hurst week 2

At a summer pool party, an adult client is found unconscious in the water. Someone calls 911, and a nurse present at the party immediately initiates what priority action? 1. Initiate chest compressions. 2. Assess client for any injuries. 3. Wrap client in warm blankets. 4. Check for any respirations.

check for respirations

The out patient surgical unit has admitted multiple clients currently awaiting early morning procedures. What client should the nurse assess first? 1. The client awaiting repair of hiatal hernia reporting chest pain. 2. The client with a torn right rotator cuff reporting shoulder pain. 3. The client with an inguinal hernia repair reporting skin irritation. 4. The client awaiting a hemorrhoidectomy reporting rectal bleeding.

. The client awaiting repair of hiatal hernia reporting chest pain.

The nurse is assisting a new mother with breastfeeding her newborn baby. The mother verbalizes concern that the baby is not getting adequate milk. Which observations by the nurse indicate adequate fluid intake? Select all that apply 1. Birth weight regained in 14 days 2. Fontanels soft and depressed 3. Pulse rate of 135/min 4. Six to eight wet diapers a day 5. Baby appears satisfied after feedings

1. Birth weight regained in 14 days 3. Pulse rate of 135/min 4. Six to eight wet diapers a day 5. Baby appears satisfied after feedings

Which discharge instruction should the nurse implement for a client diagnosed with insomnia? Select all that apply 1. Eliminate chocolate in the evening. 2. Drink a glass of red wine 1 hour prior to bedtime. 3. Perform progressive relaxation techniques at bedtime. 4. Take acetaminophen/diphenhydramine 2 tablets at bedtime. 5. Leisurely walk 3 hours prior to bedtime. 6. Increase the air flow on the continuous positive airway pressure (CPAP) machine.

1. Eliminate chocolate in the evening. 3. Perform progressive relaxation techniques at bedtime. 5. Leisurely walk 3 hours prior to bedtime.

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident for assistive devices that will be needed upon discharge. Which resources should the case manager include for this client? Select all that apply 1. Plate guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip utensils 6. Large button closures on clothes

1. Plate guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip utensils

Which signs and symptoms would indicate to the nurse that the client is having an anaphylactic response after receiving penicillin? Select all that apply 1. Reports a scratchy throat 2. Faint expiratory wheeze on auscultation. 3. Client statement, "I feel like something is wrong." 4. Bounding radial pulse rate of 100/min 5. BP 100/70

1. Reports a scratchy throat 2. Faint expiratory wheeze on auscultation. 3. Client statement, "I feel like something is wrong."

The nurse is talking with parents of school-aged children about promoting healthy eating in their children. What information should the nurse provide? Select all that apply 1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 4. Enforce rule that child must eat food even if they do not like it. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals.

1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals.

Which finding indicates to the nurse that a client is at risk for skin breakdown? 1. Weakness requiring assistance to move in bed. 2. Daily intake of at least 85 percent of food offered. 3. Occasional forgetfulness. 4. Continent of bowel and bladder.

1. Weakness requiring assistance to move in bed.

The night nurse has reported to the day nurse that a client has not had a bowel movement in 2 consecutive days. What actions should the day nurse take? Exhibit Select all that apply 1. Write prescription to initiate "Bowel Protocol" per standing order. 2. Offer client 120 mL prune juice. 3. Give Milk of Magnesia (MOM) 30 mL po. 4. Administer bisacodyl suppository. 5. Provide sodium phosphate enema.

1. Write prescription to initiate "Bowel Protocol" per standing order. 2. Offer client 120 mL prune juice.

The home health nurse is preparing to hang an IV bag of total parenteral nutrition (TPN) on a client. At what rate should the nurse set the IV infusion pump? Round to the nearest whole number. Answer in numbers and decimals only.

113

The nurse is caring for a client with chronic pyelonephritis. Which lab value noted by the nurse indicates a problem? 1. Estimated glomerular filtration rate - 90 mL/min/1.73 m2 2. Serum creatinine - 2.1 mg/dL (186 micro mol/dL) 3. Blood urea nitrogen - 19 mg/dl (6.78 mmol/L) 4. Urine culture isolates Escherichia coli

2. Serum creatinine - 2.1 mg/dL (186 micro mol/dL)

An elderly client diagnosed with terminal cancer is the sole caregiver to a developmentally delayed adult child. The client is worried that the child, with a developmental age of seven years old, will need permanent placement in a long term care facility. What statement by the nurse is most accurate? 1. "Your child will need to be under constant supervision." 2. "A supervised group home would be an ideal setting." 3. "Maybe we could find someone to take in your child." 4. "We should start getting the child used to living alone."

2. "A supervised group home would be an ideal setting."

A client hospitalized with a deep vein thrombosis (DVT) is on a heparin infusion. The client asks the nurse why it is necessary to have blood drawn every six hours. What is the best explanation for the nurse to provide to the client? 1. "The medicine might make your blood much too thin." 2. "It helps us monitor and adjust the dose to work better." 3. "It is required for anyone getting heparin intravenously." 4. "The test results tell us whether the treatment is working."

2. "It helps us monitor and adjust the dose to work better."

A client with leukemia receiving high dose chemotherapy is being evaluated for the development of tumor lysis syndrome. Which lab value should the nurse recognize as being a hallmark sign of the tumor lysis syndrome? Select all that apply 1. Thrombocytopenia 2. Hyperkalemia 3. Hypocalcemia 4. Hyperuricemia 5. Hypomagnesemia 6. Hyperphosphatemia

2. Hyperkalemia 3. Hypocalcemia 4. Hyperuricemia 6.Hyperphosphatemia

A client with a history of myasthenia gravis (MG) has been discharged from the hospital following a thymectomy. When teaching the client how to prevent complications, the home care nurse emphasizes what daily actions are most important? Select all that apply 1. Include daily weight lifting exercises. 2. Practice stress reduction techniques. 3. Complete chores early in the day. 4. Take medications on time and prior to meals. 5. Eat three large meals daily.

2. Practice stress reduction techniques. 3. Complete chores early in the day. 4. Take medications on time and prior to meals

The community health nurse is developing a presentation for adolescents on dealing with gun violence in school. What initial action should the nurse take? 1. Design a booklet for school districts on handling aggression. 2. Survey students to determine attitudes towards weapons. 3. Provide information on anger management to grade schools. 4. Investigate existing safety procedures in the schools.

2. Survey students to determine attitudes towards weapons

A client prescribed oral iron medication is reporting nausea after administration. What should the nurse teach the client to decrease this symptom? 1. Take the iron with a class of milk. 2. Eat bran cereal immediately after ingesting iron. 3. Drink orange juice with the iron medication. 4. Take docusate sodium at bedtime.

3. Drink orange juice with the iron medication.

Which action should the nurse take for a client who is of the Roman Catholic faith? 1. Notifying dietary that all food is required to be kosher. 2. Administering last rites to the client if death is imminent. 3. Ensuring there is no meat served with meals on Fridays during Lent. 4. Positioning the dying client's bed facing Mecca (east).

3. Ensuring there is no meat served with meals on Fridays during Lent

A nurse is caring for a client admitted to the hospital for a total hip replacement. In preparing the post-operative plan of care for this client, the nurse recognizes which goal as the highest priority? 1. Prevent complications of shock. 2. Prevent dislocation of prosthesis. 3. Prevent respiratory complications. 4. Prevent skin breakdown.

3. Prevent respiratory complications.

The home health nurse is caring for an elderly client who lives with an adult child. The client's child is divorced, works full-time, and is responsible for caring for two young children. Recently, the client has become incontinent of urine. Which stressor on the caregiver may increase the risk for abuse of this elderly client? 1. Care of young children 2. Being divorced 3. Recent increased care demands 4. Loneliness of the adult child

3. Recent increased care demands

The nurse is caring for a client diagnosed with pneumonia. The primary healthcare provider has prescribed erythromycin ER. What teaching points should the nurse plan to teach the client regarding this medication? Select all that apply 1. Crush the medication if unable to swallow capsule. 2. Take erythromycin 1 hour after eating. 3. Report clay-colored stools. 4. Do not take erythromycin with grapefruit juice. 5. Keep capsules in bathroom cabinet.

3. Report clay-colored stools. 4. Do not take erythromycin with grapefruit juice.

What signs/symptoms would the nurse expect to assess in an elderly client diagnosed with acute decompensated heart failure (ADHF)? Select all that apply 1. Thick, white sputum 2. Crackles that clear with coughing 3. Wheezing 4. Orthopnea 5. Apical pulse 88/min 6. S3 gallop

3. Wheezing 4. Orthopnea 6. S3 gallop

A renal transplant client has received discharge education. Which statement by the client indicates that further teaching is necessary? 1. "I will need to notify my primary healthcare provider if I develop a fever." 2. "I need to check my BP daily and report an increased B/P." 3. "I will tell my primary healthcare provider if I become easily fatigued." 4. "I will be on steroids for 3 months, then I will not have to take them."

4. "I will be on steroids for 3 months, then I will not have to take them."

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Check client's bony prominences for redness. 2. Monitor client need for suctioning hourly. 3. Explain how to collect 24 hour urine to client. 4. Take a tympanic temperature on client every two hours. 5. Perform postural drainage and chest physiotherapy on client. 6. Report client's pulse oximetry reading every hour.

4. Take a tympanic temperature on client every two hours. 6. Report client's pulse oximetry reading every hour.

A nurse is taking care of a client with major partial thickness burns. Tobramycin 125mg IVPB has been prescribed. What is the priority lab assessment prior to administering this medication? 1. Creatinine 2. Potassium 3. Magnesium 4. Blood urea nitrogen

Creatinine

A client is admitted to the pediatric unit with a diagnosis to rule out tuberculosis (TB). What room assignment should the charge nurse make? 1. Private room. 2. Private room and place on protective isolation. 3. Room with a client diagnosed with a respiratory infection. 4. Room with a client who is 24 hours post appendectomy.

Private room

The client who is scheduled for a cholecystectomy asks the nurse about her opinion on the surgeon who is going to perform the surgery. The nurse says to the client, "You should get a second opinion because your surgeon has been involved in several client lawsuits." Because the surgeon has not been involved in any client lawsuits, the nurse has initiated which tort? 1. Assault 2. Libel 3. Slander 4. Negligence

SLander

An elderly client comes to the clinic for a check-up. The client's daughter tells the nurse that her father's dementia symptoms become increasingly more difficult to handle in the evening. How would the nurse document this symptom? 1. Confabulation 2. Apraxia 3. Pseudodementia 4. Sundowning

Sundowning

A client presenting at the clinic has a history of systemic lupus erythematosus (SLE). Which finding would indicate to the nurse that the client is having a flare-up of the disease? 1. Alopecia 2. Arthritis of hands 3. Weight gain 4. Fever

fever

At what age does the nurse expect to see a child build a tower of 9 blocks? 1. One 2. Two 3. Three 4. Four

three

A palliative care client is suffering from persistent diarrhea. What foods should the nurse suggest? Select all that apply 1. Applesauce 2. Rice 3. Bananas 4. Tea 5. Yogurt

1. Applesauce 2. Rice 3. Bananas

A nurse has completed education on safe sexual practices to a group of college students. Which comments by the students would indicate that education has been successful? Select all that apply 1. "The best way to prevent HIV is to abstain from sex." 2. "Contraceptives should contain spermicide N-9." 3. "Douching is recommended after intercourse." 4. "Drinking too much alcohol can increase the risk exposure to sexually transmitted disease (STDs)." 5. "If my partner will not use a condom, I will."

1. "The best way to prevent HIV is to abstain from sex." 4. "Drinking too much alcohol can increase the risk exposure to sexually transmitted disease (STDs)." 5. "If my partner will not use a condom, I will."

A premature HIV+ infant has been admitted to the Pediatric Unit with a new diagnosis of cytomegalovirus (CMV). The charge nurse is aware the most appropriate staff to assign to this client is what individual? 1. A new nurse orienting to the unit. 2. A pediatric nurse six months pregnant. 3. An LPN with an exacerbation of eczema. 4. An experienced UAP with no health issues.

1. A new nurse orienting to the unit.

The nurse is caring for a client who has hypercholesterolemia. When evaluating the effects of atorvastatin, the nurse should monitor the results of which laboratory tests? Select all that apply 1. AST 2. Alkaline phophatase 3. Complete blood count 4. Serum cholesterol levels 5. Serum triglyceride levels

1. AST 2. Alkaline phophatase 4. Serum cholesterol levels 5. Serum triglyceride levels

A client with renal failure has returned to the unit post kidney transplant. Which postoperative interventions should the nurse provide? Select all that apply 1. Administer furosemide. 2. Maintain fluid replacement at 150 ml per hour for 8 hours. 3. Measure abdominal girth every 24 hours. 4. Weigh daily. 5. Measure urine output every 30 - 60 minutes.

1. Administer furosemide. . 4. Weigh daily. 5. Measure urine output every 30 - 60 minutes.

The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take? Select all that apply 1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. 5. Simply accept the assignment since overtime is mandatory.

1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action

Following a large hurricane, multiple clients arrive at the emergency room for treatment. The charge nurse must triage and assign clients to appropriate staff. Which clients could be assigned to an LPN? Select all that apply 1. Child with superficial burns on both upper arms. 2. Adolescent with bruising to left upper quadrant. 3. Crying toddler missing both upper front teeth. 4. Adult reporting headache and blurred vision. 5. Elderly adult reporting nausea and heartburn.

1. Child with superficial burns on both upper arms. 3. Crying toddler missing both upper front teeth.

Which clients should the nurse recommend receive the human papillomavirus (HPV) vaccine? Select all that apply 1. Twelve year old male. 2. Eight year old female. 3. Twenty-five year old bisexual male. 4. Twenty-two year old female with compromised immune system. 5. Twenty-nine year old male who has not received the HPV vaccine.

1. Twelve year old male. . 3. Twenty-five year old bisexual male. 4. Twenty-two year old female with compromised immune system.

A client with a history of schizophrenia was admitted with abdominal pain and has been undergoing diagnostic tests. When the nurse enters the room, the client is alone and looking at the wall and states "Why should I hurt them?" What would be an appropriate intervention by the nurse? Select all that apply 1. Directly ask the client "Are you hearing voices?" 2. State "Tell the voice that you do not want to hurt anyone." 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 5. Tell the client "You know that you are not being told to hurt someone." 6. Inquire about what the client believes he or she is being told to do.

1. Directly ask the client "Are you hearing voices?" 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 6. Inquire about what the client believes he or she is being told to do.

A home health nurse is interpreting Mantoux skin test results of clients who received the test 48 hours ago. Which clients have a positive tuberculin skin test reaction? Select all that apply 1. HIV+ client with an induration of 6 millimeters. 2. Client who immigrated from Haiti 6 months ago who has an induration of 10 millimeters. 3. Client working at a nursing home with an induration of 8 millimeters. 4. 3 year old client with an induration of 12 millimeters. 5. Healthy client with no known TB exposure who has an induration of 5 millimeters.

1. HIV+ client with an induration of 6 millimeters. 2. Client who immigrated from Haiti 6 months ago who has an induration of 10 millimeters. 4. 3 year old client with an induration of 12 millimeters.

The nurse is observing a new nurse inserting a nasogastric (NG) tube. Which action by the student nurse needs to be corrected by the nurse? Select all that apply 1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 3. Aspirates the NG tube to test gastric contents with a pH stip. 4. Marks the tubing at measurement mark with tape and secures to nose. 5. Places tube end into a glass of water to assess for bubbling.

1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 5. Places tube end into a glass of water to assess for bubbling.

The nurse is educating a group of teenagers who have expressed an interest in using electronic cigarettes (e-cigarettes). What information about electronic cigarettes should the nurse include? Select all that apply 1. Electronic cigarettes are a safe alternative to smoking. 2. It is difficult for consumers to know what electronic cigarette products contain. 3. Nicotine can harm adolescent brain development. 4. Electronic cigarette aerosol generally contains fewer toxic chemicals than the smoke from regular cigarettes. 5. Defective electronic cigarette batteries can cause fires and explosions.

2. It is difficult for consumers to know what electronic cigarette products contain. 3. Nicotine can harm adolescent brain development. 4. Electronic cigarette aerosol generally contains fewer toxic chemicals than the smoke from regular cigarettes. 5. Defective electronic cigarette batteries can cause fires and explosions.

A client admitted to a long-term care facility is legally blind and partially deaf. How would the nurse best provide for the client's safety in the event of an emergency? Select all that apply 1. Have roommate lead client out of the room to safety area. 2. Assign a specific UAP every shift to escort client to safety. 3. Research established protocols utilized by emergency groups. 4. Discuss best communication methods with client and family. 5. Plan for the supervisor to be responsible for evacuating the client.

3. Research established protocols utilized by emergency groups. 4. Discuss best communication methods with client and family

A client admitted to the psychiatric unit after a suicide attempt is placed on suicide precautions. Which nursing interventions would be appropriate? Select all that apply 1. Assign the client to a private room away from nurses station. 2. Make rounds to assess the client at regular intervals. 3. Secure a promise that the client will seek out staff when feeling suicidal. 4. Closely supervise the client during meals. 5. Formulate a no harm contract for the client to sign.

3. Secure a promise that the client will seek out staff when feeling suicidal. 4. Closely supervise the client during meals. 5. Formulate a no harm contract for the client to sign.

The nurse is caring for a client with body dysmorphic disorder. The client tells the nurse, "My ugly ears make everyone sick!" Which defense mechanism is this client utilizing? Select all that apply 1. Sublimation 2. Somatization 3. Symbolism 4. Projection 5. Conversion

3. Symbolism 4. Projection

The nurse is talking with several high school students after a classmate from their school died in a motor vehicular accident. Which statement by the nurse is therapeutic? 1. "Sometimes bad things happen to people we care about." 2. "I was so upset that the student who died had been drinking." 3. "Why are you angry? Tell me how you feel about losing your friend." 4. "What would you like to talk about concerning the loss of your classmate?"

4. "What would you like to talk about concerning the loss of your classmate?"

A nurse is assessing a client with abdominal surgery 24 hours postop. Which assessment finding would require an immediate intervention? 1. The nasogastric (NG) tube contents are pale green. 2. An abdominal dressing with the tape on 3 sides of the dressing. 3. Abdominal pain of 5 on 10 point pain scale when client coughs. 4. A bulb-shaped Jackson-Pratt (JP) drain with 25 mL of sanguineous drainage.

4. A bulb-shaped Jackson-Pratt (JP) drain with 25 mL of sanguineous drainage.

A fully alert and competent client is in end-stage cardiac disease. The client says, "I'm ready to die," and refuses to take nourishment. The family urges the client to allow the nurse to insert a feeding tube. What action should the nurse take? 1. Tell the family that the feeding tube will be inserted after the client becomes unresponsive. 2. Ask the primary healthcare provider to have the dietician talk with the client about food preferences. 3. Notify the case manager to arrange a meeting with the client's family . 4. Provide additional information as requested by the client concerning nourishment.

4. Provide additional information as requested by the client concerning nourishment.

An elderly client with a history of congestive heart failure has been admitted to the Telemetry Unit with new-onset chest pain and palpitations. The healthcare provider decides to change the client's hydralazine to metoprolol. In preparing to teach the client about changes related to the new medication, the nurse is aware that metoprolol will likely decrease chest pain episodes secondary to what known side effect of hydralazine? 1. Dizziness 2. Hypotension 3. Sodium retention 4. Reflex tachycardia

4. Reflex tachycardia

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? 1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms

clear urine