Synthesis Final Exam Practice Questions
A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspect abuse. Which of the following actions should the nurse take first? -document the bruises in the client's chart -report the findings to a supervisor -provide the client with a crisis hotline number -discuss respite care with the client's family
report the findings to a supervisor -The greatest risk to this client is further injury from continued abuse; therefore, the first action the nurse should take is to report the findings to a supervisor. Nurses are required to report suspected cases of child and older adult abuse.
A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? -shortly after giving birth -in the third trimester -immediately -during her next attempt to get pregnant
shortly after giving birth -The rubella immunization should be offered to the client following birth, preferably prior to discharge from the hospital. This prevents the client from contracting rubella during the current or subsequent pregnancies, which would put her fetus at risk for rubella syndrome.
A nurse is administering platelets to a client who reports having lower back pain and feeling chilled and itchy. Which of the following actions should the nurse take first? -notify the provider -stop the infusion -collect a urine sample from the client -return the platelet bag and tubing to the blood bank
stop the infusion -The greatest risk to this client is injury from a transfusion reaction, which can be more harmful if the client receives more of the blood product. Therefore, the first action the nurse should take is to stop the infusion.
A nurse is assessing a client for suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first? -urticaria -stridor -vomiting -hypotension
stridor -When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is stridor, which indicates narrowing of the airway. The nurse should position the head of the client's bed at 45° or more, if tolerable, and call for emergency assistance.
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority? -suction the nose with a bulb syringe -suction the mouth with a bulb syringe -use a suction catheter with low negative pressure -turn the newborn on his side
suction the mouth with a bulb syringe -The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action.
A nurse enters an adult client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first? -summon the code team -begin chest decompressions -administer rescue breathing -open the client's airway
summon the code team -After determining that the client is in respiratory or cardiac arrest the nurse should first summon the code team before initiating CPR.
A nurse is assessing a client who is taking lisinopril to treat hypertension. Which of the following findings is a priority to report? -dry cough -swelling of the tongue -nausea -nasal congestion
swelling of the tongue -When using the urgent vs non-urgent approach to client care, the nurse determines that the priority finding is swelling of the tongue, which is a manifestation of angioedema. The nurse should withhold the medication and notify the provider immediately if the client reports swelling of the tongue or throat. Other manifestations include giant wheals and edema of the tongue, glottis, and pharynx. Severe reactions are treated with subcutaneous epinephrine. If angioedema develops, ACE inhibitors are discontinued.
A nurse is reinforcing teaching about contraceptive methods with a client. Which of the following should the nurse recognize as a contradiction for diaphragm use? -the client is 42 years old -the client smokes cigarettes -the client has pelvic relaxation -the client has a 3-month-old infant
the client has pelvic relaxation -Pelvic relaxation and large cystocele are contraindications for diaphragm use.
A nurse is assessing a client who received IV conscious sedation for a colonoscopy. Which of the following findings indicated that the client s ready for discharge? -the client is restless -the client is cooperative and oriented -the client shows a brisk response to stimulus -the client shows a sluggish response to stimulus
the client is cooperative and oriented -A client who is cooperative, oriented, and calm will have a Ramsay Sedation score of 2, which indicates the client has recovered adequately to go home with a responsible adult.
A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first? -palpate the client's uterus -administer oxygen to the client -increase the client's IV fluid infusion rate -turn the client onto her side
turn the client onto her side -When using the urgent vs non-urgent approach to client care, the nurse determines that the priority action is to turn the client onto her left side. Late decelerations indicate that the client might have uteroplacental insufficiency, maternal hypotension, uterine tachysystole form oxytocin administration, or several other complicating factors. The client might be exerting pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply.
A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take? -check the pedal pulses -verify the most recent calcium level -request prescription for a relaxant -administer an oral potassium supplement
verify the most recent calcium level -A client who has had a thyroidectomy is at risk of hypocalcemia due to the possible disruption of the parathyroid gland during surgery. The parathyroid glands are four small glands located inside the thyroid gland that are responsible for calcium regulation. If they are damaged during a thyroidectomy, there is a risk of hypocalcemia. Low calcium levels can be manifested as numbness and tingling of the fingers and around the mouth, muscle spasms (particularly of the hands and feet), and hyperactive reflexes. If a client develops any of these manifestations following a thyroidectomy, the nurse should check the client's latest calcium level. The expected reference range for calcium is 8.5 to 10.5 mg/dL. If the calcium level is low, the provider should be notified, and oral or intravenous calcium replacement should be administered.
A nurse is collecting data on a client who has a new prescription for ampicillin. The nurse should recognize which of the following findings as a priority? -nausea -vomiting -wheezing -moniliasis
wheezing -When using the airway, breathing, circulation approach to client care, the nurse should determine the priority finding is wheezing. Wheezing is a manifestation of an anaphylactic allergic reaction due to bronchospasm and edema in the airway. Wheezing indicates a constriction of the airway and requires immediate intervention to support respiratory function. The nurse should advise the client to wear identification to indicate an allergy to this medication.
A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client? -"Are there any specific factors you think are affecting your ability to sleep?" -"Can you describe your bedtime routine to me?" -"Do you have difficulty staying awake when you are driving?" -"When did you begin to have trouble sleeping?"
"Do you have difficulty staying awake when you are driving?" -This question addresses the greatest risk to the client, which is safety, and is therefore the priority question.
A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make? -"Irregular bowel movements are an indication or poor intestinal health" -"Excessive laxative se may cause an electrolyte imbalance" -"Chronic use of laxatives can lead to a tear in the rectal mucosa" -"Decrease your intake of foods high in fiber"
"Excessive laxative se may cause an electrolyte imbalance" -Bisacodyl is a stimulant laxative that acts by stimulating intestinal motility and increasing the amount of water and electrolytes within the intestines; therefore, chronic use of laxatives can lead to fluid and electrolyte imbalance.
A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which of the following statements should the nurse make? -"We will call your family in time for them to get here" -"I wonder if you are fearful of dying alone" -"I will make sure a staff member is in your room at all times" -"I will tell your family of your concern so that they can be here"
"I wonder if you are fearful of dying alone" -The nurse is verbalizing the client's implied concerns and seeks to validate if this is the client's concern.
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? -"Information about a client can be disclosed to family members at any time" -"HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form" -"A client's address would be an example of personally identifiable information" -"HIPAA is a federal law, not a state law"
"Information about a client can be disclosed to family members at any time" -This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of his or her own personal health information.
a nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? -"It's a minor inconvenience, which you should ignore" -"In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone" -"There is no way to predict how long it will last in each individual client" -"It occurs during the first trimester and near the end of the pregnancy"
"It occurs during the first trimester and near the end of the pregnancy" -Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder.
A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make? -"It sounds like you're having a difficult time" -"Have you talked to your parents about this yet?" -"Why do you think you are so anxious?" -"How long has this been going on?"
"It sounds like you're having a difficult time" -This therapeutic response is an open-ended, empathetic statement that encourages the client to talk.
A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make? -"We can teach you some relaxation techniques to minimize your pain" -"Keep wire cutters with you at all times" -"Use a water pick device to keep your teeth clean" -"Consume a high-protein, liquid diet"
"Keep wire cutters with you at all times" -When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to include is to tell the client to keep wire cutters available at all times. When the jaw is wired shut, the client is likely to aspirate if vomiting occurs. The client should use the wire cutters to clip the wires to keep the mouth clear of emesis, and should notify the provider so the jaw can be re-wired.
A nurse is caring for a client who has cancer and is 20 weeks pregnant. The client's provider recommends chemotherapy for the client, but the client is uncertain about the recommended treatment. Which of the following statements by the nurse is appropriate? -"You should take the initial dose" -"This must be a difficult decision for you" -"The medication could save your baby's life" -"You should wait until the baby is born to begin treatment"
"This must be a difficult decision for you" -The nurse is using an open-ended statement which encourages the client to discuss her feeling and concerns.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? -positive western blot test -CD4-T-cell count 180 cells/mm3 -platelets 150,000/mm3 -WBC 5,000/mm3
CD4-T-cell count 180 cells/mm3 -A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider.
A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first? -a client who is at 38 weeks of gestation and reports a cough and fever -a client who has missed a period and reports vaginal spotting -a client who is at 14 weeks of gestation and reports nausea and vomiting -a client who is at 28 weeks of gestation and reports of painless vaginal bleeding
a client who is at 28 weeks of gestation and reports of painless vaginal bleeding -Using the urgent vs. nonurgent approach to client care, the nurse should assess this client first. The nurse should suspect placenta previa when vaginal bleeding occurs after 24 weeks of gestation. A pregnant woman can lose up to 40% of blood before showing signs of shock.
A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients? -a client who is postoperative following a lobectomy and has a chest tube -a client who is being discharged to a long-term care facility -a client who needs teaching about insulin self-administration -a client who needs teaching prior to initiating cardiac rehabilitation activities
a client who is postoperative following a lobectomy and has a chest tube -According to evidenced-based practice, the nurse from the PACU is most qualified to care for the postoperative client. Nurses in the PACU care for clients with chest tubes after surgery. This is the right client, the right task, and the right circumstances for this nurse.
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client? -a private room in a quiet location on the unit -a semi-private room with a roommate who has a similar diagnosis -a private room close to the nursing station -a seclusion room until the client's activity level becomes more subdued
a private room in a quiet location on the unit -A private room in a quiet location is ideal for a client with mania. The client may easily become overstimulated by the number of people and activities in a nursing care unit. A private room can be used for time-out during the day and to settle down to sleep at night.
A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? -clean and dress the wound -administer pain medication -administer a tetanus booster -administer IV fluids
administer IV fluids -Using the airway, breathing, circulation framework, the priority action the nurse should take is to initiate fluid resuscitation to maintain blood volume and preserve cardiac output. The nurse can utilize large bore peripheral IV cannulas. However, in extensive burns a central line should be inserted to allow for rapid infusion of fluids.
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking both control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? -prepare for mechanical ventilation -administer oxygen via face mask -prepare to administer a sedative -assess for indication of pulmonary embolism
administer oxygen via face mask -The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client's oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation.
A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care? -airway protection -decreasing intracranial pressure -stabilizing cardiac arrhythmias -preventing musculoskeletal disability
airway protection -When assessing and treating a client who has trauma, a systematic approach is taken during the primary survey. It begins with the assessment and interventions necessary to ensure a patent airway.
A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis? -albumin -calcium -sodium -potassium
albumin -Albumin levels reflect the overall body protein status and is used to detect metabolic and liver dysfunction.
A nurse in an emergency department is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse expect to administer first? -fluticasone -budesonide -montelukast -albuterol
albuterol -Albuterol is considered a "rescue" medication due to its rapid onset of action. Asthma is a chronic inflammatory disorder of the airways. Asthmatic episodes are associated with airflow limitation or reversible obstruction. Albuterol is a beta2 adrenergic agonist used for the treatment of acute exacerbations of asthma by promoting bronchodilation and suppressing histamine release in the lungs. This medication can be given by inhalation, orally, or as a parenteral preparation. The inhaled medication has a more rapid onset of action than the oral form and also reduces the risk for the adverse effects of irritability, tremor, nervousness, and insomnia.
A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall? -an older adult who is confused and has urinary frequency -a client with diabetes mellitus who has a leg ulcer -a client who is 1 day postoperative and has a nursing assistant helping him out of bed -an adolescent client who has a leg fracture and has been using crutches for the past 2 days
an older adult who is confused and has urinary frequency -An older adult client who is confused and has urinary frequency is at the greatest risk for a fall because this client might attempt to go to the bathroom without assistance. The nurse should implement interventions to prevent a fall, such as using a bed alarm, and placing the client close to the nurses' station.
A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first? -apply a tourniquet just above the wound -apply pressure directly to the wound -start two large-bore IV catheters place the client in a modified Trendelenburg position
apply pressure directly to the wound -The greatest risk to the client is hypovolemic shock. Therefore, the initial action to control bleeding is to apply pressure directly to the area or to the artery proximal to the wound.
A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? -arterial blood gases -urinary output -chest tube drainage -pain level
arterial blood gases -According to the ABC priority-setting framework, the postoperative surgical client may need supplemental oxygen in order to maintain normal blood oxygen levels. The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases.
A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first? -determine the time the client last received pain medication -measure the client's vital signs, including temperature -ask the client to rate her pain on a scale from 0 to 10 -reposition the client and offer her a back rub
ask the client to rate her pain on a scale from 0 to 10 -Using evidence-based practice, the nurse should first determine the severity of the client's pain by using a standard pain scale. Then the nurse can plan the appropriate interventions.
A community health nurse is conducting an educational program on various environmental pollutants. The nurse should emphasize that clients who have which of the following disorders are especially vulnerable to ozone effects? -osteoarthritis -basal cell carcinoma -asthma -hypothyroidism
asthma -The ozone exerts its primary adverse effects on the respiratory system, reducing lung function and increasing the risk of respiratory infection. Clients who have respiratory disorders, such as asthma and COPD, are especially vulnerable.
A nurse is assessing a client after administering IV vancomycin. Which of the following findings is the nurse's priority to report to the provider? -localized redness at the catheter insertion site -client report of a headache -client report of tinnitus -audible inspiratory stridor
audible inspiratory stridor -When using the airway, breathing, circulation approach to client care the nurse determines the priority finding is inspiratory strider. The client is at risk for bronchospasms, hypotension and circulatory collapse due to anaphylaxis. The nurse should contact the rapid response team, discontinue the vancomycin, and administer epinephrine.
A nurse is teaching a client who has gastroesophageal reflux disease (GERD) about managing his illness. Which of the following recommendations should the nurse include in the teaching? -limit fluid intake not related to meals -chew on mint leaves to relieve indigestion -avoid eating within 3 hours of bedtime -season foods with black pepper
avoid eating within 3 hours of bedtime -The nurse should instruct the client to eat small, frequent meals but to avoid eating with 3 hr of bedtime.
A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority? -platelets 200,000/mm3 -bilirubin 19 mg/dL -blood glucose 45 mg/dL -hemoglobin 22 g/dL
bilirubin 19 mg/dL -Bilirubin 19 mg/dL is above the expected reference range for a newborn at 4 hr of age. A bilirubin level greater than 15 mg/dL or an increase by more than 6 mg/dL in 24 hr is pathologic or nonphysiologic jaundice. Pathologic jaundice is a result of an underlying disease and occurs before 24 hr of age; therefore, this is the nurse's priority finding.
A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on intravenous rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse effects? -constipation -black colored stools -staining of teeth -body secretions turning a red-orange color
body secretions turning a red-orange color -Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.
A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first? -apply a fetal scalp electrode -increase the rate of the IV infusion -administer oxygen at 10 L/min win non-rebreather mask -change the client's position
change the client's position -The first action the nurse should take is to change the client's position in an attempt to increase blood flow to the fetus.
A nurse enters a client's room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first? -attach defibrillator pads to the client -check for a carotid pulse -begin chest compressions -deliver two breaths
check for a carotid pulse -The first action the nurse should take when using the nursing process is to assess the client. The nurse should check the client's circulatory status by palpating the carotid pulse for 5 to 10 seconds first before initiating further interventions.
A nurse is caring for a client that is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first? -administer a bolus of medication -check the display on the PCA pump -obtain and order for another pain medication for breakthrough pain -encourage the client to administer a demand dose
check the display on the PCA pump -The first action the nurse should take using the nursing process is to assess the client; therefore, the nurse should assess the display on the PCA pump to determine the amount of medication administered. Some clients are fearful of developing an addiction to narcotics and may be reluctant to use the PCA.
A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take? -check the potency of the client's airway -determine the poison that was ingested -identify the amount of poison that was ingested -position the client side-lying
check the potency of the client's airway -The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is checking the patency of the client's airway.
A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first? -checking capillary refill -discussing cast care -managing pain -performing range of motion
checking capillary refill -The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to check the client's capillary refill. Musculoskeletal injuries can cause changes in the neurovascular system, usually distal to the injury. Capillary refill provides data about the client's circulation.
A nurse is preparing to insert a peripheral IV catheter. Which of the following antiseptics is the nurse's best choice for preparing the client's skin at the insertion site? -alcohol -chlorhexidine -tincture of iodine -povidone-iodine
chlorhexidine -Chlorhexidine is the antiseptic preferred by the Infusion Nurses Society (INS) to decrease peripheral catheter insertion site infections.
A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? -check the client's vital signs -assess the client's pain level -cover the wound with a moist, sterile gauze dressing -obtain a culture and sensitivity of the wound drainage
cover the wound with a moist, sterile gauze dressing -The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing.
A child is admitted with a suspected diagnosis of Wilms' tumor. The nurse should place a sign with which of the following warnings over the child's bed? -do not palpate abdomen -no venipuncture or blood pressure in left arm -contact precautions -collect all urine
do not palpate abdomen -Wilms' tumor is a neoplasm of the kidney (nephroblastoma). This tumor is encapsulated, and palpation can cause it to rupture, which would allow seeding of the tumor into the pelvic cavity.
A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include int he teaching? -drink 3 L of fluid every day -take 3,000 mg of vitamin C daily -restrict calcium intake to one serving per day -eat 12 oz of animal protein daily
drink 3 L of fluid every day -The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to dilute the urine and reduce the risk for stone formation.
A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address? -swollen gums -pruritus -urinary hesitancy -dysphagia
dysphagia -Dysphagia poses the greatest safety risk to the client because it can cause choking, or result in aspiration of food or liquids leading to pneumonia and respiratory compromise. This is the priority finding for the nurse to address.
A nurse is caring for a client with infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for? -anorexia -dyspnea -fever -malaise
dyspnea -When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority manifestation to monitor for is dyspnea. Dyspnea can be an indication of left-sided heart failure, or a pulmonary infarction due to embolization
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects? -dysrhythmias -cataracts -pancreatitis -bleeding
dysrhythmias -Cardiac dysrhythmias are a risk for clients taking haloperidol and other conventional antipsychotic medications. The client should be monitored for changes in vital signs, tachycardia, and ECG changes, including prolonged QT interval, while taking haloperidol.
A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? -blistering -erythema -eschar -absence of pain
erythema -Erythema is an indication that the client has experienced a superficial burn with damage limited to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat.
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for? -hemorrhage -infection -urinary retention -pain
hemorrhage -Using the airway breathing circulation (ABC) approach to client care the nurse determines that the priority complication to monitor for is the client hemorrhaging; therefore, the nurse should monitor the client's urinary output for blood clots and bright red blood tinged urine following surgery.
A nurse is preparing to administer ampicillin and gentamicin sulfate via IV infusion. Which of the following resources should the nurse consult first regarding medication compatibility? -nurse manager -hospital pharmacist -health care provider -medication sales representative
hospital pharmacist -The greatest risk to the client is injury form medication error; therefore, the nurse should consult the hospital pharmacist first. The pharmacist will have information about medications, including adverse effects, recommended dosages, and drug incompatibilities.
A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. The nurse should use which of the following as the priority source of verification? -chart -order sheet -medication administration record -identification wristband
identification wristband -This is the best option of the four to ensure that the nurse will deliver the correct unit of blood to the client to whom the provider prescribed it. Thus, this is the nurse's highest priority.
A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for the staff following this incident? -provide professional counseling for staff members -change policies for staff observation of clients who are suicidal -identify cues in the client's behavior that might have warned them hat he was contemplating suicide -give the family an opportunity to talk about their feelings
identify cues in the client's behavior that might have warned them hat he was contemplating suicide -Identifying cues in the client's behavior is the priority intervention when taking the nursing process approach to client care. Assessment is the first step in dealing with a situation.
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first? -discuss alternative coping strategies with the client -identify precipitating factors for ritualistic behaviors -instruct the client in relaxation techniques for use when anxiety increases -provide a structured activity schedule for the client
identify precipitating factors for ritualistic behaviors -This is the priority intervention when taking the nursing process approach to client care.
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? -impaired tissue perfusion -alteration in body image -alteration in activity tolerance -impaired skin integrity
impaired tissue perfusion -When using the airway, breathing, and circulation (ABC) priority-setting framework, the nurse should identify impaired perfusion of tissues as the priority finding. The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues. The nurse should note the client has signs of chronic venous insufficiency as well which include edema, a feeling of heaviness in the legs, and the presence of venous stasis ulcers.
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (SATA) -increased heart rate -increased blood pressure -increased respiratory rate -increased hematocrit -increased temperature
increased heart rate, increased blood pressure, & increased respiratory rate -The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid. -The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid. -The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs.
A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first? -auscultate -percuss -inspect -palpate
inspect -Evidence-based practice indicates the nurse should first inspect the abdomen for external abnormal conditions first.
A community health nurse in a pediatric clinic is reviewing the history of a 12-year-old client. Which of the following immunizations should the nurse expect to administer? -meningococcal conjugate -herpes zoster -rotavirus -pneumococcal polysaccharide
meningococcal conjugate -The CDC recommends administering the meningococcal vaccine to children who are 11 through 12 years old and then giving a booster dose at age 16. The nurse should prepare to administer this immunization.
A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority? -give the client 15 to 20 g of carbohydrate -monitor the client for hypoglycemia -complete an incident report -notify the nurse manager
monitor the client for hypoglycemia -The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should immediately check the client's blood glucose level, expecting it to be low because of the excessive dose of insulin. If it is within the expected reference range, the nurse should continue to monitor the client for signs of hypoglycemia.
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? -hypotension -anuria -narrowing pulse pressure -decreased LOC
narrowing pulse pressure -Pulse pressure is the difference between the systolic and diastolic blood pressures. In the initial stage of shock there is a slight increase in the diastolic blood pressure, which narrows the pulse pressure.
A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take? -have the client stand at the bedside with her arms at her side -administer a 500 bolus of 5% dextrose in water prior to induction -inform the client the anesthetic effect will last for approximately 6 hours -obtain a 30 minute electronic fetal monitoring (EFM) strip prior to induction
obtain a 30 minute electronic fetal monitoring (EFM) strip prior to induction -The nurse should obtain a 20 to 30 min EFM strip before induction of the spinal anesthesia. The strip should be evaluated as baseline information. After induction, fetal heart rate and pattern is assessed and documented every 5 to 10 min and emergency care is provided for fetal distress, such as bradycardia or late decelerations.
A nurse is caring for a client who is on a 2,000-calorie American Diabetes Association (ADA) diet and substitutes the whole milk on his breakfast tray with skim milk. Because of this substitution, the nurse should know that the client can add which of the following items to the oatmeal on his breakfast tray? -one 1/8 tsp salt -one ounce of raisins -one tbsp low-fat margarine -one tsp of brown sugar
one tbsp low-fat margarine -Substituting skim (fat-free) milk for whole milk allows the client to add a fat exchange to his breakfast tray. A fat exchange usually varies in serving size, but one tablespoon of low-fat margarine is considered one fat exchange.
A nurse is caring for a client who is at 36 weeks gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? -painless red vaginal bleeding -increasing abdominal pain with a non relaxed uterus -abdominal pain with scant red vaginal bleeding -intermittent abdominal pain following passage of bloody mucus
painless red vaginal bleeding -Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester.
A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet? -peanut butter and jelly sandwich -baked potato topped with sour cream -bagel with cream cheese -fruit salad
peanut butter and jelly sandwich -A vegetarian diet may be low in protein, especially if the client does not substitute protein-rich beans for meat protein. Peanut butter is an excellent source of protein. A peanut butter and jelly sandwich, especially if prepared on protein-enriched bread, can provide almost 20 grams of protein.
A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first? -increase fluids -perform a badder scan -insert a straight catheter -provide assistance to bathroom
perform a badder scan -The first action the nurse should take using the nursing process is to assess the client. The nurse should assess the post void residual (PVR) using a bladder scanner.
Nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? -check the client for a fecal impaction -examine the client for areas of skin breakdown -check the client's bladder for distention -place the client in a sitting position
place the client in a sitting position -The nurse should use the least invasive intervention first. Therefore, the nurse should place the client in a sitting position to decrease the manifestation of hypertension.
A nurse is caring for a client who has heart failure and a new prescription for furosemide. Which of the following laboratory values should the nurse review before administering furosemide? -bicarbonate -carbon dioxide -potassium -phosphate
potassium -Furosemide is a loop diuretic and therefore promotes excretion of potassium. The nurse should monitor the client's serum potassium level before administering it to prevent hypokalemia.
A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first? -notify hospital security -approach the man and ask why he is making copies -inform the nursing supervisor -report the observation to the nurse caring for that client
pproach the man and ask why he is making copies -The first action the nurse should take using the nursing process is to assess the situation to determine whether this man is authorized to be in possession of the client's medical record to protect the client's confidentiality. Making copies from a client's medical record is allowed under specific circumstances. It is important to act in a timely fashion to protect the client's medical information. The nurse should approach the individual in a nonthreatening way to inquire about the copies being made.
A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse's priority? -insert an IV catheter -obtain blood culture specimens -administer an antipyretic -prepare for nasotracheal intubation
prepare for nasotracheal intubation -The client's manifestations suggest epiglottitis, which is a respiratory emergency. Airway obstruction is imminent, and that is the greatest risk to the client's safety at this time, so the priority action is to prepare for intubation to maintain airway patency.
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority? -protecting the client from injury -determining the cause of the client's anxiety -ensuring that the client feels safe -identifying the client's coping skills
protecting the client from injury -The greatest risk to this client is harm to himself through suicide or other injury when not in control of his actions, or to others while experiencing panic-level anxiety. Therefore, the priority is to protect the client from injury. The presence of panic-level anxiety is a risk factor for suicide.
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first? -administer diazepam -raise the side rails of the bed -obtain a medical history -start intravenous fluids
raise the side rails of the bed -The greatest risk to the client is injury from a fall; therefore, the first action by the nurse is to raise the side rails of the bed.
A nurse is caring for an antepartum client who has iron-deficiency anemia. When teaching the client about nutrition, the nurse should emphasize the need for an increased intake of which of the following foods? -milk and cheese -red meat and organ meat -fresh fruits -whole grain breads
red meat and organ meat -This client has a deficiency in iron and needs instruction about foods that are rich sources of iron. A diet rich in red and organ meat provides iron, which is what the client needs to improve anemia.
A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take? -remove the catheter and insert another into a different site -administer an analgesic PO -request a prescription for placement of a central venous access device -administer a local anesthetic
remove the catheter and insert another into a different site -It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere.
