P.6
An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms? a. Destruction of joint cartilage b. bone deneration
a. Destruction of joint cartilage
The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the PICTURE What action should the nurse take? a. Remind the client to hold his breath after inhaling the medication b. Confirm that the client has correctly shaken the inhaler
a. Remind the client to hold his breath after inhaling the medication
During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 f. which intervention should the nurse implement? a. Stop the transfusion start a saline b. Report to HCP
a. Stop the transfusion start a saline
When administering ceftriaxone sodium (Rocephin) intravenously to a client before... most immediate intervention by the nurse? a. Stridor b. Nausea
a. Stridor Rationale Stridor, a crowing respiration, indicates the client is experiencing bronchospasm, as a reaction to Rocephin, and antibiotic. The finding requires immediate action by the nurse. B and C are side effects that are not life-threatening. Pruritus may be the result as... and need nursing intervention but is of less immediacy than stridor.
A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother... During the assessment, the mother asks the nurse why her child is at the 5th percent...response is best for the nurse to provide? a. Does your child seem mentally slower than his peers also? b. "His smaller size is probably due to the heart disease"
b. "His smaller size is probably due to the heart disease" Rationale: Poor growth patterns are associated with heart disease.
After checking the fingerstick glucose at 1630, what action should the nurse implement? a. Notify the healthcare provider b. Administer 8 units of insulin aspart SubQ
b. Administer 8 units of insulin aspart SubQ
**When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first a. massage uterus b. Check for a distended bladder
b. Check for a distended bladder
A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine, what instruction should the nurse provide to this mother a. GIve the dose b. withold this dose
b. withold this dose
A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse? a. Teach patient to eat often to relieve pain. b.Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer
b.Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer
A client is admitted for cellulitis surrounding an insect bite on the lower, right arm and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture? a. Lay left arm straight b.Lower the left arm below the level of the heart
b.Lower the left arm below the level of the heart
A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? a- Hypernatremia b- Excessive thirst
a- Hypernatremia
A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement? a- Infuse sodium chloride 0.9% (normal saline) b- Prepare an emergency dose of glucagon
a- Infuse sodium chloride 0.9% (normal saline) Rationale DKA an increase in glucose and ketone bodies, result in hyperosmolar dehydration, so is necessary to restore fluid balance.
A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile, which assessment finding warrants immediate intervention by the nurse? a- Uncontrollable drooling b- Inability to raise voice
a- Uncontrollable drooling
When organizing home visits for the day, which older client should the home health nurse plan to visit first? a. A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools. b. A man who receives weekly injections of epoetin (Procrit) for a low serum iron level
a. A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools.
Which class of drugs is the only source of a cure for septic shock? a. Antiinfectives b. Antiobiotics
a. Antiinfectives
A male client with rheumatoid arthritis is schedule for a procedure in the morning. The... unable to complete the procedure because of early morning stiffness. Which intervention... implement? a. Assign the UAP to assist the client with a warm shower early in the morning b. Let pt. rest some more
a. Assign the UAP to assist the client with a warm shower early in the morning
Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillain-Barre syndrome? a. Avoid exposure to respiratory infections. b. Use relaxation exercise when anxious
a. Avoid exposure to respiratory infections.
An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first? a. Begin manual ventilation immediately b. Call HCP
a. Begin manual ventilation immediately
**After diagnosis and initial treatment of a 3 year old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions? a. Chest physiotherarpy should be performed TWICE a day before a meal b. Rest before every meals
a. Chest physiotherapy should be performed TWICE a day before a meal
Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning a. Cold sensitivity b. Hot sensitivity
a. Cold sensitivity
The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress? a- Contractions of the sternocleidomastoid muscle. b- Respiratory rate of 20 breath/mints
a- Contractions of the sternocleidomastoid muscle. Rationale: Force inspiration needs to use accessories muscle and rib cage.
Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective? a- Decrease abdominal girth b- Increased blood pressure
a- Decrease abdominal girth
The nurse assesses a 78-year-old male client who has left sides heart failure. Which symptoms would the nurse expect this client to exhibit? a- Dyspnea, cough, and fatigue. b- Hepatomegaly and distended neck veins
a- Dyspnea, cough, and fatigue.
The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide? a- Exercise at least three times weekly b- Monitor blood glucose levels daily
a- Exercise at least three times weekly
Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests? a- Expresses an understanding of the procedure. b- NPO for 6 hrs.
a- Expresses an understanding of the procedure.
A newly hired home health care nurse is planning the initial visit to an adult client who has had multiple sclerosis (MS) for the past 20 years and is currently bed-bound and is lifted by a hoist. And unlicensed caregiver provides care 8 hours/ daily, 5 days/week. During the initial visit to this client, which intervention is most important to the nurse to implement? a. Determine how the client is cared for when caregiver is not present. b. Develop a client needs assessment and review with the caregiver
a. Determine how the client is cared for when caregiver is not present.
In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement? a. Document the extend of the bruising in the medical record b.Let HCP know
a. Document the extend of the bruising in the medical record
*While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain? a. Does your pain occur when walking short distances? b.Tell me more about the pain you are having.
a. Does your pain occur when walking short distances?
A male client with cancer, who is receiving antineoplastic drugs, is admitted to the... what findings is most often manifest this condition? a. Ecchymosis and hematemesis b. Weight loss and alopecia
a. Ecchymosis and hematemesis
The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer's disease. What action should the nurse take? a. Explain that memory loss and confusion are common with vitamin B12 deficiency b. Let her HCP know about the situation
a. Explain that memory loss and confusion are common with vitamin B12 deficiency
A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. Which condiment should the nurse offer? a. Fresh Horseradish b. garlic salt
a. Fresh Horseradish
The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement? a. Give the prescribed antiemetic b. Hold the medication
a. Give the prescribed antiemetic
When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform? a. Hold the thermometer in place. b. Place the disposable pad under buttocks
a. Hold the thermometer in place
A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate? a. Ineffective coping related to denial b. Ineffective understanding
a. Ineffective coping related to denial
Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his bloods pressure drops to 60/40. Which intervention should the nurse implement? a. Infuse a rapid IV Normal saline bolus b. tranfuse blood rapidly
a. Infuse a rapid IV Normal saline bolus
The health care provider prescribes atenolol 50 mg daily for a client with angina pectoris...to the health care provider before administering this medication? a. Irregular pulse b. Tachycardia
a. Irregular pulse
An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue...Medications. Which medication provides the greatest threat to this client? a. Magnesium hydroxide (Maalox). b. Birth control pills
a. Magnesium hydroxide (Maalox).
A 59-year-old male client comes to the clinic and reports his concern over a lump that, "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is not overlying tissue inflammation. What do these findings suggest a. Malignancy b. non malignant
a. Malignancy
A client with urticaria due to an environmental allergies is taking diphenhydramine... Which complaint should the nurse identify to the client as a side effect of the OTC medication? a. Nausea and indigestion. b. Hyper salivation
a. Nausea and indigestion.
When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client's GCS score has been 14. What does this GCS finding indicate about the client? a. Neurologically stable without indications of an increased IC b. Unstable with chnages in GCS
a. Neurologically stable without indications of an increased IC
A-12-years old boy has a body mass index (BMI) of 28, a systolic pressure and a glycosylated hemoglobin (HBA1C) of 7.8%. Which selection indicated that his mother understands the management of his diet a. One whole-wheat bagel with cream cheese, two strips of bacon, six ounces of orange juice. b. Wheat grain diet
a. One whole-wheat bagel with cream cheese, two strips of bacon, six ounces of orange juice.
**A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room? a. Place the ID bands on the infant and mother b. Breast feed baby with mom
a. Place the ID bands on the infant and mother
The nurse determines that a client's pupils constricts as they change focus from a far object. What documentation should the nurse enter about this finding? a. Pupils reactive to accommodation b. Nystagmus present with pupillary focus.
a. Pupils reactive to accommodation
When checking a third grader's height and weight the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement? a. Refer child to the family HCP b. Let parents know that its normal
a. Refer child to the family HCP
Following a gun shot wound to the abdomen, a young adult male had an emergency bowel...Multiple blood products while in the operating room. His current blood pressure is 78/52...He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values...Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first? a. Transfuse packed red blood cells b. Obtain blood and sputum cultures.
a. Transfuse packed red blood cells Rational: The client is exhibiting signs of multiple organ dysfunction syndrome. Transfusion is the first intervention which provide hemoglobin to carry the oxygen to the tissues, is critical.
While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond? a. We need to stay focused on the topic b. Let students know that you are old enough
a. We need to stay focused on the topic
A client who is at 36 weeks gestations is admitted with severe preclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse? a. urine output 20ml/hr b. sodium of 140
a. urine output 20ml/hr Rational: urinary output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium, which is excreted through kidneys.
The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately? a.Complain of headaches and stiff neck b. Constant chest pain
a.Complain of headaches and stiff neck
The nurse is caring for four clients...postoperative hemoglobin of 8.7 mg/dl; client C, newly admitted with potassium...an appendectomy who has a white blood cell count of 15,000mm3. What intervention... a.Determine the availability of two units of packed cells in the blood bank for client B b. Let HCP know about situation
a.Determine the availability of two units of packed cells in the blood bank for client B
A client with a new diagnosis of Raynaud's disease lives alone. Which instruction should the nurse include in the client's discharged teaching plan? a.Keep room temperature at 80 b. Get checked up by HCP
a.Keep room temperature at 80
A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior any more since all she does is care for their son. What intervention should the nurse implement? a- Schedule a home visit in the afternoon to assess the son and client role as caregiver. b- Acknowledge the client's stress and suggest that she consider respite care.
b- Acknowledge the client's stress and suggest that she consider respite care. Rationale: When this amount of disclosure is offered, the client is usually seeking information focuses on the client's expression of worry, concern and stress and addresses the client's need to initiate a request for assistance with respite care.
The nurse provides feeding tube instructions to the wife of a client with end stage cancer. The client's wife performs a return demonstration correctly, but begins crying and tells the nurse, "I just don't think I can do this every day." The nurse should direct further teaching strategies toward which learning domain? a- Cognitive b- Affective
b- Affective
An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive...medication therapy, the nurse notices the client has more energy, is giving her belongings...mood. Which intervention is best for the nurse to implement b- Ask the client if she has had any recent thoughts of harming herself. c- Reassure the client that the antidepressant drugs are apparently effective
b- Ask the client if she has had any recent thoughts of harming herself.
The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate? a- Initiation of the impulses from a location outside the SA node b- Inability of the SA node to initiate an impulse at the normal rate
b- Inability of the SA node to initiate an impulse at the normal rate Rationale: A prolonged PRI reflects an increased amount of time for an impulse to travel from the SA node through the AV node and is characteristic of a first-degree heart block.
A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider? a- Insomnia b- Muscle cramping
b- Muscle cramping Rationale: SIADH causes dilution hyponatremia because of the increased release of ADH, which is treated with water restriction and demeclocycline, a tetracycline derivate that blocks the action of ADH. Signs of hyponatremia (normal 136-145), which indicate the need for increasing the dosage of demeclocycline, should be reported to the healthcare provider. The signs include: plasma sodium level less than 120, anorexia, nausea, weight changes related to fluid disturbance, headache, weakness, fatigue, and muscle cramping. AC& D are not related to hyponatremia.
In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test? a- Urinalysis b- Serum creatinine
b- Serum creatinine Rationale: Aminoglycosides can cause nephrotoxicity, so it is important for the nurse to monitor the serum creatinine level can monitor the renal function.
The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? a- Your baby is gaining weight right on schedule b- What food does your baby usually eat in a normal day?
b- What food does your baby usually eat in a normal day? R: The normal weight gain in the first year of life is approx. twice the birth weight
An adult male who lives alone is brought to the Emergency Department by his daughter who is unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and... Which nursing intervention has the highest priority? a. Offer to notify the client's minister of his condition. b. Determine if the client has an executed living will
b. Determine if the client has an executed living will Rationale: Once the client is intubated and ventilated, emergency intervention should continue until patient t be stable check if the client has an executed living will.
A male client with impaired renal function who takes ibuprofen daily for chronic arthritis...gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 ml / hour. Which intervention should the nurse include in hours? a. Maintain the client NPO during the diuresis phase b. Evaluate daily serial renal laboratory studies for progressive elevations.
b. Evaluate daily serial renal laboratory studies for progressive elevations.
The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based clean...tray to the room. The UAP rub both hands thoroughly for 2 minutes while standing at the...should the nurse take? a. Encourage the UAP to remain in the client's room, until completed b. Explain that the hand rub can be completed in less than 2 minutes.
b. Explain that the hand rub can be completed in less than 2 minutes.
An adolescent's mother calls the clinic because the teen is having recurrent vomiting and...Combative in the last 2 days. The mother states that the teen takes vitamins, calcium, mag...With aspirin. Which nursing intervention has highest priority? a. Advise the mother to withhold all medications by mouth. b. Instruct the mother to take the teen to the emergency room
b. Instruct the mother to take the teen to the emergency room
The mother of a one-month-old boy born at home brings the infant to his first well...was born two weeks after his due date, and that he is a "good, quiet baby" who almost... hypothyroidism, what question is most important for the nurse to ask the mother? a. Has your son had any immunizations yet? b. Is your son sleepy and difficult to feed?
b. Is your son sleepy and difficult to feed? Rationale: Like adults with hypothyroidism, excess fatigue is common and a "good" baby is of.... occurs with hypothyroidism and can result in poor sucking.
A client is admitted for type 2 diabetes mellitus (DM) and chronic Kidney disease (CKD)... which breakfast selection by the client indicates effective learning? a. Scrambled eggs, bacon, one slice of whole wheat toast with butter and jam. b. Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces' coffee.
b. Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces' coffee.
**A client with a postoperative wound that eviscerated yesterday has an elevated temperature...most important for the nurse to implement? a. Initiate contact isolation b. Obtain a wound swab for culture and sensitivity
b. Obtain a wound swab for culture and sensitivity
The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider? a. Hypoactive bowel sounds in the lower quadrant. b. Rebound tenderness in the upper quadrants.
b. Rebound tenderness in the upper quadrants. Rationale: Rebound tenderness in the upper quadrant may be indicative of peritonitis. A is a clinical finding associated with bowel obstruction and does not need to be reported D may be something characteristic of the client's condition.
The nurse is reinforcing home care instructions with a client who is being discharged following...prostate (TURP). Which intervention is most important for the nurse to include in the client... a. Avoid strenuous activity for 6 weeks b. Report fresh blood in the urine.
b. Report fresh blood in the urine.
A client with hypertension receives a prescription for enalapril, an angiotensin... instruction should the nurse include in the medication teaching plan? a. Increase intake of potassium-rich foods b. Report increased bruising of bleeding
b. Report increased bruising of bleeding R:ACEIs can cause thrombocytopenia and increased risk for bruising and bleeding. A is not necessary because is a potassium-sparing
A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client's mothers enter the labor suite and says in a loud voice, "I've had 8 children and I know she's in labor. I want her to have her cesarean section right now!" what action should the nurse take? a. Ask mother to not share her experiences b. Request the mother to leave the room
b. Request the mother to leave the room
A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being...18 months-old child and lives in a rural area. Her husband takes the family car to work daily...transportation during the day. What intervention is most important for the nurse to implement? b. Schedule a weekly home visit to draw hCG values. c. Make a 5 week follow- up with healthcare provider
b. Schedule a weekly home visit to draw hCG values. Rationale: To monitor for development of choriocarcinoma, a complication TD, level of hCG should be monitor for negative results.
A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10), two hours ago, he received hydrocodone / acetaminophen 7.5/7.50 mg his vital signs are elevated from reading of a previous hour: temperature 97.8 F, heart rate 102 beats / minute, respiration 20 breaths/minutes. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but left is greater than right. Preoperatively, clopidrogel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete? b. Surgeon needs to see client immediately to evaluate the situation c. Left peripheral pulses were present only by Doppler pre-procedure
b. Surgeon needs to see client immediately to evaluate the situation
While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement a. Use vasaline b. Use a water soluble lubricant on affected oral and nasal mucosa
b. Use a water soluble lubricant on affected oral and nasal mucosa
An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. What action should the nurse implement first? a. let her have space to think about the situation shes in b.Tell the client that the nurse will be back to talk to her after medications are given
b.Tell the client that the nurse will be back to talk to her after medications are given
A male Korean-American client looks away when asked by the nurse to describe his problem. What is the best initial nursing action? b- Establish direct eye contact with the client. c- Allow several minutes for the client to respond.
c- Allow several minutes for the client to respond.
A client present at the clinic with blepharitis. What instructions should the nurse provide for home care? b- Wear sunglasses when out of doors to prevent photophobia c- Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo
c- Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo Rationale: This condition is an inflammation of the eyelids edges that occurs in older adults. Is controlled with eyelid care using warm moist compresses followed by gently scrub eyelids.
A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? b- Encourage the client to move to a hands-and-knees position. c- Assist the client to sharply flex her thighs up again the abdomen.
c- Assist the client to sharply flex her thighs up again the abdomen.
During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement? b- Teach the parents about congenital heart defects. c- Document the finding in the infant's record.
c- Document the finding in the infant's record.
When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do? b- Help the client to stand. c- Get a blood pressure cuff.
c- Get a blood pressure cuff.
A 16-year-old male is admitted to the pediatric intensive care unit after being involved in a house fire. He has full thickness burns to his lower torso and extremities. Before a dressing change to his legs, which intervention is most important for the nurse to implement? b- Use distraction techniques to reduce pain. c- Maintain strict aseptic technique
c- Maintain strict aseptic technique
What is the nurse's priority goal when providing care for a 2-year-old child experiencing seizure... c- Manage the airway d- Protect the body from injury
c- Manage the airway
In determine the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition? c- Orthopnea d- Fever.
c- Orthopnea Rationale: If the client is orthopneic, the nurse needs to adapt the insertion position that does not place the client in a supine position (the head of the bed should be elevated as much as possible).
A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? b- Assist the client to the bathroom c- Perform a sterile vaginal exam
c- Perform a sterile vaginal exam Rationale: When a client in active labor suddenly expresses the urge to have a bowel movement, a sterile vaginal exam should be performed to determine if the fetus is descending.
While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition? c- Psoriasis d- Drug reaction
c- Psoriasis Rationale: Psoriasis is typically located on the elbow and knees
The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin SHOCK... medication? c- Push the undiluted Dextrose slowly through the currently infusion IV. d- Ask the pharmacist to add the Dextrose to a TPN solution.
c- Push the undiluted Dextrose slowly through the currently infusion IV. Rationale: To reverse life-threatening insulin shock, the nurse should administer the 50% Dextrose infusing IV.
A 35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery? c- The client will be restricted from eating seafood d- The remainder of the thyroid will be removed at a later date.
c- The client will be restricted from eating seafood
A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next? b. Measure the child's abdominal girth c. Collect a urine specimen for routine urinalysis
c. Collect a urine specimen for routine urinalysis Rationale: Acute glomerulonephritis is an auto-immune reaction to a precursory streptococcus. Manifestation of AGN include oliguria, edema, hypertension.
An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior? c. Compulsion d. Obsession
c. Compulsion
The nurse teaches an adolescent male client how to use a metered dose inhaler. Seen in the PICTURE. What instruction should the nurse provide? b. Press down on the device after breathing in fully c. Move the device one to two inches away from the mouth
c. Move the device one to two inches away from the mouth Rationale: Optimal position of a metered dose inhaler includes placing the inhaler one two inches away from the mouth.
In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)? c- A client with pancreatic cancer who is experience intractable pain. d- An older client post-stroke who is aphasic with right-sided hemiplegia
d- An older client post-stroke who is aphasic with right-sided hemiplegia
The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide? c- Pour warm water over the external sphincter at the distal glans d- Apply downward manual pressure at the suprapubic regions.
d- Apply downward manual pressure at the suprapubic regions. Rationale: The Crede Method is used for those clients with atonic bladders, which is a concomitant of demyelinating disorders like multiple sclerosis. The client is applying pressure in the wrong region (umbilical Are) and should be instructed to apply pressure at the suprapubic are.
An older female client tells the nurse that her muscles have gradually been getting weak...what is the best initial response by the nurse? c- Review the medical record for recent diagnosis test results. d- Ask the client to describe the changes that have occurred
d- Ask the client to describe the changes that have occurred
The nurse plans to administer a schedule dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take? c- Give the Tropol as scheduled if the client's systolic blood pressure reading is greater than 180. d- Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern.
d- Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern. Rationale: Beta blockers such as metoprolol (Tropol SR) are contraindicated in clients with second or third-degree heart block because they decrease the heart rate. Therefore, the nurse should hold the medication.
After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement? c- Encourage increased fiber in diet. d- Monitor mental status.
d- Monitor mental status. Rationale: Administer lactulose to a patient hepatic encephalopathy to lower serum ammonia level, so mental status should be improving.
The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic? c- Short half life d- Narrow therapeutic index.
d- Narrow therapeutic index.
Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client? c- Promote rest and sleep d- Reduce the risk for injury
d- Reduce the risk for injury Rationale: Paget's is a metabolic bone disorder which place the client at high risk for injury. Once the client is symptom free the next goal is reducing risk for injury
A client who is schedule for an elective inguinal hernia repair today in day surgery is seem eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications? c- Remove the food from the client d- Withhold the preoperative medication
d- Withhold the preoperative medication
Which nursing intervention has the highest priority for a multigravida who delivered? c. Observe for appropriate interaction with the infants. d. Assess fundal tone and lochia flow
d. Assess fundal tone and lochia flow Rationale D is the priority intervention because is a multigravida and this pregnancy predisposes the client to uterine atony which could result in hemorrhage.
Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscul...Which finding warrants immediate intervention by the nurse? c. Inability to swallow pills d. Evidence of hypoventilation
d. Evidence of hypoventilation Rationale: Hypoventilation indicates respiratory muscle weakness, and if the client is unable to breath... respiratory distress and life-threatening.
A newly graduated female staff nurse approaches the nurse manager and request reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide? c. I'll talked to the client about his sexual harassment and I'll insist that he stop it immediately. d. I'll change your assignment, but let's talk about you a nurse should respond to this kind of client.
d. I'll change your assignment, but let's talk about you a nurse should respond to this kind of client.
In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, The nurse assesses that the client in lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next? c. Auscultate the client's breath sounds bilaterally. d. Observe the amount and dose of morphine in the PCA pump syringe.
d. Observe the amount and dose of morphine in the PCA pump syringe.
Which instruction is most important for the nurse to provide a client who receives a new plan of care to treat osteoporosis? c. Schedule a bone density tests every year. d. Remain upright after taking the medication.
d. Remain upright after taking the medication. Rationale: Risendronate, causes reflux and esophageal erosion.
