Transition Exam 1 Review

A nurse is teaching a caregiver how to administer antibiotics at home to a client with acute otitis media. Which statement by the caregiver indicates that teaching has been successful?

ill give the antibiotics for the full 10-day course of treatment

The nurse is caring for a client with atelectasis. What is the nurse's most important intervention>

implement chest physiotherapy

An adolescent client with polycystic ovarian syndrome (PCOS) has been placed on metformin. The nurse determines the client needs more teaching about metformin if she states the medication helps achieve which outcome?

increased insulin levels

A nurse reports to the physician that a client receiving a blood transfusion has a temperature that is 1°C greater than the baseline and reports of a headache. The physician says to continue the blood infusion. What is the most appropriate action by the nurse to ensure the safety of the client?

inform the physician of hospital policy for managing transfusion reactions

An adolescent client visits the school nurse reporting back pain, fatigue, and dyspnea. The nurse suspects scoliosis. Which action does the nurse take before developing a further plan of care?

inspect for uneven shoulder height or hip height

A client is brought to the crisis response center by her family. During evaluation, the client reports being depressed for the last month and that voices are telling her to hurt herself. Which intervention is most important for the nurse to implement?

suicide precautions

The mother tells the nurse she will be afraid to allow her child with hemophilia to participate in sports because of the danger of injury and bleeding. After explaining that physical fitness is important for children with hemophilia, which activity should the nurse suggest as ideal?

swimming

Which task should the RN delegate to the unlicensed assistive personnel (UAP)?

taking a 5 pm tympanic temperature for the client in room 515

A client who has recently had a fractured hip repaired must be transferred from the bed to a wheelchair. Which of the following should the nurse consider while assisting the client?

the appropriate proximity and visual relationship of the wheelchair to the bed must be maintained

The nurse is preparing to administer medications to the following clients. Which client would the nurse question administering the medication?

the client receiving hydrochlorothiazide who is complaining of leg cramps

A nurse on a surgical unit is caring for a client who needs to provide informed consent for surgery. When the surgeon arrives on the unit to obtain consent, which of the following client conditions must the nurse immediately bring to the surgeon's attention?

the client was given morphine 6 mg IM 20 minutes ago

The nurse is caring for clients on a medical floor. Which client should the nurse assess first?

the client with essential hypertension who has epistaxis and a headache

The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?

the client's apical pulse is 56

The parent of a 17-year-old client, who is hospitalized for complications related to type 1 diabetes, requests to review the adolescent's medical record. The client reported receiving mental health counseling during the admission history but did not want his parent to know. The nurse is uncertain of how to protect the adolescent's privacy and accommodate the parent's request. Who is the most appropriate person to consult?

the organization's privacy officer

What data would cause the nurse to question administering digoxin to a client diagnosed with congestive heart failure?

the potassium level is 3.2 mEq/L

A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms and a report of chest pain. What priority question should the nurse ask this client?

what makes the pain intensify?

A very elderly, drowsy client with fragile skin is being transferred from the surgery cart to the bed. How should the nurse plan to direct the transfer to prevent skin shearing?

with two people, one at each side using a drawsheet, one person at the head, and one person at the feet

A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply.

-administration time of last does -client's pain level on a scale of 1-10 -type of medication the client has been taking -client's reaction to the previous dose -effectiveness of prior dose of medication

The nurse is making assignments for the unlicensed assistive personnel (UAP). Which tasks can be safely assigned to UAP? Select all that apply.

-bathing a client with Alzheimer's disease -turning a client who is poorly nourished

The nurse is preparing to administer medications to the client. Which identifiers will the nurse use? Select all that apply.

-birthdate -wristband -name

A nurse is caring for a client with diarrhea caused by Clostridium difficile. Which of the following personal protective equipment should the nurse use? Select all that apply.

-gown -gloves

When explaining to parents how to reduce the risk of sudden infant death syndrome (SIDS) the nurse should teach about which measures? Select all that apply.

-maintain a smoke-free environment -breastfeed the baby -place the baby on his back to sleep

A client, who weighs 165 lb (75 kg), with a pulmonary embolus, is ordered to receive heparin 20 units/kg/hr by IV infusion. How many units of heparin should the client receive each hour?

1,500

The nurse is changing intravenous fluids for a client who has hypokalemia. Place in order the steps the nurse will use to change intravenous fluids. All options must be used.

1. review the new IV order 2. obtain the correct IV fluids 3. identify the client with 2 methods 4. begin the IV fluids 5. document the start of the fluids 6. monitor the next potassium level

When placing an indwelling urinary catheter in a female client, the nurse should advance the catheter how far into the urethra?

2 inches (5 cm)

Therapy for Kawasaki disease includes a single dose of IV gamma globulin, prescribed at 2 g/kg. The child weighs 32 lb (14.5 kg). How many grams should this child receive? Record your answer using a whole number.

29

A client with a history of hypertension has just had a total hip replacement. The provider orders hydrochlorothiazide 35 mg oral solution po/day. The label on the solution reads hydrochlorothiazide 50 mg/5 ml. How many milliliters should the nurse pour to administer the correct dose? Record your answer using one decimal place.

3.5

The nurse is administering amoxicillin/clavulante potassium to a child with cellulitis. The provider has ordered 40 mg/kg to be given three times a day over 24 hours. The child weighs 33 lb (15 kg), and the pharmacy has sent amoxicillin/clavulantate 200 mg/5 ml. How many milliliters per dose should the nurse administer? Record your answer using a whole number.

5

A client develops acute otitis media and is ordered cefpodoxime proxetil 5 mg/kg P.O. every 12 hours. If the client weighs 22 lb (10 kg), how many milligrams will the nurse administer with each dose?

50 mg

A school-age child, who weighs 80.5 lb (36.5 kg), has been prescribed a 250 ml bolus of normal saline administered over one hour, followed by a maintenance infusion of 2 ml/kg/hr of the same fluid. The nurse initiated therapy at 1200 and is recording intake and output at 1800. What is the intravenous intake of this child? Record your answer using a whole number.

615

The nurse is assigning a room for a client admitted with hepatitis A. Which of the following diagnoses would be an appropriate roommate for this client?

CHF

An 18-year-old client is recently diagnosed with leukemia. What is the most appropriate short-term goal for the nurse and client to establish?

expressing the client's angry feelings to the nurse

The nurse should seek clarification about which prescription?

give 200,000 units heparin by IV drip, and infuse over 24 hours (too large of a dose)

After teaching a community class to new parents, the nurse evaluates client understanding of strategies to prevent sudden infant death syndrome (SIDS). Which statements indicates appropriate understanding?

I will place my baby in a supine position for sleep during the first year

A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client?

RN with one year of experience

A nurse, working in a rural county's public health department, has been alerted that there is an outbreak of tuberculosis (TB) in the area. Which client is at highest risk for developing TB?

a 43-year-old homeless man with a history of alcoholism

The unlicensed nursing assistant tells the primary nurse that the client diagnosed with coronary artery disease is having chest pain. Which action should the nurse take first?

go to the room and assess the client's chest pain

The following pediatric clients are in the triage area awaiting assessment. Which client will the nurse assess first?

a quiet 2-year-old with nasal flaring who is sitting in a tripod position

The client diagnosed with acute deep vein thrombosis is receiving a continuous heparin drip. The health care provider orders warfarin. What action should the nurse take?

administer the warfarin along with the heparin drip as ordered

The nurse is discontinuing an intravenous catheter on a 10-year-old client with hemophilia. What would be the most important intervention for this client?

apply firm pressure on the site for 5 minutes after removal

During assessment, a client verbally rates the pain as 9 out of 10 on a 0 to 10 pain scale. There is no indication of pain relief, even though the previous nurse signed for an opioid for this client one hour prior. The client denies receiving anything for pain since the previous night. Which action should the nurse take next?

approach the nurse who signed for the opioid to seek clarification about the missing drug

Which over-the-counter medications should the nurse tell the mother of a child with hemophilia to avoid using?

aspirin

The client is four (4) hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?

assess the client's bilateral pedal pulses

A nurse is assigned to care for a client with chest pain in the intensive care unit. The client is reading a book when the nurse observes a flat line on the monitor and the alarm rings. Which of the following is the nurse's priority intervention at this time?

assessing the client

A 24-year-old client comes into the clinic reporting sudden-onset, right-sided chest pain and shortness of breath. While assessing the client, the nurse determines that the most important intervention is to:

auscultate the breath sounds

Which laboratory data confirms the diagnosis of congestive heart failure?

beta-type natriuretic peptide

A client has been diagnosed with septic shock. The nurse would anticipate implementing which of the following orders?

blood chemistry of serum lactate

A child is brought to the emergency department and is diagnosed with status asthmaticus. The child's respiratory rate is 40 breaths/min, and there are decreased breath sounds bilaterally throughout the lung fields. The nurse administers an aerosol bronchodilator and reassesses the lung sounds. Which finding is the best indicator that the bronchodilator has been effective?

breath sounds are louder bilaterally

Before discharge, which instruction should a nurse give to a client receiving digoxin?

call the physician if your heart rate is above 90 beats/minute

The nurse is assessing a client's chest tube and notes that it is not working properly. What is the nurse's priority action?

check patency of the chest tube

The nurse is making a discharge plan for a client recovering from a total laryngectomy. What is an expected outcome?

communicate feelings about body image changes

A nurse manager is delegating the revision of the unit's educational policies to staff nurses. What is the best instructional guidance the nurse manager can offer?

complete the revision in six weeks

The client is three (3) hours post-myocardial infarction. Which data would warrant an immediate intervention by the nurse?

cool, clammy, diaphoretic skin

The nurse is transcribing the doctor's orders for a client with congestive heart failure. The order reads 2.5mg of digoxin daily. Which action should the nurse implement?

discuss the order with the HCP

During the nurse's assessment, the newborn wakes and is in a quiet-alert state. The nurse counts the apical pulse to be 157 beats per minute. Which is the most appropriate nursing action?

document this finding as on the high end of the normal range and plan to reassess

A client is receiving TPN therapy. Which finding should the nurse report to the health care provider?

elevated temperature

A client comes to the emergency department with acute shortness of breath and a cough that produces pink, frothy sputum. The client is restless and extremely anxious. Admission assessment reveals crackles and wheezes, a blood pressure of 82/45 mmHg, a heart rate of 120 bpm, and a respiratory rate of 38 breaths/min. The client's medical history includes hypertension, and heart failure. What is the nurse's priority intervention?

elevating the head of the bed

The nurse is planning care for a client with panic disorder. What is the priority nursing intervention?

evaluate for depression

A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse?

maintain a patent airway

An assessment of a client on the first day after a thoracotomy shows a temperature of 100° F (37.8° C); heart rate, 96 bpm; blood pressure, 136/86 mmHg; and shallow respirations at 30 breaths/min, with rhonchi at the bases. The client is diaphoretic, anxious, and reports of incisional pain. Which nursing action is priority?

medicate the client for pain as ordered

What is the treatment team's priority in planning the care of a client with an eating disorder?

meeting daily to discuss manipulation and countertransference

What is the nurse's priority action in caring for a client who has just had a liver biopsy?

monitor VS

The nurse is monitoring a client, who is six hours post embolectomy, for an acute arterial occlusion of the left leg. When a Doppler ultrasound fails to detect a pedal pulse, the nurse notifies the surgeon who requests that the client be prepared for immediate surgery. The client refuses to consider additional surgery. What is the nurse's initial intervention?

notify the provider immediately

A young female client with a history of sickle cell disease reports abdominal pain. What is the priority intervention by the nurse?

obtaining a history of the sequence of symptoms

The telemetry nurse notes a peaked T-wave for the client diagnosed with congestive heart failure. Which laboratory data should the nurse assess?

potassium

A school-age client with diabetes is placed on an intermediate-acting insulin and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. What does the nurse tell the client the snack is intended to do?

prevent late night hypoglycemia

When caring for a client with quadriplegia, which nursing intervention is the priority?

preventing atelectasis

Which nursing intervention is the most appropriate for a client diagnosed with functional neurologic symptom disorder who has experienced pseudoseizures?

promote independence and withdraw attention from the pseudoseizures

Which positioning technique is not appropriate when the nurse changes a client's position in bed if the client has hemiparalysis?

sliding the client to move up in bed

Which information about sublingual nitroglycerin tablets should the nurse include when instructing the client with angina?

store the tablets in a tight, light-resistant container

The client is brought to the emergency department (ED) via ambulance. A family member was talking with the client and suddenly the client began to slur words, and could not move their right side. The healthcare provider diagnoses a left-sided cerebrovascular accident (CVA) and orders a thrombolytic medication. Which medication would the nurse anticipate the healthcare provider to order?

streptokinase