ATI CBC Level 3 - Practice A
A nurse is teaching a client about family planning and the proper use of an intrauterine device. Which of the following client responses indicates an understanding of the teaching?
"I will need to check that the two strings of this device are the same length once per month." The nurse should instruct the client to check for the two strings preferably after menses each month to ensure the device is in place. Teach pt that: - length of protection varies w each device (wont need to be replaced for 3-10 years) - fertility returns AS SOON as device is removed - pain w/ intercourse indicates a potential complication and the provider should be notified
A nurse is providing discharge teaching about newborn care to a client who is 2 days postpartum. Which of the following client responses indicates an understanding of the teaching?
"It can take up to 3 weeks for my baby's umbilical cord to fall off" - average time is 14 days but can take up to 3 weeks also teach parent to: - feed baby smaller amts of formula more often when they have a URI or cold to avoid fatigue - avoid bumper pads, pillows, quilts, stuffed animals in crib bc they increase risk for suffocation - swaddle baby loosely w hips flexed and abducted to prevent hip dislocation. wrapping too tightly can cause respiratory distress
A nurse in an inpatient psychiatric facility is assessing a client who has schizoaffective disorder. Which of the following client statements indicates flight of ideas?
"My foot hurts. It's time to eat lunch. I like movies." Flight of ideas is when the client's speech jumps from one thought to the next without pausing.
An intensive care nurse is providing education about organ and tissue donation to the parent of an adolescent who has died following a motor-vehicle crash. Which of the following responses by the parent indicates an understanding of the teaching? -Autopsies do not preclude organ/tissue donation; their are no expenses w/ donation; attorney not needed for donation; it will NOT be noticeable at the funeral
"No one will notice the organs were donated if we have an open casket at the funeral". The nurse should reassure the parents that organ transplantation does not change the appearance of the body.
A nurse in an infertility clinic is providing teaching to a client about her upcoming hysterosalpingography. Which of the following statements should then nurse make?
"You might feel pain in your shoulder after the procedure" The pain indicates irritation from the contrast when it is spilled out of the uterine tubes that are patent. Mgmt of this pain is w/mild analgesics and position changes -scheduled 2-5 days after period -is an x-ray examination - dont confuse with a hysteroscopy (scope thru cervix to eval for fibroids)
A nurse in a provider's office is performing a skin assessment on a client who reports concern about a lesion on her back. Which image should the nurse identify as having the characteristics of melanoma?
*the image w/the darkest lesion* Melanoma is characterized by an irregularly shaped lesion that contains a combination fo colors such as red, black, blue-black, and brown. Melanoma can occur anywhere on the body.
A nurse is providing nutritional teaching to a client who has leukemia and is experiencing neutropenia. What instructions should the nurse include?
- Thaw frozen foods in the refrigerator - avoid buffet-style restaurants. Thawing food at room temp can increase the risk fo exposure to bacteria. The client should avoid buffets because the food is open to human contamination, potentially causing bacterial growth. Instruct pt to: - refrigerate foods immediately!! - discard leftovers after a max of 4 days
R/t last question... what would you do If an infant is experiencing hypercyanotic episodes?
-admin 100% O2 via facemask -give morphine subQ or thru existing IV line -initiate or increase rate of IVF
A client's first day of her last menstrual period was 09/02. Using Naegele's rule, which of the following is the client's estimated date of delivery?
06/09 First day of the last menstrual period, subtract 3 calendar months, and add 7 days.
1. body attitude test 2. brief patient health questionnaire 3. mini-mental state exam
1. assesses for an eating disorder 2. assesses for anxiety 3. assesses client's cognitive function
A nurse is assessing a client for alcohol use disorder. Which of the following assessment scales should the nurse use?
Addiction Severity Index Other scales the nurse can use include the Brief Drug Abuse Screen Test and the Recovery Attitude and Treatment Evaluator
A nurse is caring for a client who has a terminal illness and is approaching death. Which of the following actions should the nurse take? - position client in supine position (no, HOB should be elevated to ease breathing, if pt has congestion/nausea place them on their side) - encourage client to stay awake during daylight hours (no, a dying pt has a decreased metabolism which results in increased sleeping. nurse should allow rest and not force the pt to stay awake) - keep the clients curtains open to provide light in the room (no, dying pt's are usually restless due to slowed circulation to the brain. RN should keep room dimly lit, reduce # of people, & keep noise to a minimum) - apply a thin coat of lip balm to the client's lips (YES, pt can experience dehydration, causing lips to be dry/chapped)
Apply a thin coating of lip balm to the client's lips. A client who is dying can experience dehydration. Applying lip balm to the client's lips promotes comfort.
A nurse is caring for a client who has alcohol use disorder and recently completed detoxification. Which medication should the nurse plan to administer to assist the client in maintaining abstinence from alcohol? - varenicline (no, used in tobacco use disorder to reduce nicotine craving) - clonidine (used for pt w opiate use disorder who has HTN) - chlordiazepoxide ( no, used w pt having alcohol withdrawl, reduces risk of seizures/agitation during withdrawal) - disulfiram (YES, used in pt who has completed detoxification; will cause a toxic reaction to pt who ingests alcohol)
Disulfiram Disulfiram will cause a toxic reaction to a client who ingests alcohol
A nurse is assessing a client who has acute glomerulonephritis. Which of the following manifestations should the nurse expect?
Edema, Hematuria, and Fatigue. Edema is a result of the fluid and sodium retention and decreasing kidney function. Clients who have acute glomerulonephritis have urine and reddish brown/rusty color. Fatigue occurs because the kidneys fail to filter waste products in the blood.
A nurse is assessing a client who is 3 wks postpartum. Which of the following manifestations is associated with postpartum depression? -increased appetite (no, decreased) - emotionless affect (YES) - manipulative behaviour (no, this is a symptom of borderline personality disorder) - excessive clinginess (no this is a symptom of borderline personality disorder)
Emotionless affect. Clients who have postpartum depression exhibit a flat affect, feelings of guilt, crying, irritability, persistent sadness, mood swings, feelings of loss, and rejection of newborn. Another manifestation is lack of appetite.
A nurse is teaching a client who is experiencing preterm labor about receiving betamethasone. Which of the following outcomes should the nurse include in the teaching regarding betamethasone?
Enhances fetal lung maturity
A nurse is caring for a newborn who was born prematurely. What is the priority for the nurse to investigate further? - poor wt gain (should investigate bc it indicates anemia but not #1) - grunting on expiration (YES, ABC - indicates respiratory distress) - temp instability (investigate to prevent hypothermia, but not #1) - fluctuating blood glucose (investigate bc it may indicate GI infection, but not #1)
Grunting on expiration. Expiratory grunting indicates respiratory distress, which can be life-threatening for the preterm newborn.
A nurse is assessing an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. What manifestations should the nurse expect? - hematuria (YES, manifestion of vaso-occlusive crisis resulting from ischemia to kidneys) - pallor (no, in vaso-occlusive crisis pt will have jaundice/yellow skin) - tinnitus (no, this is not a symptom) - tingling of hands (no, they will have SWELLING of the hands/feet/ & painful joints
Hematuria Hematuria is a manifestation of vaso-occlusive crisis resulting from ischemia to the kidneys.
A nurse is caring for a client who is receiving chemotherapy for non-Hodgkin's lymphoma. Which of the following actions should the nurse take?
Instruct the client to wash drinking glasses after each use. A client undergoing chemotherapy will be immunosuppressed and at risk for bacterial infection. - obtain pt temp twice per day - instruct client to bathe daily to remove bacteria - wash hands w antimicrobial soap before eating
A school nurse is evaluating a school-age child who has ADHD. What behavioral characteristic should the nurse expect the child to exhibit?
Intrusiveness Manifestations include decreased attention span, talkativeness, decreased ability to follow directions, inability to complete tasks, poor social skills, poor impulse control and intrusive behaviors. Also have extreme disorganization & are easily distracted.
A nurse is teaching a client about ways to prevent melanoma. What instruction should the nurse include in the teaching?
Keep a body map of skin abnormalities. The client should keep a body map of skin abnormalities, including scars, spots, and lesions, to detect any changes that occur that could be precancerous also: -avoid tanning beds, avoid sun between 1100 & 1500, inspect body every month
A nurse in a mental health facility is caring for a client who has anorexia nervosa. Which of the following actions should the nurse take to help the client manage this eating disorder? (SATA)
Limit the Client's intake of caffeine, suggest high-fiber food choices, and use increments of 100 calories when advancing the client's dietary intake. Caffeine is a diuretic and can cause excess stimulation. High fiber foods decrease the risk fo constipation. Dietary intake should be increased gradually to avoid overwhelming the client. Also: reasonable wt gain = 1-3 lbs/week
A nurse manager is conducting an in-service about medications for substance use disorders with a group of staff nurses. What medication should the nurse manager include as an opioid agonist used in withdrawal therapy? - methadone (YES, used to prevent withdrawal) - diazepam (no, this a benzo used to tx anxiety, insomnia, & seizures) - morphine (no, pure opioid agonist given to relieve moderate to severe pain) - doxepin (no, tricyclic antidepressant; tx depression & insomnia due to strong sedative action)
Methadone The client can use methadone to prevent withdrawal as part of maintenance therapy/to build tolerance to opioids
A nurse is caring for a client who has diverticulitis. Which medication should the nurse expect to administer? - metronidazole (yes) -balsalazide (no this is used in crohns & ulcerative colitis) - mesalamine (no this is used in crohns & ulcerative colitis) - sulfasalazine (no, this is used in crohns & ulcerative colitis)
Metronidazole Metronidazole is a broad-spectrum antimicrobial drug and is administered in combination with other antibiotics
A nurse in an acute care mental health facility is planning care for a client who has bipolar disorder and who is experiencing acute mania. What action should the nurse take? - encourage client to take part in daily group meetings (no, they should have one-to-one activities) -allow client to pick from a variety of activities on the unit (no nurse should provide scheduled meals & rest periods) - assign the client to a semiprivate room (no, reduce stimuli and assign to a PRIVATE room w reduced noise/lighting) - provide client w finger foods (YES, pts experiencing mania are often unable to sit and eat, finger foods allow them to get up and move around
Provide the client with finger foods to eat. (pts experiencing mania are often unable to sit and eat * can become dehydrated & lose weight, finger foods (sandwiches) allow pt to eat while standing/walking & obtain nutrition even though she cannot sit down for a meal)
A nurse caring for a client who has preeclampsia and is receiving a 30 min bolus infusion of mag. sulfate. The client appears flushed and states that she feels nauseated and extremely hot. What action should the nurse take?
Reassure the client these are expected findings. -Do not D/C - have calcium gluconate available in case of magnesium toxicity -assess DTRs prior & during admin
A nurse in an acute care mental health facility is planning care for a client who has major depressive disorder and who verbalizes feelings of hopelessness. What action is the nurse's priority?
Supervise the client closely during medication administration Greatest risk for this client is self-injury. The nurse should also remove potentially dangerous material, such as belts or glass from the client's environment and should supervise during meals.
A nurse is developing a plan of care for a newly admitted client who has bulimia nervosa. What action should the nurse plan to take?
Tell the client that privileges are based on treatment compliance. also: - weigh pt 3x weekly - stay w pt for 1 hr after meals - RN make strict mealtimes that last 30 minutes
pt in preterm labor may be given IV abx to prevent
choriamnionitis
Terbutaline & magnesium sulfate
given to pts in preterm labor to decrease uterine contractions
Manifestations of borderline personality disorder
manipulative behavior, excessive clinginess, self-mutilating behavior
manifestations of acute pyelonephritis
tachypnea and nocturia
A nurse is teaching a client who has genital herpes and a new prescription for acyclovir. What information should the nurse include regarding the expected outcome of the medication?
"Acyclovir is given to promote healing of genital herpes." Antiviral medication which is administered to decrease the severity of genital herpes, as well as the frequency of recurrent outbreaks. Also reduces the healing time of the lesions.
A client has Parkinson's disease and a new prescription for levodopa-carbidopa. Which of the following instructions should the nurse include?
"Change from a lying or sitting position slowly" - Levodopa-carbidopa can cause orthostatic/postural hypotension. also teach pt: -eat shortly after taking to avoid gastric irritation, avoid high protein -he may have darkening of urine/saliva or sweat (doesnt need to be reported) -take on regular schedule during waking hours (will improve sleep)
A nurse is assessing a client who has rheumatoid arthritis and has been taking methotrexate for 4 months. What statement by the client indicates that the medication is effective?
"I have been able to go outside for walks lately." Methotrexate is a disease-modifying antirheumatic drug, which is given to RA patients to slow the progression of the disease. The desired effects of this medication include a decrease in joint pain and swelling and improved mobility for clients.
A nurse is caring for a client who has major depressive disorder. Which of the following client responses should the nurse identify as an overt statement indicating the potential for suicide? - overt : means done/shown openly - covert : (indirect) means not displayed or openly knowledged (negative statements that hint at depression w/o coming out and saying they're depressed/suicidal)
"I just can't go on living like this any longer" This is a direct/over statement indicating that the client wishes to end their life.
A nurse is teaching a client who has gestational hypertension about the condition. Which of the following statements made by the client indicates an understanding of the teaching?
"I know my blood pressure should return to normal a few weeks after delivery" Pt is not required to be on bedrest Will not require magnesium sulfate during labor to prevent seizures Is not at risk for developing preeclampsia
A nurse is teaching a client who has a tobacco use disorder about the use of nicotine patches as an aid in smoking cessation. Which of the following statements indicates the client understands the teaching?
"I should gradually decrease the dose of the nicotine patch over several weeks" -the prescribed dosage is gradually decreased over a period of 8-10 weeks depending on the brand. The gradual decrease enables the client to physically adjust to lower blood levels of nicotine. -Patch should also be worn for 16-24 & dont apply patch to same site for at least 1 week -Dyspepsia/heartburn occurs with nicotine GUM/lozenges -patch dosage is NOT adjustable, if pt still experiencing intolerable cravings w patch, may need to discuss other tx options.
A nurse is providing discharge teaching about home management strategies to a client who has multiple sclerosis (MS). Which of the following client statements indicates an understanding of the teaching?
"I should schedule rest breaks between activities" - Nurse should instruct pt to schedule rest b/w activities and use strategies to help conserve energy. A client with MS can experience muscle weakness and fatigue. Encourage use of assistive devices/modify environment to reduce fatigue during ADL's. also teach: - increased body temp can cause exacerbation of MS s/s, like increased weakness/fatigue. This is known as Uhthoff phenomenon (teach pt to avoid hot tubs & vigorous exercise) - personality changes can occur but want to Encourage pt to engage in social activities when well enough to physically do so - Pt's w/ MS often have constipation so encourage pt to drink 1.5-2 L of fluids daily & increase fiber to 25-35g daily
A nurse is providing discharge teaching to a client who is receiving radiation therapy for Hodgkin's Lymphoma. What client statement indicates an understanding of the teaching? - "i will floss my teeth after each meal" (no, avoid flossing & use soft toothbrush to prevent bleeding) - "i can take aspirin if i get a headache" (no, take acetaminophen bc aspirin can increase risk of bleeding) - "i can use a suppository if i experience constipation" (no, avoid suppositories/enemas to prevent risk of bleeding) - "I will apply ice to the area if I get a bruise" (YES)
"I will apply ice to the area if I get a bruise" Nurse should instruct client to apply ice for at least 1 hr to any bruised or bumped area on the skin. This decreases the risk fo bleeding underneath the skin and prevents further injury. Teach pt: -to avoid flossing/use soft toothbrush - to take acetaminophen for HA; NOT aspirin - DON'T use suppositories/enemas
A nurse is providing discharge teaching to a client following gastric bypass surgery for management of obesity. What is a client statement that indicates understanding of the teaching? - i will apply lotion b/w skin folds (no, you want to keep skin dry to prevent breakdown) - i will remain in a reclining position for 30 min after i eat (YES bc clients are at risk for dumping syndrome) - i will return to my normal diet in 3 weeks (no, diet should be pureed/liquid for at least 6 weeks) - i will need to take digestive enzymes weekly (no, pt will need monthly injections of B12 and iron)
"I will remain in a reclining position for 30 minutes after I eat" Following gastric bypass surgery, clients are at risk for dumping syndrome. Remaining in a reclining position slows gastric emptying and minimizes the risk of dumping syndrome.
A nurse is speaking with the family of a terminally ill client about organ donation. Which of the following statements by one of the client's sons indicates an understanding of the organ donation process?
"Our father will remain on life support until after the organs are removed" Even though the client is legally declared dead, he will need to remain on life support to provide blood and oxygen to the vital organs so they will be viable for procurement.
A charge nurse is leading an educational session about intimate partner violence for a group of newly licensed nurses. Which of the following statements by a newly-licensed nurse indicates an understanding of the teaching?
"Physical intimate partner violence is often passed on to future generations" - also likely to begin/increase during pregnancy - occurs regardless of socioeconomic status - can be very difficult for victim to leave
A nurse is providing education on expected manifestations of Parkinson's disease to a client's partner. What statement by the partner indicates understanding of the teaching? - she might have trouble swallowing so i will offer her milkshakes (YES, offer soft diet with thick cold fluids) - she will develop a shuffling gait so i should encourage her to focus on her feet when walking (no, encourage pt to be active and do ROM exercises, but focusing on feet can increase the risk of pt falling)
"She might have trouble swallowing, so I will offer her milkshakes to drink" The partner should offer a soft diet and thick, cold fluids, bc they are likely to be better tolerated by the client
A nurse is caring for a client who has schizophrenia. Which of the following statements made by the client indicates delusions of reference? - "someone is trying to get a message to me through this newspaper" (YES) - "I am possessed by the evil one & will destroy the world" (no, this is delusions of grandeur - pt has heightened sense of importance & ability) - "i know these nurses are watching my every move" (no, this is paranoia - pt is suspicious of actions/intentions of others) - "the dentist put a radio transmitter in my tooth to control me" (no, this is delusions of control - pt believes an external forced has the ability to control his thoughts or actions)
"Someone is trying to get a message to me through this newspaper." Delusions of reference occur when events are interpreted as directed at the client.
A nurse is caring for a client who is being seen for infertility and has a new prescription for clomiphene citrate. Which of the following manifestations should the nurse include in the teaching as a common adverse effect of the medication? -"you might have chills while taking this med" (no, pt may have hot flashes) -"you might experience drooling while taking this med" (no, the pt might have dry mouth while taking) -"you might have breast tenderness while taking med" (YES) -"you might experience an increase in urination while taking med" (no, increased UOP is an A/E of furosemide)
"You might have breast tenderness while taking the medication" - this is a common A/E of clomiphene citrate. - pt may also experience hot flashes, dry mouth
A nurse is teaching a client who has genital herpes simplex virus. What statement should the nurse include in the teaching about this STI? - 14-day course of acyclovir will iradicate infection (no, there is no cure and this antiviral medications will only reduce symptoms) - the law requires you to contact all sexual partners so they can be treated (no, the client should contact partners as a courtesy but it is not required by law) - avoid taking OTC meds that contain aspirin while you have lesions (no, pt should take OTC meds like acetaminophen/ibuprofen/aspirin to control pain associated w infection) - you should cleanse the lesions w a saline solution twice each day (YES, to prevent secondary infections)
"You should cleanse the lesions with a saline solution twice each day." This helps to prevent secondary bacterial infections.
A nurse is providing teaching to the parent of a school-age child who has sickle cell anemia. Which of the following statements should the nurse include? - "you should report to the provider if your child has a severe headache." (YES) - "you should apply cold compresses to your childs affected joints" (no, apply warm compresses to prevent vasoconstriction) - "you should restrict childs intake of fluids" (no, increase fluid intake to maintain hydration) - "you should administer a stool softener to your child each day" (no, bc constipation isn't a manifestation of sickle cell anemia)
"You should report to the provider if your child has a severe headache." A severe headache can be an indication of a stroke. Also: - warm compresses to affected joints to prevent vasoconstriction - increase fluid intake - no stool softeners bc constipation is not a complication of sickle cell anemia
A nurse is teaching a client about obesity management. Which of the following information should the nurse include?
"You should walk 5 days a week for 30 minutes." To increase energy and prevent discouragement with exercise, the nurse should encourage the client to engage in a low-intensity, short-duration programs also: -Client should have 1,200 cal per day (no fad diets) -Encourage drinking water during meals (this increases feelings of satiety & decreases amt of food client eats) -Pt should reward self w/ non food items (clothing/movie)
examination for neurocognitive disorder for pt w/ dementia: 1. ask pt to name similarities b/w cars & planes 2. ask pt to explain phrase "dont cry over spilled milk" 3. ask pt to name four objects in room as you point to them
1. compare two objects to test concept of relationships 2. ask pt to explain familiar sayings to test his ability of interpretation 3. name common objects to test his word-finding ability
1. pt w paranoid personality disorder: 2. pt w histrionic personality disorder: 3. pt w borderline personality disorder
1. is suspicious and feels others are attacking his reputation 2. wants to be the center of attention and is uncomfortable when this isnt possible 3. demonstrates frequent self-mutilating behavior & at risk for suicidal behavior
1. echolalia 2. nihilistic 3. grandiose delusion
1. pt repeats words/sentences they hear "its time to eat. eat." 2. client has false idea that world is nonexistent "world doesn't exist" 3. pt believes they are very important "im the president"
A nurse is assessing a group of clients who have personality disorders. What client should the nurse identify as having characteristics of schizoid personality disorder? - client who suspects that others are attacking his reputation (no, this is paranoid personality disorder) - client who is uncomfortable when she is not the center of attention (no, this is histrionic personality disorder) - client who demonstrates frequent self-mutilating behavior (no, this is borderline personality disorder) - a client who dislikes having close relationships with other people (YES)
A client who dislikes having close relationships with other people A client with schizoid personality disorder desires solitude and dislikes having close relationships with others.
A nurse is caring for a client who is in active labor. The nurse notices an abnormal pattern on the FHR monitor. Which of the following actions should the nurse take for late decelerations? - elevate HOB to 90 (no, get pt in side lying position to increase perfusion of O2 to fetus) - requestion prescription to decrease IV infusion rate (no, you want to increase rate) - admin o2 via nonrebreather mask at 10L/min (YES, late decels are primarily caused by impaired O2 to placenta) - prepare client for amnioinfusion (no, this is an infusion of ISOTONIC fluids into uterine cavity if amniotic fluid level is low. Wont help with late decels)
Administer oxygen by non-rebreather face mask at 10L/min Late decelerations are primarily caused by impaired oxygenation to the placenta.
A nurse is caring for a client who has eclampsia and has just experienced a tonic-clonic seizure. What action should the nurse take? -apply oxygen via nonrebreather at 10 L/min (YES) - admin calcium gluconate (no this is used for magnesium toxicity) - admin a 500 mL bolus of IV fluids (RN should not admin IV fluids but should monitor for fluid overload) - place pt in reverse Trendelenburg (no the pt should be placed in the lateral side-lying position *remember this pt is pregnant -> side lying is always best for them)
Apply oxygen via non-rebreather at 10 L / min - following a seizure. The nurse should also suction as needed, apply a pulse oximetry monitor, initiate IV fluids, administer magnesium sulfate, insert an indwelling urinary catheter, and monitor vital signs.
A nurse is assisting the provider in performing a mental status examination for neuro-cognitive disorder on a client who has dementia. Which of the following tasks should the nurse use to test the client's constructional ability?
Ask the client to draw a clock that displays the time as 2:30 to test constructional ability
A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. What information should the nurse include? - limit alcohol intake to 360 ml (12 oz) a week (no, avoid ALL alcohol) - avoid large crowds (YES this med increases risk of infection) - take low-dose aspirin for pain (no, avoid aspirin/NSAIDS due to the adverse effect of thrombocytopenia, these meds together can precipitate gastric bleeding) - expect to experience increased fatigue (no, notify MD ASAP if this occurs bc it can indicate infection or bleeding. methotrexate can cause leukopenia or thrombocytopenia)
Avoid large crowds of people when possible. Clients taking methotrexate are at an increased risk of infection due to the adverse effect of leukopenia.
A nurse is providing teaching to a client who has epilepsy and is starting to take carbamazepine. The nurse should instruct the client to monitor for which of the following manifestations as an adverse effect of this medication? - wt loss (no, pt should monitor for wt GAIN) - urinary frequency (no, monitor for urinary hesitancy or retention) - blurred vision (YES, blurred or double vision) - insomnia (no, monitor for drowsiness or sedation)
Blurred vision - Nurse should instruct client to monitor for blurred vision or double vision while taking carbamazepine. Other adverse effects: - urinary hesitancy/retention - weight gain - drowsiness/sedation
A nurse is assessing a 2-day old newborn who was delivered at 32 weeks of gestation. What finding would be the priority for the nurse to report? *think ABC* -temp of 97.7 -central cyanosis - poor muscle tone - wt loss of 10% birth wt (All are important but which is priority?)
Central cyanosis - this type of cyanosis is caused by an excessive concentration of decreased hemoglobin in the blood leading to deoxygenation, causing newborn to have blue discoloration around the core, lips, and tongue. Central cyanosis often indicates impaired cardiovascular function and should be immediately reported to the provider. Nurse should also report: - temp of 97.7 - poor muscle tone - wt loss 10% of birth wt but PRIORITY is to report central cyanosis (ABC's)
A staff nurse tells the nurse manager that he consistently receives work assignments with a heavier work load than the other nurses on the shift. Which of the following actions should the nurse manager take to address the staff nurse's report of bullying?
Check work assignments to validate the staff nurse's claim. A nurse consistently receiving heavier work assignments than other nurses is a form of bullying. The nurse manager should immediately address the problem
A nurse is reviewing the lab report of an adolescent client who has hemophilia A. Which of the following lab results should the nurse expect? -aPTT 110 seconds (this is WNL; it would be prolonged in hemophilia A) -coagulating factor VII 50%% (YES) - coagulating factor IX 75% ( this is WNL; would find a deficiency of coagulating factor IX with hemophilia B) -PT 14 seconds (WNL for Vit K deficiency not hemophilia a, nurse should expect to find a PT WNL for an adolescent with hemophilia A)
Coagulating factor VIII 50% 50% of coagulating factor VIII is below the expected range. This type of hemophilia reflects a deficiency of Factor VIII, a protein in the body that helps the blood to clot.
A nurse is providing family education for a client who wishes to conceive...the nurse should identify that ovulation is expected to occur on which of the following calendar dates?
D-the 19th. - The nurse should teach the client that ovulation is expected to occur 13-15 days after day one of her menses.
A nurse is teaching about an obesity management program for overweight clients. What information should the nurse include?
Decrease intake by 500 calories per day to lose 0.45 kg (1 lb) per week. This recommendation is based on the metabolism of each individual, assuming that 0.45 kg (1 lb) is equal to 3,500 calories. Also: - encourage daily exercise - do not suggest short-term fasting - discourage novelty diets (clear liquid diets)
A nurse is assessing a 12 month old infant who has down syndrome. What manifestation should the nurse expect?
Decreased muscle tone The nurse should expect the infant to exhibit hypotonia (decreased muscle tone) as well as hyper-flexibility (joints move beyond expected ROM) They will also have: - a short, broad neck - small ears with short pinna - delayed eruption of teeth
A nurse is assessing a client who is at 28 weeks of gestation and is receiving magnesium sulfate for preterm labor. Which of the following findings is the priority for the nurse to report to the provider?
Decreased respiratory rate. ABC's (nursing priority). RN should also report: increased muscle weakness decreased BP New onset of diarrhea BUT decreased RR is the PRIORITY
A nurse is providing teaching to the family member of a client who has delirium. What information should the nurse include? - pt usually develops delirium slowly over several weeks (no, usually develops quickly over several hours/days) - pt who has delirium often has flat affect (no, they will have a wide range of emotions) - delrium is not reversible (no, it can be reversed by txing underlying cause) - delirium can be brought on by stress of an illness (yes, by stress of an illness or infection/dehydration)
Delirium can be brought on by the stress of an illness. Infection or dehydration can also cause delirium
A nurse in an emergency department is assessing a client who was in a motor-vehicle crash. The client has a BAC of 0.18% and states, "I would never drink and drive." This is demonstrating use of which defense mechanism? - intellectualization (when a pt uses reasoning/logic to prevent thinking about emotional aspects of situation) - denial (pt refuses to acknowledge the reality of the situation) - rationalization (pt tries to use logical argument to excuse unacceptable behavior) - projection (pt attributes his feelings as the feelings of another person)
Denial Client refuses to acknowledge the reality of a situation.
A nurse in a mental health facility is assessing a client who has schizophrenia. What finding should the nurse identify as a cognitive symptom of schizophrenia? - periods of mood instability (NO, this is an affective symptom - involves client's expression of emotions) - difficulty in decision making (YES) - demonstration of social withdrawal (no, this is a negative symptom - involves absence of expected abilities/behaviors) - use of concrete thinking (no, this is a positive symptom of schizophrenia - positive symptoms involve presence of behaviors that are not expected)
Difficulty in decision making. Cognitive symptoms involve the client's executive functioning.
A nurse in an emergency department is creating a plan o care for a client who reports a recent sexual assault. What intervention should the nurse include? -rotate staff members (no pt is vulnerable and having additional staff may worsen anxiety/vulnerability) -explain each procedure to client (YES, this may decrease anxiety/fear, and increase feelings of trust) - discourage client from giving immediate account of assault (no, immediate is best. RN listening gives pt an avenue to vent & begin healing process) - avoid dicussing criminal charges during initial assessment (no, encourage pt to discuss & determind if pt wants to press charges/has a safe place to go. Pt safety is the nurses #1 priority)
Explain to the client the reason each procedure is conducted. It is important to explain the reason each assessment procedure is conducted and why b/c a client who reports a recent sexual assault is extremely vulnerable.
A nurse is preparing to administer immunizations to a 2 mo. old infant at a well-child visit. What immunization should the nurse plan to administer? - Varicella (2 doses starting at 12 months of age) - Measles-mumps-rubella (2 doses starting at 12 months) - Haemophilus influenzae type B (hib) (3-4 doses starting at 2 months of age) - influenza (given annually, starts at 6 months of age)
Haemophilus influenzae type b This vaccine is administered in a series of 3-4 doses starting at 2 mo. of age
A nurse is planning care for a client who has adenocarcinoma and associated thrombocytopenia. Which of the following actions should the nurse plan to take? - apply pressure to venipuncture sites for 5 min (no, apply pressure for a minimum of 10 minutes) - use firm-bristled toothbrush (no, use soft brush to prevent bleeding) - initiate fall precautions (YES, to prevent injuries in pt w thrombocytopenia) - check pt's IV site for bleeding q 8 hr (no, it should be checked q 4 hours)
Initiate fall precautions for the client. Fall precautions should be initiated to prevent injury for the client with thrombocytopenia.
A nurse is caring for a newly-admitted client who is at 37 weeks of gestation and is experiencing moderate placental abruption. What should the nurse do? -strainer device on pts bedside toilet (no, pt should have a indwelling urinary catheter) - assess fetal condition once hourly (no, it should be continuous monitoring) - insert large-bore IV ( YES 16-18 gauge in brachial artery to replace fluid being lost) - vaginal exam to determine presence of bleeding (no pt should be placed on pelvic rest)
Insert a large-bore IV catheter. A 16-18 gauge IV catheter is to be inserted into the client's brachial artery because fluid volume and blood replacement might be necessary to correct defects in coagulation.
A nurse is assessing the fluid balance of a school-age child who has acute poststreptococcal glomerulonephritis and is experiencing inflammation. What is the nurse's priority?
Maintain a strict record of the child's daily weight. - this is the priority to determine fluid balance and inflammation level Also: - do daily I&O's, - BP q 4-6 hrs to identify acute HTN - monitor BUN/Creatinine regularly. But, daily wt is FIRST priority!!
A nurse is caring for a client who is experiencing hypovolemic shock due to postpartum hemorrhage. What actions should the nurse take immediately? -massage the clients fundus (to expel clots & promote contractions) - insert indwelling urinary catheter (catheter should be place but this is not the priority action) -elevate clients right hip on a pillow (should do this but its not priority action) - admin o2 via nonrebreather facemask @ 10L/min (should do this but not priority action)
Massage the client's fundus The greatest risk to the client is hemorrhage. Massaging the client's fundus expels clots and promotes contractions. Nurse should also: - insert catheter - elevate pt right hip on pillow - admin O2 via nonrebreather face mask @ 10 L/min BUT #1 priority = massage fundus
A nurse is assessing a client who has post traumatic stress disorder. What manifestation should the nurse expect? - unable to dream at night since the event (no, pt has distressing dreams r/t traumatic event that reoccur on a regular basis) - regularly spending time where the event occurred (no, pt with PTSD avoids places that bring back memories of traumatic event) - memory loss r/t event (YES) - passive behavior since event (no, pt with PTSD will exhibit irritability and aggression toward others)
Memory Loss related to the event. A client who has PTSD has recurrent distressing memories of the traumatic event but is often unable to remember details associated with the event, also known as dissociative amnesia. Pt may have distressing dreams, avoid places that remind them of the event, and exhibit irritability & aggression toward others
A nurse is caring for a client who is in active labor and who has a history of sexually transmitted infections. Upon examination, the nurse notes a large, cauliflower-like cluster of lesions near the vagina. What should the nurse do? - prepare pt for csection (no, not recommended for HPV) - initiate contact precautions (no noot required w HPV) - monitor for progressive fetal descent (lesions can become big enough to obstruct birth canal) - admin penicillin to decrease size of lesions (no, cryotherapy is recommended)
Monitor the client for progressive fetal descent. HPV lesions can become large enough to obstruct the birth canal and impair fetal descent.
A nurse is caring for a client who is experiencing preterm labor and is receiving betamethasone. Which of the following actions should the nurse take? - assess the client's DTR's (no, you want to assess DTRs for mag sulfate) - monitor client's HR (no, you want to monitor HR w beta-adrenergic agonist) - monitor client blood glucose lvl (YES, bc it can cause hyperglycemia) - assess the client for signs of pulmonary edema (no, you want to assess for pulm edema w/ beta-adrenergic agonist)
Monitor the client's blood glucose level bc it can cause hyperglycemia. Also monitor the client's WBC count and body movements of the fetus
A nurse is caring for a newborn who has a congenital heart defect and is postoperative following a cardiac catheterization. What action should the nurse take? - admin IV lactacted ringers (no, admin an IVF that contains dextrose bc newborns are at risk for hypoglycemia) - assess VS q 30 min (no, done as often as q 15 min, auscultate heart for one FULL minute to detect bradycardia or dysrhythmias) - remove pressure dressing 2 hr after procedure (no, remove the day after) - monitor color of affected extremity (YES, assess color/temp bc blanching/coolness can indicate arterial obstruction.)
Monitor the color of the affected extremity. Blanching or coolness can indicate an arterial obstruction. Additionally, the nurse should also palpate the pulses with special attention to pulses below the catheterization site. The nurse should palpate for symmetry and equality.
A nurse is discussing palliative care with the family of a client who is terminally ill. Which of the following information should the nurse include? - palliative care begins once lifesaving tx have stopped (no this would be hospice) - palliative care includes a variety of therapies (therapies include yoga, meditation, & pet therapy to improve quality of life) - palliative care requires a DNR (no, not required) - palliative care must be in the home setting (no, both home AND inpatient)
Palliative care includes a variety of therapies. Palliative care includes a holistic approach using a variety of therapies to improve the client's level of comfort. Therapies include: yoga, meditation, and pet therapy to enhance pt's quality of life
A nurse is planning care for a client who has a benign chondroma of the tibia. Which of the following interventions should the nurse plan to include? -remind client of non-weight-bearing status (no, this is required in pts who have bonegrafting for primary/cancerous tumors) -palpate for changes in muscle of affected extremity (YES, palpate to monitor for changes that might indicate enlargement of the tumor) - prepare for needle biopsy (no, this is not needed for benign tumors) -teach about pain management w. raiation therapy (no, pain management is required for pts who have a malignant tumor. BENIGN tumors are managed w analgesics & heat/cold therapy)
Palpate for changes in the muscle of the affected extremity. The nurse should palpate to monitor for changes such as muscle spasm, atrophy, or swelling. These manifestations indicate enlargement of the tumor.
A nurse in a provider's office is assessing a 2-month-old infant. Which of the following findings indicates the infant has a congenital heart defect? - bounding femoral pulses (no, pt will have weak pulses - parent reports frequent nosebleeds (no epistaxis (nosebleeds) indicates hemophilia) - parent reports resp distress while eating (YES) - sunken anterior fontanel (no, this indicates acute dehydration)
Parent reports respiratory distress while eating - manifestations include feeding difficulties and tachypnea also: pt with CHD will have weak pulses
A nurse is assessing a client who has lung cancer. Which of the following manifestations should the nurse expect? - clear sputum (no, they will have blood-streaked or rust colored sputum) - flank pain (no, they will have shoulder, arm, or chest pain) - weight gain (no, they will have weight loss) - persistent cough (YES)
Persistent cough A client who has lung cancer will have a persistent cough/any change in the pattern of their coughing, such as increased frequency, longer duration, or producing more sputum Pt will also have wt loss, bloody/rust-colored sputum, & shoulder/arm/chest pain
A nurse is caring for an infant who has Tetralogy of Fallot. The nurse notes that the infant exhibits a sudden onset of cyanosis and is hyperpneic. What action should the nurse take?
Place the infant in a knee-chest position. This maximizes the oxygenation status of the infant during hypercyanotic episodes (Remember this was a test question you got wrong bc hyde said to calm infant then do knee chest position)
A nurse is creating a plan of care for a newborn who has a myelomeningocele. Which of the following interventions should the nurse include? - place newborn in prone-kneeling position (YES, to protect sac from injury) - cover sac with dry nonadherent dressing (no should be sterile, moist, nonadherent) - wear latex gloves when caring for newborn (no, avoid latex bc of risk of allergy) - clean sac w 0.9% sodium chloride-soaked gauze (NO, RN should avoid contact w sac bc it can rupture, release CSF, and providing entry for infection)
Place the newborn in a prone-kneeling position. This position protects the protruding meningeal sac from injury.
A nurse on an acute care unit is caring for a newly admitted client who has bipolar disorder. What action should the nurse take?
Prepare the client for hemodialysis The client's vomiting and diarrhea caused sodium loss, which places the client at risk for lithium toxicity. The client's current lithium level (2.6) indicates severe toxicity, which places the client at risk for death. Hemodialysis promotes removal of lithium and is indicated as a treatment for lithium toxicity for lithium levels greater than 2.5
A nurse is caring for a client following a stroke. What action should the nurse take? - report client's BP (139/88)(no, you would report BP over 180 systolic - Dr may prescribe anti-HTN meds for this pt) - recommend a referral to the speech pathologist (YES) - request an additional dose of digoxin from pt's provider (no, shouldnt request another dose unless the pt's HR is over 100/min) - initiate oxygen at 2 L/min via nasal cannula for pt (NO, bc O2 sat should be less than 93% before starting O2 therapy)
Recommend a referral to the speech language pathologist (SLP). The client is experiencing difficulty swallowing following his stroke. Aspiration can be a complication for this client who is experiencing dysphagia. The SLP needs to evaluate the client and modify the client's diet (thickened liquids and head positioning to prevent aspiration)
A school nurse is observing a preschooler who has autism spectrum disorder. Which of the following behavioral characteristics should the nurse expect the child to exhibit?
Ritualistic A child who has ASD may demonstrate compulsive ritualistic or repetitive movements. (hand-clapping, banging/hitting head) child w/ ASD: has difficulty with social relationships, insists on repetition and is inflexible regarding routines
A nurse is assessing a client who has acute glomerulonephritis. Which finding should the nurse expect? - wt loss (no, they will have wt gain from retaining sodium & fluid resulting in wt gain, fluid overload, & circulatory congestion) - rust-colored urine (YES, hematuria causes color) - tachypnea (no, this occurs in acute pyelonephritis which is a bacterial infection in renal pelvis and kidneys) - nocturia (no, this occurs in acute pyelonephritis)
Rust-colored urine This disease process is a result of damage to the glomeruli, and the client will develop hematuria as a result of the microscopic blood in the urine. The RBC's in urine will cause the color of the urine to change. (reddish brown, rust-colored, cola-colered)
A nurse is planning medication teaching for a client who has erectile dysfunction. Which of the following medications should the nurse plan to include in the teaching? - hydrochlorothiazide (no, thiazide diuretic to tx HTN) - finasteride (no, 5-alpha reductase inhibitor medication to tx benign prostatic hypertropy, & alopecia) - sildenafil (YES, PDE5 inhibitor oral first-line tx for ED) - carbidopa/levodopa (no, dopaminergic to tx Parkinson's)
Sildenafil Sildenafil is a PDES inhibitor, which is prescribed as an oral first-line treatment for erectile dysfunction
A nurse in a pediatric unit is assessing a preschooler who has autism spectrum disorder. What findings should the nurse expect? - spends long periods of time staring at spinning objects (YES) - becomes easily upset when the parent leaves the room (no, they become upset when they are the sole focus of parents' attention, parent should bring fav possessions from home in order to decrease anxiety of hospitalization) - primarily plays with imaginary friends (no, they are more focused on solitary activities & excel in areas such as math, art, music, & puzzle building) - enjoys being held & cuddled by strangers (no, they require decreased stimulation & physical contact often upsets them. they may have outbursts if they experience too much eye contact or physical contact)
Spends long periods of time staring at spinning objects. The nurse should expect the client to display unusual stereotypes and repetitive behavior patterns such as spending extended time periods staring at spinning objects, rocking, flapping hands, and head nodding They also become upset when they are the sole focus of parents attention, and physical contact upsets them
A nurse in an acute care mental health unit is caring for a newly admitted client who has obsessive-compulsive disorder. The client is repeatedly washing her hands. Which of the following actions should the nurse take?
Teach the client to use thought-stopping techniques. Thought-stopping, where the client is taught to stop herself from performing compulsions, can interrupt impulsive actions. Other activities that accomplish this include the physical activity and relaxation techniques Do not physically prevent pt from doing it, provide a structured schedule of activities to prevent anxiety. Meds used for OCD include anxiolytics and SSRI antidepressants
A nurse is assessing a newly admitted client who has borderline personality disorder. Which of the following manifestations should the nurse expect? - client needs others to be responsible for decisions ab his life (no, a pt w BPD uses splitting to admire others & reject them) - pt has a sense of self-importance & requires admiration (no, this is narcissitic personality disorder. a pt w BPD is freq. depressed and has a disturbed self-image) - pt exhibits pattern of unstable interpersonal relationships (YES, pt w BPD has trouble being alone & needs companionship even though his friendships are unstable) - pt is preoccupied w following rules/being organized (no, this is OCD. a pt w BPD is impulsive and acts without thinking of consequence)
The client exhibits a pattern of unstable interpersonal relationships. A client with BPD has difficulty being alone and requires companionship, even though their friendships are unstable and the client often displays anger and anxiety around others.
A nurse is assessing a young adult client for behaviors that indicate addiction. What characteristic should the nurse recognize as potentially indicating addictive behavior? - client exhibits histrionic personality traits (no, they would have antisocial personality traits) - client has decreased self-image (YES) - client has a proactive attitude toward life (no they would have a passive attitude) - the client exhibits manic behavior (NO, they would have anxiety, depression, or a hx of depressive episodes)
The client has a decreased self-image (this is common in pts who develop addictive behaviors) Other common behaviors: - anxiety, depression, hx of depressive episodes, being anti-social, and having a passive attitude
A nurse is assessing a client who is in the early stages of Alzheimer's disease. Which of the following findings should the nurse expect? - pt cant recall year (no, this is a later stage) - pt has a more aggressive personality (no, this is a later stage) - client misplaces familar objects (YES, expected for pt to display forgetfulness & forget location of familiar objects in EARLY stages) - client unable to manage personal finances (no this is in later stage)
The client misplaces familiar objects The nurse should expect the client to display forgetfulness and forget the location of familiar objects in the earlier stages.
A community health nurse is assessing an older adult client. Which of the following situations should the nurse identify as a possible indication of undue influence? - client stays w her son one night a week (no, a pt who is exhibiting indications of undue influence isnt allowed to be left alone or function independently) - clients niece moves into her home to provide care (YES. client is at risk, abuser has access/control to pt at all times making it easier to influence pt's decisions) - client rarely signs legal documents regarding her care (NO, bc a pt showing indications of undue influence suddenly begins to sign documents frequently regarding care, property, & finances) - client has increased her attendance at family gatherings (no, pt would become suspicious of friends/family due to abuser's influence and begin to avoid family gatherings)
The client's niece moves into her home to provide care. Undue influence can occur when an older adult moves into someone's home, or when someone moves into their home to provide better care for the client. This allows the abuser to have access and control to the client at all times, and makes it easier for the abuser to influence the client's decisions about medical care, property, and finances.
A nurse is assessing a client who has inflammatory bowel disease and is 1 day postoperative following a permanent ileostomy placement. What finding should the nurse report to the provider?
The stoma is retracted into the abdominal wall. - The stoma should not be prolapsed or retracted into the abdominal wall. It should not be pale, bluish, or dark in color. Expected findings: Output should be loose & dark green Stoma should be cherry red in color Ostomy output will have small amounts of blood
A nurse is reviewing the labs for a client who has acute pancreatitis. Which of the following laboratory results should the nurse expect? - amylase 200 units/L (no, this is WNL. it would be increased in acute pancreatitis) - Lipase 150 units/L (no, this is WNL and would be elevated in acute pancreatitis) - fasting blood glucose 100mg/L (no, this is WNL. would be increased in acute pancreatitis) - WBC of 21,000 (YES, this is elevated . normal range is 4,500-11,000)
WBC count 21,000/mm^3 - nurse should expect to find elevated WBC (leukocyte) count in a client who has a cute pancreatitis due to acute inflammation.
adverse effect of furosemide
increased UOP
pt receiving beta-adrenergic agonist:
monitor HR and assess for indications of pulmonary edema
National Organ Transplant Act
protects donor's estate from liabilty for any damage or injury that occurs as a result of the use of donated organs
