HURST REVIEW

While the postpartum nurse was in the report, 4 clients called the nurse's station for assistance. Which client should the nurse see first?

Client reporting blood running down legs upon standing.

The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial data collection, the client reports experiencing "numb feet." What is the nurse's first action?

Observe the client's feet for signs of injury.

Parents bring their child to the clinic with left knee pain after suffering a fall on the playground. Which action should the nurse initiate first?

Compare the appearance of the left knee to the right knee.

The nurse is caring for a client with right-sided paresis due to a stroke. The client is preparing for discharge in a few days. The nurse discovers that the spouse has been feeding the client. What should the nurse do?

Determine the reason why the spouse in not encouraging self-care by the client.

The nurse if preparing to collect a capillary blood specimen for measuring blood glucose. Which action is most likely to result in an adequate stick for the client?

Warm the finger prior to the stick.

What action should the nurse take when a client receiving 40 ml.hr of enteral feedings has a gastric residual volume of 250 ml?

Recheck gastric residual volume in 1 hour.

Which findings will direct the nurse towards determination that a Clint is experiencing normal grief?

The client states, "I am having fewer bad days". Smiles at the nurse while talking about life. The client states, "I have been crying less".

What factor would most likely predispose a client with a compound femoral fracture to develop shock?

Loss of blood into soft tissues surrounding the fracture.

The nurse is helping a client to bed when the client begins having generalized seizure. Which action should the nurse take?

Assist the client to the floor in a side-lying position.

The palliative care nurse is reinforcing instructions with the family of a client who is experiencing N & V on methods of controlling these symptoms. What methods should the nurse include?

Offer electrolyte replacement drinks or broths. Avoid cooking close to the client. Provide light bland food.

Which task would be appropriate for the nurse to assign to the UAP?

Prepare a site bath for a postpartum client.

Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult?

Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery.

The nurse is gathering data on a health history with a client who is 10 weeks pregnant. During the interview, the client states, "I'm not so sure I'm really happy about this pregnancy." Which response by the nurse is most appropriate?

Tell me more about how you're feeling.

The newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate?

Tell me what the voices are saying to you.

After the nurse administers ear drops to an adult client, it is important for the nurse to implement which action?

Gently massage the Tagus of the ear.

The nurse is caring for an immobile client. Which complication is the nurse's priority?

Deep vein thrombosis

Which tasks would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? (SATA) 1. Prepare a client's room for return from surgery. 2. Observe for pain relief in a client after receiving acetaminophen with codeine. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube. 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG).

1. Prepare a client's room for return from surgery. 3. Assist a client with perineal care after having diarrhea 4. Clean nares around a client's NG tube

The primary healthcare provider prescribed fentanyl 75 mg IM. The pharmacy dispensed fentanyl 50 mg per ml. How many ml will the nurse administer? Round to nearest decimal point.

1.5

Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client? 1. Clinical nutritionist 2. Primary nurse each shift 3. Primary healthcare provider 4. Case manager

4. Case manager

The nurse is caring for a client of the pediatric unit. The primary healthcare provider prescribes phenytoin 30 my by mouth every 8 hours for a client weighing 18 kg. Recommended dosage is 5mg/kg/day. What does the nurse determine is the safe dosage for the child in mg/day? Round your answer to the nearest whole number.

90 mg/day

A client diagnosed with schizophrenia comes up tp the nurse and says, Tick, took, duck clock, tick tick. How would the nurse document this impaired communication?

Clang association

Which task would be appropriate for the LPN to accept from the charge nurse?

Changing a colostomy bag.

Which client assignment should the LPN accept from the charge nurse?

Child needing pre=operative medication prior to reduction of a fracture.

Which task would be appropriate for the LPN to accept from the charge nurse?

Collect data on a new client admit. Bonus feeding a client who has a gastrostomy tube. Reinserting a NG that a client accidentally pulled out. Monitor PCA pump pain medication being delivered to a client.

When caring for young adult clients, which developmental tasks would the nurse expect to see?

Developing meaningful and intimate relationships. Giving and sharing with an individual without asking what will be given or shared in return.

Which documentation entries by the LPN would be appropriate to place in a client's electronic record?

Forty year old admitted with diagnosis of cholecystokinin to room 410 for surgical services. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. Transferred to surgical suite per stretcher with side rails up, in stable condition.

Three hours after delivery of a client's newborn, the nurse monitors for bladder dissension. What signs would the nurse note if the client's bladder is distended.

Fund us 3 cm above umbilicus Excessive lochia Tenderness above symphysis pubis.

Which suggestion should the nurse provide to a client reporting frequent episodes of constipation?

Increase intake of fruit in the diet.

What info should the nurse give a pregnant client who comes to the clinic reporting hemorrhoids and constipation?

Increased rectal pressure form the gravid uterus may result in hemorrhoids. Hormones decrease maternal GI motility, resulting in constipation. More fluid and fiber is needed in the diet. Increase daily fluid intake.

A client with persistent vomiting reports weakness and leg cramps. Which acid base imbalance wold the nurse anticipate?

Metabolic alkalosis

A nurse enters a client's room to find the client on the floor having a grand mal seizure. What action should the nurse take?

Place a towel or sheet under the client's head.

A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last.

Remove the client from the room. Activate the fire alarm. Close the door to the client's room. Obtain the fire extinguisher. Extinguish the fire.

Which task would be appropriate for the nurse to assign to UAP?

Report if any client indicates pain.

The LPN is verifying that a new LPN understands the principle of least restrictive interventions on a psychiatric unit. In what order should the new LPN correctly place interventions from least to most restrictive? Place in correct order form least restrictive to most restrictive.

Verbally tell the client to stop the unacceptable behavior and escort client to another part of the day room. Walk the client out to the courtyard. Take the client to the client quiet room for a time out. Place client in the isolation room with staff observation. Restrain client's arms with wrist restraints. Use four point soft cloth restraints.

Which client diagnosis would require the nurse to initiate droplet precaution?

Whooping cough

A client is going home on a potassium sparing diuretic, spironalactone. What should the nurse tell the client about this medication?

You may be at risk for high potassium levels. Check with primary healthcare provider before taking over the counter potassium. Consume potassium rich foods in moderation.