h
A client is prescribed lorazepam (Ativan) 0.5 mg oral suspension every 6 hours as needed for anxiety. The medication is available as 2 mg/mL oral suspension. How many mL of the medication will the PN provide for each dose?
0.3 mL
A client prescribed to receive terbutaline sulfate (Brethren) 0.25 mg subcutaneous injection three times a dat at 6 hour intervals. The medication is available as 1 mg/mL. How many mL of the medication will the PN provide to the client for one day?
0.75
A client has a prescription to discontinue intravenous therapy when the liter that is infusing at 150 mL per hour is...1200 the PN notes that there are 750 ml of solution remaining.At what time should the nurse expect to discontinue the intravenous therapy?
1700
A male client receives a prescription for 3,000 mg of medication daily, which is available...taken twice daily in equal dosages.How many tablets should the PN...
3
77 After three weeks of antibiotic therapy, a child who weighs 55 pounds develops painful oral lesions, so the heal care provider prescribes acyclovir (Zovirax) 20 mg/kg daily. How many mg should the PN administer to this child?
500
Based on the principle of asepsis the PN should consider which situation to be sterile?
An open Foley catheter kit set up on a table at the PN waist level
put in order Remove existing tubing and spike new tubing into bag Clamp the IV catheter and attach the new tubing Unclamp the tubing and IV catheter and begin to infusion Assess the condition of IV site Loosen tape that secures the existing tubingAssess the condition of IV site
Assess the condition of IV site Loosen tape that secures the existing tubing Remove existing tubing and spike new tubing into bag Clamp the IV catheter and attach the new tubing Unclamp the tubing and IV catheter and begin to infusion
The PN assesses a moon-shaped face and muscle wasting in a client receiving dexamethasone (Decadron). What will these manifestations suggest to the PN?
Cushings syndrome
The hearing of ringing in the ears what medication should be reported to the Health provider ?
Gentamicin
Why would the PN schedule physical therapy in the morning for a client with myasthenia gravis?
The muscles are strongest in the morning
... he is accompanied by his male partner, who is ... PN asks the client. when the PN asks the partner to leave the room the partner refuses to go. the PN suspects the injuries may be result of .... take? a arrange to take the client to the operating room holding are for privacy b tell the partner that security will need to be called if he does not comply c ask the client if he wants his partner to leave the room during the preparation d inform the partner that it is hospital protocol for the client to answer questions
a
61 A client with a fractured left hip fracture is in Bucks's traction. The PN should expect the client to exhibit which outcome? a the left foot is warm to touch with a palpable dorsalis pedis pulse b decreased peripheral pulses and capillary refill >3 seconds in the left foot c a positive Homan's sign in the left calf d a burning, tingling sensation under the left foam boot
a
73 Immediately after birth, which nursing intervention has the highest priority for the newborn infant? a preventing heat loss and neonatal cold stress b placing the neonate to the breast c administering ophthalmic antibiotic ointment d evaluating the neonate's 1 and 5 minute Apgar scores
a
83 After report, the PN receives the laboratory values for four clients. Which client requires the PNs immediate intervention? a client who is trembling and has a glucose level of 50 mg/dl b a client who has hemoglobin of 8 grams and is short of breath after a shower c a client who is febrile and has a WBC count of 14,000/mm3 d a client whose prothrombin time is 30 seconds and finger stick site is bleeding
a
99 which product should the PN provide to ensure effective oral care for a client undergoing chemotherapy? a soft-bristled toothbrush b mint-flavored dental floss c alcohol-based antibacterial mouthwash d water pressure gum cleaner
a
A client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug? a provide oral care b give water c do nothing d mouthwash
a
A clients chief complaint is being able to swallow only small bites of solid food...PN should assess for what additional information? a history of alcohol and tobacco use b daily consumption of hot beverages c past traumatic injury to the neck d daily dietary intake of roughage
a
A young adult male tells the PN he has declared to change his hours at work so that he can...his community. Which stage of Maslow's development is this young adult attempting to achieve? a Self actualization b Purposefulness c Intimacy versus isolation d Altruisma
a
After applying alcohol based hand rub to the palms of the hand and rubbing paps together what action should the PN take next? a place hands on top of each other and interlace fingers b I am uncomfortable performing a skill which I am not certified c on the stronger side of the body d measure appropriate vital signs
a
An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the the PN, who is taking the client the clients vital signs. What action should the PN implement ? a reinforce the needs for extra rest periods and plenty of sleep b offer to reschedule for treatment for the following week c plan to monitor the client's vital signs every thirty minutes d notify the healthcare provider or charge nurse immediately
a
The PN is caring for a client whose urine drug screen is positive for...exhibit during cocaine withdrawal? a powerful craving for more b elevated energy level c high self-esteem d euphoria
a
a 18 year old female client with pelvic inflammatory disease asks the PN "how...." which information is the best for PN to provide? a a history of untreated gonorrhea can lead to PID b PID is related to a flare-up of genital warts c there is no known cause attributed to PID d PID can result from inadequate perineal cleansing
a
an adolescent male with severe acne recently started treatment with isotretinoin, a form of vitamin A. During a follow-up clinic appointment, which assessment is most important for the PN to complete? a ask about occurrence and frequency of nosebleeds b measure the number and size of acne cysts c assess for dry mouth and chapping of the lips d discuss the client's feelings and emotions
a
A 3 year old child returns to the pediatricians' office for a postoperative visit after having a procedure. The PN should expect to observe which behavior? a Plays doctor and nurse with dolls b Points to the nose and says nose c Cuts out and pastes pictures d Plays a board game with another child
a Plays doctor and nurse with dolls
The PN is assisting an unsteady client to ambulate from the bed to the ba client loses balance and falls into the beside table. What actions should the PN take first? a Stay with the client and call for assistance b Assist the client back to bed c Take the client vital signs d Reassure the client that everything will be okay
a Stay with the client and call for assistance
The PN is assigned the care of four clients on a medical-surgical...prioritze client assessments put in order an older male adult with Alzheimer's who wanders out of the room a client who is admitted with a suspected ruptured appendix a client who is post lumbar puncture is reporting a severe headache a postoperative client who needs reenforcement of discharge instructions
a client who is admitted with a suspected ruptured appendix a client who is post lumbar puncture is reporting a severe headache an older male adult with Alzheimer's who wanders out of the room a postoperative client who needs reenforcement of discharge instructions
64 A resident of a long-term care facility who has a drainage stage 2 pressure ulcer receives a prescription for sterile, warm, moist compress q12 hours for 20 minutes to the site. What precautions should the PN take when performing this procedure? select all that apply. a remove soiled dressings with procedure gloved and don sterile gloves for moist dressing application b place 4x4 gauze sponges on the pressure ulcer and pour warmed water on the dressed site c apply moisture resistant cover over the saturated dressing during the 20 minute application d pour warmed sterile solution to an open sterile dressing tray that contained sterile gauze pads e after the procedure, place all supplies and dressings into the trash can for removal from the bedside
abd
A mother brings her 5-year old child to the clinic for school physical examinations. Which assessment... PN that intergenerational violence may be occurring in the home? a The 6-year old son hits his younger sister during the interview b The adolescent daughter rolls her eyes at her mother's comment c The 10-year old daughter has circular burns on her trunk and legs d The 3-year old has multiple bruises on the chest and both legs e The 3 month old is crying because the mother says it is feeding time
acd
While measuring an orthostatic blood pressure the client becomes dizzy. What would the PN do?
assist the client to site down
103 In administering nystatin suspension to the gums of an infant with a candida infection, which approach should the PN take? a draw up the medication in a needle less syringe which the infant can suck b use a gloved finger to rub the suspension over the infected area c irritate the infected area with medicated solution after applying sterile gloves d measure the prescribed amount of solution into the infant's bottle
b
104 While the PN and UAP are turning a client with an abdominal incision, the clients incision eviscerate. Which task is best for the PN to assign to the UAP? a cover the wound b gather supplies c keep the client calm d reposition the client
b
14 A client with Alzheimers disease (AD) is receiving trazadone (Desyrel) a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the clients mood and sleep patterns are improved but there is no change in cognitive ability. How should the nurse respond to this information? a explain that it may take several weeks for the medication to be effective b confirm that the desired effect of medication has been achieved c notify the healthcare provider that a change in dosage may be needed d evaluate when and how the medication is being administered to the client
b
50 The PN is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. what is most important to reinforce in this clients plan of care? a precaution about avoiding sunlight b interventions to decrease emotional stress c instructions about applying an anti-fungal ointment d strategies to increase omega 3 fatty acids in the diet
b
56 when the PN plans daily care for a group pf clients, which client should the PN see first due to the risk of complication? a young adult reporting pain following gall bladder surgery b an older client with a stroke who is febrile and confused c a middle aged client with blood pressure of 140/88 d an adult client with a peptic ulcer who is feeling nauseated
b
57 which foot care instructions is most important for the PN to reinforce that minimizes a Long term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)? a make sure shoe size fits to minimize rubbing and blisters b report any foot injury or sore that does not readily heal c monitor finger stick glucose daily for tight control d after washing feet, dry thoroughly between toes
b
69 To obtain an estimate of a clients systolic blood pressure, what action should the PN take first? a release the blood pressure cuff valve b palpate the client's brachial pulse c pump up the blood pressure cuff d position the stethoscope diaphragm
b
88 During recovery after the delivery of a normal infant a client is receiving...ringers 1000 mL with oxytocin 20 units. The PN should evaluate the client for which therapeutic response? a delivery of the placenta b stimulation of uterine contractions c promotion of the let down reflex d return uterus to a pre-pregnancy size
b
89 The spouse of a hospitalized client asks the PN for acetaminophen for a tension headache. Which action should the PN take? a give the spouse acetaminophen from the nurse's personal supply b explain that medication can only be provided to clients c determine if the spouse has any medication allergies d request the pharmacy to send acetaminophen to the unit
b
A 28-year old client is in active labor and complains of a cramp in her leg. What intervention should the PN implement? a Massage the calf and foot b Extend the leg and flex the food c Check the pedal pulse in the affected leg d Elevate the leg above the heart
b
A client recovering from a stroke is learning how to use a cane. How should it be placed? a weak side b on the stronger side of body c 2 inches to the left side d 2 inches to right side
b
A female Native American client who is receiving chemotherapy places a native artifact...the health care provider removes the medicine wheel and tells the client "this type..hospital" what intervention should the PN implement ? a Report the client's feeling of culture shock to the health care provider b Act as the client's advocate when discussing the issue with the health care provider c Consult with a native american healer regarding proper use of the medicine wheel d Teach the client the importance of implementing the prescribed chemotherapy regimen
b
A female client arrives to the clinic for an annal physical examination. when reviewing...the PN that she takes herbs for high blood pressure instead of the prescribed..important for the PN to reinforce with the client? a Tell the client to rise carefully when standing from a sitting or lying position b Explain the risks associated with using herbs instead of prescribed antihypertensive c Keep a log of blood pressure measurements taken at the same time each day d Inform client that herbal supplements can interact with prescribed antihypertensive
b
A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal with breast engorgement and discomfort? a Take acetaminophen as needed b Wear a supportive bra at all times c Apply a heating pad to the breasts d Manually express breast milk
b
A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take? a Check for engorgement and check the nipples for cracks or lesions b Ensure that all the areolar tissue of the nipple is in the infant mouth c Have the mother reposition the infant from the cradle to the football hold d Apply an ice pack to the breast for 10 minutes before each feeding
b
A new mother is breastfeeding her newborn for the first time and complains of nipple pain when the baby sucks. What should the nurse tell the mom? a she needs to deal with it b ensure that all the areolar tissue of the nipple is in the infants mouth c apply ointment d stop breastfeeding
b
Because of staffing shortages the charge nurse assigns a PN to perform a skill which the PN is not yet certified to perform what is the best response by the PN? a do the task anyway b I am uncomfortable performing a skill which I am not certified c I am not going to do it d No
b
Before inserting medication into a clients vagina, what instructions should the pn... a Place feet in stirrups b Urinate until bladder is empty c Bear down during insertion d Contract pelvic muscles
b
Client with Hungtingtons disease starts jerking around while the family is there what should the PN do? a tell him to stop b offer emotional support to family c ignore it d report to charge nurse
b
The PN is with a client when the health care provider explains that the..tumor.Later in the morning the client asks the PN "What do the letters T,N,M: star for? a are you confused? would you like to talk? b the letters stand for tumor size, node involvement, and metastasis c let me refer you to the charge nurse d the letters are used to predict the prognosis of the cancer or tumor
b
The PN is working the day shift in a long term facility and is preparing..delegate to the UAP to perform during the change of shift? a Assess the pain level of each client and provide comfort measures as indicated b Total the clients PO intake, fill the water pitchers, empty urinals and catheter bags c Mark NG tube suction canisters and empty wound drainage collection units d Assist two postoperative clients on the unit to ambulate in the hallway
b
The PN notes that an elderly client has developed nonproductive...the previous day. Vital signs are temperature 99.8 F; pulse 94; respirations 22; and BP...important for the PN to implement? a monitor the client's temperature hourly b report the findings to the charge nurse c provide care to moisten oral mucosa d offer the client fluids frequently
b
The PN obtains a finger stick glucose for a client with type 1 diabetes mellitus who is conscious and demonstrating hand tremors and shaking. The PN reports the clients result of 55 mg/dL to the nurse. What action should the PN implement next? a assist the RN with initiating an IV access and saline lock b provide the client of glass of milk and crackers c give a prescribed dose of glucagon IM d administer a dose of regular insulin per sliding scale
b
While performing the apical pulse of an adult male client the PN notes that the point of maximal impulse is located at the 4th intercostals space medial to the midclavicular line what is the assessment for? a abnormal b expected finding c needs to notify RN d do it again
b
While taking the vital signs of a older male client who takes psychotropic medication...uncontrollable hand movements ad is excessively blinking his eyes, which information..? a Recent urine drug screen report b Screening for tardive dyskinesia c Prescription for lorazepam d History of parkinson's disease
b
A male client who is admitted the morning of his scheduled surgery tells the pn that he drank a glass of water last night. What interventions will the PN implement first? a Reassure the client that a small amount of water is not harmful b Determine the amount of water and exact time it was taken c Auscultate the client for bowel and ability to urinate d Notify the healthcare provider of the client's fluid intake
b Determine the amount of water and exact time it was taken
The PN reviews the procedure for measuring fluid intake and output ...glomerulonephritis and is preparing for discharge from the hospital. What... select all that apply a Fluid intake needs to be the same amount every day b Why the fluid measurements need to be recorded c The importance of recording output every hour d Which food types are included when measuring fluid intake e What container to use for the most accurate measurement
b c d
The PN administers an antibiotic to a client with a respiratory tract infection...evaluate the medications effectiveness, which laboratory values should the PN monitor? select all that apply a prothrombin time b sputum culture and sensitivity c capillary glucose d white blood cell count e serum potassium f urinalysis
bd
The PN is making shift assignment at an extended care rehabilitation...assign to the UAP a recent admission of a client with recurrent transient ischemic attacks b Toileting assistance for a client receiving therapy after a total hip replacement c pain management for a client with patient controlled analgesia pump d daily skin care for a client with a descending double barrel colostomy d morning care for a client with a staph wound infection
bde
10 when assessing an adult male who present at the community health clinic with a history of hypertension the nurse notes that he has 2+ pitting edema in both ankles. he also has a history of gastroesophogeal reflux disease and depression. which interventions is most important for the PN to implement? a arrange to transport the client to the hospital b instruct the cleint to keep a food journal, including portion size c review the client' use of over the counter (OTC) medications d reinforce the importance if keeping feet elevated
c
105 A client develops generalized edema associated with chronic kidney disease (CKD). The PN understands the formation of the edema is the result of which physiological process? a inflammation of the vessel intima resulting in an aggregation of immune complexes b decreased capillary hydrostatic pressure releasing atrial natriuretic hormone (ANH) c plasma protein resulting in decreased oncotic pressure within the vessels d increase in the serum osmolality influencing a decreased release of vasopressin
c
60 During a clinic visit for a sore throat a clients basal metabolic panel reveals a serum potassium of 3.0 mEq/L. Which action should the PN recommend to the client based on this finding? a force liquid intake to 1,500 ml daily b encourage use of a soft toothbrush c increase intake of dried peached and apricots d reduce intake of red meats
c
63 Prior to giving digoxin, the PN assesses that a 2-month old infants heart rate is 120 beats/min. Based on this finding what action should the PN take? a request the charge nurse to administer the medication b withhold the medication until the next scheduled dose c give the medication and document the heart rate d withhold the medication and notify the charge nurse
c
65 A male client who is diagnosed with schizophrenia is taking an antipsychotic medication and calls the psychiatric clinic. The client tell the PN that he is achy and stiff, has a temperature of 103.4 F and is sweating. How should the PN respond to this client? a recommend that the client arrive at the clinic within the next 2 hours b tell the client a prescription will be called into the pharmacy by the psychiatrist c direct the client to obtain immediate transportation to the emergency center d suggest the client treat the flu-like symptoms with over the counter medication
c
66 The Glasgow coma scale is being used to monitor a client in the critical care unit. The scale is used to evaluate what client status? a mental status b cranial nerve status c level of consiouness d ability to communicate
c
67 A client is diagnosed with with hyperthyroidism. Which symptoms should the PN expect this client to exhibit? a bradycardia and constipation b lethargy and lack of appetite c muscle cramping and dry, flushed skin d palpitations and shortness of breath
c
74 The PN overhears a female client with Cushings syndrome tell her family in a...very loud and angry voice to leave her room and not come back. The response by the PN is baed on recognizing which common manifestation of the syndrome? a memory loss b impaired cognition c mood alterations d hearing loss
c
75 A 0800 a clients apical pulse rate is 98 beats/minute> Four hours later the apical pulse rate is 54 beats/minute. What action should the PN take next? a obtain blood glucose measurement b measure the apical radial deficit c determine the level of consciousness d auscultate for adventitious breath sounds
c
80 which client information is most important for the PN to consider when providing instructions to the UAP about providing morning care to a postoperative client? a oriented to person only b blood pressure of 144/84 c urinary output of 50 ml/hour d oxygen saturation measurement of 95-96%
c
81 A male client who was admitted with gangrene of the right lower extremity is confused ad his wife refuses to sign the operative permit for an above the knee amputation. What action should the PN take first? a explain the consequences of sepsis if the amputation is delayed b notify the RN that the client's wife needs further explanation about the procedure c encourage the client's wife to express concerns about making the decision d document on the client record the refusal for surgical treatment
c
92 A client with hypertension complains of a persistent dry cough. The PN should tell the client that this is a common side effect of which daily medication? a Clonidine (Catapres) b Spironolactone ( Aldactone) c Quinapril (Accupril) d Losartan (Cozaar)
c
93 The PN enters the room of a client who is disoriented and has a wrist restraint secured as seen in the picture what action should the PN take? photo is of hospital bed and restraint Is on the bed frame in a bow tie a raise the upper side rail b release the restraint tie c use a full knot to secure the restraint tie d secure the tie to the bathroom side rail
c
95 A new mother asks the pn about an area of swelling on her baby head that lies across the suture line near the posterior fontanel. How should the PN respond? a cephalhematoma causes no problems b caput succedaneum may need to be drained c caput succedaneum will be absorbed and cause no problems d cephalhematoma may cause jaundice as it is absorbed
c
98 A client who is primigravida at term comes to the prenatal clinic and tells the PN that she is having contractions every 5 minutes. The PN monitors the client for 1 hour using a external fetal monitor and determines that the clients contractions are 7 to 15 minutes apart lasting 20-30 seconds with mild intensity by palpation. What action should the PN take? a direct the client to check into the hospital within the next hour for evaluation of possible urinary tract infection b send the client home and tell her to drink at least 1,000 ml of fluid each day to flush her bladder c send the client home and instruct her to call the clinic when her contractions occur every 5 minutes apart for one hour d tell the client to go directly to the hospital for admission to labor and delivery for active labor
c
A client is complaining of a tightening sensation in the fingers, nose tip and ear lobes...24...PN should be prepared to implement what measure first? a prepare for emergency tracheotomy at the bedside b apply sequential compression devices bilaterally c obtain prescribed calcium gluconate for tetany d initiate prescribed l-thyroxine replacement therapy
c
A client on bed rest refuses to wear the prescribed pneumatic compression device after surgery, what action should the PN implement in response to the clients refusal ? a place hands on top of each other and interlace fingers b wear a supportive bra at all times c emphasize the importance of active foot flexion d I am uncomfortable performing a skill which I am not certified
c
A client with schizophrenia reports auditory hallucinations when admitted to the hospital. PN to include in the assessment of this client? a When are the voices most disturbing b How do you cope with the voices c What are the voices uttering? d Which medication works best
c
A client with type 2 diabetes becomes unresponsive and says I'm not feeling right which action should the PN take? a give him water b expected side effects c give 4 ounces of apple juice d give him milk
c
A new mother is bottle feeding instead of breastfeeding the PN should instruct the to most effective way to deal with breast engorgement and discomfort is to? a stop breastfeeding b apply a cream c wear supportive bra at all times d let breast air dry
c
The PN is caring for a client who had a total laryngectomy, left radical neck dissection... client is receiving nasogastric tube feedings via an internal pump. today the rate of the feeding was increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding? a Daily weight b Bowel sounds c Gastric residual volumes d Urinary and stool output
c
The PN is planning care for a client who has generalized tonic clonic seizures and is vomiting and having frequent diarrhea stools to reduce the risk of injury to this client which nursing measurements should the PN implement? a tympanic temperatures and oral tongue blades b rectal temperatures and perineal skin barrier creams c axillary temperatures and padded side rails d oral temperature and oral suction equipment
c
The PN observes that a male clients urinary catheter drainage tubing is...the attached to the bed frame. What action should the PN implement? a raise the bed to ensure the drainage bag remains off the floor b secure the tubing to the client's gown instead of his abdomen c observe the appearance of the urine in the drainage tubing d attach the drainage bag to the side rail instead of the bed frame
c
Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client? a Rectus abdominus b Dorsogluteal c Deltoid d Vastus lateralis
c
before her menstrual period. the PN determines the client is not pregnant... of days. what action should PN take? a suggest that client schedule a mammogram after her next menstrual period b explain to the client that an ultrasound of the breast will most likely be necessary c request return visit for examination after her period when hormones are lowest d assure the client that her breasts are normal, and advise annual examinations
c
what site should the PN use when administering RHO D? a gluteus maximus b stomach c deltoid d gluteus medial
c
The client receives ondansetron prior to chemotherapy therapy. How should the PN evaluate medication? a Determine if the client feels calm and relaxed before treatment b Observe the client for signs of pain and discomfort during the treatment c Monitor the client for nausea/ vomiting following the treatment d Assess for changes in vital signs during and after treatment
c Monitor the client for nausea/ vomiting following the treatment
A client with a compound fracture of the left ankle is being discharged with a below PN provide to the client prior to discharge? a Keep the left leg in a dependent position b Expect some increase in pain c Never scratch under the cast d Apply a cold pack to any hot spots on the cast
c Never scratch under the cast
At the end of a 12 hour shift the PN observes the urine in a clients drainage action should PN take next? a Determine if the clients bladder feels distended b Offer to administer a prescribed PRN analgesic c Note the most recent WBC d Obtain a fingerstick capillary glucose level
c Note the most recent WBC
During morning rounds a client who is admitted with obsessive compulsive disorder is in the same table. What interventions should the PN implement when approaching? a Encourage the client to be calm and relax for a little while b Assist the client to identify stimuli that precipitates the activity c Provide time for the behavior then guide the client to other activities d Assist the client to a chair after taking away the cleaning materials
c Provide time for the behavior then guide the client to other activities
during morning rounds, a client who is admitted with obsessive compulsive disorder is in the...of the same table. what intervention should the PN implement...? a encourage the client to be calm and relax for a little while b assist the client to identify stimuli that precipitates the activity c provide time for the behavior then guide the client to other activities d assist the client to a chair after taking away the cleaning materials
c provide time for the behavior then guide the client to other activities
A client with a fever is diaphoretic and the linens are saturated. After assessing the clients vital signs, which action would the PN take?
change the bed linens
Which picture of nailbeds indicate hypoxia?
choose the one that has a bump right below the nail bed
The nurse assesses a child in 90-90 traction. Where should the nurse assess for signs of compartment syndrome? the picture will show a child in traction with left left in traction
click on the toes of the elevated leg
The charge nurse is making assignments for client care. Which client would be assigned to the PN for the assessment?
client with confusion and sundowner syndrome
How should the PN assist the client to provide sputum sample?
coach the client to take deep breaths and cough deeply to mobilize secretions
When preparing to administer medications to an older resident the PN notices that several medications that were supposed to be administered during the previous shift have not been entered as given In the computer. What action should the PN take?
contact the medication nurse to clarify the findings
100 The PN plans to evaluate an adults response to a prescription for colchicine. Last week the client was seen in the clinic for pain in the great left toe, which was the result of an acute attack of gout. which data should the PN obtain to evaluate the therapeutic effectiveness of this medication? a appearance of the great toe on the affected foot b range of motion of lower extremities c fatigue level since staring to drug treatment d pain scale level during walking
d
102 The PN is caring for a client who was recently diagnosed with hepatitis B virus (HBV). The PN observes that the clients urine is the color of dark tea. What action should the PN take? a document the appearance of the urine b check the client's white blood cell count c obtain a urine sample to test for bleeding d encourage increased oral fluid intake
d
106 The PN and UAP are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement? a ask the UAP to leave the room and assess the client's body for bruising b carefully observe the interaction between the client and family members c instruct the UAP to protect the client's left side when transferring to a chair d demonstrate to the UAP how to approach the client from the client's left side
d
109 An older adult female is admitted with syncope and laboratory findings indicate that her hemoglobin is 8.0 grams /dL . She has a recent history of headaches and frequent falls. Admission prescription orders include continuation of all home medications. Which medication should the PN withhold until consulting with the charge nurse? a docusate sodium b levothyroxine c calcium citrate d aspirin
d
52 The PN is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue. How should the PN respond? a describe how liver damage may result in lifelong fatigue b encourage frequent activity to restore sleep awake cycles c obtain a prescription for PRN sedative to promote rest d affirm the importance of rest to promote liver healing
d
62 When entering the room of an older female resident of a long term care facility, the PN finds one of the male residents in bed with her. What action should the PN take? a tell the couple to dress and that you'll be back in 10 minutes b explain to the couple that they are violating the rules of the residence c quietly escort the male client back to his room d close the door and report the finding to the charge nurse
d
72 A client reports feeling numbness and tingling in extremities. What action should the PN implement? a provide a high protein snack to the client b encourage increased oral fluid intake c assess the client's temperature d review the client's serum electrolyte levels
d
78 The PN is assisting a client to the bathroom after right cataract extraction. The client has an eye shield over the right eye. How should the PN asset the client during ambulation? a support the client on the right side while walking to the bathroom b walk on the client's left side while assisting the client to the bathroom c place the client in front of the nurse while both walk to the bathroom d stand in front of the client and lead the client forward to the bathroom
d
87 Based on the nursing diagnosis of "risk for infection" which intervention should the PN implement when providing care for an elderly client with urinary incontinence? a insert an indwelling urinary catheter b initiate contact isolation precautions c utilize and antibacterial perineal wash d maintain standard precautions
d
90 A 5-year old child is admitted with full thickness burns over 30% of the total body surface areas (TBSA). After fluid replacement therapy is initiated, which finding should the PN use to evaluate the effectiveness of the therapy? a skin turgor b mucous membranes c heart rate d urine output
d
91 when the PN attempts to assist an 18-year old female client with mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and yells at the PN "get out of here! Ill get up when I'm ready!" which response is best for the PN to make? a you must ambulate to avoid complications which could cause more discomfort when ambulating b your healthcare provider has left specific instruction to ambulate on the first postoperative day c i will be back in 30 minutes to help you get out of bed and walk around the room today d I know you feel angry about the pain of ambulation, but this is a necessary part of getting well
d
94 The PN views the mid-line episiotomy of a client who reports pain in her stitches. What action should the PN take first? a initiate daily warm sitz baths during onset of pain b check medication administration record for last PRN analgesic c apply an ice pack for 20 minutes to the episiotomy d observe suture line for separation and hematoma formation
d
A 150 pound adult client with Partial-thicknees burns over 40% of the body..hospital burn unit. Which observation is most important for the Pn to report... a painful moaning and crying b poor appetite and refusing to eat c systolic blood pressure of 102 d urinary output of 20 ml/hour
d
A client is transferred to the surgical unit from the intensive care unit after evacuation of bilateral..primary observation should the PN monitor? a Fever related to pneumonia or urinary tract infection b Intake and output related to fluid related to fluid retention or overload c Homan's sign related to immobility and thrombophlebitis d Neuro vital signs related to bleeding and intracranial pressure
d
A female client tells the PN that her hemorrhoids are inflamed and hurt..the PN to implement to complete a focused assessment? a Ask the client how long she has experienced discomfort related to hemorrhoids b Determine if the client uses any over the counter preparations for hemorrhoids c Place the client in a standing position, leaning over the exam bed for inspection d Position client in left lateral position to inspect perianal area for fissures or sacs
d
A male client takes one baby aspirin daily to prevent heart attack. He asks the practical nurse... administer to his visiting eight year old grandchild who has developed a fever and sore...PN? a You can safely use children's aspirin as long as you check the dose on the label correctly b Be sure to give the med with some crackers or milk to reduce stomach upset c Giving a prescribed med to anyone else, whether a child or adult, is not safe practice d It is better to obtain children's acetaminophen to prevent possible side effects from the aspirin
d
An adult female client with type 1 diabetes mellitus is receiving 35 units of NPH insulin...PN document as evidence that the amount of insulin is inadequate... a a wound on the ankle that starts to drain and becomes painful b complaints of feet that feel cold accompanied by numbness c complaints of nausea in the morning but able to eat breakfast d consecutive evening serum glucose readings of >260 mg/dl
d
The PN is caring for a client in bucks tract what is the priority goal for the client in traction? a patient's head is lower than their fee b visualization of the lower abdomen and pelvis c for patients who develop hypovolemic shock d maintain straight body alignment
d
The PN is caring for a client receiving chemotherapy who has thrombocytopenia..important to include in the nursing care plan? a Maintain protective isolation precautions b Obtain the client's blood pressure frequently c Observe the signs of dehydration d Watch the client for abnormal bleeding
d
The PN is implementing the plan of care for a client who admits having...indicates the highest risk for the client acting on these suicidal thoughts? a Describes being very depressed b Has little appetite and neglects personal hygiene c Is not interested in the activities of family and friends d Begins to show signs of improvement
d
The PN is reviewing diet instruction with a female client who has hyper she has increased her intake of protein and calories. What action should the PN take? a Reinforce with her the need to also increase intake of dietary fiber b Remind the client to increase physical activity to prevent weight gain c Emphasize the need to reduce caloric intake, rather that increasing it d Encourage the client to continue the dietary changes she has made
d Encourage the client to continue the dietary changes she has made
The PN is caring for an older adult client who is confused and spends factor contributes to an increased risk for impaired skin integrity for this client? a Refuses to use a walker when ambulating b Likes to drink several cola drinks every day c No recorded bowel movement for several days d Has increasing episodes of urinary incontinence
d Has increasing episodes of urinary incontinence
Thirty minutes after receiving IV morphine, a postoperative male client continues to rate action should PN implement first? a Call healthcare provider to request a different analgesic b Observe dressing to determine presence of bleeding c Determine when morphine can be given again d Implement complementary pain relief methods
d Implement complementary pain relief methods
The PN is assisting a female client to obtain a voided specimen for urine meatus, which intervention is performed next? a Separate the labia b Position the collection cup c Observe the urine d Initiate the urine stream
d Initiate the urine stream
A client is admitted to the postoperative surgical unit after a left lobectomy with two chest observes that the water sealed chambers set at the prescribed suction of 20 cm water and bubbling. What action should the PN implement? a Notify the RN of the malfunction b Apply a partial occlusive dressing to chest c Clamp the chest tube to see if activity stops d Maintain system integrity to promote lung reexpansion
d Maintain system integrity to promote lung reexpansion
A male client who has been diagnosed with schizophrenia withdrawn, isolates himself in with one or two word responses. This morning , the PN observes that he. Which intervention is most important for the PN to implement? a Observe the client during the shift b Persuade the client to lie down c Provide a drink high in electrolytes d Measure appropriate vital signs
d Measure appropriate vital signs
An 8 year old is placed in 90-90 traction for a fractured femur that resulted from further action by the PN? a Child moves the toes freely when tickled b Weights are touching the foot of the bed c Mother helps child change positions d No bowel movement for two days
d No bowel movement for two days
The PN determines that a client with cirrhosis is experiencing peripheral take? a Apply a heating pad to affected area b Assess the feet and legs for jaundice c Keep the clients feet elevated d Protect the client's feet from injury
d Protect the client's feet from injury
While administering morning care to a client, the UAP informs the PN that the clients lower extremity wounds are leaking bloody drainage. What action would the PN take?
direct the UAP to accumulate wound dressing supplies
on admission to the medical unit a client who is homeless and has a history of HIV with persistent cough?
erythema and indurations of 5mm at site
28 year old client is in active labor and complains of a cramp in her leg. what intervention should the PN implement ?
extend the leg and flex the foot
The PN is caring for a client with atrial fibrillation. What would be an expected finding when assessing this client?
heart rate 88 and irregular
A client is admitted for observation after experiencing a TIA
high risk for injury
A client with multiple sclerosis has developed a bladder infection. What would the PN identify as a possible cause for this infection?
immunosuppressant therapy
A 40 year old client has obtained a baseline mammogram. When would the PN recommend that the next mammogram be performed?
in 1 year
The PN has identified the howling statement as a desired outcome for a client "client will report effective pain management when using analgesic medication every 6 hours as prescribed." This outcome statement would be appropriate for which client problem?
ineffective pain management
The PN is reviewing actions for a mother to take to prevent her toddler from being injured in the home. What will the PN emphasize with this mother?
keep poisonous and other materials locked away
A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the PN to provide to the UAP who is completing morning care for this client?
measure all emeisies accurately
Client who has four gold seed implants on a chest wall tumor is on radiation precautions what basic precautions should the PN nurse observe when administering direct client care?
minimal time maximum distance and protective shielding
During morning report the PN learns that an assigned client has phlebitis from an intravenous access device. What manifestations will the PN assess in this client?
palpable cord along the vein
A client recovering from surgery to the fibula has bleeding on the cast. The PN outlines the border of bleeding to serve at a baseline. Which action would the PN do next?
recheck the cast within the next 15 minutes
During morning report the PN learns that an assigned client has phlebitis from a intravenous access device. What will the PN observe in this client?
redness, warmth, and edema of the site
A client with lower back pain has been prescribed a transcutaneous electrical nerve stimulator (TENS) unit for pain control. Why would the client be instructed to use this device on the low frequency setting?
stimulate serotonin levels
A clients blood pressure is unusually elevated. Which factors would contribute to this clients blood pressure elevation?
stress exercise heart rate body temp
Client voiding small amounts every 24 hours
the catheterized volume determines the need to reinsert the indwelling catheter
The mother of a toddler demonstrating a sudden onset of stridor says that the child was playing with an old shirt and suddenly could not breathe very well. What would the PN suspect has occurred with this client?
the child aspirated a button from the shirt
the PN is reviewing new orders for a client and notes that medication doses have been adjusted to lower levels than what is routinely prescribed. Why would this action be taken for the client?
the client has renal failure
A client who received 10 units of regular insulin is diaphoretic and is shaky. Why would the PN provide the client with graham crackers and milk?
the client is experiencing hypoglycemia
Single mother of a child with head injury comes crying to the clinic what should the PN tell her?
this must seem overwhelming to you right now
The PN is positioning a client recovering from a radical mastectomy. Why will the PN place the client in the semi-fowlers position with the arm of the operative side elevated?
to prevent edema in the arm
Why does the PN administer ophthalmic ointment in the eyes of a newborn?
to prevent gonorrheal or chlamydial ophthalmic infections
Why does the PN wear a pair of clean gloves when providing care to a client with clostridium difficile ?
to protect the nurse from microorganisms that is within the client
The PN provides a prescribed analgesic perianal spray to a postpartum client. For which problem will this nursing action address?
vaginal lacerations
when should a person use additional birth control precautions?
when taking antibiotics for an infection