Testing and Remediation Advanced Test

a nurse is caring for a client who is from a culture different than his own. which of the following actions by the nurse is most important in the provision of culturally competent care

identify one's own beliefs and values to provide culturally competent care, it is essential to identify one's own cultural background, values, and beliefs, especially those that are related to health and health care

a nurse is caring for a client who has a borderline personality disorder. which of the following is a manifestation of the disorder?

unstable interpersonal relationships

a nurse in a long-term care facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. which sites should be included?

urinary tract, surgical wound, respiratory tract, blood stream

a nurse in a ped office is conducting a telephone triage and receives a call from a client regarding her 4-day-old newborn who was circumcised 2 days ago. the mother states her son has a yellow discharge around his penis and asks the nurse what she should do. what is an appropriate response from the nurse

"do not attempt to remove it" the yellow exudate covers the penis 24 hr after the circumcision and will persist for 2-3 days. this is an expected finding and should not be removed

a nurse is reinforcing teaching methods to decrease nausea to a client who is receiving chemotherapy. which of the following statements by the client indicates a need for further teaching

"i should eat low carbohydrate foods" clients experiencing nausea should eat foods high in carbohydrates such as crackers, yogurt, toast, bananas, and sherbert

a nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. which of the following statements by the parent indicates a need for further teaching

"the illness will not recur because my child has now had it" rheumatic fever occurs from untreated strep or staph infection. both of these can recur so rheumatic fever can also recur

a nurse is caring for an infant who has been prescribed a one-time dose of ceftriaxone 50 mg/kg IM. the infant weighs 17.6 lb. available is 500 mg/mL. how many mL should the nurse administer?

0.8 mL

a nurse is collecting data on a client who has appedicitis. where should the nurse palpate to determine the presence of tenderness at McBurney's point

RLQ

a nurse is reviewing the lab results of four clients. which of the following should be immediately reported to the provider

a client who is prescribed digoxin and furosemide with a potassium of 3.1 mEq/L normal potassium is 3.5-5.0 mEq/L and must be maintained at such a level otherwise great complications could occur

a nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. in which of the following roles is the nurse functioning

advocate

a nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril. the nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril

aspirin aspirin and other NSAIDS can reduce the antihypertensive effects of captopril, which is an ACE inhibitor

a nurse is collecting data on a child who is diagnosed with bacterial epiglottis. which of the following clinical findings are associated with the illness

drooling, stridor, difficulty swallowing, and high-grade fever

a nurse is assessing a client who is postop following a gastric bypass. which finding indicates the client could be experiencing an anastomotic leak

oliguria oliguria, or decreased urine production, is a finding consistent with peritonitis which is the result of an anastomotic leak of gastric/intestinal fluids

a nurse is assisting with the care of a client who is in labor. following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. after calling for assistance/notifying the provider, which is the priority action by the nurse?

place client in knee-chest position placing them in this position will aid in keeping the pressure of the presenting part of the fetus off the cord.

a nurse caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the client's total parenteral nutrition (TPN) is turned off. the client tells the nurse that they battery went dead while she was in physical therapy. the nurse should monitor the client for which manifestation?

shakiness and diaphoresis these are manifestations of hypoglycemia which can occur if there is a sudden interruption in the delivery of TPN

A nurse is caring for a client who is prescribed lithium. which of the following clinical findings should be immediately reported to the provider

slurred speech this is an early clinical finding associated with lithium toxicity and precipitate the onset of seizures or coma

a nurse is reinforcing teaching regarding foods containing complete protein to a client. which of the following should be included in the teaching?

soybeans soybeans contain all 9 essential amino acids to support body growth and maintenance so they are considered a source of complete protein

a nurse is caring for a client who is admitted with acute alcohol withdrawal. which finding should the nurse report to the provider?

tachycardia symptoms of acute alcohol withdrawal include tachycardia, hypertension, diaphoresis, disorientation, and hand tremors. these can progress to visual or tactile hallucinations, paranoid delusions, agitation, hyperthermia, and gran mal seizures.