Final
8 month; febrile seizure; weighs 17 lb; order 270 mg every 12 hr;sends 500 mg; add 2ml; administer how many ml
1.08
recently had a bowel resection; HGB 8, HCT 30%; triple lumen central cath at 125; orders; how many mL to document
1470
weighs 165 with pulmonary embolus; receive heparin 20 units/kg/hr; how many units each hour
1500
deep vein thrombosis has IV infusion of heparin infusing at 1500 units/hr; concentration is 25000 units/500ml; ml after 8 hr shift
240
deep vein thrombosis; heparin 1500 units/hr; concentration 2500/500ml; 12 hr; infuse how many ml
360
furosemide 40 mg; furosemide 10mg/ml available; how many mL
4
acute otitis media; ordered cefpodoxime proxetil 5mg/kg every 12 hours; weight 22 lb; how many mg
50
expectant mother about breastfeeding; immediate follow up
I have been HIV positive for 4 years
childs atopic dermatitis; topical application of hydrocortisone cream twice daily; effective teaching
I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently
new nurse says uncomfortable assessing a fetus from the fetal monitor strip
I'll go with you to interpret this strip and then we'll look at several others
evaluating pregnant clients knowledge of symptoms to report immediately; understands information
If i have blurred or double vision, I should call the clinic immediately
anxious to know her baby's due date; Nageles rule: correct to state which comment when discussing the use of the rule
Nageles rule provides a good approximation of due date I will add 7 days to the first day of my last menstrual period and count back 3 months Nageles rule may be used in conjunction with other assessment findings
antenatal clinic; brother was born with cystic fibrosis; include what information
To inherit CF; each parent must carry a recessive trait for the disease if both parents carry the trait, each offspring has 25% change of inheriting the disease Chorionic villi sampling can identify prenatally if their child carries the trait or has the disease
teaching parents about the risk of airway obstruction in young children; info appropriate to share regarding risk of obstruction
a small airway makes it easier for foreign objects to cause obstruction
ED with crushing chest injuries sustained in a car accident; respiratory status; sign indicates complication to report to HCP immediately
absent breath sounds on affected side
IV antibiotic in ED; 15 min client reports itching, SOB, difficulty swallowing; interventions to implement
administer epi per order discontinue medication apply oxygen
26 year old primigravida 40 weeks; meconium staining; after 1 hour of IV oxytocin; late fetal heart rate decelerations; do next
administer oxygen at 8 to 10 L by mask
active labor suddenly sits up and says "I can't breathe! my chest hurts really bad!" turns dusky gray color
administer oxygen by face mask
3 year old with acetaminophen poisioning; acetylcysteine every 4 hours for 72 hrs; lab finding confirm effectiveness of this drug
alanine aminotransferase and asparate aminotransferase
cesarean birth 12 hours ago; distended abdomen with faint bowel sounds x 1 quadrant, fundus firm at umbilicus, lochia scant; nurse do first
ambulate the client from the bed to the hallway and back
physician orders digoxin for client with HF; immediately before administering this drug; check clients
apical pulse
4 year old, pediatric office; upper respiratory symptoms and fever for 2 days; viral illness and treat with rest, fluids, antipyretics; question what order
aspirin 294 mg q6h with intermittent doses of acetaminophen 217 mg q4h
priority intervention for toddler who has just had hip spica cast
assess sensation, circulation, motion of child's feet and toes
2 hour old newborn; nasal flaring and acrocyanosis; priority intervention
assess the newborns oxygen sat
ECT; most important intervention
assessing the clients vital signs
nurse and NA; task to delegate to NA
assisting adolescent dx with paraplegia with a meal
active genital herpes admitted to labor and birth unit; first stage of labor; type of birth should nurse anticipate
cesarean
actions most likely ensure correct client receives a medication
check the name on armband with name on medication compare date of birth on the clients medical record
deep vein thrombosis; change in assessment findings does the nurse find most concerning
chest pain and dyspnea
highest to lowest priority; after receiving morning report
cirrhosis; confused and disoriented acute pancreatitis 1 day postop cholecystectomy hepatitis B
assessment findings would lead the nurse to suspect that the client has an addiction to pain medication
client compulsively uses the pain medication client loses control of use of pain medication client continues use of pain medication despite of risk or harm
ED with parents; abdominal pain 8 and low grade fever; most serious assessment finding
client has rigid, boardlike abdomen
older adult; acute respiratory distress has become confused and disoriented; picking invisible items off blankets; alprazolam; safety measures
client will be placed on withdrawal precautions and treatment started immediately prescription should be obtained to help with hallucinations client's medical and mental status will be evaluated frequently and treated as needed
late decelerations on external fetal monitor; actions in plan of care
contact HCP administer oxygen change clients position
admitting neonate; mother received mag sulfate; assess baby for what complication
decreased muscle tone decreased respirations
diabetes mellitus who is in labor; trouble controlling blood glucose level; didn't take insulin; fruity odor to breath
diabetic ketoacidosis
13 year old; anorexia nervosa; IV fluid therapy and nutritional mgmt; weight gain; nursing dx
disturbed body image
pneumonia refuses prescribed oral antibiotic; alert and oriented, vital signs within normal range, crackles scattered; nurse perform
document that the client refused to take medication address the clients concern about medication by clarifying its purpose notify physician
vaginal birth 1 hour ago voices anxiety because she has a nephew with down syndrome; additional teaching
down syndrome is an abnormality that can result from a missing chromosome
client in a coma; suffered a closed head injury; intervention implement to prevent increase in ICP
elevate the head of the bed 15 to 30 degrees
ED; right sided dull, abdominal and flank pain, nausea, vomiting; temp 101.2, pain 10, rebound tenderness; orders to question
enemas until clear regular diet
hour old newborn; observations nurse note as being abnormal
expiratory grunting temperature 97.4 nasal flaring
32 year old primigravida 39 weeks; active labor; Leopolds maneuvers; why; major purpose
fetal presentation
administering IV fluids to infant; vulnerable to
fluid overload
celiac disease; how long must I stay on this diet; response
for the rest of his life
neonate 4 hours of age; heart murmur; what should the nurse do
further assess for signs of distress
lung cancer; cared for by wife at home; pain increasing in severity; teaching effective when wife uses which pain relief strategies
gives husband long acting or sustained release oral med around the clock use immediate release med for breakthrough pain uses music for distraction as well as heat or cold has husband use pain rating scale
discharge care with parents of 16 year old; attempted suicide; advise parents to notify HCP immediately for
giving away valued personal items
32 weeks gestation; mild preeclampsia; home with instructions to remain on bed rest; call HCP if she experiences
headache blurred vision epigastric pain severe nausea and vomiting
retroperitoneal abscess; receiving gentamicin 300 mg IV every 8 hrs; monitor
hearing urine output BUN and creatinine
abdominal aortic aneurysm; prior to surgery, assess for what that puts the client at risk for rupture
high blood pressure
dizziness and requests to go back to the room; P 50, BP 80/40; verapamil and atenolol; actions best
hold the medications call HCP and report events and vitals
change of shift report on four clients; assess first
immobile client with a sudden onset of shortness of breath
ammonia level elevated; HCP prescribes 30 mL of lactulose; effect is common
increased bowel movements
expected outcome when a client is receiving IV administration of furosemide
increased urine output
preterm infant 2 hours ago; rapid respirations, grunting, no breath sounds on one side, shift in location of heart sounds; assist with
insertion of chest tube into the neonate
school nurse reporting back pain, fatigue, dyspnea; scoliosis; action
inspect for uneven shoulder height or hip height
diagnosis rule out leukemia and HCP performs bone marrow biopsy; do post biopsy
instruct client on the need to lie still administer analgesics as ordered monitor vital signs and assess site for bleeding
recovering from an acute asthma attack experiences respiratory alkalosis; respiratory rate of 46, HR 110, BP 162/90, temp 98.6; help improve respiratory alkalosis
instruct the client to breathe into a paper bag
11 year old; asthma attack; immediate intervention
intercostal retractions
mental status change may occur; pneumonia is first experiencing hypoxia
irritability
crutches at home for 1 week; trouble using because armpits hurt and fingers tingle; tell client
let me watch you ambulate. your crutches or technique may need some adjustment
postpartum assessment; parameters should nurse include in assessment
lochia fundus bowel sounds bladder
mag sulfate by IV drip; eclampsia at 32 weeks gestation; medication is having therapeutic effect
mag level of 2.4 blood pressure 120/60 absence of seizures
basis for teaching plan about avoiding nonprescription medication for primiparous client who is breastfeeding
medications may be excreted in breast milk to the nursing neonate
receiving dopamine hydrochloride for treatment of shock; action to take
monitor blood pressure continuously
acute myocardial infarction receiving nitroglycerin; statement indicates therapeutic effect
my chest pain is decreasing
assessing neurovascular status of right arm; cast; notify HCP with what symptom
nail bed capillary refill of 10 seconds
neurological assessment on 1 day old; possible asphyxia in utero
neonates toes do not fan out when soles of the feet are stroked neonate doesnt respond when nurse claps her hands above him neonate displays weak, ineffective sucking
LPN acting inappropriately and smells of alcohol; step should charge nurse take
notify shift supervisor and rearrange the client care assignment
assess pain in 18 mon old
observce for behavioral changes
neurological unit completed assessment on five clients; task to delegate to the NA
obtain an oxygen sat
newborn who has developed sepsis; order to implement first
obtain blood cultures
blood gases; acute respiratory distress syndrome; respiratory acidosis
pH 7.25, PACO2 48, HCO3 24
ED receives ABG results on four clients; lab result requires immediate intervention
pH 7.28, PaCO2 60, PaO2 58
ABG on four clients; report immediately to the HCP
pH 7.31, PaO2 84 mm Hg, PaCO2 50, O2 sat 90%
ABG results will the nurse investigate first
pH 7.94, PaCO2 30, PaO2 75, HCO3 22
CPR; finding indicates external chest compressions are effective
palpable pulse
child with tetralogy of Fallot; why clubbed fingers; due to
peripheral hypoxia
findings in newborn would require the nurse to notify HCP
positive ortolani's sign absence of moro reflex
3 year old acute kidney injury; lab finding should immediately report to HCP
potassium level 6.5
fetal malpresentation, green amniotic fluid, FHR 98; priority intervention
prepare for an emergency cesarean birth
what oral contraceptive is considered safe for use while breastfeeding because it will not affect the breast milk once breastfeeding has been well established
progestin
chest pain rated 8 on a 10 scale; 12 lead reveals ST elevation in inferior leads and troponin levels elevated; do first
reduce pain and myocardial oxygen demand
6 year old how to administer eye drops for bacterial conjunctivitis; include
remove any drainage from eye prior to administration of eye drops after administration of eye drops, keep the eye lid closed for several seconds
school teachers about seizures; generalized tonic clonic; action performed first; teaching successful
remove any nearby objects that could harm the child
toddler admitted; physically abused by mother; required to
report the case to local authorities
pneumonia; sudden SOB; ABG pH 7.21, PaCO2 64, HCO3 24; reflects
respiratory acidosis
client after lung biopsy; assessment finding requires immediate intervention
respiratory rate of 44 breaths/minute
after bronchoscopy under local anesthesia; the nurse should
restrict oral intake until the gag reflex returns
administering medication; rights
right client right dose right medication right time right route
suicidal risk in children and adolescents require the nurse to know what information
risk of suicide increases during adolescence, with those who have recently suffered a loss, abuse, or family discord
newborn exposed to drugs while in utero; behaviors expect the newborn to exhibit
tachypnea with excessive secretions sensitive gag reflex hyperactivity and increased muscle tone
throbbing headache when nitroglycerin is taken for angina; nurse instruct client to do
take acetaminophen or ibuprofen
type 1 diabetes monitoring blood glucose level at home; understands appropriate care mgmt strategies; level 250
taking insulin
she fell from the sofa an hour ago and has not been herself since; unsure of time and other facts; most effective in obtaining more info
tell me what was happening before she fell
28 weeks pregnant is admitted for testing; best explains why pregnant should lie on her left side when resting or sleeping in the later stages of pregnancy
to prevent compression of the vena cava
sexually abused as children; mutilate themselves; how does interpret this behavior
use of physical pain to avoid dealing with emotional pain
newly ordered narcotic medication' safety steps included
verify HCP order assess the client for allergies identify the client assess client's pain level
priority instruction; medication for active tuberculosis
you must comply with the medication regimen to treat TB
