Missed questions part 4

The nurse is giving discharge instructions to an Asian client following a colonoscopy. During the instructions, the client stares directly at the floor, despite being able to speak English. Based on the client's body language, how would the nurse classify this behavior?

attentiveness *making eye contact with the nurse would be rude and offensive

balloon angioplasty

avoid flexion of affected leg

RF otitis media

contact with siblings day care season of year *usually follows an URI or common cold

An 82 year old client tells the nurse at the clinic, "I have lived a good, successful life and married my best friend". Which of Erikson's developmental tasks does the nurse recognize that this client has probably accomplished?

ego integrity vs despair

A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment?

fever shivering agitation increased HR diarrhea

A client is admitted to the emergency department reporting abdominal discomfort and constipation lasting 3 days. Which abdominal assessment data would the nurse report to the primary healthcare provider?

high pitched bowel sounds *indicates early bowel obstruction

duodenal ulcer

take lansoprazole first THEN wait 30 minutes take sucralfate

Which immunizations obtained by the age of two would indicate to the pediatric nurse that the child is up-to-date on immunizations?

DTAP IPV Hib

What assignment would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

serving diet tray to a diabetic client

A client with a history of command hallucinations was admitted to the hospital yesterday. What questions are most important for the nurse to ask?

"Are you hearing voices today?" "What are the voices saying?" "Are the voices telling you to harm yourself or anyone else?"

A newly admitted client with schizophrenia has an unkempt appearance and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic?

"Its time to take a shower"

gastroscopy

can NOT have an NG tube

HPV

increases your risk of cancer

The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of emergent care?

2 you with excessive drooling and weak cough

non tunneled central venous catheter

Cleanse access port Connect 10 mL normal saline to access port Gently aspirate for blood Flush saline using push-pause method Administer phenytoin Flush with normal saline, then with heparin

The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client?

Client will report a pain level of less than 2 on a Faces scale.

Which clients would be appropriate for the RN to assign to an LPN/LVN?

Forty eight year old client who is five days post right-sided cerebral vascular accident (CVA). Eighty four year old client with heart disease and mild dementia. Sixty six year old client with chronic emphysema experiencing mild shortness of breath.

Which client should the nurse place in the room with a 6 year old with glomerulonephritis?

Four year old with nephrotic syndrome. Rationale: not infectious, close in age

The nurse is teaching the Type II diabetic about monitoring average blood glucose levels over time. The nurse evaluates teaching has been effective when the client verbalizes the need to return to the clinic for which test?

Glycosylated hemoglobin aka HbA1c!!

A 70 year old client was admitted to the vascular surgery unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's BP is 198/94. What would be the best action for the charge nurse to delegate at this time?

Have the LPN/LVN administer the 0900 furosemide and enalapril now.

An elderly male, diagnosed with chronic renal failure and depression, lives alone. Which question should the home health nurse ask first when assessing this client?

Have you had thoughts of harming yourself?

The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What assessment question is most important?

Have you recently worked with any farm animals or any animal-skin products?

Which statement, made by a client scheduled for a total laryngectomy, indicates to the nurse a need for further preoperative teaching?

My wife will have to get a hearing aid because I will not be able to talk above a whisper. *vocal cords are removed

The nurse is performing morning care on a client on the medical unit. What should the nurse do after changing a client's bed linen?

Place the linen into a leak proof container sitting outside the room.

The nurse is assisting an unlicensed assistive personnel (UAP) move an obese and dependent client toward the top of the bed. Which action is most important to prevent shearing forces on the skin?

Place turn sheet under the client and use it to slide the client toward the top of bed.

A client suffers from migraine headaches. What assessment finding would the nurse expect to find during a migraine attack?

Unilateral, pulsating pain quality.

A client, who only speaks Spanish, is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure?

Use an audiotape made in Spanish to inform the client of the pre-surgical procedure.

A client has been taught guided imagery as a method to relieve pain. How should the nurse first assess for pain relief after completion of guided imagery by the client?

Use of pain intensity scale

The nurse is caring for a client in the emergency department after a violent altercation with her husband. She describes increasingly violent episodes over the past 10 years. She says, "This is the last time he will hit me." Which response by the nurse demonstrates understanding of the violence cycle?

You are at greatest risk when you leave.

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client?

alternating pressure mattresses, hospital bed, suction equipment, oxygen

A child is being admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent?

hx of pharyngitis 4 wks ago *untreated GABHS, such as pharyngitis

A low income family with children lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be most important for the home health nurse?

lead poisoning

What should a nurse teach family members prior to them entering the room of a client who has agranulocytosis?

meticulous hand washing do NOT visit if you have any infection children under 12 can NOT visit flowers are Not allowed

A client had an abnormal maternal serum alfa fetoprotein (MSAFP) at 18 weeks gestation. She is now 22 weeks gestation, and an amniocentesis has just been completed for genetic analysis. Which nursing action has priority?

monitor fetal heart tones and uterine activity *risk of pregnancy loss after this procedure

Wernicke's Encephalopathy

most severe form of thiamine deficiency in alcoholics Symptoms include paralysis of the ocular muscles, diplopia, ataxia, confusion, somnolence, and stupor If thiamine replacement therapy is not given, death will ensue.

shingles

negative pressure room private room respirator mask

A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the rationale for the client being NPO with an NG tube to low suction?

reduce pancreatic secretions * In clients with pancreatitis, the pancreatic enzymes cannot exit the pancreas. These enzymes, when activated, begin to digest the pancreas itself. The enzymes become activated in the pancreas when fluid or food accumulates in the stomach. The goal in treating this client is to stop the activation of the pancreatic enzymes. Treatment is focused on keeping the stomach empty and dry. This allows the pancreas time to rest and heal. Note: Autodigestion (pancreas digesting itself) is painful for the client and can lead to other problems such as bleeding.

chest tube

semi fowlers prevent dependent loops below level of chest

Benztropine

treats SE of chlorpromazine

The nurse is caring for a client admitted to the skilled nursing unit approximately 3 months ago. Since admission, the client has lost 8 pounds. There have been no documented changes in the client's physical health. Which strategy may help to improve caloric intake for this client?

Take the client to the dining room for all meals.

The nurse is teaching a newly diagnosed diabetic about the action of regular insulin. The nurse verifies that teaching has been successful when the client verbalizes being at greatest risk for developing hypoglycemia at what time following the 8:00 a.m. dose of regular insulin?

11 AM *Regular insulin peaks 2-3 hours after administration. Clients are at greatest risk for hypoglycemia when insulin is at its peak.

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the least amount of time that the nurse can safely administer this medication?

2.2 minutes *The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes.

A nurse is at highest risk for blood-borne exposure during which situation?

A clean needle sticks the nurse through blood-soiled gloves.

An angry client visits the primary healthcare provider's office and requests a copy of their medical records. The client is angry after being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this client?

A copy of the record may be obtained within 24 hours of the request.

The nursing supervisor notified the charge nurse on a pediatric unit that a child with a history of developmental delays is being admitted with shingles. The nurses on the floor have the following assignments. It would be inappropriate for the charge nurse to assign the new admit to which nurse?

A pregnant nurse caring for clients with cystic fibrosis, myelomeningocele, and rheumatoid arthritis.

A client was admitted to the medical unit with pneumonia 2 days ago. There is a history of drinking 5-6 martinis every night for the past 2 years. Today, the nurse notes that the client is disoriented to time and place and is seeing imaginary spiders on the ceiling. The nurse cannot understand what the client is saying. What is this client most likely experiencing?

Alcohol Withdrawal Delirium

After reviewing the nursing notes on a client receiving a unit of packed red blood cells, what action should the charge nurse take?

All blood from each unit of packed red blood cells must be completed within a 4 hour time frame due to risk of hemolysis and bacterial invasion. If the unit of blood is not completed in a 4 hour time frame, the blood must be sent to the lab to be discarded. Keep in mind that the time frame for administering platelets and fresh frozen plasma differs (20-30 min).

correct order of nursing actions

Assess newborn's airway and breathing Bulb suction excessive mucus. Assess newborn's heart rate. Place identification bands on newborn and mom. Administer sterile ophthalmic ointment containing 0.5% erythromycin.

The nurse should question which prescription for a client diagnosed with acute heart failure?

Start IV with NS at 125 mL/hr. *client is in FVE, this is an isotonic solution that could lead to further overload

A client experiencing chest pain is prescribed an intravenous infusion of nitroglycerin. After the infusion is initiated, the occurrence of which symptom would prompt the nurse to discontinue the nitroglycerin?

cool clammy skin *indicates decreased CO

Gunthrie test

determines presence of phenylalanine in blood positive test= metabolic disorder sample of blood taken from baby's heel normal level is 0.5 to 1.0

The nurse is teaching a client about foods containing tyramine which should be avoided while taking a monoamine oxidase inhibitor (MAOI). Which meal selection, if chosen by the client, indicates successful teaching?

Fried catfish, French fries, coleslaw and apple juice. Rationale: Tyramine is found in protein-containing foods and the levels increase as these foods age. Food such as strong or aged cheese, cured meats, smoked or process meats, liver (especially aged liver), pickled or fermented foods, sauces, soybeans, dried or overripe fruits, meat tenderizers, brewer's yeast, alcoholic beverages and caffeine- such as in tea, cokes and coffee are considered to be high in tyramine and should be avoided in clients taking MAOIs.

During a conversation with a client on a psychiatric unit the client tells the nurse, "Everyone here hates me." Which response by the nurse is best?

I can't speak for the other people, but I don't hate you.

Two hours after a gastrectomy, a client has pink tinged drainage from the nasogastric (NG) tube, and the tube appears occluded. What is the nurse's initial action at this time?

call doctor *do NOT tamper with fresh surgery tubes

A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation?

do you have periods of muscle jerking? *Myoclonus, high body temperature, shaking, chills, and mental confusion are some of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal.

The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting?

gradual increase of BUN

A client asked the nurse what could have caused them to develop right sided heart failure? What would be the best response by the nurse?

high BP in lungs *Yes, the right side of the heart pumps to the lungs. When the client has higher pressure in the pulmonary circuit from such things as emphysema, the pulmonary pressure can exceed the systemic pressure. The result is back flow to the right side of the heart and resulting right sided heart failure.