All NCLEX Challenges Summer 2018
nurse is caring for a client with a tracheostomy. client's partner has been taught to perform suctioning. which action by the partner should indicate a readiness for the client's discharge?
performing the procedure independently
nurse is in urgent care center caring for pt having an acute asthma exacerbation. which of the following actions is the nurse's highest priority
administering nebulized beta-adrenergic greatest risk is safety to airway obstruction, beta-adrenergic meds act as bronchodilators
nurse is teaching pt who has been taking prednisone to treat asthma and has a new prescrip to d/c med. the nurse should explain to the pt to reduce the dose gradually to prevent what
adrenocortical insufficiency
a nurse is preparing to administer 250mg. available is 3 g/5 mL. how many mL should nurse administer?
0.4
nurse is preparing to administer meperidine 75 mg IM to a client who reports post op pain. available is meperidine 100 mg/mL. how many mL should the nurse administer?
0.8
nurse is caring for pt who is to receive a unit of packed RBCs. nurse should prime blood admin tubing using which IV solution
0.9% sodium chloride LR, 5% dextrose in water, and 5% dextrose in 0.45% sodium chloride hemolyzes RBCs
a nurse is teaching a client who is to begin long-term therapy with prednisone to treat RA. the nurse should instruct the client to take which supplements?
calcium and vitamin D glucocorticoids such as prednisione place pt at risk for osteoporosis, Ca and vitamin D reduce this risk
a nurse is instructing a group of clients regarding calcium rich foods. which food should the nurse include as the best source of calcium?
1 cup of milk although ice cream, swiss cheese, and cottage cheese all contain calcium, milk contains the most
300 mg by intermittent IV bolus over 30 min to a client with a staph infection. available is 50 mL premixed in 0.90% sodium chloride. IV pump should be set to deliver how many mL/hr?
100 mL/hr mL/hr= 50mL/30min x 60min/hr (in this case I guess 300mg = 50mL?)
nurse is completing 8hr I&O record for a client. client consumed 4 oz soda, 1 piece of toast, 12 oz water, 1 cup gelatin, 1/2 cup broth, 300 mL sodium chloride. how many mL should record?
1140 1oz=30mL 1cup=8oz
nurse preparing 40mEq in 500mL IV to infuse 10mEq/hr. nurse should set the IV pump to deliver how many mL/hr?
125
nurse in a community health center is assessing the results of a TB skin test she performed for a pt. which result indicates exposure to and possible infection with TB?
15 mm induration (hardened area)
nurse is calculating pt intake and output for an 8-hr shift. the client's intake included 1000 mL 0.9% sodium chloride IV, one 6-0z cup of coffee, 6 oz water, one 180-mL bowl of soup, 3 oz of flavored gelatin, and 3 oz of ice cream. how many mL should the nurse document as the client's total intake for the shift?
1720 1oz=30mL
5 mg/kg q12h for 5 days. client weighs 88lb. how many mg should nurse administer/dose?
200
nurse is preparing to administer 0.9% sodium chloride 3000 mL IV to infuse over 24 hr. drop factor on manual IV tubing is 10 gtt/mL. nurse should set the manual IV infusion to deliver how many gtt/min?
21 (20.83) gtt/min = 10gtt/mL x 3000mL/24hr x 1hr/60min
nurse is calculating intake of a client during past 9 hours. client's intake includes LR IV at 150mL/hr, cefazolin 2g/100mL, two units of packed RBCs of 275mL and 250mL, two IV bolus infusions of 250mL sodium chloride, ranitidine 50mg in 50 mL of dextrose 5%. how many mL of intake should nurse record?
2525
nurse is caring for a client who is receiving oxygen at 2L/min via nasal cannula. nurse recognizes client is receiving which of the following inspired oxygen concentration?
28% flow rate of 2L/min delivers 28%; flow rate of 4L/min delivers 36%; simple face masks deliver oxygen concentrations of 40-60% with flow rates of 5L/min or greater; nonrebreather mask with a minimum flow rate of 10L/min can deliver oxygen concentrations of 60-80%
a nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain. the amount available is 300 mg/capsule. how many capsules should the nurse administer per dose?
3
a nurse is caring for a client who has OA and asks about the use of glucosamine. which statements should the nurse make?
??? no right answer shown??? glucosamine alone or with chondroitin can increase risk of bleeding
a nurse is caring for a client who has a fungal infection and has a new prescription for amphotericin B. which of the following lab values should the nurse report to the provider before initiating the medication?
BUN amphotericin B is nephrotoxic and is contraindicated if BUN is > 40
a client who is receiving magnesium sulfate has a urine output of 20 mL/hr. which med should the nurse expect to administer?
calcium gluconate treats magnesium sulfate toxicity; flumazenil is for sedative effects of benzodiazepines; naloxone reverses opioid overdose; protamine is for heparin overdose
a nurse is caring for a pt who has a prescription for potassium chloride 20 mEq PO daily. nurse reviews pt most recent lab results and finds the pt potassium level is 5.2 mEq. which action should the nurse take?
call prescribing physician and inform her of the pt serum potassium level results
a nurse manager is providing an educational program on antibiotic sensitivity to bacterial infections. the nurse should include in the teaching that vancomycin is indicated for which of the following infections?
Methicillin-resistant Staphylococcus aureus
a nurse is preparing an in-service for annual skills fair at a community medical facility about fire safety. place the steps in order in which they should be performed in case of a fire emergency
R.A.C.E. rescue, alert, confine, extinguish
a nurse is reviewing the diagnostic test results of an older female client who is preoperative for a TKA. the nurse should notify the surgeon of with of the following results
WBC count 20,000
nurse caring for pt who has a central venous catheter and reports hearing a gurgling sound on side of catheter insertion. which of the following complications should the nurse suspect?
catheter migration gurgling sound means migration; change in length means dislodgment; fluid leaking from site or pain and swelling mean rupture; difficulty administering fluids or drawing up blood through line mean occlusion
nurse is planning care for a pt who has dehydration and is receiving a continuous IV infusion of sodium chloride. which intervention should the nurse include in plan of care?
check pt IV infusion q8h nurse should monitor pt intake and urine output q2h; offer 60-120mL of fluids q1-2hr; furosemide is a loop diuretic that will increase dehydration
a nurse is caring for a client receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale of 0-10. which of the following actions should the nurse take first?
check the display on the PCA pump
nurse is preparing to insert a peripheral IV cath. which antiseptic is nurse's best choice for preparing the client's skin at insertion site
chlorhexidine
nurse is assessing four clients for fluid balance. nurse should identify which of the following pt is exhibiting manifestations of dehydration?
client has temp of 39 C (102 F) increased temp, high urine specific gravity, and elevated hematocrit are signs of dehydration. weight gain is fluid volume excess
nurse is assessing client prior to administering seasonal flu vaccine. pt says he read about flu being given as nasal spray and wants it. nurse should recognize which is a contraindication
client is 62 must be 2-49 to receive nasal spray
charge nurse is reviewing guidelines for initiating airborne precautions. which client should nurse ID as requiring airborne precautions?
client who has measles
a nurse is teaching a client who has a new prescription for prednisone to treat RA. the nurse should inform the client that which of the following is a therapeutic effect of this medication?
decreases inflammation
nurse is admitting pt who has pertussis. what precaution should nurse initiate
droplet
nurse is teaching pt who is beginning treatment for TB. the nurse should instruct client that which of the following herbs can interact with treatment
echinacea appears to be an immune system booster, but reduces the actions of medications used to treat TB milk thistle reduces effects of oral contraceptive; green tea helps treat cancers of stomach skin bladder and breast; st. john's wort can increase effects of antidepressants
nurse is caring for pt who has COPD. pt tells nurse "I can feel congestion in my lungs, and I certainly cough a lot but can't get anything up." what should nurse to do help with tenacious bronchial secretions
encourage pt to drink 2-3L of water daily
nurse caring for pt with pneumonia. which of the following actions should the nurse take to promote thinning of respiratory secretions
encourage to increase fluid intake increasing fluid promotes liquefaction and thinning of pulm. secretions which improves pt ability to cough and remove secretions IS use, coughing, and deep breathing promotes expectoration, not thinning; ambulation prevents accumulation of respiratory secretions
nurse has just finished wound irrigation for pt who requires contact precautions. which PPE should nurse remove first?
gloves
a nurse is wearing personal protective equipment and is preparing to leave a clients room after providing care. after untying ties, which of the following actions should the nurse take? put in order
gloves, eye wear, gown, mask
nurse is preparing to exit room of a client who has MRSA in a draining wound. ID the sequence the nurse should follow before leaving the client's room
gloves, eyewear, gown, mask nurse should remove the most contaminated item of PPE first then the least contaminated last, then perform hand hygiene
nurse is assessing client who has fluid overload. which findings should nurse expect?
increased HR, increased BP, increased RR (as well as crackles)
a nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." which of the following actions should the nurse take?
leave a nightlight on in the client's room night vision may be impaired in older adult clients and nightlight may help the client recognize the surroundings and the path will be illuminated and the client will be less likely to trip over objects in the room
nurse is preparing to obtain a blood specimen from a client by venipuncture. the client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. which sites should the nurse plan to use to obtain blood specimen
left forearm site is the antecubital fossa which allows for easy access and does not interfere with IV
nurse is assessing a client who has pulmonary TB. which findings should nurse expect
lethargy low-grade fever, weight loss, and a productive cough with purulent sputum streaked with blood are other indications
nurse is caring for a client who requires droplet precautions. which PPE should nurse wear when setting up pt food tray?
mask
older adult client who lives alone tells a clinic nurse he is unable to drive himself to the store and is afraid to cook on the stove. which of the following community resources should the nurse recommend for this client?
meals on wheels
nurse is caring for pt receiving TPN via peripherally inserted central catheter (PICC). when assessing pt, nurse notes swelling above PICC insertion site. which action should nurse take first
measure circumference of both upper arms once you measure, you can notify the provider to recommend removal of PICC line or initiating other treatment such as low-dose thromolytic therapy
nurse is inserting IV catheter for an older pt in prep for an outpatient procedure. which vein should nurse select
median vein in the forearm
nurse is assessing a pt who has IV therapy-related phlebitis. nurse uses the infusion nurses societ's phlebitis scale to assess the severity of phlebitis and documents pt phlebitis as grade level 1. which assessment finding correlates with grade level 1?
redness at IV access site with pain is level 1 level 3: red streaks, palpable venous cord level 4: purulent drainage at IV site
nurse is caring for client who has serum potassium level of 5.5. provider prescribes polystyrene sulfonate. if this med is effective, the nurse should expect which of the following changes on the client's ECG?
reduction of T-wave amplitude hyperkalemia causes peaked T waves and sometimes widened QRS on ECG; hyperkalemia does not generally affect P waves or the amplitude of the QRS complex
nurse is attempting to flush IV saline lock for pt. pt reports pain above cath site. which action should the nurse take?
remove IV saline lock evidence indicates the lock is not functioning properly
a nurse is caring for a client who has chemo induced peripheral neuropathy. the nurse should expect the client to report having experienced which of the following symptoms?
tingling feeling in the extremities
nurse is caring for a pt who had total thyroidectomy and serum calcium level of 7.6 mg/dL. which of the following findings should the nurse expect?
tingling of extremities SE of hypocalcemia is tingling and numbness of extremities and around the mouth, muscle tremors, cramps, and cardiac dysrhythmias
a nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. which of the following foods should the nurse instruct pt to avoid?
tomatoes, bananas, raisins are all high-potassium foods
a nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. the nurse does not complete an incident report because no harm came to the client. which of the following ethical principles did the nurse violate?
veracity veracity is the duty to tell the truth. the nurse violated this when choosing not to report the error instead of being truthful. (autonomy is accepting responsibility and meeting organizational expectations; beneficence is helping others to promote good; confidentiality is disclosing info to only those involved in client's care)
a nurse is assisting an older adult client who is sedentary plan a new exercise regimen. which of the following activities should the nurse recommend?
walking
a nurse is providing discharge teaching to a client who has SLE. which should the nurse include?
wash hair with a mild protein shampoo SLE pt are prone to hair loss; apply non-perfumed moisturizing lotions liberally to the skin; should not use powder or other drying skin products; should use sunscreen of at least 30spf
a nurse is talking with a client who is about to start using transcutaneous electrical nurse stimulation (TENS) to manage chronic pain. which of the following statements should the nurse identif as an indication that the client needs further teaching?
"its unfortunate that I have to be in the hospital for this treatment" TENS units are portable and can be used at home or wherever client chooses
a nurse is caring for a client who requests prescription pain medication. which of the following actions should the nurse perform first?
determine location of the pain
a nurse is reviewing the lab results of a client who has acute radiation syndrome and notes the client has leukopenia. which of the following assessment findings should the nurse ID as being consistent with leukocytosis?
fever
nurse is caring for a client who received dx of systemic scleroderma 5 years ago. the nurse plans to assess client to document disease's progression. in addition to skin changes, which of the following findings should the nurse expect?
finger contractures
nurse is caring for pt who suspects recent exposure to inhalation anthrax. which finding indicates possible exposure
flu-like symptoms
nurse is teaching clients about tick-borne illnesses. which should be included?
grasp as close to skin as possible
as part of an annual physical exam, nurse is preparing a client to undergo a chest x-ray. which of the following instructions should the nurse give the client prior to the procedure?
remove all metal necklaces metal objects block visualization
nurse is preparing pt for outpatient surgery. after nurse inserts IV cat, the client reports pain in the insertion area. which action should nurse take
remove cath and insert into a different site it is possible the cath is against a valve for near a nerve and causing more pain than an IV cath should
nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. which of the following interventions should the nurse take?
repeat auscultation after asking client to breathe deeply and cough it is premature to intervene based on a one-time finding. confirm finding before implementing
what acid-base imbalance is shown by these ABG values: pH: 7.30 PaCO2: 50
respiratory acidosis
a nurse is caring for a client who is post op following abdominal surgery and reports incisional pain. the surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. before administering the medication, the nurse should complete which priority assessment?
respiratory rate
nurse is planning discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BiPAP) at night. nuse should plan to consult with which of the following health care team members?
respiratory therapist
nurse is prepping pt for placement of cath for TPN. which access sites should nurse plan to prepare for cath instertion
right subclavian vein
nurse is admitting pt who has active TB to a room on med-surge unit. which room assignment should nurse make for client
room with air exhaust directly to outdoor environment eliminates contamination of other client-care areas. this type of ventilation is referred to as airborne infection isolation room
nurse is caring for a client with a tracheostomy. which intervention should nuse implement when performing trach care?
secure new trach ties before removing old ones
nurse is instructing pt newly Dx with TB about use of antitubercular meds. which info should nurse include in teaching?
typical course of treatment involves 6-9 months of consistent medication use
a charge nurse is teaching a group of health care workers about hand hygiene to prevent infection. which of the following information should the charge nurse include in the teaching?
use chlorhexidine to wash hands if client is immunosuppressed
a nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. which of the following actions should the nurse take first to resolve conflict?
identify the problem
nurse is planning care for a client who is post op following THA. which intervention should the nurse include in plan of care?
prevent hip flexion of the affected extremity
nurse is admitting a pt who is having an exacerbation of his asthma. when reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following meds?
propranolol meds that block beta-2 receptors are contraindicated in pt with asthma
nurse is teaching pt with asthma how to use albuterol inhaler. which action by client indicates understanding of teaching?
pt holds breath for 10 sec after inhaling med pt should take a slow, deep inhale for 3-5 sec while administering med; wait 20-30 secs between inhalations and 2-5 min between different meds
a public health nurse is assessing an older adult client who lives with a family member. the nurse identifies several bruises in various stages of healing. the client and family say they are results of clumsiness. however, based on the distribution, the nurse suspects abuse. which of the following actions should the nurse take first?
report findings to a supervisor
a public health nurse is assessing an older adult client who lives with a family member. the nurse identifies several bruises in various stages of healing. the client and family member explain that the bruises are a result of clumsiness. however, based on the distribution, nurse suspects abuse. what action?
report findings to supervisor
a nurse is caring for a female client who has rheumatoid arthritis and a new prescription for methotrexate. the client tells the nurse she is planning a pregnancy. which of the following instructions should the nurse give the client?
the medication should be discontinued 3 months prior to a planned pregnancy because of the risk of birth defects
nurse is teaching a client who has OA. which of the following instructions should nurse include in teaching?
"take acetaminophen as the primary medication to treat the pain"
nurse in ED is assessing older adult client who has community-acquired pneumonia. which should nurse expect
confusion due to hypoxemia dull sounds upon chest percussion and hypotension are expected findings for pneumonia pt; unequal pupils mean increased intracranial pressure
nurse is assessing for cyanosis in pt who has dark skin. which site should the nurse examine to identify cyanosis in this client?
conjunctivae to assess skin colour changes in clients with dark skin, nurse should check body areas with minimal pigmentation such as the conjunctivae, plantar surface (soles) of feet, palmar surface (palms) of hands, and mucous membranes
a nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). which of the following precautions should the nurse plan to initiate?
contact
when reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. which of the following actions should the nurse take?
contact the provider to question the dosage
client has right subclavian central venous cath. when reconnecting new admin set, which instruction should nurse give pt?
"bear down while holding breath" this prevents air from entering lumen, heart, and pulmonary circulation pt should be in trendelenburg position so catheter exit site is at/below level of heart; head should turn to left for better access
nurse is caring for a client who is 1 day post op following a total laryngectomy and has begun a soft diet. the client is not eating well and tells the nurse that hospital food has no taste. which of the following responses is appropriate?
"because of your surgery, you have an altered ability to smell and taste" laryngectomy pt breathe through tracheal stoma rather than mouth/nose which bypasses the location of the olfactory and gustatory nerve cells therefore decreasing taste and smell. a new set of food is unlikely to improve the situation, and closed-ended nontherapeutic responses do not help the patient
a nurse is caring for an older adult client whose provider will discharge him to an extended-care nursing facility the following morning. the client asks the nurse why he has to go to "that place." which of the following responses should the nurse make?
"did your doctor or anyone else talk to you about going to the nursing home?"
a nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. which of the following statements by the new nurse indicates understanding?
"documentation is a communication tool for the interprofessional health care team"
a nurse is providing teaching for a client who has a new diagnosis of fibromyalgia. which of the following client statements indicates the need for further teaching?
"fibromyalgia causes joint inflammation" fibromyalgia is a noninflammatory disorder
a charge nurse is supervising a newly licensed nurse provide care for a client who has a PCA pump. which of the following statements made by the nurse requires further action by the charge nurse?
"i discarded the remaining 2 mg of morphine from the PCA pump. please document you witnessed it" two nurses are required to witness the wasting of a narcotic
nurse is teaching a newly licensed nurse about methods to reduce costs of client care. which of the following statements indicates understanding?
"i should encourage clients to receive an annual flu immunization"
a nurse is caring for a client who is dying. the client says "my mother died in the hospital, but i did not get there before she died." which of the following statements should the nurse make?
"i wonder if you are fearful of dying alone"
nurse is caring for pt who is taking naproxen following an exacerbation of RA. which statement by client requires further discussion by nurse?
"i've been taking an antacid to help with indigestion" NSAIDS like naproxen can cause serious adverse GI reactions and if pt feels the need to take antacid it my indicate adverse effects of naproxen
nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. which statement indicates an understanding of the teaching?
"if i could lose 50 lbs, i might stop having so many apneic episodes" laying flat on back increases apnea and sleeping pills (hypnotics) aggravate it and can also cause increased daytime somnolence
nurse is reviewing prescriptions for a pt who had a THA. which of the following prescriptions should nurse verify with provider?
"instruct client to restrict flexion of the hip past 120" client should restrict flexion of hip past 90 to avoid dislocation
an older adult client is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a "do not resuscitate" (DNR) case. which of the following responses should the nurse provide?
"your provider needs to talk with you concerning your request" the provider is responsible for consulting with the client and writing a DNR order
nurse is assessing a client prior to administering a seasonal influenza vaccine. pt says he read about nasal spray and wants to receive it. nurse should recognize that which of the following findings is a contraindication for receiving the live attenuated influenza vaccine (LAIV)?
client's age is 62 must be between 2-49 to receive LAIV, must not be pregnant or immunocompromised either
a nurse is giving change-of-shift report using SBAR to the oncoming nurse of a client who has a traumatic brain injury. which of the following information should the nurse include in the background segment of SBAR?
code status (glasgow results and intracranial pressure readings are under the assessment segment; plan of care is under the recommendation segment)
a nurse is providing teaching to a client who take opioid pain medication and has a new prescription for docusate sodium. which of the following statements by the client indicates an understanding of the teaching?
"it might take up to 3 days for the medication to work" docusate sodium is a stool softener and the therapeutic effect may take up to 3 days
a nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. as the nurse accepts the flowers, the messenger says "I know mrs. welch from the neighborhood. what happened to her?" what does the nurse say
"its my responsibility to remind you that we have the respect our clients' privacy"
nurse is assessing pt who is to undergo a left lobectomy to treat lung cancer. pt tells nurse she is scared and wishes she had never smoked. what should nurse say
"its ok to feel scared. let's talk about what you are afraid of"
a home health care nurse is visiting an older adult client who tells the nurse she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. shopping and performing personal errands for the client is prohibited in the nurse's job description. which of the following is an appropriate response?
"lets look at some other resources to solve this problem"
a nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. the client tells the nurse she wants to try nontraditional treatments first. which of the following responses should the nurse make?
"tell me more about your concerns about taking chemotherapy"
a nurse is planning to use the SBAR communication tool when calling a provider. which of the following statements should the nurse include in the B step?
"the client was found unconscious on the floor in her home"
nurse is providing discharge teaching about nutrition to parents of child who has cystic fibrosis (CF). which response by parents indicates an understanding of the teaching
"we will give our child pancreatic enzymes with snacks and meals" CF messes with digestion and absorption of nutrients so digestive enzymes must be taken a diet high in calories and protein with unrestricted fats and salt is typically recommended to meet the nutritional needs of the child who has CF; fluids should not be restricted either
nurse is caring for a client who has RA and tells the nurse she wears a copper bracelet to help her feel better. which response is appropriate?
"yes, I understand that you feel better wearing your bracelet" nurse demonstrates knowledge that the bracelet is harmless for the client and shows respect for the client's beliefs
a nurse is monitoring an older adult client immediately following a bronchoscopy. the nurse's priority is to monitor the client for which of the following?
confirming the gag reflex when using ABC priority, nurse should first assess the gag reflex to ensure pt has an open airway
nurse in a provider's office is assessing an older adult pt whose son reports pt has been sick w respiratory illness for the past 5 days. which of the following assessment findings is a manifestation of pneumonia in older adult cilent
confusion confused, weakness, tachycardia and anorexia are manifestations of pneumonia in older adults. narrowed pulse pressure is hypovolemic shock, night sweats mean TB
a nurse in the ER is caring for a pt who collapsed after playing football on a hot day. after reviewing the admission labs, the nurse recognizes the findings are consistent with which of the following conditions? NA: 152 glucose: 102 potassium: 3.6 chloride: 105 BUN: 18 creatinine: 0.7
dehydration (as indicated by the increase in Na) createinine and BUN are within normal range, which does not indicate renal failure; syndrome of inappropriate antidiuretic hormone (SIADH) is associated with hyponatremia)
nurse is caring for pt receiving oxygen therapy via nasal cannula. nurse explains to the client that this method does which of the following?
delivers a low concentration of oxygen venturi mask delivers specific O2 concentrations; nonrebreather masks deliver high concentrations; face masks restrict pt ability to eat, speak or drink
a nurse manager is preparing to confront a staff nurse who is abusing alcohol. which of the following defense mechanisms should the nurse manager expect the staff nurse to use
denial this is a common defense mechanism used by people who are dealing with substance abuse
a nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. the client is to begin outpatient radiation therapy the next day. which of the following instructions about maintaining skin integrity should the nurse include?
do not apply heat to the area of irridiation radiated tissue becomes thinner and might lack tissue receptors that would otherwise alert the client to a potential burn injury; client should avoid both wet and dry heat
nurse is teaching a client who will undergo a bronchoscopy procedure. the provider will use a rigid scope and general anesthesia. nurse should explain the client's neck will be in which position?
hyperextended position this aligns the pharynx and trachea to allow insertion of the scope far enough to adequately view airway structures to obtain tissue samples. if neck position is only extended, the provider could only insert the scope as far as the secondary bronchi
a nurse is assessing a client in labor who has had epidural anesthesia for pain relief. which of the following findings should the nurse identify as a complication from the epidural block?
hypotension maternal hypotension is an adverse effect of epidural anesthesia. the nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication
nurse is providing teaching to a group of adult athletes about preventing dehydration. what manifestations should the nurse include in the teaching?
impaired motor control rise in body temp, loss of appetite, and increased heart rate occurs with dehydration
nurse of med-surge unit is performing an admission assessment of a client who has COPD with emphysema. pt reports he has frequent productive cough and is SOB. the nurse should anticipate which assessment finding
increased anteroposterior diameter of chest because of chronic hyperinflation of lungs pt will have respiratory acidosis because of increased arterial CO2 and decreased O2 levels; petechiae on chest/abdomen is seen on pt who has pulmonary embolism
nurse is caring for pt who has emphysema and has difficulty with mobility. pt receives home health care and spends most of day in a reclining chair. which physiological response to prolonged immobility should the nurse expect
increased calcium excretion prolonged immobility leads to breakdown of bone tissue. results in increased calcium excretion. prolonged immobility also leads to reduction of metabolic rate, increased risk for thrombus formation, and other electrolyte imbalances
nurse in ED is preparing to administer theophylline by continuous IV infusion to a client who is experiencing an asthma attack. which action should nurse take?
infuse medication with an IV pump rapid administration may cause hypotension and death. no faster than 25 mg/min
nurse is teaching pt who has asthma how to use a metered-dose inhaler (MDI). nurse identifies the sequence of steps the client should follow which are:
inhale deeply then exhale completely, place lips firmly around mouthpiece, breathe in deeply over 2-3 seconds while pushing down on canister, hold breath for 10 sec, exhale slowly through pursed lips, wait 60 sec between each puff
nurse is collaborating on care for pt who has COPD. which task should the nurse recommend be referred to an occupational therapist for assistance?
instructing how to use kitchen tools to prepare a meal
nurse is preparing to apply wrist restraints to a client to prevent her from pulling out an IV catheter. which action should nurse take first
keep padded portion of restraints against the wrists to protect the skin from breakdown and abraison must have 2 fingers of room; must be attached to movable part of bed; knot must be able to be quickly released in an emergency
a nurse is planning care for a client who has immunosuppression following chemotherapy. which of the following interventions should the nurse include in the plan of care?
limit the number of health care workers entering the room to prevent possible overexposure to microorganisms that can lead to infection
a nurse is teaching a class of older adults about the expected physiologic changes of aging. which of the following changes should the nurse include in the discussion?
more difficulty seeing due to a greater sensitivity to glare, decreased cough reflex, decreased bladder capacity, dehydration of intervertebral discs older adults have increased systolic BP
a nurse manager is presenting to a group of unit nurses the categories regulated under the controlled substances act. which of the following medication prescriptions should the nurse include under schedule II?
morphine requires the provider to complete a written prescription with a signature
a nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. which of the following actions should the nurse take to address the client's safety needs?
move client to a room closer to the nurse's station
nurse assessing a client who has Na level of 116. which finding should the nurse expect?
nausea and vomiting pt has hyponatremia. SE of this is nausea and vomiting. extreme thirst, flushed skin, and fever are SE for hypernatremia
a charge nurse has access to the facility's electronic client records. it is appropriate for the charge nurse to share her personal password with whom?
no one
a nurse is caring for a client who has C. diff infection. which of the following cleansing agents should the nurse use for hand hygiene?
nonantimicrobial soap CDC recommends this type of soap be used
a nurse is caring for a client who is participating in a research study for an experimental chemo med. after three treatments, the experimental med is discontinued due to evidence of rapid kidney failure. the nurse should understand discontinuing this med demonstrates which ethical principle?
nonmaleficence
a nurse is caring for a client who is dying of metastatic breast cancer. she has a prescription for an opioid pain medication PRN. the nurse is concerned that administering a dose of pain medication might hasten the client's death. which of the following ethical principles should the nurse use to support the decision not to administer the medication?
nonmaleficence the duty to do no harm (utilitarianism refers to actions that are right when they contribute to the greatest good; fidelity is the duty to keep one's promise)
a nurse is providing care for a surgeon on a medical-surgical unit. a nurse from another unit asks the nurse about the surgeon's medical diagnosis. the nurse responds that he is unable to provide the info requested. the nurse is displaying which of the following ethical principles
nonmaleficence (wtf) the nurse is obligated to protect the client's confidential information (aka... confidentiality???????). a breach of confidentiality can place the client at risk for harm, nonmaleficence is the ethical duty to prevents harm to the client
a nurse is discussing culturally competent care at a nursing staff inservice. which of the following information should the nurse include when discussing clients' cultures?
nurses should focus on the clients' cultures, rather than their ethnicity, when providing care.
a nurse is caring for a client who is receiving radiation therapy to treat lung cancer. which of the following actions should the nurse take?
observe for signs of infection radiation therapy to sites containing bone marrow (such as the sternum) can lower the WBC count thus increasing a risk for infection
a nurse on a med-surge unit is planning to delegate tasks to an adult volunteer. which of the following tasks should the charge nurse avoid assigning the volunteer?
observing a post-op client who is confused
a nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. which of the following actions should the nurse take?
obtain a sputum culture to determine which antibiotic is needed cough and deep breathing should be implemented every 2-4h; HOB should be 30-45 degrees; fluid intake should be around 3000mL/day to loosen sputum
a nurse is caring for a client who has RA and is experiencing difficulty feeding herself using adaptive devices. the nurse should initiate a referral with which of the following members of the interprofessional health care team?
occupational therapist OTs assist clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding
nurse is selecting staff member to double check blood label with client ID bracelet prior to infusing a unit of blood. nurse should identify that which of the following persons is qualified
oncology nurse another nurse or provider must double check the blood label and client ID prior to an infusion
nurse is assessing pt who has asthma. which ares should nurse evaluate as most reliable indicator of central cyanosis
oral mucosa
nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. which action should the nurse take
perform Heimlich maneuver
a nurse is caring for a client who has an infection. the nurse should use which of the following strategies to prevent the transmission of the client's infection?
performing hand hygiene before, during, and after direct contact with the client
a nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. it is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care?
performing hand hygiene frequently and consistently
nurse is caring for a pt who has central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. nurse suspects air embolism and clamps cath immediately. what other action should nurse take
place client of left side in trendelenburg position position helps trap air in apex of right atrium rather than allowing it to enter the right ventricle and move to pulmonary arterial system chest tube insertion is for pneumothorax; remove catheter for rupture; replace infusion system for central line-related sepsis
nurse is caring for pt who is confused and has pulled out her peripheral IV cath 3 times. which should the nurse do?
place mitten resstraints on the client's hands must obtain a prescription; moving the client closer to nurse station will not improve the client's confusion nor keep her from pulling out IV; administering sedative can increase confusion
a nurse is assessing a client who has systemic lupus erythematosus (SLE). which of the following findings is the highest priority for the nurse to report to the provider?
presence of peripheral edema SLE pts are at greatest risk for death from lupus nephritis so indications of impairment of renal function are the highest priority
a nurse is teaching a client who has RA about self-care strategies for managing the disease. which of the following activities should the nurse include in the teaching?
press water from a sponge rather than wringing it fine motor activities should be modified by using larger joints or body surfaces to substitute for smaller ones; client should turn doorknobs using a counterclockwise motion to avoid twisting the arm which promotes ulnar deviation; rushing to finish tasks may exhaust client and place excess stress on the joints over a brief period of time; repetitive ROM exercises can help with joint mobility, but repetitions should be reduced when inflammation is present
nurse is caring for pt who experienced an infection at insertion site of her IV catheter. which finding should nurse expect
purulent drainage is noted from site numbness at IV insertion site means nerve damage; cord-like, hard vein means phlebitis; sloughing comes means infiltration of some meds (antineoplastics)
a nurse is receiving a provider's prescription for a client via telephone. which of the following actions should the nurse take to ensure the accuracy of the telephone prescription?
repeat the order back to the provider, question any part of the order that is unclear or inappropriate, transcribe the order into the client's health record. (the usual rule for obtaining a signature is within 24 hrs; never leave a message)
a nurse is developing a plan of care for a client who practices Islam. which of the following actions should the nurse include in the plan?
request a tray without pork
client is admitted to ED with resp rate of 7/min. ABG reveals these values. which is an appropriate analysis of ABGs? pH: 7.22 PaCO2: 68 base excess: -2 PaO2: 78 saturation: 80% bicarb (HCO3): 26
respiratory acidosis
nurse is caring for client who is post op and resp are shallow and 9/min. which of the following acid-base imbalances should the nurse id the client as being at risk for developing initially?
respiratory acidosis
nurse is reviewing the AGB values for a pt. pH is 7.32, PaCO2 is 48, and HCO3 is 23. which acid base imbalance is indicated?
respiratory acidosis
a newly licensed nurse is applying prescribed write restraints on a client. which of the following actions should the nurse take?
secure the restraints using a quick-release tie
a nurse is performing a pain assessment for a client who is alert. the nurses should recognize that which of the following measures is the most reliable indicator of pain?
self-report of pain
a nurse is reviewing lab values for a patient who has SLE. which of the following values should give the nurse the best indication of the client's renal function?
serum creatinine a renal function disorder reduces the excretion of creatinine, resulting in increased levels of blood creatinine. it is a specific and sensitive indicator of renal function
a nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemo. which of the following actions should the nurse take?
serve cooked fruit with meals to prevent possible bacterial contamination from raw fruit
nurse assessing pt taking chlorothiazide sodium. nurse recognizes which of the following as a manifestation of hypokalemia?
shallow respirations (weakness in accessory muscles of breathing) slow tendon responses, constipation, fatigue, and dysrhythmias are also manifestations of hypokalemia
nurse is assessing pt receiving one unit of packed RBCs to treat intraoperative blood loss. pt reports chills and back pain, client BP is 80/64. which action should nurse take first
stop infusion
nurse is caring for pt and identifies an infiltration at IV cath site. wht is the order the nurse should perform following actions
stop infusion, remove IV catheter, apply sterile dressing, elevate extremity, apply warm/cold compresses
nurse is performing trach care for a pt and suctioning to remove copious secretions. which action should nurse take?
suction two to three times with a 60-second pause between passes
a staff nurse has applied for a promotion. the hiring manager insinuates that if there was a sexual relationship between the two of them, the nurse's promotion request would get increased consideration. which of the following actions should the staff nurse take first?
tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately
a nurse is reviewing the goals of the nurse-client therapeutic relationship with a client who is seeking counseling. which of the following information should the nurse include in this discussion?
the client achieves optimal personal growth
a hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. the client reports that he had to increase the dose of morphine this week to obtain pain relief. which of the following scenarios should the nurse document as the explanation for this situation?
the client has developed a tolerance to the medication
a nurse at a providers office is teaching to a client who is taking chemo and losing weight. which of the following should the nurse recommmend to increase calorie/protein intake?
top fruits with yogurt, add cream to soup, use milk instead of water in recipes, and dip meats in eggs and bread crumbs before cooking.
nurse is caring for a client who is receiving IV fluids to correct dehydration. which of the following lab values should indicate the client is effectively responding to treatment?
urine specific gravity 1.020 this is within the expected range (1.005-1.030)
nurse is providing discharge teaching to a pt who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. which indicates a client understanding?
"I will take albuterol before taking cromolyn" bronchodilator must always be used prior to the leukotriene modifier so the airways may be opened ensuring the max dose of med will get to client's lungs albuterol is used for acute broncospasms (short-acting), cromolyn used for asthma treatment (long acting); should administer these meds before exercising; should inhale different meds 2-5 min apart
a nurse is completing discharge instructions with a client following an acute onset of gout. which of the following client statements indicates an understanding of the treatment regimen?
"I will limit my alcohol intake' pt with gout should avoid excess uric acid which can be found in foods high in purines such as organ meats and shellfish; fluid intake of a minimum 2,500 mL/day is recommended to minimize uric acid stones; aspirin and other salicylates can inactivate drugs used to treat gout, interfere with uric acid excretion, and may precipitate acute onset
nurse is teaching a pt who has COPD about ways to facilitate eating. which indicates further need for teaching
"I will take my bronchodilators after meals" bronchodilators must be taken before meals; resting before meals for 30 min decreases fatigue; eating small frequent meals decreases SOB; foods that are not gas-forming are ideal
a nurse is caring for a client who has fallen while getting out of bed and states "I'm okay! I guess I should have called for help to the bathroom." after assessing the client, the nurse notifies the provider. which of the following documentation should the nurse include in client's medical record?
"the provider was notified" the nurse should document factual information, including objective and subjective data ("the patient was not injured" is a supposition)
a nurse is in a clinic talking with a pt who has a new diagnosis of OA. nurse should anticipate the client will require teaching about which of the following meds?
acetaminophen DOC for OA
nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. nurse auscultates decreased breath sounds in the lower lobes of both lungs. nurse should realize this is most likely an indication of which of the following conditions?
atelectasis atelectasis is the collapse of part or all of a lung by blockage of air passage. prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis although pulmonary edema and delayed gastric emptying can cause decreased breath sounds, they are not the most likely cause in this patient; although the spleen plays a role in bacterial immunity, the nurse would be more concerned about the risk of an upper respiratory infection in a client who has undergone a splenectomy (removal of spleen)
nurse is assessing pt who has COPD. nurse should expect the pt chest to be which shape
barrel
nurse is caring for pt scheduled to receive external radiation to the neck for cancer of the larynx. during pre-treatment exam, the nurse explains to the client that the most likely SE would be
dysphagia radiation therapy doesn't hurt when its given, but may cause pain of discomfort later. only the area of treatment is affected. trouble swallowing, hoarsness, xerostomia (dry mouth), loss of taste, and skin redness are expected
a nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. which of the following client statements indicates an understanding of the teaching
"I can use either heat or ice to help relieve the discomfort" medication of choice for OA is acetaminophen (tylenol), not NSAIDS like ibuprofen; exercise should be encouraged as it has been shown to slow progression of OA; pillows should not be used under the knees in OA pt as it contributes to the development of flexion contractures
a nurse is teaching a client how to follow a low-purine diet as prescribed by the provider for the management of gout. which of the following statements indicates the client understands the teaching?
"I should avoid eating liver and other organ meats" fruit servings should be part of a healthy diet, alcohol intake should be avoided, and red meat intake should be limited for patients with gout
nurse caring for client with advanced lung cancer. pt provider has recommended hospice services. which statement by client indicates understanding of hospice care
"I should expect hospice team to help me manage my dyspnea" hospice care is in any setting; must be 6mo to live or less to be eligible; does not provide treatment, only comfort
nurse is teaching pt who has emphysema about self-management strategies. which of the following statements from pt indicates understanding
"I will follow a daily diet high in calories and protein" these pt have a greater than usual nutritional requirements for calories and protein and often need nutritional supplements between meals pt should lay on back to practice diaphragmatic breathing; pt must get flu shot and avoid crowds; when pursed lip breathing inhale slowly through nose and exhale slowly through pursed lips
nurse is teaching client who is about to undergo the insertion of a nontunneled central venous access device. which statement should nurse id as indication the pt undersatnds instructions
"I will turn my head in the opposite direction during insertion" bed rest is not a requirement for central cath insertion, but it is for cardiac cath insertion; Valsalva maneuver should be performed to prevent air embolus; persistent hiccups is a complication of pacemaker insertion, not central cath insertion
a nurse is providing discharge therapy for a client who requires home oxygen therapy. which statement should the nurse identify as an indication that the client needs further teaching?
"I will wear synthetic clothing and woolen socks when using my oxygen" woolen and synthetic materials can generate static electricity and oxygen is a flammable gas. pt should wear cotton clothing and use cotton bedding and blankets
a nurse observes that a client who has depression is sitting alone in the room crying. as the nurse approaches, the client states "i'm feeling really down and don't want to talk to anyone right now." which of the following responses should the nurse make?
"I'll just sit here with you for a few minutes then" this is a therapeutic response by offering self, demonstrating care and concern and showing the client that the nurse is available if the client wants to talk
a nurse is caring for a group of older adult clients. which of the following manifestations indicates one of the clients is experiencing delirium?
a client attempts to climb out of bed and repeatedly states she must get home asking time of day may be an indication of dementia as pts lose the ability to recognize familiar object, read, and write; older adults have trouble regulating body temp; lethargy and lack of motivation are manifestations of depression
a nurse is caring for several clients. which of the following situations should the nurse complete an incident report?
a client discovers that his dentures are missing. this situation is a variation from the normal standard of care and a change in the client's plan of care may be necessary. additionally, the facility may be liable for replacing the missing dentures
a clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). which of the following finding should the nurse expect?
a dry red rash across the bridge of the nose and on the cheeks also called a "butterfly" rash
a nurse manager received a client request to not have a specific staff care for her while at the acute care facility. which of the following is the appropriate action by the nurse manager?
address the concern with the specific staff nurse
nurse is preparing to suction a client who has a tracheostomy. what is the sequence of actions the nurse should take?
adjust suction, don sterile gloves, check function of suction cath, hyperoxygenate, insert suction cath without suction, apply suction (for no more than 10 seconds) while rotating cath, then assess for clearance of secretions
nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. which action should nurse take first?
administer abdominal thrust maneuver
nurse planning care for child with cystic fibrosis and prescrip. to receive chest physiotherapy (CPT). what should nurse do
administer albuterol prior to CPT improves airways clearance vibration is performed during expirations; never do CPT after eating; percussion is for conditions that cause atelectasis or increased sputum
nurse is caring for a female client in ED who reports SOB and pain in lung area. pt started taking BC pills 3 wks ago and she smokes. HR is 110/min, RR is 40/min, BP is 140/80. ABGs are pH 7.50, PaCO2 29, PaO2 60, HCO3 20, and SaO2 86%. which is the priority nursing intervention?
administer oxygen via face mask
a nurse is teaching a client about risk factors for osteoarthritis. which of the following should the nurse include in the teaching?
aging, obesity, smoking bacterial infections lead to infectious arthritis; diuretics is a risk factor for gout not OA
nurse caring for pt who is in the immediate post op period following a partial laryngectomy. which of the following parameters should nurse assess first?
airway patency
a nurse is caring for a pt with gout. which med to administer?
allopurinol is a xanthene inhibitor that reduces uric acid synthesis
nurse is caring for a pt who has HTN and develops epistaxis. which of the following actions should the nurse take?
apply pressure to nares, place ice on bridge of client's nose, move client into high-fowler's position
nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. nurse should begin the infusion at which of the following times
as soon as the nurse can prepare the pt and administration set procedure should be completed within 4 housr
a nurse on a medical-surge unit is preparing to contact a provider about a clients condition. the client is 6 hr post-op from a total hysterectomy. the nurse notes the client's postop oxygen saturation is 94 and her apical HR is 110. the nurse should include info about the clients O2 sat level and HR in which component of SBAR?
assessment
a clinical nurse educator is preparing an educational program about transmission of MRSA in hospitalized clients. which should be included?
bathe clients with water and chlorhexidine gluconate MRSA can live on hands for more than 3 hrs; pt should be placed on contact precautions; antiviral med is not appropriate Rx
nurse is caring for pt who has active TB and is to be started on IV rifampin Rx. nurse should instruct the pt of what adverse effects that can happen with this med?
body secretions turning a red-orange colour also causes diarrhea and nausea teeth stained from taking liquid iron preps; black stools from iron supplements
a nurse notices an AP preparing a food tray to client who practices orthodox Jewish faith. on the tray is a roast beef dinner with nonfat milk. which of the following actions should the nurse take?
call the dietary department and ask for a kosher tray
nurse caring for pt who has lung cancer and is scheduled for lobectomy. nurse should prepare pt to expect what after the procedure
chest tube pt will have a chest tube for air and fluid drainage and severe chest pain. will require a posterolateral or anterolateral chest incision. pulmonary function studies will be performed before lobectomy
nurse caring for pt with exposure to inhalational anthrax due to bioterrorism. which meds should nurse expect as common Rx?
ciprofloxacin, doxycycline, and amoxicillin
nurse is caring for pt who has central venous catheter and develops acute SOB. which action should nurse take first?
clamp catheter
nurse is preparing to insert IV cath for pt and has selected insertion site. place the steps in which nurse should perform them
cleanse with antiseptic swab, apply tourniquet/BP cuff, dilate vein, insert catheter, release tourniquet, flush catheter, secure it
nurse is reviewing med record of pt who has K level of 3.0. which should the nurse recognize as a potential causative factor?
client has an NG tube NG tube to gastric suction can put pt at risk for developing hypokalemia due to the GI loss of potassium; spironolactone is a potassium-sparing diuretic and can cause hyperkalemia; alcohol abuse disorder puts pt at risk for hypomagnesaemia; drinking 3.5-4 L of water each day can cause hyponatremia
nurse is caring for four hospitalized clients. which should the nurse identify as being at risk for fluid volume deficit?
client who has gastroentirits and is febrile (showing s&s of fever) gastroenteritis is characterized by diarrhea and possible vomiting which can cause significant fluid loss. fever can lose fluid via diaphoresis and raises metabolic rate. renal failure and heart failure cause fluid excess
nurse is caring for client who has an infection and a prescription for gentamicin intermittent IV bolus q8h. a peak and trough is required with next dose. which action should the nurse take to obtain an accurate gentamicin serum level?
draw trough level immediately prior to administering the medication and a peak level 30 min after the dose trough level is the lowest serum level after med effects have taken place, peak is the highest serum level of the med. correct timing for trough is just before administration and correct timing for peak is 30-60 min after the dose has finished infusing
a nurse working for a home health agency is assessing an older adult male client. which of the following findings is the priority for the nurse to address?
dysphagia
nurse is caring for pt who has emphysema. which of the following findings should nurse expect to assess in this pt?
dyspnea, barrel chest, and clubbing of fingers heart rate will increase and respirations will be shallow
a nurse is preparing to measure a pt oxygen saturation level and observes edema of both hands and thickened toe nails. the nurse should apply the pulse oximeter to which location?
earlobe
a nurse is caring for a client who is postop following hip arthroplasty. the nurse should anticipate which of the following prescriptions for this client?
enoxaparin as prophylaxis therapy for venous thromboembolism (pt with a THA are usually on anticoagulants for 3-6wks after sx)
a nurse is assessing a client for early manifestations of RA. which of the following changes is an early manifestation of RA?
fatigue morning stiffness, temporomendibular joint pain, and baker's cysts are late manifestations of RA
a nurse is teaching a client about the physical effects of chemotherapy. following the teaching, the nurse asks the client to describe one physical effect. the nurse is focusing on which of the following elements of the communication process?
feedback this indicates whether the client understands the message (a channel is the means of conveying/receiving messages through senses; environment is the setting between nurse and client; message is the content)
a nurse is planning care for a client who is being treated with chemo and radiation for metastatic breast cancer, and who has neutropenia. the nurse should include which of the following restrictions in the client's plan of care?
fresh flowers and potted plants micro-organisms are likely to be present on plants which can then get to the client
a nurse in a public clinic is planning a health fair for older adult clients in the community. in teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?
grapefruit juice grapefruit juice has a high rate of food-drug interactions, especially lipid-lowering agents
a nurse is preparing to administer morphine 4 mg IV bolus to a client who reports pain. available is morphine 10 mg/mL. which of the following actions should the nurse take?
have another nurse witness the disposal of the extra medication
nurse is caring for pt with single lumen central venous cath. which action should the nurse take when accessing the catheter
use 10mL syringe to flush catheter ...because the pressure that is exerted by smaller barrel syringes increases the risk for rupture caths should be flushed with sterile normal saline (not water); sterile technique is used when accessing central venous cath; slow, gentle pressure must be applied to syringe plunger so if there is resistance, you can stop procedure immediately to prevent damage to cath/dislodge clots
nurse is developing a POC for a pt who has COPD. Nurse should include which of the following interventions?
use pursed-lip breathing this type of breathing lengthens expiratory phase of respiration and increases pressure in the airway during exhalation. reduces airway resistance and decreases trapped air. COPD pt have poor exercise tolerance in early morning due to pulmonary secretions that build up at night; should have high calorie high protein diet to prevent weight loss; should drink 2-3 L of water/day unless otherwise indicated
a home health nurse is conducting a home safety assessment for an older adult client. which of the following are safety risks?
water heater temp 130F, throw rugs
nurse is planning care for a pt who requires airborne precautions. which actions should nurse take?
wear N95 respirator mask or high-efficiency particulate air (HEPA) filter mask
a nurse is providing teaching to a client who has a new prescription for hydroxychloroquine to treat mild manifestations of RA. which of the following info should the nurse include in the teaching?
wear sunglasses when out in the bright sunshine this medication can cause retinopathy should be taken with food or milk; can cause blue-black discolouration of skin and urine a rust/brown colour; can be crushed and mixed with foods/fluids
nurse is auscultating breath sounds of pt who has asthma. when client exhales, nurse hears continuous high-pitched squeaking sounds. the nurse should document this as which of the following adventitious breath sounds
wheezes crackles sound like rolling hair between fingers behind ear; rhonchi are continuous rumbling, snoring, or rattling sounds from fluid or mucous; stridor is a continuous, shrill musical sound of constant pitch (and very bad!)
nurse in PACU is admitting a pt who is post op following a tonsillectomy. which of the following actions should the nurse plan to take to prevent aspiration?
withhold fluids until the client demonstrates a gag reflex to prevent aspiration, gag reflex must be present before the client is allowed to have fluids. suctioning nasopharynx can cause trauma to denuded tonsil sockets leading to hemorrhage.
