Concepts 139/167 Review Questions
A nurse on a medical-surgical unit is assisting with the admission of a client who has vision loss. What action is the nurse's priority
Describe the environment to the client
A nurse is caring for an older adult climbing and in a long term care facility. Where tell the following measures should the nurse take 1st went assisting with planning the client's care
Determining the client's mobility
Which thrombolytic event affects the heart
Myocardial Infarction
Heparin diagnostic test
Partial Thromboplastin Time (PTT)
A nurse is caring for a client who is receiving IV tobramycin and has a prescription for peak and trough blood levels with the next dose scheduled for 1800. The nurse should expect the lab to draw samples at which times
1745 and 1830
The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take
Allow the family to view the body privately
A nurse is caring for a client who has a prescription for metoprolol. The nurse measures the client's vital signs and notes that the client's apical heart rate is 49/min. The nurse should prepare to administer which medications
Atropine
A nurse is reinforcing teaching to a newly licensed nurse about caring for a client who is a member of the Seventh Day Adventist church. The nurse should include in the teaching that which foods are restricted with this religion
Caffeinated coffee
A nurse in a long term-care facility finds and older adult client laying on the floor next to the bed. Which of the following actions to the nurse
Check the client for injuries
A nurse is going through the medical history from a client that takes herbal supplements and is scheduled for surgical procedure in 10 days, the nurse informed the client that which of following dietary supplements increase the risk of bleeding
Feverfew
A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of heparin. The client ask the nurse how long it will take for the heparin to dissolve the clot. Which are the following responses should the nurse make
Heparin prevents new clots from forming rather than dissolving establish clots
An herb used to help relieve joint pain, swelling, and stiffness caused by arthritis.
Glucosamine
A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a prescription for enoxaparin. Which of the following instructions should the nurse include in the teaching
Have protamine available in case of overdose
A nurse is caring for an older adult client who has dementia and whose family reports he get up and wanders around at night. Which of the following actions for the nurse take
keep the client's personal items within reach
A nurse is assisting with the admission of a client to the medical unit. The client's valuables include a container of ginkgo biloba. The client states he takes a dose each day to improve his memory. Which of the following statements should the nurse make?
I will check with your doctor to be sure it's okay for you to take it while you're in the hospital
What is a trough?
lowest serum level of the drug
A nurse's inadvertent medication error results in a severe allergic reaction and prolongs the client's hospitalization. They client could rightfully sue the nurse for
malpractice
A nurse is administering an IM injection using a passive needle safety devices. After injection, which actions should the nurse take
Make sure the needle retracts into the barrel of the syringe
Which groups of people are especially sensitive to medication effects?
Older adults
warfin diagnostic test
Prothrombin Time (PT)
A nurse is caring for a client who states, "I am not going to take my medication anymore". Which of the following responses should the nurse make
Tell me more about this decision
A nurse is discussing respite care with the caregiver of an older adult client. When the caregiver ask about the purpose of a respite care program, the nurse should reply that it provides which of the following services
Temporary care
A nurse is reinforcing teaching for a client who has a new prescription for warfarin. Which of the following information the nurse include
The client should use an electric razor while on this medication
A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which purposes
To promote digestion
A nurse is performing wound care for an older adult client who has a stage one pressure ulcer. Which of the following types of dressings should the nurse apply to the wound
Transparent
A nurse is caring for a client who has a large surgical wound healing by secondary intentions. The nurse should recommend a diet high in protein and which nutrients
Vitamin C
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown
apply a moisture barrier ointment to the skin
A nurse is the planning to administer a vaginal cream to a client. The nurse should instruct the client to lie in which all the following positions while in bed
dorsal recumbent
A nurse is caring for a client who has a stage 3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for incisions in the plan of care
cleanse with 0.9% sodium chloride irrigation
A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which other following medications should the nurse have available to reverse heparin's effect
protamine sulfate
A patient has received an overdose of intravenous Heparin, and is showing signs of excessive bleeding. Which substance is the antidote for Heparin overdose
protamine sulfate
A nurse is caring for a client who has a new prescription for warfarin. The nurse should use the results of which of the following diagnostic test to monitor the effect of this therapy
prothrombin time (PT)
Herbal supplement that may help reduce testosterone levels, improve prostate health, reduce inflammation, prevent hair loss and enhance urinary tract function.
saw palmetto
A nurse is preparing to use the Z-track technique to administer a medication to a client. Which of the following actions should the nurse plan to take
aspirate for 5 to 10 seconds
A nurse is preparing a presentation for coworkers about the various herbal remedies clients might report using. Which on the following should she include as an herbal supplement clients might use to treat menopause-related hot flashes
black cohosh
An herb used to treat symptoms of menopause, premenstrual syndrome, painful menstruation, acne, weakened bones, and for starting labor in pregnant women
black cohosh
what is a peak
highest serum level of the drug
A nurse is caring for several clients at various developmental stages. The nurse understands that according to Erikson, acceptance of death occurs at which of the following stages of psychosocial development
integrity vs despair
A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection
perform hand hygiene prior to dressing changes
A nurse is caring for an older adult client who is at risk for skin breakdown. Which of following interventions should the nurse use to help maintain the client's skin integrity
provide the client with a diet high in fiber
An LPN is teaching a patient about the side effects of his hypertension medication. Research has shown that the nurse should tell the patient about all the side effects of this medication for what reason?
Patient must be able to recognize side effects correctly
A nurse is caring for a client who has a deep vein thrombosis, who received IV Heparin for the past 5 days, and now has a new prescription for oral warfarin in addition to the Heparin. The client ask the nurse if both medications are necessary. Which of the following is an appropriate response by the nurse
Heparin will be continued until warfarin reaches a therapeutic level
A nurse is caring for a client who has been taking warfarin and has a prothrombin time of 30 seconds. Which of the following medications should the nurse anticipate the provider to prescribe?
Vitamin K
A nurse is caring for a client who is receiving warfarin therapy to prevent a deep vein thrombosis. Which medications should the nurse have available in the event of an overdose
Vitamin K
A patient who has been anticoagulated with warfarin (Coumadin) has been admitted for gastrointestinal bleeding. The history and physical examination indicates that the patient may have taken too much warfarin. The nurse anticipates that the patient will receive what antidote
Vitamin K
A nurse is reinforcing discharge teaching with a client who is postoperative following hip arthoplasty and is to continue use of enoxaparin at home. Which statement by the client indicates an understanding of the teaching
I will need to give myself an injection in my abdomen twice a day
A nurse is caring for a client who is receiving total parenteral nutrition (TPN)via infusion pump. When collecting data about the client receiving this therapy, what factor should the nurse monitor
IV insertion site
A charge nurse in a long term care facility will be in implementing a new protocol to meet The Joint Commission's National Safety goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority
Identifying the clients at the greatest risk for development pressure ulcers
A nurse is preparing to administer heparin subcutaneously to a client. Which of the following is an appropriate action by the nurse
Inject the medication into the abdomen above the level of the iliac crest
A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse used to describe a stage 3 pressure ulcer
A deep crater without visible bones, tendon, or muscles
An older adult client in a long term care facility had a stroke 4 weeks ago and has been unable to move independently since that time period. The nurse caring for her should observe for which other following findings that indicates a complication of immobility
A reddened area over the sacrum
A new observes a new,y licensed nurse administer enoxaparin subcutaneously using a pre-filled syringe. Which indicates appropriate medication administration
Administering the injection 6.35 cm (2.5) from the umbilicus
Before administering client medication, the nurse must identify the client. Which of the following methods of identification should the nurse use
Ask the client's full name and date of birth
A nurse is planning care for a group of clients. When planning the assignment for an assistive personnel (AP), which activities should the nurse consider unsafe for the AP to perform
Assisting an older adult client to take acetaminophen the AP crushed in applesauce
A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which is the priority nursing actions
Check the client's vital signs
A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action
Check the client's vital signs
A nurse is assisting in the education of a group of clients about the contraindications of warfarin therapy. Which out the following statements is appropriate to include in the instructions
Clients who are pregnant should not take warfarin
A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the clients privacy
Close the curtains around the clients bed
A nurse is reinforcing teaching with a client who has frequent urinary tract infection (UTIs). The nurse should identify that the client can use which herbal supplements to help prevent UTIs?
Cranberry Juice
A nurse on a medical unit is planning to administer a nicotine transdermal patch to a female client. Which of the following actions should the nurse plan to include
Date, time, and initial the patch after before applying to the client
A nurse is contributing to the plan of care for a client who is a Seventh Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client
Do not schedule diagnostic tests for Saturday
A nurse is caring for a group of clients. For which tasks should the nurse wear gloves
Emptying urine from an indwelling urinary catheter collection bag Providing oral care Changing an o stony pouch
A nurse is preparing to administer Heparin subcutaneously to a client who has deep vein thrombosis. Which action should the nurse take
Insert the needle at a 90 degree angel
A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the manifestations should the nurse identify as an indication that the client has developed phlebitis
Erythema
A nurse is reviewing the medication history of a client. The nurse should identify that which of the following medications places the client at risk for hypokalemia
Furosemide 80 mg PO daily
A nurse is preparing a presentation for coworkers about the various herbal remedies clients my report using. Which of the following should she include as an herbal supplement clients might use to treat constipation
Garlic
A green used to test mental health conditions, Alzheimers disease and fatigue
Ginkgo biloba
A nurse is reinforcing teaching with a client who has hypertension and a new prescription for verapamil. The nurse should instruct the client to avoid taking this medication with which food
Grapefruit juice
A nurse is preparing a presentation for coworkers about the various herbal remedies clients my report using. Which of the following should she include as an herbal supplement clients might use to lose weight and improve mental clarity
Green Tea
A patient has been prescribed warfarin (Coumadin) in addition to a Heparin infusion. The patient asks the nurse why he has to be on two medications. The nurse response is
Heparin is used to start anticoagulation so as to allow time for the blood levels of warfarin to reach adequate levels.
A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of Heparin. The client ask the nurse how long it will take for the Heparin to dissolve the clot. Which of the following responses should the nurse make?
Heparin prevents new clots from forming rather than dissolving established clots
A nurse on a telemetry unit is reviewing laboratory results for a client who has atrial fibrillation and is taking warfarin. Which laboratory values should the nurse report to the provider
PT 45 seconds
A nurse's sibling had a diagnostic test at the nurse's facility. The sibling asks the nurse to look up the results in the computer. They nurse should identify which are the following as the reason for her decision about her sibling's request
It is not permissible because there is no nurse-client relationship between the sibling and nurse
A nurse is caring for a client who practices Orthodox Judaism. The nurse should identify that which foods together on the same dinner tray violates the client's religious practices
Kosher roast beef and ice cream
A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions should the nurse take to help the client cope with the feelings of loss
Listen attentively when the client talks about the past
A nurse is assisting a client who has generalize weaknesses out of bed to a wheelchair. Which of the following actions should the nurse take
Lock the wheels of the bed and the wheel chair
A nurse is caring for an older adult client who has confusion and weaknesses. The client has a Hct of 53%, a BUN of 25 mg/dL, and a urine specific gravity of 1.232. Which actions should the nurse contribute to the client's plan of care
Monitor the client's intake and output Weight the client daily Instruct the client to sit on the side of the bed for a few minutes before standing Check the client's orientation to person, place, and time regularly
A nurse in an extended care facility is reinforcing teaching for with a group of newly licensed nurses about the expected physiologic changes of aging. Which information should the nurse include
More difficultly seeing due to a greater sensitivity to glare Decreased cough reflex Decreased bladder capacity Decreased systolic blood pressure Dehydration of intervertebral
A nurse is caring for a client when the safety on the bed plug's electrical outlet pops and begins to smoke. Which of the following actions is the nurse's priority
Move any clients and the immediate vicinity
Why do nurses need to be aware of which OTC medications their patients are taking
OTC medications are sometimes interfere with the effect of prescribed medications
A nurse is preparing to administer heparin intravenously to a client. Which of the following actions should the nurse take
Obtain an infusion pump to regulate the continuous flow of the medication
A nurse is the preparing to administer an intradermal injection for a client who requires a tuberculin skin tests. Which of the following actions should the nurse plan to take
Pitch the skin up to the choosen site with the nondominant hand before inserting the needle
A nurse is reinforcing teaching with a group of newly licensed nurses about preventing needle stick injuries. Which I'll the following actions should the nurse recommend
Place on uncapped needles in a puncture-proof container after use
A nurse is reviewing laboratory data from a client who has pulmonary embolism and is receiving IV Heparin. Which findings should the nurse report to the provider
Platelets 74,000/mm3
A nurse is assisting with the care of a client who is receiving Heparin by IV infusion. Which medications should the nurse have available in the event of an overdose
Protamine
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 Heparin's effects
Protamine sulfate
A nurse is caring for a client whose hand movement is limited. Which action should the nurse take to assist the client with feeding
Provide an adaptive feeding device for the client
The nurse is preparing to care for a patient who will be taking an anti-hypertensive medication. Which action by the nurse is part of the assessment step of the nursing process
Questioning the patient about the over the counter medication
A nurse observes an assistive personnel (AP) taking the call light away from a client and reprimanding him for using it frequently. Which on the following action should the nurse take first
Reassure the client
A nurse is caring for an older adult client who has cancer and is receiving opioids for pain relief. The client has a new prescription for docusate PO daily. When collecting data from the client, which are the following therapeutic effects of docusate should the nurse expect
Relief from constipation
A nurse is preparing to administer a rectal suppository to a client. The nurse instructs the client to lay in what position while in bed
Sim's
A nurses plan to administer a rectal suppository to a client. The nurse should instruct the client to lay in which position
Sim's
A nurse is assisting with the preparation of an educational program about the use of oral contraceptives. The nurse should include that which of the following herbal supplements reduces the effectiveness of oral contraceptives
St. John's wort
A nurse is collecting data from a client who is to start taking digoxin for heart failure. They nurse should instruct the client to avoid taking which of the following herbal supplements
St. John's wort
A nurse is preparing a presentation for coworkers about the various herbal remedies clients my report using. Which of the following should she include as an herbal supplement clients might use to treat depression
St. John's wort
A nurse is caring for an adult client who has dementia and wanders at night. Which intervention should the nurse take
Take the client to the bathroom on a regular schedule
A nurse is playing an attraction using a single dose glass ampule. Which of the following actions should the nurse take
Tap the top of the ampule, place a gauze pad or unwrap alcohol swab around the ampule neck, and break off the top with a forward motion away from the hands
The authority to administer medication is specified for nurses in
The Nurse Practice Act of each state
When administering Heparin subcutaneously, the nurse will
Use a 1/2 to 5/8 inch 25 to 27 gauge needle
A nurse on a medical-surgical unit is caring for a client who asks to review his medical record. Which of the following responses should the nurse make
You will have to sign a written request for access to your records
A nurse is caring for a client who is postoperative and receiving fentanyl via patient controlled analgesia. The client has a prescription for naloxone. The nurse understands that the purpose of the naloxone is to?
block the effects of opioids on the central nervous system
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture
cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen
A nurse is checking the apical pulsations of a client who is taking several cardiovascular medications. Which of the following actions of the nurse take
count the apical pulsations for a full minute
A nurse is reinforcing teaching with a client who is to self-administer regular insulin and NPH insulin from the same ceramic. Which of the following instruction should the nurse provide
discard regular insulin if it appears cloudy
A nurse is caring for a client who tells him, he does not want to take his morning medication. Which of the following actions should the nurse take
document the client's refusal of the medication
Herbal supplement that stimulates immune system. Widely touted as an immune booster that can help prevent cold and flu
echinacea
what medication is used to prevent deep vein thrombosis
enoxaprin
A nurse is caring for a client who is competent, refuses further treatment, and asked to sign out of the hospital against medical advice (AMA). The nurse notifies the charge nurse, who tells the nurse that the provider has recommended restraining the client, if necessary to keep her from leaving the hospital. The nurse refuses to implement the actions based on the knowledge that restraining this client would be committing
false imprisonment
A nurse is caring for a client who is receiving furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client
serum potassium
A nurse is reinforcing teaching for a client who has angina pectoris and a new prescription to apply a nitroglycerin transdermal patch daily at home. Which only following instruction should the nurse give the client
shave excess hair from skin before applying a nitroglycerin patch
During an admission interview, a client tells the nurse that he takes echinacea, but does not remember why his provider recommended it for him. The nurse should remind the client that this herbal supplement
stimulates the immune system
A nurse is reviewing the goals of a nurse-client therapeutic relationship with a newly licensed nurse. Which of the following information should the nurse include in the teaching
the client allows the nurse to satisfy his personal needs
A nurse is collecting data from a client who has prosthetic aortic valve and take coumadin daily at bedtime. Which of the following data finding should the nurse report to the provider
the client uses garlic as a daily supplement (garlic enhances bleeding)
A nurse is preparing an in-service presentation about preventing health care associated infections (HAIs). The nurse should include which of the following as a common cause of these infections
urinary catheterization
A nurse is preparing an injection using a single dose glass ampule. Which of the following actions should the nurse take?
use a filtered needle to draw up the medication
A nurse is preparing a presentation for coworkers about the various herbal remedies clients my report using. Which of the following should she include as an herbal supplement clients might use to treat insomnia
valerian
A nurse in an urgent care center is collecting data from a client who reports taking an excessive amount of acetaminophen. Which of the followings should the nurse identify as an indication of acute acetaminophen toxicity
vomiting
A nurse is collecting data from a client who is postoperative from a mastectomy and was administered hydromorphone 1 hour ago. The nurse should identify that which of the following findings is an adverse effect of this medication
vomiting
A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should be nurse take
wash the puncture site with soap and water
