chapter 12 and 13 test

A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following findings?

Tugging on the affected ear lobe

A nurse is obtaining a 4-month-old infant's vital signs. The infant's heart rate is 190/min, and her temperature is 40° C (104° F). The father asks the nurse, "Why is my baby's heart beating so fast?" Which of the following is an appropriate response by the nurse?

"The fever is causing an increase in your baby's heart rate."

the nurse is caring for a client who takes ibuprofen for pain. the nurse is gathering information on the clients medicatin history and determines it is necessary to consult with the registered nurse if the client is also taking which medications ?

1. Warfarin 2. climepiride 3. Amlodipine

the nurse is reviewing the client's health record and notes that the client elicited a positive romberg sign based on this finding the nurse should institute which intervention?

1. collect data to determine factors for fall risk 2. instruct the client to ask for assistance when getting up to walk

Several laboratory tests are prescribed for client and the nurse reviews the results of the tests. which laboratory test results should the nurse report?

1. platelets 35,000 mm3 (35 x 10/L) 2. Sodium 150 mEq/ (5.0 mml/L) 4. Segmented neutrophils 40% to 0.40) 6. white blood cells 3000mm ( 3.0 x 10/L)

a client has been admitted to the hospital for urinary tract infection and dehydration the nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops in which value ?

15 mg/dl ( 5.25mmol/L)

A nurse is reviewing blood pressure classifications with a client who has been newly diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension?

154/96 mm Hg

the nurse is caring for a client with a diagnosis of cancer who is immunosuppressed the nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the clients's whote blood cell count was which value/

2000 mm (2.0x10/L)

a client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level when reviewing the clients results the nurse determines that which requires a call to the primary health care provider for intervention ?

240 mg/dl 13.7mmol/l)

A client with ahistory of cardiac disease is due for morning dose of furosemide. which serum potassium level, if noted in the client's laboratory report should be reported before administering the dose of furosemide/

3.2mEq/L 3.2mmol/L

A client with diabetes mellitus has a glycosylated hemoglobin ALC level of 9% on the basis of this test result the nurse plans to reinforce teaching the client about the need for which measure?

4. Preventing and recognizing hyperglycemia

A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

A client who has gastroenteritis and is receiving oral fluids

A nurse is planning to assign obtaining the vital signs of postoperative clients to an assistive personnel (AP). Which of the following clients should the nurse assign to the AP?

A client who is 3 days postoperative following gastric bypass surgery

A nurse is talking with a client who says she knows someone who takes metoprolol for blood pressure and asks if the medication would be appropriate for her as well. Which of the following data from the client's medical record should the nurse identify as a contraindication to metoprolol?

A history of sinus bradycardia

A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

An increase in neutrophils Localized edema

A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse?

Apical

​A nurse is collecting data from a newborn and finds an apical pulse of 130/min. Which of the following actions should the nurse take?

Document this as an expected finding.

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week after noting that the client plans to assist the registered nurse with which action?

Drawing a sample for prothrombin time (pt) and international normalized INR

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 (35) seconds and an international national normalized ratio (INR) of 3.5 on the basis of these laboratory values the nurse anticipates which prescription ?

Holding the next dose of warfarin

A license practical nurse is preparing a student assigned to care for a client with chronic pain which statement if made by the student indicates the need for further teaching regarding pain management?

I will be sure to cue in to any indicators that the client may be exaggerating their pain .

A nurse is measuring an adult client's tympanic temperature. Which of the following actions should the nurse take?

Insert the probe with a circular motion.

A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?

Low BP and high pulse rate

A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

Place the client's arm above the level of the heart.

A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/84 mm Hg places him in which of the following categories?

Prehypertension

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen

A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?

Skin tenting

An assistive personnel (AP) asks a nurse what precautions he should take when measuring the vital signs of a client who has pneumonia. Which of the following responses should the nurse make?

Wear a mask when entering the client's room."

A licensed nurse is caring for a postoperative client who is receiving demand dose hydromorphone via a patient-controlled analgesia (pca) pump for pain control. the nurse enters the client's room and finds the client drowsy and records the following vital signs temperature 36.2 97.2 orally pulse 52 beats per minute blood pressure 101/58mm hg respiratory breaths per minute spo2 of 93% on 3 liters of oxygen via nasal cannula which action should the nurse take first?

attempt to arouse the client

the nurse learns in report that a client is exhibiting cheyne-strokes respiration based on this data, which action is most appropriate for the nurse to take initially ?

determine the clients ability to follow verbal commands

A nurse is monitoring a client's peripheral circulation. Identify where the nurse should palpate to check the posterior tibial pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

dorsalis pedis pulse.

an adult female client has hemoglobin level of 10.8g/dl (109 g/l) the nurse interprets that this result is most likely caused by condition noted in clients history?

iron deficiency anemia

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The clients activated partial thromboplastin apt time is 65 seconds the licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed?

leaving the rate of the heparin infusion as is

the nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough , and lung congestion. which should the nurse include for this type of data collection?

listening to lung sounds obtaining client' temperature obtaining information about the clients respiration

a client with a history of gastrointestinal bleeding has a platelet of 300,000mm 3 (300x 103) the nurse should take which action after seeing laboratory results?

place the normal report in the clients medical record

a licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (uap) which method if noted by the UAP as being an appropriate method. indicates the need for further teaching ?

taking an oral temperature for a client with a cough and nasal congestion

a client with a diagnosis of asthma is admitted to the hospital with respiratory distress. which signs should the nurse expect to note in the health record when collecting data related to the respiratory system for this client?

wheezes and use of accessory muscles

A nurse enters a client's room and finds the client pulseless. The nurse knows the client's family has requested do-not-resuscitate (DNR) status from the provider, but the provider has not written the prescription yet. Which of the following actions should the nurse take?

​Call the emergency response team