Fund Saunders

Report the finding to the registered nurse. Gather data from the client related to signs of toxicity.

A nurse about to give a daily dose of digoxin and notes that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL. The nurse should take which actions? Select all that apply.

Preventing and recognizing hyperglycemia

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure?

Antistreptolysin titer

A lethargic, pale child is brought to the primary health care provider's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the mother if the child has had any recent infections, to which the mother responds that the child had a very sore throat a few weeks ago. The primary health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which laboratory test would rule out a past streptococcal infection in the child?

Baked turkey

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet?

Institute contact precautions

After attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4-day period with fever; an itchy, reddish brown papule; and complaints of nausea, vomiting, and severe abdominal pain. Cutaneous anthrax is suspected by the health care team. Which is the nurse's priority for client care?

Insert the suppository 1 to 2 cm into the rectum

The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action?

Notify the primary health care provider (PHCP) of the client's signs and symptoms.

A client receiving enteral feedings develops abdominal distention and diarrhea shortly after initiation of the feedings. Which is the appropriate intervention for the nurse to implement?

Occult blood

A client who has been prescribed indomethacin for gout is asked to provide a stool sample for guaiac testing. The nurse explains that the purpose of the test is to make which determination?

The CD4+ count is measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. The CD4+ count is used to determine the child's immune status The CD4+ count is used to identify the risk for disease progression. The CD4+ count identifies the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age. More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered.

A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The mother asks the nurse about the purpose of the test and why the test needs to be done if it is already known that the child has HIV. The nurse should reinforce which information to the mother? Select all that apply.

"Tube feedings can provide adequate amounts of required nutrients."

A caregiver states that the client eats only about 25% of the food that is offered and is losing weight. The caregiver asks the nurse about feeding the client by a tube into the stomach. Which initial response by the nurse would be appropriate?

Monitoring for the gag reflex

A client has just undergone a gastroscopy. Which action should be taken by the nurse as the essential postprocedure nursing intervention?

Aspirin Furosemide Gentamycin

A seriously ill client in the hospital tells the nurse that he thinks he has lost some of his ability to hear over the past few days. The nurse reviews the medications the client is currently receiving. Which medications are known to be ototoxic? Select all that apply.

Potassium 5.4 mEq/L

An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory should be most concerned with which result?

The test requires the client to lie still for short intervals.

An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. Which should the nurse explain to the client about this test?

A

The client is to receive a soapsuds enema. Which is the best position for administering an enema? Refer to figure.

I know I need to monitor my infant's stools, and if there are more than four stools a day, I will increase the pancreatic enzyme."

The mother of an infant newly diagnosed with cystic fibrosis is being taught proper nutritional needs for the infant. The nurse determines that the mother understands nutritional needs when the mother gives which response?

Handgrips are positioned so the elbows are bent approximately 30 degrees The space between the axilla and the top of the crutch pad is 1½ to 2 inches. The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.

The nurse determines that the client has a proper fitting of the crutches when which criteria have been fulfilled? Select all that apply.

Observe the incision line for redness and drainage. Change gloves between removal of the old dressing and applying the new.

The nurse is changing a dressing on the wound of a postsurgical client who is receiving contact precautions because of a history of methicillin-resistant Staphylococcus aureus (MRSA) from a previous surgery. Which interventions should the nurse follow? Select all that apply.

Use indwelling urinary catheters judiciously. Remove indwelling catheters when no longer needed. Use strict aseptic technique when inserting all urinary catheters.

Which are the most important interventions that can help reduce the incidence of hospital-acquired urinary catheter infections? Select all that apply.

Warfarin Glimepiride Amlodipine

he nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to consult with the registered nurse if the client is also taking which medications? Select all that apply.

Cool, clear liquids

A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which items during an episode of nausea?

Notify the RN about the value immediately

A licensed practical nurse (LPN) is assisting in the care of a client receiving a continuous intravenous (IV) infusion of heparin sodium for deep vein thrombosis (DVT). The LPN notes that the result of a newly drawn activated partial thromboplastin time (aPTT) level is 90 seconds. The client's baseline before the initiation of therapy was 30 seconds. The LPN should take which action?

"I need to breastfeed my baby."

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that the need for further teaching is necessary when the client makes which statement?

HIV testing of the newborn within 48 hours Antiretroviral prophylaxis for newborns testing HIV positive. Periodic testing for HIV at set intervals until the age of 6 months.

A primary health care provider is caring for a client who is human immunodeficiency virus (HIV) positive and has delivered a newborn baby. The nurse anticipates which interventions should be employed for the newborn to decrease the risk of HIV. Select all that apply.

Allergy to shellfish

The nurse is assisting in preparing a client for a cardiac catheterization. The nurse understands that it is important to check the client's record for which history?

Frequency of bowel movements

The nurse is assisting in the care of a client receiving codeine sulfate for pain. The nurse should make note of which finding to detect an adverse effect of this medication?

"Fresh foods such as fruits and vegetables are high in sodium."

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?

Remove any necklaces before presenting for the procedure. Avoid applying skin lotion on the day of the test.

The nurse has just confirmed that a client has been scheduled for a mammogram for the following week. The nurse reinforces that the client should take which actions? Select all that apply.

It is all right to drive an hour after the test is finished.

The nurse has reinforced postprocedure instructions to a client who has undergone a colonoscopy. The nurse determines that there is a need for further teaching if the client makes which statement?

300 units/L

The nurse is assigned to a hospitalized client with chronic pancreatitis. The nurse reviews the client's record and expects to note a serum amylase level that is most like which value?

Promoting venous return to the heart

The nurse is assigned to assist in caring for a client who has had surgery and has pneumatic sequential compression devices (SCDs) in place. The client asks about these devices. The nurse instructs the client that SCDs are used for which purpose?

Checking color, sensation, and pulses distal to the restraints

The nurse is caring for a child following a cleft palate repair who has elbow restraints in place. The nurse assists in preparing a plan of care and determines that which nursing intervention should receive highest priority regarding the restraints?

Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through the saliva.

The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members. Which instructions should the nurse reinforce to the mother?

Securing the oxygen tubing to the client's bottom sheet Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible

The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply.

It helps to make sure that the primary health care provider is aware of all of the medications the client is taking and has been taking at home.

The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?

Removes gloves and immediately uses computer to document care Uses soap and water to wash hands for 5 seconds and then dries hands Empties collection bag of an indwelling urinary catheter without wearing gloves

The nurse is working with an unlicensed assistive personnel (UAP) to care for clients. While observing the UAP's delivery of care, the nurse notes which actions by the UAP that indicates the need for further teaching regarding standard precautions? Select all that apply.

The client's temperature The date the specimen was drawn The time the specimen was drawn Any supplemental oxygen the client is receiving

The nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which data will be needed by the laboratory for adequate evaluation of the specimen? Select all that apply.

Milk Wild caught salmon

The nurse is instructing a client with osteomalacia about appropriate food items to include in the diet. Which food items should be included in the client's diet? Select all that apply.

Clamp the NG tube for 30 minutes after medication administration. Before medication administration, verify correct placement of tube. Flush the NG tube with saline before and after medication administration. Discontinue the suction from the tube during administration of medication.

The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply.

Listen to the client's bowel sounds. Question the client regarding nausea. Determine whether the client has abdominal distension. Hold the feeding after flushing the tubing with 30 mL saline.

The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric (NG) tube. The nurse checks the residual and obtains an amount of 200 mL. Which actions should the nurse take? Select all that apply.

"I need to refer to medication as 'candy' only when really necessary." "I can place several medications in the same bottle if I am going for an overnight trip."

The nurse is reinforcing instructions about home safety measures regarding medications and toxic substances to a parent. Which parent statements indicate a need for further teaching? Select all that apply.

Placing the scan head on the symphysis pubis and aiming toward the bladder Applying a generous amount of transmission/conductivity gel across the client's abdomen

The nurse observes a student nurse using a bladder scanner to determine a postoperative hysterectomy client's post-void residual (PVR). Which actions observed demonstrate the need for further teaching? Select all that apply.

A client who was admitted 2 days ago with a pelvic fracture

The nurse on a medical unit is instructing the unlicensed assistive personnel (UAP) regarding toileting needs of the assigned clients. The nurse should instruct the UAP to prepare to assist which client first?

dry mouth

The nurse prepares to administer a prescribed dose of scopolamine. The nurse should monitor for which side effect of this medication?

Kiwi Bananas Avocados

The nurse teaches the family of an infant with spina bifida that the infant should not be given which baby foods that may trigger a latex-type food allergy? Select all that apply.

Change dressing as needed. Change infusion tubing every 24 hours. Use strict aseptic technique when caring for the catheter.

A client has arrived back to the nursing unit from special procedures with an epidural catheter in place for pain control. The nurse is revising the plan of care to reflect the epidural catheter and the interventions needed to prevent infection at the site. Which interventions should the nurse include in the plan of care? Select all that apply.

Providing information about the blood vessels

A client is scheduled for a digital subtraction angiography (DSA). The nurse tells the client that the test is directed toward which outcome?

Troponin I

A client is seen in the urgent care center for complaints of chest pain 2 days ago. Since that time, the client has not been feeling well and fatigues easily. The nurse reviews the results of the laboratory tests. An elevation of which laboratory test indicates a myocardial infarction occurred at the time of chest pain 2 days ago?

Red meat

A clinic nurse has given a client the materials needed to test the stool for occult blood as part of a routine screening for colorectal cancer. When the client asks the nurse whether there are any special precautions that must be followed in doing this test, the nurse tells the client to avoid eating which food for at least a day before performing the test?

Eggs Chicken

The nurse is reinforcing instructions to a client about complete/high quality protein foods. Which food choices would indicate the client understood the teaching? Select all that apply.