Boo

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

Change GCS score from 13 to 11

A 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 the client to breathe deeply and cough

A nurse is teaching self management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?

Rest frequently throughout the day

A nurse is caring for a client who has a traumatic brain injury. Which of the following should the nurse identify as an indication of increased intracranial pressure (ICP)?

Restlessness

Which statement by a patient who had a cystoscopy the previous day should be reported immediately to the health care provider?

Temperature 101.2

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

The client states having a severe headache

A nurse is assessing a client who has a wrist restraint applied. For which of the following should the nurse loosen the restraints?

The clients radial pulse is weak

A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?

The nurse separates the clients labia with her dominant hand

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?

Troponin I

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the clients right nostril. Which of the following actions should the nurse take first?

Visual assessment for the halo sign

A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate?

What do you think your spouse would have wanted?

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

ask the clients full name and DOB

A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

azotemia

A nurse is caring for a client who has hypernatremia and required IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

0.45% Sodium Chloride

An IV with nitroglycerin is infusing at 8 mL/hr. The concentration of the IV is 50 mg in 250 mL of D5W. How many mg/hr is the patient receiving?

1.6

The doctor orders Zosyn 2.25 mg IVPB q8h. The pharmacy sends up Zosyn 2.25 mg premixed in 50 mL of D5W to infuse over 30 minutes. Which of the following should the nurse set the pump at mL/hr?

100

A provider prescribes esmolol 45 mcg/kg/min by continuous IV infusion for a patient who weighs 39 kg. Available is esmolol 2500 mg in 250 mL dextrose 5% of water (D5W). The nurse should set the IV pump to deliver how many mL/hr?

105.3

The physician reduces an IV to 30 mL/hr. The total volume to be infused indicates 270 mL are remaining in the present IV bag. THe nurse notices that it is exactly 1030. At what time will the infusion be complete?

1930

The nurse is caring for a patient admitted yesterday for an ischemic stroke. The nurse is to begin a Heparin infusion at 1,000 units per hour and titrate per hospital protocol. Available is Heparin 25,000 units in 500 mL D5W. At what rate (mL/hr) will the nurse begin this infusion to run the ordered dose?

20

A nurse is monitoring the urinary output of an adult client who had a colon resection. Which of the following 24 hr output total's most likely indicates oliguria?

300

A client who has type 1 diabetes mellitus is to have IV fluid that contains 51 units of Regular insulin (Humulin ..) in 1,000 mL to infuse at 2 units/hr. The nurse should set the IV pump to deliver how many mL/hr? (round to the nearest whole number)

39

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client total body surface area (TBSA)?

54

A nurse is preparing to administer moxifloxacin 400 mg by intermittent IV bolus over 60 min. Available is moxifloxacin 400mg in 250 ml dextrose 5% (D5W). The drip factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

63

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

Assess for signs of infection

A nurse is teaching a client who has a new prescription for NPH insulin. Which of the following instructions should the nurse include?

Abdomen allows for best absorption

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

Acetone breath odor (fruity breath odor)

A nurse in the emergency department is preparing to care for a client who received multiple injuries during a fight. The nurse should plan to base his primary focus on which of the following? (SATA)

Airway Disability Exposure

A nurse is the triage office in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

An unconscious adult who has a sucking chest wound, respirations of 38, and a capillary refill of < 2 seconds

A nurse in the emergency department is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following should the nurse initiate

Assess Cranial Nerves

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

DIC is caused by abnormal coagulation involving fibrinogen

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Dehydration

A nurse in a dialysis center is caring for a client who has a new-diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following Kubler Ross stages of grieving?

Denial

A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following?

Dysrthythmias

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia. The nurse should indicate the need for taking which of the following actions?

Electro cardioversion

A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care?

Elevate the affected legs

A nurse is assessing a client who is in skeletal traction. Which of the following should the nurse identify as an indication of infection at the pin sites?

Fever

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (SATA)

Headache Slurred Speech Pupillary Changes Disorientation

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingual for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?

Headache is an adverse effect of the medication

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Heparin

The student nurse is reviewing the signs of kidney transplant rejection and realizes which of the following is not a sign of rejection?

Hypotension

A nurse is teaching about self monitoring to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

I will check my blood sugar every 4 hours when I am sick

A nurse is providing a discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?

I'll use my electric razor for shaving

A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse?

ICP 18

A nurse is providing discharge teaching for a client who has chronic pancreatitis. which of the following statements should the nurse make?

Increase protein in the diet

A nurse is teaching an older adult client who has diabetes mellitus about preventing long term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

Maintain stable blood glucose levels

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

Mannitol 25%

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

Massaging her legs

A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan?

Monitor hemoglobin and hematocrit

A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer?

Observing a postoperative client who is confused.

A nurse is teaching a client about causes of biliary cirrhosis. Which of the following information should the nurse include in the teaching?

Obstruction of biliary duct

A hospice nurse is reviewing the prescriptions for a client who is receiving hospice care. Which of the following prescriptions should the nurse reject? SATA

Obtain Vitals every 2 hours Perform diagnostic testing

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Oliguria

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?

PaCO2 50

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

Pacemaker spikes before each QRS complex

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member request that the nurse apply restraints. Which of the following responses should the nurse make?

cover the catheter

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy . The client's spouse asks the nurse what happens during the procedure. Which of the following nursing statements is appropriate?

cut open eschar to keep circulation

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

decrease fluid intake

A nurse is assessing a client in shock. Which of the following findings support this conclusion?

Confusion

A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

Take an ABG specimen to the lab

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

Epinephrine

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparins effects?

protamine sulfate

A nurse is teaching a client who has a new prescription for regular insulin and NPH insulin. Which of the following instructions should the nurse include in the teaching?

room temperature

A client who is having burn debridement states "You are the worst nurse I have ever seen. All you do is hurt me." which of the following responses should the nurse make?

tell me more...

A nurse is at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client rehabilitation program?

Establish the ability to communicate effectively

A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes mellitus?

Fasting blood glucose 155

A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations?

Fatigue

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?

Gallstones

A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching?

Practice effective hand hygiene

A nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Remind the client to look for food on the left side of the tray

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone(SIADH) and a sodium level of 123. Which of the following precautions should the nurse anticipate?

Restrict fluid intake to 1000 mL per day

A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? a. Sodium 126 b. Potassium 3.5 c. Magnesium 1.9 d. Chloride 99

Sodium 126

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8. Which of the following medications should the nurse plan to administer?

Sodium polystyrene

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?

Standard

A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider?

Stridor

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

Talk with the client during wound care

A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?

alcoholism/chronic infections/HIV

A nurse is reviewing the laboratory data of a client who has cirrhosis. The nurse should expect to find which of the following values?

ALT, ALP, AST

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the clients restored rhythm is symptomatic bradycardia?

Atropine

A nurse is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the nurse place at the client's bedside?

Bag valve mask device

A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care?

Check USG

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations.

Cheyne-Stokes breathing

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Continue to monitor the client's respiratory status

A nurse is caring for a client who is 12 hours postoperative and has a chest tube to a disposable water seal drainage system with suction. The nurse should intervene for which of the following observations?

Continuous bubbling in the water seal chamber

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (SATA)

Contractures of Extremities Crackles in the lungs Pressure Ulcers

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

Encourage the client to flex down when swallowing

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Increased HR

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?

Increased respiratory rate from 18-28

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider inspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

Increased serum amylase

A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client. What is the sequence of events the nurse should follow? (move the stages of mixing insulin on the left into the box on the right, placing them in the selected order of performance. All steps must be used.)

Inspect Roll Inject NPH Inject Regular Withdraw Add

A nurse in an emergency room is caring for a client who sustained partial-thickness to both lower legs, chest, face, and both forearms. Which of the following is the priority actions the nurse should take?

Inspect the mouth for signs of inhalation injury

A nurse is caring for a client who has a new prescription for propranolol. The nurse should monitor the client for which of the following reactions to this medication?

Postural hypertension

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

Reduce the clients intake of protein

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?

wash with soap and water

A nurse in an emergency department is caring for a client who has deep partial and full thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation phase of injury?

airway

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the station?

disoriented pt

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

heart rate

A nurse is an emergency department is reviewing the medical record of a client who has extensive burn injury. The nurse should expect which of the following laboratory findings in this client?

hyperkalemia

A nurse is assessing a client in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C?

illicit drug use

A nurse is admitting a client who has acute pancreatitis and is NPO. Which of the following provider prescriptions should the nurse anticipate?

pantoprazole (PPI)