Test yourself quiz 1 (B)
The nurse is caring for a woman who is starting medroxyprogesterone injections for birth control. What statements by the client would indicate a need for further teaching? Select all that apply. "I may experience some weight gain." "I may not have regular periods while taking this medication." "Because it is highly effective, I can use this medication for many years." "Depression is a side effect, and I should let my doctor know if I experience any mood changes." "I should return in approximately 6 months for my next injection."
"Because it is highly effective, I can use this medication for many years." "I should return in approximately 6 months for my next injection." Medroxyprogesterone is an injectable progestin given every 3 months to prevent ovulation and pregnancy. It suppresses ovulation for 15 weeks, and therefore, timing of the next injection is very important and should be no longer than exactly 3 months. Although medroxyprogesterone is highly effective, it should not be taken for more than 2 years due to the risk of osteoporosis. Weight gain, irregular periods, and depression are all known side effects.
The nurse on a post-partum floor is assessing a client for signs of post-partum depression. Which statements would be the most appropriate for the nurse to make, in order to assess the client for depression? Select all that apply. "It is not very common to feel sad after giving birth". "How are things going for you today?" "I'm sure you're so happy with your new baby". "Can you tell me how you are feeling today?" "Do you have anyone to help you at home?"
"How are things going for you today?" "Can you tell me how you are feeling today?" "Do you have anyone to help you at home?" To recognize symptoms of post-partum depression as early as possible, the nurse should be an active listener and demonstrate a caring attitude. Nurses cannot depend on women volunteering unsolicited information about their depression or asking for help. The nurse should observe for signs of depression and ask appropriate questions to determine moods, appetite, sleep, energy, and fatigue levels, and ability to concentrate. The nurse should make an effort to engage in conversation with the client, in order to gain an understanding of how the client is feeling. Asking if the client feels sad, how things are going, and inquiring if the client has help at home, are good ways to engage the client in conversation and determine if there is evidence of depression. Assuming that the client feels happy or making general statements are not ways that the nurse can effectively assess for post-partum depression
The nurse is instructing a postoperative client how to use a demand-only patient controlled analgesia (PCA) pump. What statements made by the client would indicate teaching was effective? Select all that apply. "I should push the button as many times as I want if I have any pain at all." "If I fall asleep, my wife can push the button for me so I continue to get pain medication." "My oxygen and breathing will be monitored while using this machine to prevent being over medicated." "This machine will deliver pain medication when I push the button." "Itching is a normal side effect and I do not need to worry if I experience this."
"My oxygen and breathing will be monitored while using this machine to prevent being over medicated." "This machine will deliver pain medication when I push the button." A patient controlled analgesia (PCA) pump allows the client to feel more empowered in the treatment of pain. A demand-only PCA will only deliver medication when the button is pushed. Oxygen levels and breathing should be assessed frequently to prevent respiratory sedation. Inform the client that pain should be tolerable, but may not be completely gone and to notify the nurse if any adverse side events develop such as itching, nausea or trouble breathing occurs. Instruct the client that no other individual, including the nurse, should push the button.
The nurse is attending an educational session on substance abuse during pregnancy. Which statements by the nurse indicate that the education has been effective? Select all that apply. "Social stigma, labeling, and guilt are barriers to treatment." "Substance abuse generally has no effect on the fetus." "Most pregnant women end up receiving treatment for their addictions." "In some states, pregnant women who abuse substances may face criminal charges." "Pregnant women often do not seek help for fear of losing their child."
"Social stigma, labeling, and guilt are barriers to treatment." "In some states, pregnant women who abuse substances may face criminal charges." Pregnant women often do not seek help for fear of losing their child."
The nurse is caring for a client who is in labor and preparing for birth. The nurse has been advised that the pregnancy is the result of a rape. Which statements by the nurse would be the most appropriate? Select all that apply. "You do not need to be concerned about anything because your baby is ok." "You are in labor and preparing to give birth to your baby." "You are safe here." "We have done this many times before." "Just relax; we know what we are doing."
"You do not need to be concerned about anything because your baby is ok." "You are in labor and preparing to give birth to your baby." "You are safe here.
Which clients are at high risk for venous thromboembolism (VTE)? Select all that apply. A 88 year-old admitted with confusion A 45 year-old recovering from a total hysterectomy A 35 year-old with intractable nausea A 28 year-old recovering from a paralytic ileus A 45 year-old in a motor vehicle accident who sustained multiple fractures
A 88 year-old admitted with confusion A 45 year-old recovering from a total hysterectomy A 45 year-old in a motor vehicle accident who sustained multiple fractures
The charge nurse on a women's health unit is making a client room assignment. Which clients would be least appropriate to assign to share a room with a woman who is pregnant? Select all that apply. A client with pyelonephritis A client with hepatitis B A client with hashimotos thyroiditis A client with a urinary tract infection A client with herpes zoster
A client with hepatitis B A client with herpes zoster
The charge nurse is making a client assignment for the upcoming shift. In order to create a safe assignment, the charge nurse plans to assign those clients requiring airborne precautions amongst different nurses. Which clients should be assigned to different nurses? Select all that apply. A client with influenza. A client with tuberculosis. A client with pneumonia. A client with C. difficle. A client with measles.
A client with tuberculosis. A client with measles. Airborne precautions are used for those clients that are diagnosed with or suspected to have a condition spread through airborne transmission. Measles and tuberculosis are transmitted via airborne transmission. A client with influenza should be placed on droplet precautions. A client with <i>C. difficile</i> should be placed in contact and enteric precautions and a client with pneumonia only requires standard precautions.
The nurse is caring for a client who has been diagnosed with rheumatoid arthritis. The health care provider has just started the client on methotrexate, to manage symptoms. When creating the plan of care for this client, which adverse effects should the nurse monitor for? Select all that apply. A decrease in the platelet count Increased thirst Elevated blood pressure Elevation of liver enzymes An increase in white blood cells (WBC)
A decrease in the platelet count Elevation of liver enzymes Methotrexate, an immunosuppressive <strong>medication</strong>, administered in a low, once-a-week dose (generally 25 mg or less per week) is a possible treatment for rheumatoid arthritis. When creating the plan of care, the nurse should monitor for certain adverse effects, and be prepared to treat them. The nurse should assess for an elevation in liver enzymes and a decrease in platelet count. Increased thirst and elevated blood pressure are not adverse effects of methotrexate. The client would experience a decrease in the WBC count, not an increase, during methotrexate therapy.
The nurse is examining an infant with burns that are suspicious for child abuse. Which findings should the nurse report as highly suspicious for abuse? (Select all that apply). A stocking pattern of burn marks on the infant's feet and legs. A dark brown marking on the infant's lower back. A bright pink coloring on the infant's cheeks. A burn mark on the child's finger. Circular burn marks on the infant's buttocks.
A stocking pattern of burn marks on the infant's feet and legs. Circular burn marks on the infant's buttocks. Examination findings for interpersonal violence range from subtle to obvious. Some may manifest as old or new injuries that may seem mild to more significant and may not raise concern. For this reason, it is critical to consider the history in relation to injuries seen. The nurse should also maintain a high degree of awareness for injuries that are not typically seen in the context of day-to-day living—such as unusual patterns of bruising or burn marks. Findings during the physical assessment that would raise suspicion for the nurse are circular burns or burns that occur in a stocking pattern. A burn mark to the finger should be questioned, but is not highly suspicious for child abuse. Bright pink coloring to the checks is typically normal in infants. Dark brown markings located on the lower back or buttocks are known as Mongolian spots.
The home care nurse is providing care to a client with heart failure. Which assessment findings should alert the nurse to worsening heart failure? Select all that apply. Activity intolerance Pallor Warm extremities Confusion Chest pain
Activity intolerance Pallor Confusion Chest pain
The nurse in the emergency department is caring for a client just brought in with partial thickness burns to 50% of the body. What actions should the nurse implement as part of the care plan? Select all that apply. Administer tetanus vaccine for prophylaxis Assess airway patency and provide oxygen as needed Provide the client with a large glass of water to stay hydrated Elevate extremities Keep burns uncovered to allow for cooling air to reach the wounds
Administer tetanus vaccine for prophylaxis Assess airway patency and provide oxygen as needed Elevate extremities
The nurse is assisting in the examination of a five year old child who was removed from an abusive home. The social worker alerts the nurse that there is a history of violence in the child's home, which has resulted in the removal of the child and siblings. Which behaviors should the nurse expect the child to express? Select all that apply. Blaming the abuser for the injury. Aggressive behavior towards the nurse and health care provider. Feeling guilty for causing the abuse to occur. Smiling during the exam. A need to find and protect a sibling.
Aggressive behavior towards the nurse and health care provider. Feeling guilty for causing the abuse to occur. A need to find and protect a sibling. In homes where intimate partner violence (IPV) occurs, children are exposed to that violence at the very least and often become additional recipients of that violence. IPV usually predates abuse of the child. Younger children seem to have more behavioral problems when exposed to intra-family violence. For instance, they often have problems with anxiety, depression, and aggression. They often experience many fears and worries that are developmentally inappropriate. Expressing the need to find and protect a sibling is an example of worry that is developmentally inappropriate for a five year old child. Guilt is another aspect that abused children frequently struggle with, as children often blame themselves for abuse. The nurse would expect the child to portray aggressive behaviors out of fear. Due to the history of violence that this child has been subjected to, the nurse would not expect the child to smile and be receptive to the exam, or blame the abuser for the injury. Another issue of concern that the nurse should be aware of is post-traumatic stress disorder (PTSD). Associated features of PTSD may be more detrimental than the violence itself.
A client with left-sided heart failure has arrived on the cardiac unit. Which actions should the nurse initially include in the care plan for this client? Select all that apply. Allow the client rest time between activities Toilet the client every hour and as needed Teach the client how to regulate breathing Take the apical heart rate for one minute Allow the client to walk in the hallway a few times a day as desired
Allow the client rest time between activities Toilet the client every hour and as needed Teach the client how to regulate breathing Take the apical heart rate for one minute
On assessment of a client with a normal saline intravenous (IV) infusion, the nurse notes that the IV site has infiltrated. Which actions by the nurse would be appropriate? Select all that apply. Apply a warm compress to the IV site Stop the IV infusion Restart a new IV below the current IV site Elevate the extremity Apply a sterile dressing if weeping occurs
Apply a warm compress to the IV site Stop the IV infusion Elevate the extremity Apply a sterile dressing if weeping occurs
The nurse is creating a plan of care for a client who was admitted with an infection. The nurse has been informed that the client will need a peripherally inserted central catheter (PICC) line placed, and in the next few days will be discharged home. Which information about the PICC line should the nurse include in the plan of care? Select all that apply. Keep the extremity immobile Avoid heavy lifting once Reason for PICC line placement How to care for the PICC line How to get dressed with the PICC line
Avoid heavy lifting once Reason for PICC line placement How to care for the PICC line How to get dressed with the PICC line
The home health nurse is caring for an older client recovering from pneumonia. A concerned family member believes that the client is no longer capable of caring for self effectively. The nurse conducts an assessment of the client's basic activities of daily living (BADLs). What activities would the nurse assess? Select all that apply. Balancing a checkbook Bathing Dressing Taking medications Cooking Eating
Bathing Dressing Eating ADL's are basic activities that assess functional ability. Daily activities such as eating, bathing, and dressing are considered basic every day needs. Activities such as cooking, taking medication, and balancing a checkbook are considered more complex, instrumental activities.
The nurse on a medical surgical telemetry unit notes an abnormal cardiac rhythm. After quickly assessing the client, which cardiac rhythm would indicate the need for immediate cardiopulmonary resuscitation (CPR)? Refer to figures 1-4.
Cardiac monitoring is an important aspect of care for the hospitalized client. Frequent assessment of the rhythm and client is critical. Ventricular fibrillation is a life threatening emergency and CPR should begin immediately after quickly assessing the client. Option 2 denotes normal sinus rhythm with premature ventricular contractions (PVCs), Option 3 demonstrates atrial fibrillation, and option 4 shows sinus tachycardia. While all abnormal, options 2, 3, and 4 are not life-threatening.
The nurse is preparing the client for a bronchoscopy. Which actions should the nurse take to ensure client safety? Select all that apply. Clarify and document the client's allergies Verify the client using two types of identifiers Keep the client NPO for 2 hours prior to the test Explain the procedure to the client Ensure that pre-procedure laboratory studies are drawn
Clarify and document the client's allergies Verify the client using two types of identifiers Explain the procedure to the client Ensure that pre-procedure laboratory studies are drawn A bronchoscopy is the insertion of a tube in the airways, usually as far as the secondary bronchi, for the purpose of viewing airway structures and obtaining tissue samples for biopsy or culture. It is used to diagnose and manage pulmonary diseases. Safety is a priority in nursing care. In order to ensure safety for the client, the nurse should explain the procedure to the client, ensure that pre-procedure laboratory studies are drawn and results are reviewed to detect any abnormalities, clarify and document the client's allergies, and verify the client using two different identifiers. The client should be kept NPO 4-8 hours prior to the exam to reduce the risk of aspiration.
A 22-year-old African American woman is 28 weeks pregnant. She is concerned about pre-term labor and asks the nurse what she should look out for. What statements made by the client would indicate the need for further teaching? Select all that apply. "Stress levels can impact my chance of preterm labor." "I am at a higher risk because of my race." "As long as I'm not obese, my weight does not increase my risk." "My age puts me at a higher risk of having the baby early." "I should stay well hydrated."
Correct Answer "As long as I'm not obese, my weight does not increase my risk." Correct! "My age puts me at a higher risk of having the baby early." Preterm labor is defined as delivery between 20 to 37 weeks gestation. A woman aware of the possibility, risk factors, and signs and symptoms of preterm labor may be more likely to take action and prevent it. Age impacts the risk for preterm labor. Less than 18 or over the age of 40 increases the risk. Obesity increases the risk of preterm labor, as does being underweight for height. Hydration is important, and non-whites have a greater risk for preterm labor.
The nurse is listening to an information presentation on the new objectives for Healthy People 2020. Which statements by the nurse indicate an understanding of the objectives? Select all that apply. "Healthy People 2020 will strive to increase the percentage of newborns to receive formula supplementation during the first two days of life." "One of the objectives is to increase the 1 year survival rates for infants with Down Syndrome." "Healthy People 2020 will aim to increase the percentage of women ages 18 to 44 who have impaired fecundity." "An objective of Healthy People 2020 is to increase the percentage of employers who have worksite lactation programs." "Healthy People 2020 aim to increase the percentage of live births that occur in facilities that provide recommended care to lactating mother and their babies."
Correct Answer "Healthy People 2020 will strive to increase the percentage of newborns to receive formula supplementation during the first two days of life." Correct Answer "One of the objectives is to increase the 1 year survival rates for infants with Down Syndrome. Correct! "An objective of Healthy People 2020 is to increase the percentage of employers who have worksite lactation programs." Some objectives for Healthy People 2020 include: increasing the survival rates for infants born with Down Syndrome; increasing the percentage of employers with worksite lactation programs; and increasing the percentage of live births that occur in facilities that provide recommended care to lactating mothers and their babies. Healthy People 2020 aim to decrease the percentage of women ages 18 to 44 who have impaired fecundity and strive to increase the percentage of newborns to be breast-fed during the first two days of life.
The nurse is creating a plan of care for a client with chronic pain. Which alternative therapies should the nurse add into the plan, to increase the client's comfort? Select all that apply. Increase the client's dosage of pain medication Educate the client to plan for rest time Providing therapeutic massage Play soft music during rest times Assist with a warm, soothing bath
Correct Answer Educate the client to plan for rest time Correct! Providing therapeutic massage Correct! Play soft music during rest times Correct! Assist with a warm, soothing bath
The nurse is at a local pool when alerted of a near drowning event. Which actions should the nurse take? Select all that apply. Handle the client gently to prevent ventricular fibrillation Initiate cardiopulmonary resuscitation (CPR) Send a by-stander to call for help Maintain spinal immobilization immediately Obtain client history from a family member
Correct Answer Handle the client gently to prevent ventricular fibrillation Correct! Initiate cardiopulmonary resuscitation (CPR) Correct! Send a by-stander to call for help
The nurse is monitoring a client who is receiving a blood transfusion. The blood has been infusing for 15 minutes. The nurse interprets which assessment findings as a possible allergic reaction? Select all that apply. Increased pallor Palpation of a rapid, thready pulse New onset of hypertension A change in the client's level of fatigue The client reports feeling nervous
Correct Answer Increased pallor Correct Answer Palpation of a rapid, thready pulse Nursing actions during transfusions aim at prevention or early recognition of transfusion reactions. Reactions include palpation of a rapid thready pulse, and increased pallor or cyanosis. These findings should alert the nurse to a possible reaction. It is important that the nurse immediately stop the blood infusion if a reaction is suspected. Findings such as hypertension, nervousness, or a change in fatigue level do not typically indicate an allergic reaction. However, the nurse should continue to monitor these symptoms and intervene as necessary.
The nurse is caring for a client with severe anxiety. What should the nurse include when creating the care plan for this client? Select all that apply. The client will state where to obtain support group information. The client will state when it is appropriate to ignore the symptoms. The client will understand how medication helps stop panic attacks. The client will understand when to seek treatment. The client will be able to perform deep breathing exercises.
Correct Answer The client will state where to obtain support group information. Correct! The client will understand how medication helps stop panic attacks. Correct! The client will understand when to seek treatment. Correct! The client will be able to perform deep breathing exercises.
The nurse is providing education to the client who is receiving external radiation therapy to the face. Which statements by the client indicate understanding? Select all that apply. "I should not use soap at all when washing my face." "I should use my hands to wash my face, rather than a washcloth." "I need to avoid exposing the irradiated area to the sun." "It is okay to wash off the ink or dye markings." "I can use lotions or powders that are prescribed by the radiation oncology department."
Correct! "I should use my hands to wash my face, rather than a washcloth." Correct! "I need to avoid exposing the irradiated area to the sun." Correct! "I can use lotions or powders that are prescribed by the radiation oncology department." The immediate and long-term side effects of all types of radiation are limited to the tissues exposed to the radiation. When educating the client, the nurse should evaluate the client's understanding. Education has been successful when the client states understanding of the need to avoid sun exposure, use hands rather than a washcloth when washing the skin, and only using lotions and powders that are prescribed. These actions will help protect the integrity of the skin. The nurse should also educate the client to avoid washing off the ink or dye markings until radiation is complete, and that it is ok to use a mild soap to wash.
The nurse on the labor and delivery unit notes the following fetal heart rate pattern on the fetal monitoring strip (refer to figure). What is the priority nursing action? Increase oxytocin (Pitocin) infusion Continue to monitor fetal heart rate patterns Administer oxygen via face mask at 8 to 10 L Assist client to the supine position
Correct! Administer oxygen via face mask at 8 to 10 L Late decelerations are a drop in fetal heart rate after the peak of contraction. They are generally a sign of impaired placental exchange and therefore, the nurse should administer oxygen to the client to increase maternal blood oxygenation and increase available oxygen to the fetus. Repositioning the client may be helpful, but the supine position is not recommended as this could decrease perfusion to the fetus. Uterine stimulants such as oxytocin should be stopped. Continued monitoring of the fetal heart rate pattern is important, but late decelerations are a non-reassuring sign requiring intervention.
The nurse is caring for a client with chronic pain. Which actions should the nurse take, in order to assess the client's quality of life? Select all that apply. Ask the client to describe how the pain has affected the daily routine. Ask if the client has difficulty sleeping or eating due to pain. Withhold pain medications to determine the client's need. Ask the client about the side effects of prescribed medication. Ask the client if there are activities that are no longer possible due to pain.
Correct! Ask the client to describe how the pain has affected the daily routine. Correct! Ask if the client has difficulty sleeping or eating due to pain. Correct Answer Ask the client about the side effects of prescribed medication. Correct! Ask the client if there are activities that are no longer possible due to pain.
The emergency department nurse has just received a client who was struck by lightning. On initial assessment, the nurse notes a pulse and that the client is breathing. Which actions should the nurse to take? Select all that apply. Assess for occult traumatic injuries. Perform a 12-lead electrocardiogram (ECG). Monitor for rhabdomyolosis. Request a creatinine kinase measurement. Prepare the client for discharge.
Correct! Assess for occult traumatic injuries. Correct! Perform a 12-lead electrocardiogram (ECG). Correct! Monitor for rhabdomyolosis. Correct! Request a creatinine kinase measurement. Lightning produces injury by directly striking a victim, by splashing off a nearby object, or by traveling through the ground. Although few people die after a lightning strike, many survivors are left with permanent disabilities. The nurse should be prepared to deliver quick and effective care to the client. After the initial assessment, the nurse should perform a 12-lead ECG to detect any cardiac abnormalities. The nurse should continually assess for rhadomyolosis, along with occult traumatic injuries, and intervene if necessary. The nurse should collaborate with the health care provider to request a creatinine kinase measurement, in order to monitor closely for rhabdomyolosis. The nurse should not prepare the client for discharge at this time.
The nurse is caring for a client with cancer who has just been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). On assessment, the client complains of weakness, muscle cramps, and loss of appetite. Which specific actions should the nurse include in the plan of care? Select all that apply. Assess for the presence of crackles in the lungs Observe urine for changes in color or characteristic Check for peripheral edema Monitor the client for neck vein distention Monitor the client for a bounding pulse
Correct! Assess for the presence of crackles in the lungs Correct! Check for peripheral edema Correct! Monitor the client for neck vein distention Correct Answer Monitor the client for a bounding pulse
The emergency department nurse is caring for a client at risk for respiratory failure. Which nursing actions are important in the care of this client? Select all that apply. Request a needle decompression Assess for trauma to the chest Look for physical abnormalities Listen to breath sounds Evaluate chest expansion
Correct! Assess for trauma to the chest Correct Answer Look for physical abnormalities Correct! Listen to breath sounds Correct! Evaluate chest expansion
The nurse is counseling a client who has been diagnosed with the human immune deficiency virus (HIV). In creating a plan of care, which interventions should the nurse include? Select all that apply. Instruct the client not to share towels Discuss options for medication therapy Educate the client about proper condom use Discuss the client's HIV status and ensure understanding Provide education about needle exchange programs
Correct! Discuss options for medication therapy Correct! Educate the client about proper condom use Correct! Discuss the client's HIV status and ensure understanding Correct Answer Provide education about needle exchange programs
The nurse in an assisted living facility is providing care to an older client, who has just moved to the facility. Which actions should the nurse include in the plan of care to decrease relocation stress, and help the client adjust to the new environment? Select all that apply. Ask the client's family to refrain from bringing special keepsakes to the facility. Establish a trusting relationship with the client as soon as possible. Allow the client to participate in decision making activities. Explain each procedure to the client as they occur. Take the time to assess the client's usual lifestyle.
Correct! Establish a trusting relationship with the client as soon as possible. Correct! Allow the client to participate in decision making activities. Correct! Explain each procedure to the client as they occur. Correct Answer Take the time to assess the client's usual lifestyle.
The nurse is caring for a client in labor. During assessment, the nurse notes that the client is hypotensive and that the fetus has an abnormal heart rate pattern. Which interventions should the nurse take? Select all that apply. Encourage the client to ambulate in the room Increase the rate of the primary intravenous (IV) infusion Place the client in a lateral or trendelenburg position Prepare the client for induction of labor with oxytocin Prepare the client for a cesarean section
Correct! Increase the rate of the primary intravenous (IV) infusion Correct! Place the client in a lateral or trendelenburg position
The nurse works in a busy emergency department and would like to reduce the potential for adverse events. Which actions can the nurse take to accomplish this? Select all that apply. Look for the presence of medical alert bracelets or necklaces Utilize automated electronic track systems Obtain an accurate medical history from the client or family Wash hands frequently Look through the client's belongings for medication bottles
Correct! Look for the presence of medical alert bracelets or necklaces Correct Answer Utilize automated electronic track systems Correct! Obtain an accurate medical history from the client or family Correct! Wash hands frequently
The nurse is caring for a client with Addison's disease in acute crisis. What priority actions should the nurse implement into the care plan? Select all that apply. Monitor strict intake and output Apply telemetry monitoring Rapidly infuse normal saline as prescribed Administer spironolactone as prescribed Administer oxygen via non-rebreather mask
Correct! Monitor strict intake and output Correct! Apply telemetry monitoring Correct Answer Rapidly infuse normal saline as prescribed
The nurse is providing care to a client following thoracentesis. Which actions should the nurse add to the client's plan of care, in order to promote health and safety? Select all that apply. Instruct the client to avoid deep breathing Monitor vital signs as prescribed Auscultate breath sounds for absent or reduced sounds Assess the dressing for bleeding Ensure that a chest x-ray is obtained
Correct! Monitor vital signs as prescribed Correct! Auscultate breath sounds for absent or reduced sounds Correct! Assess the dressing for bleeding Correct! Ensure that a chest x-ray is obtained The client should be monitored closely following a thoracentesis. The nurse should adjust the plan of care as needed based on the client's needs. The nurse should plan to monitor vital signs as prescribed to detect changes that could indicate bleeding or pneumothorax, assess the dressing for bleeding and intervene as necessary. A chest x-ray should be obtained right away to rule out a pneumothorax or mediastinal shift from the procedure. Breaths sounds should be assessed for absent or reduced sounds indicating pneumothorax. The nurse should encourage the client to take deep breaths to promote the expansion of the lung.
A client asks the nurse what can be done to prevent colon cancer as his father passed away from it. What information would be appropriate for the nurse to include in the teaching? Select all that apply. Notify your healthcare provider of any changes in your bowel habits A diet high in fat can increase your risk of colon cancer Screening for colon cancer should begin at age 60 Fiber can irritate the gastrointestinal tract and should be limited Limit alcohol consumption and avoid smoking
Correct! Notify your healthcare provider of any changes in your bowel habits Correct! A diet high in fat can increase your risk of colon cancer Correct! Limit alcohol consumption and avoid smoking Individuals with a family history of colon cancer should discuss their risk with their healthcare provider. Risk factors for colon cancer include a diet high in alcohol and fat, and smoking. The health care provider should be notified of any changes in bowel habits such as constipation, diarrhea, or blood in stools. Screening for colon cancer should begin at age 50, or earlier if a strong family history exists. Fiber is helpful for gastrointestinal health, and a diet high in fiber is recommended.
The nurse is working in the emergency department when a client is brought in by ambulance. The client reports being bitten by a North American pit viper. Upon assessment, the nurse notices a bite mark on the client's left leg. Which actions should the nurse to take? Select all that apply. Prepare to administer oxygen Apply ice to the bite mark Start two large-bore intravenous (IV) lines Initiate cardiac monitoring Measure the circumference of the bitten extremity every 15 to 30 minutes
Correct! Prepare to administer oxygen Correct! Start two large-bore intravenous (IV) lines Correct! Initiate cardiac monitoring Correct! Measure the circumference of the bitten extremity every 15 to 30 minutes When providing emergency care to a victim of snakebite, determine if the venom has been injected into the body. The primary functions of venom are to immobilize, kill, and aid in digestion of prey. Therefore venom causes local and systemic toxic effects. The enzymes in venom break down human tissue proteins, alter membrane integrity, and impair blood clotting. The pathophysiologic effects of pit viper envenomation can lead to local tissue necrosis, massive tissue swelling, intravascular fluid shifts and hypovolemic shock, pulmonary edema, renal failure, hemorrhagic complications from disseminated intravascular coagulation (DIC), and death. The nurse should take action to prevent further injury to the client. The nurse should initiate cardiac monitoring to determine the presence of cardiac ischemia as a result of the venom. Establishing two large bore IV line is a priority in the care of this client for the administration of fluids and possible antidotes, as well as preparing to administer oxygen. The nurse should measure the bitten extremity every 15 to 30 minutes, and document the size and assess the site. The nurse should refrain from applying ice to the bite mark; ice can promote tissue necrosis.
The nurse is providing discharge instructions to a client who has been diagnosed with cystitis. The nurse has been notified that the client does not have health care insurance. Which instruction from the nurse would be the most important for the client to complete in order to continue treatment? Follow up with a health care provider within one week. Call the case manager, in order to arrange payment for care. Review the provided list of available community resources and initiate contact. Fill the prescriptions that have been provided by the health care provider.
Correct! Review the provided list of available community resources and initiate contact. Cystitis is an inflammation of the bladder. It can be caused by irritation or, more commonly, by infection from bacteria, viruses, fungi, or parasites. It is important that the client receive proper treatment, and is properly educated about how to manage care at home. For the client without health care insurance, the nurse should focus on assisting the client to obtain needed resources, such as follow-up and medications, at a low cost. Otherwise, the client may need to return to the hospital for repeat treatment. The nurse should provide the client with a listing of available community resources, such as a free clinic, and instruct the client in how to initiate contact. Once the client has made contact with the resources, the nurse should instruct the client to receive follow-up care and contact the case manager. Prior to discharge the nurse should assist the client in obtaining the medication needed to continue treatment. This can be completed by contacting a case manager for assistance.
The nurse is creating a plan of care for a client who is planning to become pregnant. What should the nurse include in the plan to help the client have a good pregnancy outcome? Select all that apply. Take the recommended amount of folic acid each day Avoid the use of alcohol and tobacco Eat a healthy diet Prevent sexually transmitted infections Refrain from exercising during preconception
Correct! Take the recommended amount of folic acid each day Correct! Avoid the use of alcohol and tobacco Correct! Eat a healthy diet Correct! Prevent sexually transmitted infections In recent years the concept of preconception care has been recognized as an important contributor to good pregnancy outcomes. The nurse should emphasize the importance of good health including exercise during this time. When creating a plan of care the nurse should include activities such as eating a healthy diet, avoiding the use of alcohol and tobacco, and preventing sexually transmitted infections. The nurse should also direct the client in choosing foods that are rich in folic acid, or recommend an appropriate prenatal vitamin that contains folic acid.
The nurse is caring for a client with urinary calculi, who is preparing for a surgical procedure to remove the stones. Which action by the nurse is a priority for maintaining the client's psychosocial integrity? Administer pain medications upon the client's request Explain to the client that the surgeon will provide education on the procedure Teach the client actions to take after the procedure if problems arise Prepare the client's consent form and chart to transport to the surgical area
Correct! Teach the client actions to take after the procedure if problems arise Urolithiasis is the presence of <i>calculi </i>(stones) in the urinary tract. Stones often do not cause symptoms until they pass into the urinary tract, where they can cause excruciating pain. Once the nurse has made the client comfortable, it is important to give attention to the client's psychosocial integrity. Psychosocial preparation is enhanced when clients know what to expect and what actions to take if problems develop. It is a priority for the nurse to educate the client on the surgical procedure, as well as what actions to take after the procedure if problems arise. While administering pain medications it is important for the client's physical comfort, it is not the nurses priority when maintaining psychosocial integrity for the client. Once the client's needs have been met, the nurse can prepare the consent form. The nurse should also be well educated about the surgical procedure so that the client's questions can be answered.
The nurse reviewing the surgeon's prescriptions in preparation for the client's surgery. Which of the Surgical Care Improvement Project (SCIP) core measures does the nurse identify as appropriate? Select all that apply. Prophylactic antibiotic will be initiated 15 minutes prior to surgical incision Temperature will be measured 15 minutes after the end of anesthesia administration Prophylactic antibiotics discontinued within 24 hours after surgery end time Indwelling catheter will be removed on post-operative day 4 Electric clippers are used to remove hair
Correct! Temperature will be measured 15 minutes after the end of anesthesia administration Correct! Prophylactic antibiotics discontinued within 24 hours after surgery end time Correct! Electric clippers are used to remove hair Perioperative nursing places special emphasis on safety, advocacy, and client education, and ensuring a safety is the responsibility of all health care team members. The nurse should be familiar with the SCIP core measures and be prepared to incorporate them into client care. The nurse should identify the core measures as using electric clippers to remove excess hair, instead of using razors which can irritate the skin; discontinuing prophylactic antibiotics within 24 hours after the surgical end time, and measuring the client's temperature 15 minutes after anesthesia administration has ended. The nurse should recognize that indwelling catheter should be removed no later than 48 hours after placement, and that prophylactic antibiotics should be initiated no later than 1 hour prior to the surgical incision.
The nurse is discharging an older client who was admitted for dehydration. Which instructions would be the most appropriate for the nurse to include in the discharge teaching? Select all that apply. Understand how prescribed medications work. Drink caffeine in moderation. Be sure to drink 6 to 8 glasses of water each day. Eliminate juice drinks totally from the diet. Avoid drinking water right before bed.
Correct! Understand how prescribed medications work. Correct! Drink caffeine in moderation. Correct! Be sure to drink 6 to 8 glasses of water each day.
The nurse is working at a health fair, educating the public on how to prevent heat-related illnesses. Which information would be the most appropriate for the nurse to provide? Select all that apply. Wear clothing suited to the environment Avoid alcohol and caffeine Heat illnesses only occur to those who work outside Wear sunscreen of at least SPF 30 Limit activity at the hottest time of day
Correct! Wear clothing suited to the environment Correct! Avoid alcohol and caffeine Correct Answer Wear sunscreen of at least SPF 30 Correct! Limit activity at the hottest time of day
A client with diabetes mellitus, heart failure, and hypertension is being seen by the health care provider. The health care provider prescribes lispro insulin pens at mealtime. The client asks the nurse how to store the insulin pens. The nurse should include what information in the teaching? Select all that apply. When traveling, do not store the insulin pens in a warm car. The insulin pens should be stored in the refrigerator at all times. Keep the insulin pens away from children, for example on a high windowsill. Once opened, insulin pens are good for one month. Unopened insulin pens may be stored in the freezer to lengthen the shelf life.
Correct! When traveling, do not store the insulin pens in a warm car. Correct! Once opened, insulin pens are good for one month.
The nurse is volunteering at a local health fair to educate the public on primary prevention of stress. Which interventions would be the most appropriate for the nurse to recommend to the public, in order to reduce stress levels? Select all that apply. Counseling for chronic anxiety Finding a source of pleasure. Learning relaxation and deep breathing exercises. Developing a positive attitude. Engaging in stressful situations.
Counseling for chronic anxiety. Finding a source of pleasure. Learning relaxation and deep breathing exercises. Developing a positive attitude
The nurse is caring for a client who has recently undergone a right-sided mastectomy for stage 3 breast cancer. When giving report to the next shift, what information would be essential to communicate to the oncoming nurse? Select all that apply. Educate that a medical alert bracelet is being worn. Ensure the client refrains from any physical activity. Monitor skin color and for the presence of edema. Take blood pressure measurements on the right side only. Elevate the right arm on a pillow.
Educate that a medical alert bracelet is being worn. Monitor skin color and for the presence of edema. Elevate the right arm on a pillow
The nurse is assessing a client who is two days post-partum, and preparing to be discharged from the health care facility. Which interventions would be the most appropriate for the nurse to perform? Select all that apply. Educate the client and family on the signs of post-partum depression. Spend time observing the interactions between the client and infant. Determine if a follow-up after discharge is necessary Provide a listing of community resources to the client and family. Assess the client for risk factors of depression.
Educate the client and family on the signs of post-partum depression. Spend time observing the interactions between the client and infant. Provide a listing of community resources to the client and family. Assess the client for risk factors of depression.
The nurse at a long-term care facility is conducting a medication review of a newly admitted older client with dementia, hypertension, diabetes mellitus, and depression. Which medication prescription would warrant the need to contact the health care provider? Select all that apply. Fluoxetine 20 mg orally once daily. Cyclobenzaprine 5mg every 8 hours as needed. Metformin 500mg orally twice daily. Furosemide 20mg orally once daily. Lisinopril 10 mg orally once daily.
Fluoxetine 20 mg orally once daily. Cyclobenzaprine 5mg every 8 hours as needed. A close review of medications is necessary for safe care of any client client but because the aging process affects physiological functioning, medication prescriptions for the older client need to be carefully monitored. The use of fluoxetine and cyclobenzaprine are considered inappropriate in the older client according to the Beers criteria and should not be used. All other medications listed would be appropriate.
A client informs the nurse that she has recently started taking the herbal supplement black cohosh for her menopausal symptoms. When reviewing the client's medical record, what finding would warrant the need for follow-up? Refer to chart. History and Physical Laboratory Results Medications Renal Insufficiency Thyroid Stimulating Hormone (TSH) 2.45 mIU/L Glipizide 5mg oral once daily Heart failure B-type natriuretic peptide (BNP) 204 pg/ml Simvastatin 40 mg once daily Heart failure TSH result Glipizide prescription BNP result
Glipizide prescription Black cohosh is an herbal product used to treat hot flashes, irritability, and palpitations. It potentiates insulin, oral hypoglycemic agents, and anti-hypertensive agents. Therefore, follow-up would be necessary if the client was taking glipizide, a sulfonlyrea oral hypoglycemic agent. The TSH result is a normal finding. The BNP result would be expected with a known diagnosis of heart failure and additionally would not be affected by black cohosh.
The nurse is creating a plan of care for a client with a chest tube. Which actions should the nurse include to promote client safety? Select all that apply. Strip the chest tube as needed to improve suction Correct! Keep sterile gauze and padded clamps (per agency procedure) at the bedside You Answered Check the system every 4 hours to ensure patency Correct! Position the drainage tubing to prevent kinks Correct Answer Tape tubing junctions to prevent accidental disconnections
Keep sterile gauze and padded clamps (per agency procedure) at the bedside Position the drainage tubing to prevent kinks Tape tubing junctions to prevent accidental disconnections
The nurse is caring for a client with neutropenia. To monitor for infection, which action by the nurse is a priority? Encourage a nutritious diet Take the client's vital signs every shift Place the client in a room close to the nurse's station Listen to lung sounds
Listen to Lung sounds The priority nursing interventions for the client with neutropenia are protect the client from infection within the health care system and teach the client and family how to reduce infection in the home. To monitor for infection, the priority action for the nurse is to listen to the client's lung sounds to monitor for an infectious process. Hospitalized clients are susceptible to hospital-acquired pneumonia, which could be life-threatening to the client with neutropenia. The remaining options are not interventions that will monitor for infection.
The nurse is caring for a client who has had a myocardial infarction. After administering intravenous morphine sulfate, which interventions should the nurse take? Select all that apply. Monitor the client's blood pressure Monitor the client's respiratory rate Prepare the client for cardiac catheterization Ask the client to obtain a urine specimen Determine the client's oxygen saturation
Monitor the client's blood pressure Monitor the client's respiratory rate Determine the client's oxygen saturation Intravenous morphine sulfate (1 to 2 mg) is often prescribed to reduce myocardial oxygen demand by triggering blood vessel dilation. The nurse should be prepared to monitor the client's status. After administering morphine sulfate, the nurse should monitor the client's respiratory rate, oxygen saturation, and blood pressure. The nurse would not prepare the client for the cardiac catheterization unless specifically indicated by the health care provider. While a urine specimen may be needed, it is not the most important intervention after administration of the medication. <br><b>Test-Taking Strategy: </b>Focus on the subject, nursing interventions after the administration of morphine sulfate. Think about the physiological action and adverse effects of morphine to answer correctly.
A client is admitted to hospital for treatment of a respiratory infection. The client was treated with an intravenous (IV) course of ampicillin and is ready to be discharged home on oral antibiotics. What information present in the chart would warrant the nurse to provide further teaching? History and Physical Laboratory and Diagnostic Findings Medications Anemia Chest X-Ray: consolidation in left upper lobe norgestimate and ethinyl estradiol oral once daily Poly Cystic Ovarian Syndrome (PCOS) Potassium level of 4.5 meq/L Metformin 500 mg oral twice daily Chest X-ray result Norgestimate and ethinyl estradiol prescription Potassium result Anemia
Norgestimate and ethinyl estradiol prescription Broad-spectrum antibiotics such as ampicillin are commonly used to treat upper respiratory infections. These medications can decrease the effectiveness of oral contraceptive medications and the client should be advised to use alternative birth control options. Anemia has no impact on the use of ampicillin. The chest x-ray results, although abnormal, are expected with a respiratory infection. Serum potassium level is within normal limits. PCOS and the use of metformin is not affected by the oral antibiotic.
The nurse has been assigned a client who is receiving enalapril therapy. After receiving report and looking at the client's chart, which action should the nurse take first? Perform a full physical assessment Administer the client's morning medications Obtain a blood pressure Order the client's breakfast tray to be delivered at 0800
Obtain a blood pressure Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that is used to treat hypertension. Therefore, after receiving report and gathering information from the
The nurse is assessing a client with mitral valve regurgitation. Which manifestations should the nurse expect to note? Select all that apply. Orthopnea Low blood pressure Chronic weakness Fatigue Atypical chest pains
Orthopnea Chronic weakness Fatigue Atypical chest pains
Upon assessment of a client with heart failure, the nurse notes that the client is dyspneic. Which actions should the nurse take initially? Select all that apply. Place pillows under each of the client's arms Assist the client with deep breathing exercises Prepare the client for intubation Administer oxygen to keep O2 saturation greater than 90% Place the client in the Trendelenburg position
Place pillows under each of the client's arms Assist the client with deep breathing exercises Administer oxygen to keep O2 saturation greater than 90%
The nurse is providing care to a client who has a tracheostomy. Which actions should the nurse take to prevent a tube obstruction? Select all that apply. Assess the client every shift for tube patency Provide inner cannula care Teach the client how to cough and deep breathe Humidify the oxygen source Suction the tube as needed
Provide inner cannula care Teach the client how to cough and deep breathe Humidify the oxygen source Suction the tube as needed
A pregnant client has a history of depression and has been noncompliant with treatment in the past. What actions by the nurse would be the most appropriate? Select all that apply. Respect the client's decisions. Ask the client what methods of managing the depression have worked in the past. Provide education to the client about depression and treatment options. Discuss the noncompliance with the client, if the client brings it up. Maintain a hopeful, caring relationship with the client.
Respect the client's decisions. Ask the client what methods of managing the depression have worked in the past. Provide education to the client about depression and treatment options. Maintain a hopeful, caring relationship with the client.
Following thyroid surgery, the nurse notes this response (refer to figure) when taking the client's blood pressure. On further assessment, which laboratory finding would the nurse expect to find? Serum potassium of 5.1 mEq/L (5.1 mmol/L) Thyroid Stimulating Hormone (TSH) of 1.5 mU/L Serum calcium of 8.4 mg/dL (2.1 mmol/L) Sodium level of 138 mEq/L (138 mmol
Serum calcium of 8.4 mg/dL (2.1 mmol/L) Hypocalcemia is characterized by tetany, or sustained muscle contractions. Chvostek's sign is facial contractions seen after a light tap of the facial nerve in front of the ear. Trousseau's sign is carpal contraction when a blood pressure cuff is inflated. These two signs are observed in hypocalcemia.
The nurse at an outpatient clinic is performing a health assessment on a 67 year-old client. Her health history includes chronic obstructive pulmonary disorder (COPD) and diabetes mellitus and she currently has no complaints. On assessment, the client tells the nurse that she has not received any vaccinations other than a tetanus vaccine four years ago. Which routine vaccinations should be recommended given the client's age? Select all that apply. Rotavirus vaccine Shingles vaccine Pneumococcal vaccine Tetanus vaccine Influenza vaccine
Shingles vaccine Pneumococcal vaccine Influenza vaccine The Centers for Disease Control (CDC) recommends that a healthy individual over the age of 65 years old should receive the shingles vaccine, an annual influenza vaccine, and a pneumococcal vaccine. Rotavirus is given to infants and the client is not due for a tetanus booster. <br><b>Test-Taking Strategy</b>: Focus on the data in the question and recall the recommended immunization schedule. Also focus on the client's age to assist in answering.
The nurse is caring for a client with infective endocarditis, who is preparing to be discharged home. Which self-management techniques should the nurse teach the client? Select all that apply. Take prescribed antibiotics exactly as directed. Ask the health care provider for prophylactic antibiotics prior to invasive procedures. Follow instructions for care for the infusion site. Clean open sores and apply prescribed antibiotic ointment. Brush teeth once a day, with a soft toothbrush.
Take prescribed antibiotics exactly as directed. Ask the health care provider for prophylactic antibiotics prior to invasive procedures. Follow instructions for care for the infusion site. Clean open sores and apply prescribed antibiotic ointment.
The nurse is assisting a family with end-of-life care for their child. Which actions by the nurse would be the most appropriate? Select all that apply. Taking time to listen to the family talk about their child Reminding the family that their feelings and emotions are normal. Limiting communication with the family, to allow grieving. Gently reminding the family that they must focus on their remaining children. Acknowledging the emotions of the family members.
Taking time to listen to the family talk about their child. Reminding the family that their feelings and emotions are normal. Acknowledging the emotions of the family members. Chronic and terminal conditions involve the loss of health and result in grief. Grief is a normal psychophysiological process that occurs in response to a specific loss. As adjustment to the condition progresses, many parents experience chronic sorrow related to the unending nature of the child's condition and the ongoing feelings of loss. It is important that the nurse take the time to listen to the family as they talk about their child. The nurse should also acknowledge the emotions of the family members and remind them that their feelings and emotions are normal. Not acknowledging the family members feelings are often triggers for grief. It would be inappropriate, or even hurtful, to the family if the nurse limited communications or suggested that the family focus on the remaining children. During this time, family members need therapeutic and caring support from the nurse.
A client will be started on peritoneal dialysis. The nurse should consider which statements in planning care for the client? Select all that apply. The client may experience respiratory distress. Bowel perforation is very rare. A complication of peritoneal dialysis is hyperglycemia. The client will experience few hemodynamic complications. The client will require a diet that is high in protein.
The client may experience respiratory distress. A complication of peritoneal dialysis is hyperglycemia. The client will experience few hemodynamic complications. The client will require a diet that is high in protein.
The nurse is preparing to administer bumetanide to a client. What information is the priority for the nurse to obtain prior to administering this medication? The client's current weight The time of the client's last meal The client's potassium level The time of the last bumetanide administration
The client's potassium level Bumetanide is a loop diuretic that causes the kidneys to excrete potassium, which can lead to hypokalemia. Therefore it should be the nurse's highest priority to obtain the client's potassium level prior to administering the potassium. While the other options are important in the care of the client, the potassium level is the highest priority for client safety and well-being.
The nurse is assessing the client for placement of a midline catheter. Which factors would prompt the nurse to select a different type of catheter for this client? Select all that apply. The use of vesicant medications Dialysis fistula on the right arm The need for parenteral therapy with osmolarity greater than 600 mOsm/L (600 mmol/kg) The need for long-term antibiotics Client history of bilateral mastectomy with lymphedema
The use of vesicant medications The need for parenteral therapy with osmolarity greater than 600 mOsm/L (600 mmol/kg) Client history of bilateral mastectomy with lymphedema
The nurse is caring for a client with known chronic kidney disease (CKD), who is taking digoxin. When assessing the client, which signs/symptoms would alert the nurse to the possibility of digoxin toxicity? Select all that apply. Sudden ear pain Visual changes Anorexia Muscle aches Nausea and vomiting
Visual changes Anorexia Nausea and vomiting Clients with CKD are particularly at risk for digoxin toxicity because the medication is excreted by the kidneys. The symptoms include confusion, visual changes, gastrointestinal (GI) disturbances such anorexia, nausea, and vomiting. Muscle aches and sudden ear pain is not indicative of digoxin toxicity.
The nurse manager is educating a group of nursing students on the educational needs of bariatric clients post-surgery. Which statement by one of the nursing students indicates that the teaching has been effective? Select all that apply. "During weight loss, the client may become depressed or even anxious." "It is not necessary for clients to adhere to a community-based treatment plan." "Clients should be provided with a list of available community resources." "The client should be encouraged to keep follow-up appointments." "Clients are followed by a surgeon and dietician for a few months after the surgery."
orrect Answer "During weight loss, the client may become depressed or even anxious." "Clients should be provided with a list of available community resources." "The client should be encouraged to keep follow-up appointments."
