RN question trainer test 3 NGN

the nurse plans care for a neonate diagnosed with tetralogy of Fallot. It is most important for the nurse to take which action?

USE A SOFT NIPPLE OR BREAST FOR FEEDING *** Allows the baby to practice suck and swallow and use less energy. feed q 2-3 hrs and soon after awakening so the newborn does not cry. feedings should be completed in 30 mins and NG tube can be used to complete an uncompleted feeding. newborn is supported and fed in a semi-upright position

the nurse prepares to admin meds to a client. the nurse recalls which is needed to verify the client's identity?

VERBAL VERIFICATION FROM THE CLIENT AND ID BAND

the parent of a toddler calls the clinic and tells the nurse, " I think my child has croup" which parental statement requires immediate follow up by the nurse?

"MY CHILD IS RESTLESS, AND THE CHILD'S HEAD IS WET WITH PERSPIRATION" *** increasing restlessness, profuse sweating, flaring nares, and increased RR indicate distress. intercostal retractions are early signs of impending airway obstruction..

the nurse prepares med for admin to a pt. the nurse recalls which is true about admin of oral liquids? SATA

- bottle caps should be placed upside down on the counter when removed -suspensions should be thoroughly mixed by the nurse before pouring - when pouring the liquid, the cup should be at eye level for accuracy - liquids less than 1 teaspoon (5ml) should be given using a syringe

secondary prevention

- early diagnoses and prompt treatment - screenings - prevents spread of communication

why is taking hydrochlorothiazide and citalopram concerning???

Hydrochlorothiazide (diuretic) and citalopram (selective serotonin reuptake inhibitor) can lead to HYPONATREMIA

Braden Scale for Predicting Pressure Sore Risk

19-23 not at risk 15-18 low risk 13-14 moderate risk 10-12 high risk Less than or equal to 9 very high risk

accountability=

responsibility to remain competent for using reasonable care while practicing nursing.

moro reflex

sudden jarring causing extension and abduction of extremities and fanning of fingers with index and thumb forming a C shape. -disappears after 3-4 mo

tonic neck reflex

the head is turned to the side, arm, and lef extend on that side, and the opposite arm and leg flex. - disappears by 3-4 mo

what is a myelogram?

the test involves a lumbar puncture with injection of contrast medium, allowing xray visualization of the vertebral canal.

grasp reflex

touching the palms of hands or soles of feet causing flexion of hands and toes. - palmar grasp disappears after 3 mo of age -plantar grasp lessens by 8 mo

the nurse provides care for a client newly diagnosed with anxiety and prescribed buspirone. the nurse understands which instruction is needed? SATA

- grapefruit juice should be avoided when taking buspirone -drowsiness and lightheadedness are adverse effects - it can take several weeks to notice decreased anxiety *** never take double doses and avoid drinking alcohol

the client is scheduled to have an intravenous pyelogram (IVP). Nursing management includes which action?

ADMINISTERING CLEANSING ENEMAS THE EVENING BEFORE TO PROVIDE ADEQUATE VISUALIZATION OF THE URINARY TRACT

the nurse plans a diet for a child client diagnosed with cystic fibrosis. Which dietary requirement does the nurse consider? SATA

- high protein - high calorie *** impaired intestinal absorption due to cystic fibrosis necessitates a diet high in protein and calories. - pancreatic enzymes are required at the beginning of all meals and snacks bc of pancreatic insufficiency - Fat soluble vitamins (A,D,E, K) also must be supplemented bc of malabsorption.

early signs of impending airway obstruction and indications of distress?

- increased pulse and RR - substernal, suprasternal, and intercostal retractions - flaring nares - increased restlessness -profuse sweating

the nurse provides care for a client with a peripheral intravenous (IV) saline lock. The nurse recalls which is an advantage to using a saline lock? SATA

- it provides IV access for clients on a fluid restrictions - it provides access for intermittent IV meds - it allows the pt more mobility than continuous IV fluids - it is more cost effective than continuous IV infusions (less cost)

the nurse educated a client newly diagnosed with type 2 about metformin and how it lowers glucose production by the liver. Which common adverse effect of metformin does the nurse include in the education? SATA

- nausea - diarrhea -vomiting *** metformin rarely causes hypoglycemia

the nurse provides wellness education to a class of school-age children. The nurse recalls wellness includes which aspect at this age? SATA

- nutritional - physical - social - emotional - intellectual

the nurse plans to include which action in the care for the client? (stage 1 pressure ulcer) SATA

- report skin findings to the attending physician - request an order for an alternating pressure mattress - turn the client hourly -apply a hydrocolloid dressing to the sacrum *** dont do high fowler (= increased friction and shear)

The nurse provides care for a client with a diagnosis of guillain barre syndrome. Which initial symptom supports this diagnosis ? SATA

- respiratory failure - flaccid paralysis - urinary retention (due to loss of sensation of the bladder)

Tertiary prevention

- restoration and rehabilitation - minimizes effects of already existing disease (chronic condition) - prevents further disability

the nurse provides care to clients in a community health clinic. The nurse recalls which is a level of disease prevention? SATA

- tertiary - secondary - primary

the home health nurse completes a fall screening tool during a visit to an older adult client's home. The nurse determines the client is a fall risk. The nurse recalls which factor can decrease the client's rf falls? SATA

- use of grab bars in the shower - removal of throw rugs - wearing nonslip footwear - moving slowly when getting out of bed *** "relocation to a one story home" is not right bc they can fall in a one story home too and it isn't a factor that decreases the rf falls.

the nurse prepares for med admin to a pt. the nurse identifies which is true about preventing needlestick injuries? SATA

- using needleless syringes helps prevent needlestick injuries - used syringes with needles should be immediately placed in approved sharps containers. - needles should not be bent or manipulated before disposal in a sharps container. *** " a needle safety mechanism should only be used when a sharps container is not close" is not right bc safety mechanisms on the needle should be utilized whenever possible

if the nurse suspects the client has developed acute alcohol withdrawal syndrome....

-after notifying the physician the nurse will plan to... transfer the client to ICU - an appropriate med for this client would be... lorazepam 2 mg IV q 4 hrs - the nurse understands the client is at risk for ... seizures

common s/s of dehydration

-low bp - fatigue -dizziness -high BUN

the nurse returns phone calls at an outpatient clinic. 4 clients taking haloperidol called in with status reports. place the pts in the correct order for the nurse to call back.

1. i dont understand why my tounge keeps moving (tardive dyskinesia) 2. my neighbors dont like me (paranoia and can mean the pt is deteriorating) 3.) I have a meeting with the governor later this afternoon (delusion and another deterioration sign) 4.) i seem to get sleepy every afternoon around 4 (reporting drowsiness which is an adverse effect)

the nurse receives report on assigned clients from the previous shift. In which order does the nurse see the clients?

1.) the client receiving ciprofloxacin IV who reports a fine macular rash on the chest. 2.) the pt receiving IV potassium who reports burning at the IV site. (potential hypersensitivity and prevent irritation) 3.) the pt scheduled to received heparin and the activated thromboplastin time is 70 secs (adjustment of heparin dose by HCP is required for an aPTT < 50 secs or >100 secs) 4.) the client receiving a blood transfusion who reports a dry mouth

the nurse receives clients after a train derailment. after making initial assessments, in which order does the nurse see these clients?

1.) the young adult client with blood pulsating from a cut on the right leg 2.) the unconscious pt with the right leg shorter than the left leg (possible hip fracture) 3.) the pregnant client who states clothing is wet 4.) the preschool child who is scared of the surroundings

the nurse provides care for clients on a psychiatric unit and is suddenly faced with multiple issues. in which order does the nurse address these situations?

1.)the pt diagnosed with depression says to the nurse "may plan is complete, and i'm ready to go" (suicide) 2.) the client diag with schizophrenia tells the nurse the TV should be destroyed (prevent harm to the pt and others) 3. the client with substance abuse reports harassment by another client. ((decrease environmental stimuli) 4.) the client diag with bipolar disorder walks into the day room wearing only underwear *** think about physical danger first

a pt diagnosed with bipolar disorder is in a manic phase with combatitive behavior. Which is the priority nursing action?

ADMIN AND MONITOR SEDATIVE AND MOOD STABILIZING MEDS *** most important to gain control when a client is physically aggressive. the client has significant SNS stimulation and will require psychopharmacologic intervention and sedative meds and mood stabilizing agents. - just decreasing stimuli will not diminish the client's internal sense of aggression

the school nurse attends the end-of-the-year picnic for school-age children. A child screams, "I got stung by a bee, and I am feeling really hot now!" The child has a large welt at the site of the sting and a raised red rash on the extremity. Which action does the nurse take first?

ASSESS THE RATE AND QUALITY OF RESPIRATIONS ***Child at risk for anaphylaxis. cutaneous signs and report of a warm feeling are the 1st signs of an anaphylactic reaction. the child is at rf bronchospasm - if anaphylaxis is present the priority would be to admin epinephrine

A client diagnosed with an OCD. The nurse recognizes the client is attempting to achieve which outcome?

AVOID SEVERE LEVELS OF ANXIETY *** OCD traits are an attempt to avoid or alleviate increasing levels of anxiety. these behaviors do not have a significant impact on others. the client does not want to repeat the act but feels compelled to do so.

the parent brings a 9 mo infant to the peds office with a fever of 102 and frequent vomiting. the nurse expects to find which reflex?

BABINSKI REFLEX *** the foot one but it disappears at 1 yo. and the pt is 9 mo

the nurse provides care for a client 1 hr after electroconvulsive therapy treatment. The nurse reports which observation to the HCP?

BACKACHE *** not expected - headache, short and long term memory loss, and transient confusion all are expected

a client brought into the ED by ambulance has traumatic injuries from an accident. The client is unconscious and needs emergency surgery. The next of kin is unknown. Which ethical principle does the health care provider to provide care for the client?

BENEFICENCE ***beneficence= ethical principle involving the duty for promo of good and prevention of harm. the principle of beneficence, when it overrides an individual's autonomous choice in order to service that individual's interests, is appropriate when a person lacks the capacity to make personal decisions.

an older adult client is prescribed 2 units of PRBC to be infused. Which assessment finding does the nurse report to the health care provider prior to admin?

BILATERAL CRACKLES AUSCULTATED *** auscultation of bilateral crackles indicates excess fluid and should be evaluated by the HCP to avoid circulatory overload with the blood transfusion.

the nurse provides care for a client with an exacerbation of gout. the nurse understands which laboratory test is monitored while the client receives allopurinol?

COMPLETE BLOOD COUNT (cbc) *** allopurinol depresses the bone marrow.

the nurse provides care for an older adult client who has been hospitalized for over 2 mo after being in a car accident and having multiple surgeries. which safety concern does the nurse anticipate for this client?

CONFUSION *** Confusion can occur when a client has spent an extended period in the hospital. the nurse will reorient the client frequently.

the nurse provides care for a client during the first prenatal visit. the clients last menstrual period began may 8 and ended may 12. which estimated date of birth (EDB) will the nurse calculate for this client?

FEBURARY 15

the nurse provides care for a client in the health providers office. the pt is prescribed fiber daily for constipation. The nurse understands that fiber helps bowel elimination in which way?

FIBER INCREASES THE BULK OF FECAL MATTER, MAKING IT EASIER TO PASS

a young adult primigravida client id diagnosed with type 1 diabetes. the nurse reviews the insulin regimen with the client. Which statement by the nurse explains how insulin needs will change?

INSULIN NEED INCREASES DURING PREGNANCY AND DECREASES AFTER DELIVERY

2 hrs after NG tube is inserted and attached to suction, a client vomits a moderate amount of green fluid. which action by the nurse is best?

IRRIGATE THE NG TUBE WITH 20 ML OF NS ***if a client with an NG tube is vomiting= tube is obstructed. -the nurse will use NA for irrigation, as water is a hypotonic solution and could cause electrolyte imbalances.

the nurse reviews the health care provider prescription for sildenafil for a client. the nurse understands which med listed in the pts hx is a contraindication to sildenafil?

ISOSORBIDE DINITRATE *** isosorbide dinitrate is a nitrate that is contraindicated while taking sildenafil since taking both meds can cause profound hypotension

the charge nurse makes client assignments for a med surg unit. the nurse who is floated from which unit needs a longer orientation?

LABOR AND DELIVERY *** They would be the least familiar with caring for med-surg clients

antidote for acetaminophen

N-acetylcysteine (Mucomyst)

a complaint has been filed against a nurse citing an unintentional failure of the nurse to perform an act that a reasonable person with the same Knowlege, experience, and background would or would not perform in similar circumstances. With which legal judgement is the nurse charged?

NEGLIGENCE **** unintentional failure of the nurse

the nurse provides care for an older adult client just transferred from a long-term care unit. the record indicates that the client has refused to eat or drink for several days. Which action by the nurse is best?

OBTAIN THE BP IN THE SITTING AND STANDING POSITIONS *** - older adult clients who are dehydrated have an increased rf orthostatic hypotension. -safety is priority

the nurse provides care for a client prescribed furosemide 40 mg iv. the client reports SOB at rest, and the nurse notes bilateral 2+ pretibial pitting edema. which action is most important for the nurse to take after admin of the med?

OBTAIN THE CLIENT'S BP *** intravenous furosemide can cause circulatory collapse, and it can be a rapid change.

the nurse cares for a multipara pt who delivered a newborn 1 hr ago. the nurse observes the client's breasts are soft, the uterus is boggy to the right of the midline and 2 cm below the umbilicus, and there is moderate lochia rubra. Which action is most important for the nurse to take?

OFFER THE CLIENT THE BEDPAN *** A boggy uterus that is deviated to the right= full bladder

the nurse admins a dose of streptomycin to a client with severe infection. The nurse recalls which are symptoms of aminoglycoside toxicity?

OTOTOXICITY AND NEPHROTOXICITY

a client diagnosed with hypothyroidism receives levothyroxine. the nurse understands the pt may be at rf for which adverse effect?

PALPITATIONS ***palpitations are an adverse effect of levothyroxine - BP increase, weight loss, tachycardia are signs of hyperthyroidism

Prior to admin asthma action plan medication to a child. Which action will be the most important for the nurse to take?

REASSURE THE CHILD *** helps slow the RR and allow for better inhalation of rescue meds.

the nurse provides care for a pt on suicide precautions. the client is sleeping and eating better and has indicated a willingness to interact more with fam members. the client denies any adverse effects with the current meds and verbalizes alternatives to self-harm. Based on this data, which nursing action is most appropriate?

RECOMMEND THE TX TEAM REEVALUATE THE CLIENT'S TX PLAN ***because pt is demonstrating improvement. evaluation of a client with suicidal ideations is ongoing, and decisions surrounding suicide precautions can be changes gradually based on continued progress.

The parents of a terminally ill pediatric client decide to remove their child from life support. Which nurse action displays the role of client advocate in this situation?

RESPECTING THE PARENTS DECISIONS ***the nurse best advocates for the family by supporting the family's right to make this decision - referring the parents to another entity points (social services) to feelings of unease about parents' choice

the nurse instructs a client who is newly prescribed hydralazine. the nurse understands which information about hydralazine is helpful?

SIT UP IN BED FOR A FEW MINUTES BEFORE STANDING ***hypotension is an adverse effect and can occur with quick position changes - hydralazine is a vasodilator that is used for hypertension and heart failure

the nurse provides care for a toddler after bronchoscopy and removal of an aspirated peanut. Which assessment requires an immediate intervention by the nurse?

SITS FORWARD WITH THE NECK EXTENDED, CONTRACTION OF SUPRACLAVICULAR MUSCLES *** Pneumothorax is a possible complication of bronchoscopy. these are signs of resp. distress.)

A client has partial thickness and full thickness burns over 75% of the body. The nurse is most concerned if which symptom is observed?

TACHYPNEA *** responds to early hypovolemic shock by adrenergic stimulation that can cause tachycardia.

the nurse provides care for a client after right cataract surgery. The nurse intervenes if which observation is made?

THE CLIENT IS LYING ON THE RIGHT SIDE *** the client should not be positioned with the operative side in a dependent position or against the bed bc this can increase intraocular pressure -sitting with the head elevated decreases swelling and pain

NAEGELE RULE (EDB)

add 7 calendar days and substract 3 mo - use the FIRST day of last menstrual period not the last day

justice=

ethical principle dealing with fairness in tx of various individuals and in the utilization of resources.

Veracity=

ethical principle that deals with truthfulness and conformity to facts

primary prevention

health promo and specific protection -decreases vulnerability to disease and harm - immunizations