose testing"

A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has extensive burn injury. Which of the following information should the nurse include? A.) "This type of nutrition is more effective than eating by mouth" B.) "You will receive fingersticks for blood glucose testing" C.) "TPN" is a way to provide vitamins and minerals without increased calories" D.) "Taking TPN can increase the risk of developing a latex allergy"

B.)"I should pull the top of the ear upward and back while instilling the medication."

A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? A.) "I should administer the ear drops as soon as I remove them from the refrigerator." B.)"I should pull the top of the ear upward and back while instilling the medication." C.) "I should massage behind the ear after I instill the drops." D.) "I should have my child lie on the affected side for a few minutes after I put the drops in the ear."

B.) diced steam carrots

A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? A.) popcorn B.) diced steam carrots C.) whole celery sticks D.) marshmallows

D.) the client is able to accurately describe the upcoming procedure

A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? A.) the client's partner tells the nurse that the client understands the procedure B.) the nurse locates the provider's prescription for the surgical procedure C.) the nurse witnesses the provider's explanation of the procedure D.) the client is able to accurately describe the upcoming procedure

1.) Action to take 1- A.) apply graduated compression stockings 2.) Action to take 2- b.) elevate extremity 3.) condition most likely expected-b.) varicose veins 4.) parameter to monitor 1- b.) pruritis of right lower extremity 5.) Parameter to monitor 2- d.) edema of right lower extremity

A nurse on a medical-surgical unit is caring for a client who is postoperative following an emergency appendectomy. Vital Signs • Temperature 37.7° C (99.8° F)• Heart rate 82/min• Respiratory rate 16/min• Blood pressure 127/80 mm Hg• Oxygen saturation 99% on room air Assessment Height 157.5 cm (62 in)Weight 90 kg (198 lb)Bilateral lower extremities warm to touch, pedal pulses 2+ bilaterally. Spider veins noted on bilateral lower extremities. Distended veins noted on right lower extremity. Nurses' Notes Client reports pain at abdominal incision site as 4 on a 0 to 10 scale.Client also reports right lower extremity pain as 5 on a 0 to 10 scale, and itching.Reports that right lower extremity pain has been intermittent for about the last 2 months.Denies current left lower extremity pain. 1.) Action to take 1 2.) Action to take 2 A.) apply graduated compression stockings b.) elevate extremity c.) apply a warm compress d.) apply ice e.) prepare to administer an anticoagulant 3.) condition most likely expected a.)buerger's disease b.) varicose veins c.) deep vein thrombosis d.) venous insufficiency 4.) parameter to monitor 1 5.) Parameter to monitor 2 a.) ecchymosis of right lower extremity b.) pruritis of right lower extremity c.) intermittent claudication of right lower extremity d.) edema of right lower extremity e.) painful vasospasms of right lower extremity

1.) Action to Take 1- c.) insert a large-bore IV catheter 2.) Action to Take 2- e.) avoid cervical examination 3.) Condition Most likely Experiencing- a.) abruptio placentae 4.) parameter to monitor 1- a.) blood pressure 5.) parameter to monitor 2- d.) platelet count

A nurse on an antepartum unit is caring for a client who is at 33 weeks of gestation. Vital Signs Blood pressure 130/84 mm HgHeart rate 104/minRespiratory rate 22/minTemperature 37.3° C (99.2° F)Oxygen saturation 97% on room air Nurses' Notes Client is a primigravida who presents with report of decreased fetal movement and new onset of a small amount of dark red vaginal bleeding. External fetal monitor applied; FHR 116/min. Scant amount of dark red blood noted on perineal pad. Client reports sudden onset of pain above umbilicus and occasional uterine tightening over past hour. +1 nonpitting edema noted to feet and ankles. Denies visual changes, heartburn. Diagnostic Results WBC count 9,800/mm3 (5,000 to 10,000/mm3)Hgb 13 g/dL (greater than 11 g/dL)Hct 41% (greater than 33%)Platelet count 170,000/mm3 (150,000 to 400,000/mm3)BUN 20 mg/dL (10 to 20 mg/dL)Lactate dehydrogenase (LDH) 80 units/L (100 to 190 units/L)Aspartate aminotransferase (AST) 18 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 19 units/L (4 to 36 units/L)Uric acid (serum) 5.4 mg/dL (2.7 to 7.3 mg/dL)Kleihauer-Betke (fetal hemoglobin test) 3% (less than 1%)Blood type: ARh: positiveUrine reagent stripGlucose: nonepH: 6.0Specific gravity: 1.020Ketones: noneNitrates: noneLeukocyte esterase: negativeProtein: negativeNitrites: none 1.) Action to Take 1 2.) Action to Take 2 a.) request a prescription for glyburide b.) administer Rh immune globulin c.) insert a large-bore IV catheter d.)administer labetalol e.) avoid cervical examination 3.) Condition Most likely Experiencing a.) abruptio placentae b.) preeclampsia with severe features c.) gestational diabetes mellitus d.) placenta previa 4.) parameter to monitor 1 5.) parameter to monitor 2 a.) blood pressure b.) presence of clonus c.) capillary blood glucose level d.) platelet count e.) lo

A.) "There's a protocol for reviewing your medical record, and I can initiate the process."

A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the the nurse give? A.) "There's a protocol for reviewing your medical record, and I can initiate the process." B.)"The medical record has a lot of medical terminology, and it might be difficult for you to understand." C.)"You should really talk to your provider if you have any questions about your treatment." D.) "Some parts of your medical record are restricted, but I can show you the parts that you are allowed to see."

C.) decreased deep tendon reflexes

A nurse is caring for a client who has a potassium level of 3 mEq/L. For which of the following manifestations should the nurse monitor? A.) Increased bowel sounds B.) dry, sticky mucous membranes C.) decreased deep tendon reflexes D.) numbness and tingling of the extremities

B.) Discontinue the IV medication C.) monitor vital signs frequently D.) Administer epinephrine IM E.) administer 0.9% sodium chloride IV

A nurse is caring for a preschooler on the pediatric unit. History and Physical: 2250: Admitted from the emergency department with a diagnosis of pneumonia on the right side with mild pleural effusion. Medical history: Preschooler has a history of asthma. Allergies: No known allergies Provider Prescriptions: Day 1: 2350: Admit for observation. Obtain vital signs every 4 hours and PRN. Administer oxygen 2L/min via nasal cannula to maintain an oxygen saturation above 95. Initiate saline lock. Administer ceftriaxone 250mg IV q12h. Administer acetaminophen oral suspension 240 mg q4h prn for temperature greater than 38 C (100.4 F). Place on regular diet and encourage oral fluids of preschooler's choice. Monitor intake and output every 8 hours. Assessment: Day 2: 0030: Preschooler lying on bed, awake and alert. Breath sounds with wheezing auscultated on expiration on the right side. Nonproductive cough with no retractions or nasal flaring observed. Abdomen soft and non-distended, bowel sounds active in all four quadrants. Preschooler reports headache and pain in abdomen. Rates pain in abdomen as a 2 on a 0-10 FACES pain scale. Vital Signs: Day 2: 0030: Temp: 38.1 C (100.6 F); HR: 122; RR: 25; O2 sat: 98 on oxygen at 2L/min via nasal cannula. Weight 17.3kg (38lb); Height 102.3cm (40.3in) Nurse's notes: Day 2 0100: Saline lock inserted on first attempt. Assisted preschooler on right side-lying position for splinting. Administered ceftriaxone IV. Caregiver at bedside. Day 2 0130: Preschooler sitting up in bed, appearing anxious and flushed. Lips swollen. Preschooler scratching hives that have appeared on both upper extremities. After reviewing the assessment findings, which of the following actions should the nurse take? Select the 4 actions the nurse should take: A.) Discontinue supplemental oxygen B.) Disc

D.) "I will provide you with information about medical treatment to include in your living will"

A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make? A.) "You will need to draft a health care proxy so a designee can make this decision for you" B.) "I will make sure that no one performs any lifesaving measures if your heart stops C.) "Your provider determines if you should have lifesaving measures if your heart stops" D.) "I will provide you with information about medical treatment to include in your living will"

C.) "It seems like you feel your visits are a waste of time"

A nurse is caring for a client who has end-stage Alzheimer's disease. The adult child of the client says to the nurse, "I don't know why I bother to visit my mother anymore". Which of the following responses should the nurse make? A.) "Your mother might still know who you are" B.) "Why do you feel that way"? C.) "It seems like you feel your visits are a waste of time" D.) "Are you sure you would not want to see your mother again"

B.) Dysuria D.) Frequency E.) Urgency

A nurse in a provider's office is caring for a client. Nurses' Notes: Day 1 0900: Client is a. 65-year-old who reports pain and burning on urination. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented x3. Bilateral breath sounds clear. Respirations even and unlabored. S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2. Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. Vital Signs: 0900: Temperature 37.2 C (99F). HR: 88; BP: 142/88; RR: 20; O2 Sat: 92 on room air The nurse is assessing the client. Which of the following assessment findings should the nurse report to the provider? Select all that apply: A.) Blood pressure B.) Dysuria C.) Edema D.) Frequency E.) Urgency F.) Oxygen Saturation

A.) Gently cleanse the perineum before intercourse

Nurses' Notes: Day 1 0900: Client is a. 65-year-old who reports pain and burning on urination. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented x3. Bilateral breath sounds clear. Respirations even and unlabored. S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2. Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. Vital Signs: 0900: Temperature 37.2 C (99F). HR: 88; BP: 142/88; RR: 20; O2 Sat: 92 on room air Provider Prescriptions: Day 1: 0930: Collect urine specimen for urinalysis and urine culture and sensitivity. Trimethoprim/sulfamethoxazole 160/800 mg PO bid x10 Phenazopyridine 200mg PO q6h x2 Laboratory Results Day 1: 1100: Urinalysis: Color: amber (amber yellow); appearance: cloudy (clear); specific gravity: 1.04 (1.005-1.03); pH: 9 (4.6-8); Glucose: None (None); Ketones: None (none); bilirubin: None (none); Blood: trace (none); Nitrite: Positive (negative); Leukocyte esterase: positive (negative); RBC: 18 (less than 2); WBC: 30 (0-4) Urine culture: pending The nurse is planning to teach the client how to prevent further UTIs from occurring. Which of the following instructions should the nurse plan to include? A.) Gently cleanse the perineum before intercourse B.) Drink approximately 4L of fluids daily C.) Drink orange juice daily D.) Void every 4 to 6 hours during the day