Comp 6
A nurse working on a medical surgical unit has just received a hand off report on the following clients, the nurse should first plan to assess the client who has:
Acute pancreatitis and is reporting the development of pain on deep inspiration Rationale - acute could burst (septic)
The primary health care provider has prescribed ampicillin 150 mg 3 times a day to a doodler the weighs 22lbs the drug available is ampicillin suspension that is 250mg/5ml. Which action should the nurse take
Administer 3ml (do the math)
The nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with severity of 6 out of 10. The nuse administers 1 sublingual nitroglycerin tablet, after 5 minutes the client states the pain is a severity level of 3 which of the following actions should the nurse be prepared to do next?
Administer another nitro sublingual tablet
The nurse has provided medication instruction to a patient who has asthma and been prescribed beclomethasone which of the following client statements indicates a correct understanding of this instruction?
I should rinse my mouth out after this medication
The nurse is caring for a 2month old infant that is post operative following a surgical repair of a cleft lip and is crying
Rock the baby
The nurse is planning care for a newly admitted client who has major depressive disorder following the death of her newborn 2 weeks ago, which of the following goals should the nurse identify as the priority?
Signing a no harm
The nurse working in the psychiatric inpatient unit is caring for a client who has bipolar disorder and is in the manic phase the client states to the nurse " I am bored" which of the following activities is appropriate for the nurse to suggest to the client?
Waking with the nurse in the courtyard
A nurse is caring for a client who has a sealed radiation implant, which of the following precautions should the nurse implement?
Wear the lead shield while providing client care.
The nurse has instructed the client who has a UTI about prescribed drug ciprofloxacin—which of the following instructions should the nurse give the client?
You should report the development of tendon pain while taking this medication, since tendon rupture is a potential complication
The nurse has provided dietary teaching to a client who recently had a surgical colostomy placed, which of the following statement made by the client indicates a correct understanding of the instructions?
Eating yogurt can help decrease the amount of gas that I have
A charge nurse is planning to admit several clients in the medical unit, it would be necessary for the nurse to admit which client to a private room?
Has a fever of unknown origin
The nurse working in the ED has received the following prescriptions for a newly admitted client, which prescriptions should the nurse implement first?
Initiate IV sodium and potassium for a client admitted with diarrhea and dehydration who has a serum potassium level of 2.9
The nurse is caring for a client who is currently prescribed bed rest which of the following actions should the nurse take to help prevent the development of pulmonary embolism?
Instruct the client to perform leg exercises (prevent DVT)
The nurse is teaching a group of clients about insulin administration which of the following informations should the nurse include?
Insulin absorption is fastest when injected into the abdomen
Declomethasone is a corticosteroid
It is a daily use inhaler to prevent asthma flare ups, it is not a rescue inhaler. It can increase the risk of oral thrush, therefore, you need to rinse your mouth after each use.
The nurse is caring for a pregnant client whose last menstrual period began on October 21st using the naegel's rule which of he following dates would be the due date?
July 28
A nurse is teaching a female client about positive signs of pregnancy which of the following client statements would indicate a correct understanding of the teaching?
Heartbeat (lung sounds)
The nurse is prioritizing patient care after a change of shift report and nurse should first plan to see the patient who:
-had an endoscopic retrograde cholangiopancreatography 30 min. Ago and is reporting difficulty swallowing
A nurse is working on a pediatric cardiac unit is reviewing the telemetry monitors for assigned clients, which client should the nurse initially plan to assess?
2yr old toddler who is walking in the hallway and has a HR of 160 BPM (abnormal HR)
CT contrast cannot receive meteor in within
48hrs.
The nurse working on a pediatric unit is caring for the following children who have been admitted in the past 12 hrs. It would be a priority goal for the nurse to initiate an interdisciplinary conference for the child who:
5yrs old with diagnosed cystic fibrosis at birth and has been hospitalized 4 times in the past 2 months.
A nurse is working in a community health clinic is assessing clients who are waiting to be seen, which client should the nurse have the primary health care provider see first?
A 57 yrs old with Graves' disease with a team. 100.5 (thyroid issue)
The nurse is monitoring a client following at Horace tests it would be a priority for the nurse to notify the primary health care provider if the client develops
A heart rate that has increased from 95 to 110BPM
The nurse working on the mom/baby unit has become aware of the following client situation, which of he following clients should the nurse initially assess?
A neonate who is 4hr. Old, whose resting HE is 95BPM NormalHR 120-140
The nurse is caring for a client who is receiving prescribed magnesium sulfate IV which of the following client finding s would indicate the client is experiencing a side effect of that medication?
A respiratory rate of 10 breaths per minute
A nurse is caring for a male client who has a deep partial thickness and a full thickness burn 45%of the lower body, it would be a priority for the nurse to notify the primary health care physician if the client has:
A urinary output of 45ml over the past two hours (normal 30ml/hr)
The nurse working on a medical surgical unit is delegating tasks to unlicensed personnel which of delegated task would require follow up by the charge nurse?
Assisting a client who had a paracentesis 2 hours ago to get out of bed for the first time. -RN needs to do the first
The nurse is preparing to administer prescribed medication to the following client it would be essential for the nurse to follow up the primary health care provider for the client who has?
Diabetes mellitus, just had a CT scan with IV contrast and has been prescribed met for in.
RhoGam is given for the mom so that she
Does not develop antibodies toward an A+ baby. RhoGam is given once per pregnancy
A nurse is teaching another of five tear old child about age appropriate toys which of the following toys would be appropriate for the nurse to recommend?
Doll and coloring book (do not pick the 100 piece puzzle)
Sequence for doffing (removing )PPE
Gloves Goggles Gown Mask
The nurse has instructed a female client who recently received hearing aids. Which of the following client statements indicates the need for additional teaching?
I will clean them with alcohol wipes
The nurse has provided discharge teaching to a client who had an open radical prostatectomy and has been discharged home with a urinary catheter which of the following statements made by the patient would require follow up by the nurse.
I will not be able to take a shower for the next 2 weeks
The nurse has instructed a client who regularly menstruates about performing self-breast examinations at home which of he following client statements indicates correct understanding of eh teaching?
I will perform myself breast examination 7 days after my period ends-you do it 7 days post as the hormones have decreased and any natural lumps will disappear, and breast will not be at tender and sore.
The nurse has instructed a client who must ambulate with a cane which of the following client statements indicates a correct understanding of the teaching?
I will place the cane on the side of the unaffected lib and walk with the weaker leg first.
The nurse is working on a crisis hotline speaking with a client who states " I just took an entire bottle of amitriptyline" which of the following responses should the nurse initially make to the client?
I'm glad you called, and I want to sen an ambulance to help you
The nurse is teaching a class on health promotion and illness prevention which of the following actions by the nurse is an example of secondary prevention?
Performing monthly self-breast examinations.
The nurse is caring for a patient who has paranoid schizophrenia and a history auditory hallucinations the client is yelling and pacing in the day room " I will do it" what of the following actions will the nurse take?
Obtaining increased supervision for the client
The charge nurse in the ED is reviewing the care provided for recently admitted clients: which of the following reflects implementation of an accepted standard of care?
Placing the client who has suspected hemophilia influenza on droplets precautions.
A preceptor is working with a newly hired nurse who is preparing to perform a sterile dressing change,which of the following actions by the newly hired nurse would require intervention by the preceptor?
Putting on sterile gloves prior to opening the outer packaging.
The nurse is assessing clients at the scene of a mass casualty disaster and is prioritizing care based on the disaster triage tag system which of the following clients should be transported to the health care facility first?
The client who has multiple compound fractures and is reporting chest pain
A nurse is teaching a client who had a spontaneous abortion about the need to receive a RhoGam shot, which of the following client statements indicates a need for further teaching?
This medication will allow my body to fully remove the placenta lining -false statement
