Question Trainer 2 Content

The nurse plans discharge teaching for a client after a lumbar laminectomy. Which muscle or muscles does the nurse encourage the client to exercise regularly?

--Abdominal bc it adds support for the muscles supporting the lumbar spine

The school nurse conducts a class on childcare at the local high school. during the class, one of the participants asks the nurse at which ate to begin toilet training a child. What is the best response?

-20 months of age to begin, 24mos to be able to achieve daytime bladder contril

A client with T1DM asks the nurse why the HCP prescribed regular insulin instead of intermediate insulin. Which response by the RN is best?

-Blood glucose levels can be controlled more accurately with regular insulin -tighter BG control occurs with regular insulin especially initially

During an initial interview at the outpt clinic, a 34yo single parent tells the nurse of having had difficulty forming personal relationships and is worried that her 7yo will have the same problem. Which statement, if made by the RN is best?

-Children develop trust from birth to 18mos This comes from a predictable, dependable primary caretaker.

Which symptoms will a nurse expect to see in a client admitted 2 ays ago with a dx of closed head injury who has developed DI?

-Cracked lips, urinary outbid of 4L/24h, urine spec gravity of 1.004 -weight loss will occur -glucoseuria occurs with regular DM not DI

Nurse cares for a client during a radium implant. During the removal of the implant, it is out important for the nurse to

-Document the date and time of removal together with the total time of plant tx *at no time should the nurse or client handle the radium, radiology dept is responsible for handling the implant

The client is brought to the ED after being raped int he home. They ask the nurse to call their spouse to come to the ED. The nurse knows that most common reaction of the SO to a rape victim is reflected in which behavior?

-Emotionally distressed and needing assistance. *they may want to be helpful, however, generally don't have immediate coping strategies to handle the situation *Usually the family members will need assistance and respond well to psychological intervention

The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings?

-Hypotension, low back pain, fever *Not wet breath sounds severe shortness of breath (circulatory overload), Urticaria is sign of allergic reaction.

Which psychosocial stage does the nurse identity as a priority to consider when planning care for a 20 year old client?

-Intimacy vs isolation for 19-35 year olds

Then nurse reviews procedures with the health care team. RN intervenes if another RN staff member makes which comment?

-It is my responsibility to explain the sx and ask the client to sign the consent. -The nurse should ensure it is signed and attached to record, sign the form showing they witnessed and should answer questions after the HCP has obtained the consent.

The older adult receives dexamethasone for chronic lymphocytic leukemia. It is most important for the nurse to report which finding the the HCP?

-Serum K 3.4 mEq and serum Ca+ 7.8 mEq *normal K is 3.5-5 *normal Ca is 8.5-10.2 -this indicates hypokalemia and hypocalcemia

The NAP reports to the RN that the client with anemia reports weakness. which response from the RN to the NAP is best?

-Set up the client's lunch tray *anything involving assessment can't be delegated to the NAP

Nurse assesses the client dx'd with a spinal cord injury. which findings suggest the complication of autonomic dysreflexia?

-Severe pounding HA -profuse sweating -nasal congestion -goose bumps *urinary bladder overfilling may cause this but doesn't cause the pain *pulse slows, BP increases

The HCP prescribes lithium carbonate 300mg PO QID for an adult client. The nurse in the out patient clinic instructs the client about the med. They should encourage the client to maintain an adequate intake of which substance?

-Sodium, alkali metal salt acts like sodium ions in the body. excretion of lithium depends on normal sodium levels . sodium reduction causes marked lithium retention leading to toxicity.

the adult client is admitted to the hospital unit diagnosed with Hep A . Which precautions does the nurse include in the client's overall care during hospitalization.

-Standard precautions should be used on everyone, sources for Hep A are saliva, feces, and blood.

The older client with a hx of HTN and closed angle glaucoma visits the clinic for a routine check up. What med if ordered by the HCP should the RN question?

-Tetrahydrozoline, 2 drops in both eyes TID is contra indicated as it is an ophthalmic vasoconstrictor and contraindicated in the glaucoma and used with caution in HTN

The HCP orders chlorpromazine to control an alcoholic client's restlessness, agitation and irritability. The nurse should check the order with the HCP bc of which rationale?

-The nurse believes that the client's symptoms reflect alcohol withdrawal. Medication is contraindicated for the tx of alcohol withdrawal symptoms, medication will lower the BP, causing potentially serious medical consequences.

Which assessment findings should the nurse recognize as pertinent to a diagnosis of Cushing's syndrome?

-Thin extremities with easy bruising. -BP increases and client gains weight

When obtaining a specimen from a client for sputum culture and sensitivity, the nurse identifies which instruction is best?

-Upon waking, cough deeply and expectorate into a container. *no pursed lip breathing is necessary, only keep 3 samples if doing acid fast stain for TB, the earliest specimen of the day is most desirable.

the HCP dx'd Graves' disease in a client. The nurse expects the client to exhibit which S/S?

-Weight loss of 10lb in 3 weeks. *pt will be restless in the early morning. will have heat intolerance due to increased metabolic rate. reflexes will be hyperactive

The HCP suggests play therapy for the 7 yo having some difficulty adjusting to the parent's impending divorce. The nurse identifies which reason this type of therapy is effective for this age group?

-Young children have difficulty verbalizing emotions so they express themselves through play

The nursing team consists of an RN, two LPNs, three NAPs. The RN should care for which client?

-a client declining meds to treat colon cx *a client who has a chest tube and ambulating is stable *a client with a colostomy needing irrigation help is stable *a client with R side stroke who needs help bathing is stable and can be seen by NAP

The nurse cares for the client diagnosed with schizophrenia. The nurse knows that questioning the client about their false ideas will solicit which response?

-cause the client to defend the idea *we should reality test, not question. *questioning is not therapeutic and may cause client to avoid the nurse *the client needs defense, questioning will further distort the reality or cause them to elaborate on a delusion

The RN recognizes which nursing intervention is most important when caring for a client just placed in physical restraints?

-check that the restraints have been applied correctly. *All staff members should be aware of hospital policies before use. *it is important to attend to the client's nutrition and hydration after the client is safely restrained.

Which action is the most reliable for the nurse to evaluate the desired client response to diuretic therapy?

-daily weights, evidenced by decreased edema and measured by taking weights at the same time, same scale daily.

an older client is on PN for several weeks. If the PN were abruptly discontinued, the nurse would expect to see which signs and symptoms.

-diaphoresis, confusion, tachycardia bc insulin levels remain high while glucose levels decline. results in hypoglycemia and will also see restlessness, irritability , apprehension, lack of muscle coordination.

The clinic nurse obtains health hx from a client newly dx'd with Buerger's disease. What symptoms does the nurse expect to find?

-digital sensitivity to cold vasculitis of blood vessels in the upper and lower extremities causes this.

A client dx'd with a adjustment disorder with depressed mood has the greatest chance of success in activities that require physical a psychological energy if the nurse schedules activities at which time?

-during morning hours. clients with depression have highest energy levels in the AM.

An adolescent is scheduled for a BKA following a motorcycle accident. The nurse knows preop teaching for this pt should include which info?

-encourage the client to share feelings and fears about the sx as they are importing in dealing with anxiety RT change in body image.

The RN cares for a client during an acute manic episode. They identify which client behaviors as most characteristic?

-gradiose delusions, difficulty concentrating, agitation *paranoia is related to schizophrenia *somatic difficulties are related to personality disorders *distorted perceptions are related to depression

The HCP prescribes estrogen 0.625mg daily for a 43 year old woman.. The nurse identifies which as a primary side effect of this medicaiotn when treatment begins?

-nausea, common at breakfast time, will subside after weeks of medication use. Take after eating to reduce incidence of nausea. *Visual disturbances, ringing in the ears may be seen with long term use *ataxia is rarely seen with this medicaiton

Client returns from sx with a fine, reddened rash noted around the area where provide iodine prep had been applied. Nursing notation in the chart should include which observation?

-notation on an allergy list and notification of the HCP *time and circumstances would eventually be noted as well as location.

The nurse cares of ra homebound client with a urinary catheter, the client's spouse states that the catheter is obstructed. Which observation would confirm the suspicion?

-nurse notes the bladder is distended which is one of the earliest signs of obstructed drainage tube

The nurse anticipates a client dx'd with gastric ulcer to experience pain at which time?

-one half to 1 hour after a meal and rarely at night. not helped by ingestion of food *duodenal ulcers hurt 2-3h after meals, during the night, and prior to ingestion of food.

The nurse recognizes which client symptoms as a characteristic of panic attack?

-palpitaitons, decreased perceptual field, diaphoresis, fear of going crazy

The nurse preps a client for MRI. Which client statement indicates to the nurse that teaching was successful?

-procedure will take about 90 minutes to complete, there will be no discomfort. *contrast doesn't change the color of the urine *no anesthesia *there are no wires attached during the test

A client dx'd with Addison's comes into the clinic. When assessing the skin, the nurse expects

-skin that is darker and more pigmented RT to increase in melanocyte stimulating hormone results in an eternal tan

When assessing orientation to person, place and time for an elderly hospitalized client, which principle should be understood by the nurse?

-stress of an unfamiliar environment may cause confusion. - long term memory is more efficient than short term in these situations. -mental status and learning ability are not affected by aging, although elderly clients may be slower at doing things.

RN prepares discharge teaching for parents of a newborn. Which info should the nurse provide to the parents regarding the accuracy of the PKU test?

-the initial specimen should be collected as close to discharge as possible and may be repeated within 2 weeks -there is no restriction of formula intake, repeating in 2 weeks will help ensure accuracy, only one blood sample is needed

The client is at the clinic to have an A1C performed. Which client statement indicates to the nurse an understanding of this procedure?

-this test indicates how well my blood sugar has been controlled the past 4 months *a blood sample is needed from finger stick or venipuncture, timing of the test is not important. Current blood sugar does not effect the test.

The nurse knows which action is an important consideration in the care of a newborn with FAS?

- Replace vitamins depleted as a result of poor maternal diet. *infant needs to be held and cuddled due to poorly developed CNS

A client receives morphine after admission to the ED in acute resp distress. the client is very anxious, edematous and cyanotic. Which finding shield the nurse recognize as the desired response to the meds?

-Decrease in anxiety

The nurse cares for the client dx'd with a recurrent UTI. The HCP prescribes ciprofloxacin. The nurse plans to tell the client to limit intake of which fluid?

-Milk as it is alkaline. avoid any alkaline foods and fluids *cranberry juice may be used to acidify urine

Promethazine hydrochloride 25mg IV push is ordered for a client. Prior to admin this medication to the client, the nurse should assess what?

-Patency of the client's vein as extravasation will cause necrosis *should also check color of the medication -promethazine is used as an adjunct to analgesics but has no analgesic activity itself.

The geriatric residents of a LT care facility participate in a reminiscing group. The nurse identifies which goal of this group activity?

-Provides an environment for social interaction and companionship. *groups that facilitate orientation to time, person, place, and current events are called reality orientation groups

An older client has a modified radical mastectomy and axillary dissection. Which nursing dx is correctly stated priority nursing dx for this pt?

-Px RT surgical incision

A Miller-Abbott tube is ordered. The nurse knows that the main reason this tube is inserted is for which reason?

-Removes fluid and gas from the small intestine for decompression. Often used for paralytic illeus. -the tube would be placed in an area of reduced peristalsis and would slowly work past an obstruction *it does not primarily decompress the stomach like a Levin or Salem sump *its primary purpose is not for instillation of meds

The nurse develops a comprehensive care plan for the young client diagnosed with anorexia nervosa. The client is referred for assertiveness classes. This is appropriate intervention bc the client may exhibit which problem?

-Self identity and self esteem issues. -these client sod have issues with feelings of anger, though family therapy sessions can be helpful in this case -these clients have issues with family boundary intrusion, family therapy can help define these boundaries.

The nurse cares for a client the first day post op after a TURP. The client has a CBI set up an the client's spouse asks why. Which is the best response by the nurse?

-The CBI enables urine to keep flowing *doesn't directly prevent urinary stasis and infection

The client develops a low intestinal obstruction, the nurse anticipates which findings?

-nausea, vomiting, abd distention

Rank the clients in order you'd see them- -elderly client who used all the diuretic meds and is expectorating pink tinged mucus. -elderly client dx'd with pneumonia and discharged from hospital 3 days ago -client discharged yesterday after IV heparin tx for DVT -the client who is breastfeeding a 2 day old infant born 5 days before due date

1. client with pink tinged mucus a s/s of pulmonary edema and requiring immediate attention 2. client on heparin, still potential for issues RT heparin, assess for bleeding, hematuria 3. client w pneumonia, potential for relapse, assess breath sounds, encourage fluids and TCDB 4. breastfeeding client, stable, least critical

Which is the best method for the nurse to use when evaluating the effectiveness of tracheal suctioning?

Auscultate the chest for change or clearing of adventitious breath sounds. -pt comments are only subjective data -decreased RR and pulse are objective but not as effective

Client returns from sx after a R mastectomy. An IV of 0.9% NaCl infusing at 100mL/h into the left forearm. The IV infiltrates a few hours later. This nurse supervises the student nurse preparing to insert a new peripheral IV catheter. What would require the nurse to intervene.

The student nurse selects a site close to the wrist joint. movement could displace the IV again *A site proximal to the infiltrated area may be used if the same extremity must be used though you'd avoid theR side after a R side mastectomy.