CAT 2 Review

A client who is pregnant is prescribed a medication that is pregnancy category D. Which statement does the nurse make to the client when explaining this drug category?

"Studies indicate that a possible fetal risk in humans has been reported."

The nurse provides care for a client diagnosed with idiopathic thrombocytopenic purpura (ITP). The client asks the nurse why the health care provider (HCP) is not performing a splenectomy since the spleen is causing the thrombocytopenia. Which response by the nurse is best?

"The spleen is important in immune function, and without it the chance of overwhelming infection becomes high."

during the initial home care visit the nurse should?

-evaluate safety of clients neighborhood -arrange the visit at at time when it is safe to be in area -collect info about the clients diagnosis/treatment

The nurse provides care for a client diagnosed with diabetes mellitus (DM). The nurse prepares to administer 33 units of insulin to the client. Which syringe is the best choice for the nurse to use to draw up the insulin?

0.5 mL U-100 (unit) syringe

A client asks for an explanation about advance directives. Which entity should the nurse include in the response to this client? (Select all that apply.) 1. Living will. 2. Health care proxy. 3. Organ donor card. 4. Hospice benefit guide. 5. Do-not-resuscitate prescription.

1, 2, 5

The nurse educator teaches a group of staff nurses about measures to prevent the transmission of healthcare-associated infections when providing care for clients. Which intervention does the nurse educator include in the teaching? (Select all that apply.) 1. Clean stethoscopes between clients. 2. Empty bedpans as soon as possible. 3. Limit fresh flowers in client rooms. 4. Use personal protective equipment (PPE) 5. Perform handwashing and alcohol-based sanitizing.

1, 4, 5

The nurse notes that a client diagnosed with Parkinson disease moves slowly, has difficulty dressing, and experiences bowel and urinary incontinence. Which intervention is appropriate for this client? (Select all that apply.) 1. Provide an elevated toilet seat. 2. Make modified clothing without buttons available. 3. Transfer to a skilled nursing facility. 4. Arrange for gait training. 5. Lower the dose of Parkinson medications.

1,2, 4 there is no indication that a transfer to a snif is needed at this time

The nurse assesses a 4-hour-old newborn for acrocyanosis. Which finding does the nurse expect? (Select all that apply.) 1. Blue extremities rated "1" for color on the Apgar Score. 2. Cyanosis of the trunk and thoracic region. 3. Cyanosis of the hands and feet. 4. Color returns quickly after blue area is blanched. 5. Cyanosis of the lips and mucous membranes.

1. Blue extremities rated "1" for color on the Apgar Score. 3. Cyanosis of the hands and feet. 4. Color returns quickly after blue area is blanched.

The nurse suspects cardiac arrest in a pulseless, unresponsive client. Which nursing action is appropriate? (Select all that apply.) 1. Position the client flat and open the airway. 2. Provide the client with a 100% oxygen source. 3. Call for help and request the crash cart. 4. Auscultate for heart and lung sounds. 5. Check client's pupil reaction to light.

1. Position the client flat and open the airway. 2. Provide the client with a 100% oxygen source. 3. Call for help and request the crash cart.

The nurse provides care to clients on a progressive care unit. Which client does the nurse see first? 1. The client recovering from a transjugular intrahepatic portosystemic shunt (TIPS) procedure. 2. The client who received subcutaneous insulin to treat a blood glucose of 317 mg/dL. 3. The client newly diagnosed with systemic lupus erythematosus (SLE). 4. The client receiving continuous octreotide infusion to treat portal hypertension.

1. The client recovering from a transjugular intrahepatic portosystemic shunt (TIPS) procedure. After a TIPS procedure the client is at risk for bleeding. This client's clotting factors are likely to be altered due to liver dysfunction. The procedure shunts blood away from esophageal varices and requires an assessment by the nurse.

The nurse assesses a client diagnosed with heart failure. The nurse's findings include a heart rate of 126 beats/min and an altered level of consciousness. Which action should the nurse take next? 1. Assess the client for jugular distention. 2. Evaluate the client's peripheral pulses. 3. Administer the prescribed diuretic medication. 4. Notify the health care provider of the status change.

1. assess the client for JVD Assessing jugular distention based on the client's heart failure diagnosis immediately gives the nurse additional assessment information regarding the source of the change in mental status. 2) After jugular distention, peripheral pulses are examined for presence and strength to determine the degree of the client's perfusion issue, which is also evidenced by the change in mental status. 3) When the client is exhibiting changes easily attributable to fluid overload and a diuretic is ordered and available, the nurse should give the diuretic. This action assumes the nurse has established there are no accompanying signs of cardiogenic shock or pulmonary embolus. 4) The nurse should notify the health care provider of the status change after the assessment is complete.

normal urine specefic gravity?

1.010-1.030

the nurse should start screening a child for lead poisoning at what age?

12 months

infants up to age 2 sleep ___-___ hours

12-15 hours

The nurse is assisting in the care of a client with ventricular fibrillation. The "code" leader called to shock the client uses a biphasic defibrillator. The nurse sets the defibrillator at which energy level?

120 to 200 joules

the suppository should be inserted a minimum of ____ inches for the medication to be effective

2 inches

The nurse provides care for a client preparing to go to sleep. The client states to the nurse, "I just can't relax, and I don't want to take any sleep medication. What else can I do?" Which action by the nurse can help promote relaxation for sleep? (Select all that apply.) 1. Provide a large snack with warm milk. 2. Remove the wrinkles from the bed linen. 3. Provide a backrub. 4. Reposition the client. 5. Provide extra pillows.

2,3,4,5

The nurse observes a graduate nurse care for a client receiving continuous feedings via a nasogastric (NG) tube. Which action by the graduate nurse requires the nurse to intervene immediately? 1. Aspirates a small amount of the gastric contents prior to instilling the tube feeding. 2. Administers two medications together after instilling 5 mL of water to flush the tube. 3. Maintains the head of the bed elevated at 45 degrees. 4. Checks for gastric residual every 4 to 6 hours and measures the gastric content.

2. Administers two medications together after instilling 5 mL of water to flush the tube. Each medication is followed with water before the next medication is given. To prevent clumping or interactions, medications are not combined. The second medication must be followed by more water to irrigate the tube so that it does not clog.

The nurse reviews medications prescribed for a client recovering from surgery. Which prescription causes the nurse the most concern? 1. Diphenhydramine 50 mg PO at bedtime, as needed. 2. Furosemide 40 mg IV q.d. 3. Morphine sulfate 2 mg IV every hour, as needed, for pain. 4. Oxygen at 2 L/min via nasal cannula.

2. Furosemide 40 mg IV q.d. The Institute for Safe Medication Practices reports that the abbreviation "q.d." can be mistaken for q.i.d., especially if the period after the "q" or the tail of the "q" is misunderstood as an "I"; therefore, they recommend that the word "daily" be used instead. For example, furosemide 40 mg IV daily.

The nurse provides care for a client who takes digoxin for heart failure. Which finding is a priority for the nurse to communicate to the health care provider (HCP)? 1. Presence of 1+ edema in the ankles. 2. Intermittent nausea and loss of appetite. 3. Serum potassium level 3.8 mEq/L. 4. Weight gain of 2 pounds in one week.

2. Intermittent nausea and loss of appetite. Nausea, anorexia, and vomiting are early signs of digitalis toxicity. It is a priority to communicate this data to the HCP.

A client's IV alarm sounds. A nurse states, "I'll get it! That alarm has been beeping all shift. Maybe it's broken." During client rounds, the charge nurse finds the IV pump alarm button covered with a heavy layer of tape. Which immediate action by the charge nurse is appropriate? 1. Report evidence of "alarm fatigue" among staff to the unit manager. 2. Replace the pump, label the current pump, and send it for repairs. 3. Fill out an incident report, citing the behavior that endangered a client. 4. Approach the nurse and discuss how to handle broken equipment.

2. Replace the pump, label the current pump, and send it for repairs. Focus the immediate action on the client and the safe use of equipment. Arrange for the replacement or repair of the pump that is alarming continuously.

The nurse provides care for a client in the final stage of chronic kidney disease. The client's serum calcium level is 7.5 mg/dL (1.8 mmol/L) and the phosphate level is 6.0 mg/dL (1.9 mmol/L). Which priority nursing diagnosis does the nurse use to plan care for this client? 1. Activity intolerance. 2. Risk for injury. 3. Imbalanced nutrition. 4. Failure to thrive.

2. Risk for injury. The client in the final stage of chronic kidney disease is at risk for osteodystrophy due to bone mineral loss leading to an increased risk for fractures or osteoporosis. Due to this condition, the client is at risk for serious injuries during a fall.

The nurse auscultates heart sounds in a school-age client. Where does the nurse place the stethoscope to listen to the aortic area of the heart? 1. Second left intercostal space. 2. Second right intercostal space. 3. Fifth intercostal space, left midclavicular line. 4. Fifth right and left intercostal spaces.

2. Second right intercostal space.

A client relieves severe abdominal pain that radiates to the back by sitting forward with the knees bent. Which laboratory test will the nurse expect to be prescribed for this client? 1. Creatinine. 2. Serum amylase. 3. Creatinine kinase. 4. Blood urea nitrogen.

2. Serum amylase. amylase is a digestive enzyme secreted by the pancreas. since the client is demonstrating signs of acute pancreatitis

The nurse discharges a client diagnosed with Parkinson disease to live at home with the family. Which teaching will the nurse provide as part of this client's discharge? (Select all that apply.) 1. Provide intermittent oral suctioning for aspiration precautions. 2. Arrange for sides of bed to be padded for seizure precautions. 3. Keep bed at lowest position. 4. Wear surgical masks for neutropenia precautions. 5. Use non-skid socks for fall precautions.

3 and 5

what is normal phosphate range?

3-4.5

The nurse follows up with a client diagnosed with insomnia. The nurse seeks to determine if treatment was successful. Which response by the client best indicates treatment was successful? 1. "I am sleeping 4 hours a night." 2. "I fall asleep within 1 to 2 hours at night now." 3. "I am not napping in the day anymore." 4. "I am waking up twice a night."

3. "I am not napping in the day anymore."

The nurse assigns rooms to clients admitted to the unit. The nurse wants to place clients as far away from the nurses' station as possible to promote rest and relaxation. Which client would be most appropriate for the nurse to place away from the nurses' station? 1. 84-year-old client diagnosed with Parkinson disease. 2. 73-year-old client diagnosed with congestive heart failure. 3. 58-year-old client who had a total abdominal hysterectomy. 4. 68-year-old client diagnosed with a cerebellar tumor.

3. 58-year-old client who had a total abdominal hysterectomy. A client of this age who has had a total abdominal hysterectomy is the most appropriate to be away from the nurses station

The nurse develops a teaching plan to promote optimal cardiac output during pregnancy. Which information is most important for the nurse include? 1. Take frequent rest periods between activities. 2. Modify aerobic exercise as pregnancy progresses. 3. Avoid resting or sleeping in the supine position. 4. Elevate both lower extremities whenever sitting.

3. Avoid resting or sleeping in the supine position. Particularly in second half of pregnancy, the weight of the pregnant uterus compresses the vena cava (which can lead to maternal hypotension syndrome) and aorta (which can lead to fetal hypoxia). It is a priority to prevent compression of these major vessels.

The nurse observes the umbilical cord protruding from the vagina of a client in labor. Which action does the nurse take next? 1. Place client in high Fowler's position. 2. Attempt to reinsert cord into cervix. 3. Contact the health care provider. 4. Administer oxygen via nasal cannula.

3. Contact the health care provider. 3) CORRECT - This situation is a medical emergency. The nurse needs to contact the health care provider and prepare for immediate vaginal birth if the cervix is fully dilated or cesarean birth if it is not. 4) The nurse should administer oxygen via nonrebreather mask at 8 to 10 L/min to increase oxygen availability to the fetus. Priority is to prepare for immediate delivery of the fetus.

The nurse prepares to administer prescribed amoxicillin to four clients. Which client condition causes the nurse to question the health care provider's prescription for this medication? 1. Lyme disease. 2. Scarlet fever. 3. Hay fever. 4. Syphilis.

3. Hay fever. Hay fever is not caused by bacteria; therefore, is not treated with amoxicillin. Hay fever is managed with antihistamines and removal of known allergens.

The nurse provides care for a client diagnosed with human immunodeficiency virus (HIV) infection. The client receives epoetin alfa for zidovudine-induced anemia. The nurse is most concerned about which of the laboratory test results? 1. Alanine aminotransferase (ALT) 42 units/L (0.7 µkat/L). 2. Aspartate aminotransferase (AST) 36 units/L (0.6 µkat/L). 3. Hemoglobin 12.8 mg/dL (128 g/L). 4. Creatinine level 1.2 mg/dL (106.08 µmol/L).

3. Hemoglobin 12.8 mg/dL (128 g/L). Epoetin should not be administered with a hemoglobin values of 12 mg/dL (120 g/L) or above because of the increased risk for myocardial infarction and stroke.

The nurse provides dietary teaching to a client with an acute kidney injury. Which menu selection made by the client indicates to the nurse that teaching is effective? 1. Potatoes. 2. Raisins 3. Pasta. 4. Bananas.

3. Pasta. A client with an acute kidney injury is at risk for hyperkalemia. Pasta is not a good source of potassium and should be selected. Pasta is also good to meet caloric requirements and spare using protein for energy. The other options are high in potassium

the infusion should be started within ____ minutes of removing the blood from the blood bank

30

A 16-year-old client visits the community health clinic. The client tells the nurse, "I think I got an infection from having sex with my boyfriend. I can't tell my parents. They will kill me!" Which is the best response by the nurse? 1. "Since you are a minor, I will have to notify your parents." 2. "Your parents will appreciate your maturity in seeking help." 3. "Does your boyfriend understand that he will need treatment?" 4. "Your parents do not need to know, but will you give me consent for treatment?"

4. "Your parents do not need to know, but will you give me consent for treatment?" The nurse needs to obtain informed consent for treatment from the unemancipated minor. The nurse is not obligated to notify the parents.

The nurse assesses a client with obsessive compulsive personality disorder. Which finding will the nurse expect to observe? (Select all that apply.) 1. Requires excessive support from others when making decisions. 2. Believes is able to know what others are thinking. 3. Possesses exaggerated feelings of helplessness when alone. 4. Demonstrates unwillingness to delegate tasks unless others follow strict rules. 5. Imposes perfectionism in own completion of tasks.

4. Demonstrates unwillingness to delegate tasks unless others follow strict rules. 5. Imposes perfectionism in own completion of tasks.

The nurse reviews the medications of a client who reports daily daytime sleepiness. Which medication will the nurse consider as causing this client's sleepiness? 1. Diltiazem. 2. Famotidine. 3. Fenofibrate. 4. Duloxetine.

4. Duloxetine.

The nurse provides care for a very low birth weight (VLBW) preterm newborn receiving oxygen therapy. The nurse assesses the infant for which complication of oxygen therapy? 1. Nonshivering thermogenesis. 2. Hyperbilirubinemia. 3. Polycythemia. 4. Retinopathy of prematurity.

4. Retinopathy of prematurity. Visual impairment or blindness in preterm infants, especially VLBW, due to injury of developing retinal blood vessels is sometimes precipitated by high levels of oxygen.

The nurse provides care for a client newly diagnosed with a benign brain tumor. The nurse teaches the client about the diagnosis. Which property of benign tumors should the nurse include in the teaching? 1. They are poorly differentiated. 2. They metastasize to other organs. 3. They grow at an aggressive rate. 4. They can cause tissue destruction.

4. They can cause tissue destruction. malignant tumors are poorly differentiated, benign tumors are more differentiated, meaning they more closely resemble the cells of the tissue from which they arose

absence of plantar creases?

Full- and post-term neonates have deep plantar creases. A preterm newborn has few creases on the foot.

why do you want to feed the newborn fresh milk after recovering from NEC?

It is the preferred enteral nutrient because it confers some passive immunity (IgA), macrophages, and lysozymes. Also, breast milk is more easily digested than formula.

how to position newborns recovering for necrotizing enterocolitis (NEC)?

NEC are left undiapered and in a supine or side-lying position to avoid pressure on the distended abdomen and facilitate continuous observation.

sevelamer?

Sevelamer is used to manage hyperphosphatemia in clients with chronic kidney injury. It binds phosphate in the bowels to facilitate excretion in the stool. Effective treatment with sevelamer results in a serum phosphate value within the normal range of 2.4 to 4.4 mg/dL (0.78 to 1.42 mmol/L).

alendronate should be taken with a full glass of water to prevent?

acid reflex

contractions occuring at 2-4 min intervals lasting 50-60 seconds are seen in ____ phase of labor

active

severe abd pain that radiates to the back indicates

acute pancreatitis

main complications of central venous access device (CVAD) insertion include?

air embolism and pneumothorax

measles precautions?

airborne

The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp, face, and trunk. Which transmission-based precaution does the nurse implement for this child?

airborne and contact the client demonstrates varicella infection

A mother brings her 1-week-old newborn to the clinic for a wellness checkup. She verbalizes frustration with breastfeeding because of nipple soreness. Which recommendation by the nurse may help alleviate nipple soreness?

apply ice to nipples after feeding due to numbing effect allowing breast milk to dry on nipples helps relieve soreness

symptoms of lung cancer?

are often vague and present late in the disease late symptoms include constant coughing and bloody sputum

The nurse provides care to a client of Native American descent who has traditional beliefs about health and illness. Which action is most appropriate for the nurse to take?

ask if cultural healers should be contacted

The nurse provides care for a postoperative client. The nurse notes the client is restless. The client grabs at the incisional area. The nurse notes the client's blood pressure to be 146/96 mm Hg. Which action should the nurse take next?

ask the client to rate the pain level

A client takes a statin as prescribed. Which action does the nurse implement to identify if the client is experiencing any side effects of the medication? 1. Measure height and weight. 2. Check recent cholesterol level. 3. Inquire about the consistency of stool. 4. Assess for muscle tenderness.

assess for muscle tenderness myalgia or muscle tenderness may indicate development of rhabdomyolysis, which is an adverse reaction to statin meds monitoring cholesterol evaluates the effectiveness of the med. not the side effects

The nurse provides care for a client diagnosed with advanced stage dementia. client walks to nursing station and says "I dont want to be here, i am going to leave." which action is best?

assign a sitter to remain with client. assessing clients orientation is pointless cause you already know they are confused

low serum ______ frequently occurs with pancreatitis

calcium

A client with a gastric feeding tube is prescribed metoprolol XL 50 mg by mouth twice daily. Which action will the nurse take when providing this medication? 1. Crush the medication and administer via nasogastric tube. 2. Have the client swallow the pill with a sip of water. 3. Call the health care provider. 4. Call the pharmacy to ask for a different form of metoprolol.

call HCP the pharmacy cannot change a med order

______ has cross reactivity with penicillins

cefazolin (cephalosporins)

the peripheral IV dressing is loosened...what should you do?

change IV dressing (not site)

a yellow brown coating on the clients tongue indicates?

client smokes cigarettes

to prevent catheter associated UTIs do you want to maintain an open or closed drainage system?

closed

The nurse prepares to administer fondaparinux to a client. Which laboratory test result will the nurse monitor in the client receiving this medication?

creatinine level Fondaparinux is excreted by the kidneys; creatinine level should be monitored periodically, and the drug stopped in clients who develop unstable kidney function or severe renal impairment.

during the second or entry phase home care visit then nurse should then....?

determine nursing diagnoses and establish desired outcomes with client

The nurse provides care to a school-age child suspected of being sexually abused. Which assessment data best supports this suspicion? 1. Difficulty walking. 2. Bald spots on scalp. 3. Fear of parents. 4. Welts on buttocks.

difficulty walking fear of parent and the others are more likely associated with physical abuse

when treating an adult for scabies, where do you NOT apply the scabicide?

do not apply on face or scalp should apply from neck down

The nurse uses a paper-based documentation system to write a client care note. The previous nurse's documentation appears incomplete. Which action should the nurse take next?

draw a line through any empty space and continue documenting... empty spaces should not be left because it allows others to document in that space in an incorrect manner

what is red man syndrome?

due to rapid infusion of vancomycin

the final stage of chronic kidney disease is associated with what abnormal labs?

elevated creatinine anemia hypocalcemia elevated phosphate levels

how much of the areola should the infant grasp with moutg?

entire areola

A client diagnosed with thrombocytopenia calls the clinic nurse. The client states, "I just cut my skin while shaving; the bleeding won't stop even though I placed a bandage over the cut." Which response by the nurse is best?

hold the pressure to the wound for 10 min and call back

The nurse provides care for a client diagnosed with chronic obstructive pulmonary disease (COPD). The client is having difficulty clearing lung secretions. Which technique is best for the nurse to teach the client to perform?

huff cough the huff cough is a forced expiratory technique that mobilizes secretions from the small airways for easier expectoration

you are giving an IV push med and there is a change of color in the tubing....what does this mean?

incompatibility

The nurse provides care to a client diagnosed with second- and third-degree burns on the anterior thorax and legs. Which finding will the nurse expect to observe during the emergent phase of the burn injury?

increased hematocrit increased heart rate decrease BP decreased UO (blood shunted away from kidneys to more vital organs)

hemoglobin ____ with dehydration

increases

The nurse provides care to a client with a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Which action will the nurse take first?

initiate seizure precautions

what is a synergistic effect?

is when the combination of two meds causes a response that is greater when the meds are given separately

The nurse learns that a client was not prescribed a treatment for a disease process because of age. For which principle violation will the nurse bring this issue to the organization's ethics committee?

justice

jewish and meals?

kosher clinet must unwrap their own utensils and prepare to eat themselves

dry skin, poor wound healing, and fatigue indicate?

malnutrition

veracity?

means telling the truth

creatinine kinase is used to evaluate?

muscle function

can an NAP administer a tap water enema for a colonscopy in 2 hours?

no

should a client with a bleeding disorder do ballet?

no

client has insomnia, do you tell them to keep alarm clock out of room to help?

no, not having an alarm clock in the room may increase anxiety. but the alarm clock should not be facing the client

nurse auscultates bowel sounds and hears a bruit over the aorta....what does this indcate and what do you do?

notify HCP cause it indicates turbulence within this major artery

The nurse suspects that a newly admitted client might be a victim of elder physical abuse. Which is the nurse's priority action?

notify the HCP it is not the nurses responsibility to contact the local police

The nurse provides care for a client who has norepinephrine infusing through a peripheral intravenous catheter (IV). The client reports pain at the IV insertion site. The nurse stops the infusion. Which action does the nurse take next?

notify the HCP the client displays signs of extravasation. the nurse should notify before tissue damage occurs. after notification the nurse should elevate the extremity

when it says wear opaque clothing and hat outside...that is good and means protecting from sun

okay

what is the goal of steriod therapy in metastatic cancer?

palliative reduction of pain

how should a patient with acute pancreatitis lie?

position side lying with HOB 45 degrees. side lying decrease tension on the abdomen and may help decrease pain

what positioning helps reduce intracranial pressure?

positioning head in neutral alignment

slow recoil of the pinna is seen in ?

preterms less than 34 weeks the ear has little cartilage to keep it stiff. It will remain folded over or return slowly when folded longitudinally and horizontally. In a full- or post-term neonate, the ear springs back to the original position immediately.

A client who is pregnant is prescribed a medication that is pregnancy category X. Which statement does the nurse make to the client when explaining this drug category?

reports indicate fetal abnormalities occur

PPE for rubeola?

respiratory

The nurse completes a minimum data set on each assigned client as a standardized, primary screening and assessment tool of health status. In which clinical area does the nurse work?

skilled nursing facility Nurses who work in a in a Medicare-certified or Medicaid-certified long-term care facility, nursing home, or skilled nursing facility are required to complete a minimum data set for each resident.

how to teach a client how to take alendronate sodium?

take with at least 8 oz water sit upright for 30 min after taking take on empty stomach

contractions occuring 2-3 min intervals lasting 2 minutes seen with ____ phase

transition

contractions occuring at regular intervals lasting 1-2 min seen at _____ phase

transition

what is an additive effect?

when two meds with similar actions are given together

how quickly must urine specimen be sent to lab via tube system?

within the hour if that cannot be done, urine can be refridgerated for up to 24 hours

can an LPN help a client with a colostomy who requires assistance with colostomy irrigation?

yes

can an NAP add up intake and output for each client?

yes

is there a correlation to access to gun at home and increased risk of suicide?

yes

do you want clients with bleeding disorders to be on stool softeners and why?

yes because it prevents rectal bleeding from straining

teaching for newborn care of circumcised penis?

~wash are by squeezing warm water over it ~avoid wipes that contain alcohol ~report any redness, bleeding, or drainage ~fasten diaper loosely to prevent rubbing or pressure on incision site ~yellow crusting over area is normal and should not be removed