BSN366 EXIT HESI
NGN: a client is a 42 year old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place in a surgical dressing that will need to be changed by the surgeon on postop day. (for each statement, click to indicate whether the statements by the student nurse indicates understanding or no understanding of naloxone.) -"If the first dose does not work you can give as many doses as needed to reverse respiratory depression." -"Naloxone works best on pure agonist opioids." -"Naloxone will not affect the clients level of pain." -"You can give naloxone IV, IM or subcutaneously." -"When given IV in the lock zone starts working immediately and can last several hours."
-"If the first dose does not work you can give as many doses as needed to reverse respiratory depression." (UNDERSTANDING) -"Naloxone works best on pure agonist opioids." (UNDERSTANDING) -"Naloxone will not affect the clients level of pain." (NOT UNDERSTANDING) -"You can give naloxone IV, IM or subcutaneously." (UNDERSTANDING) -"When given IV in the lock zone starts working immediately and can last several hours." (NOT UNDERSTANDING) ???????????
NGN: Orders: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start a PIV, start oxygen 3L via nasal cannula, normal saline 150 ML per hour, acetaminophen 350mg PO every six hours for temp greater than 101F, chest x-ray. 0500: Oxygen 8Lvia simple facemask, titrate to keep oxygen saturation greater than 94%. (mark whether the statements by the new grad nurse indicate understanding or no understanding of the use of facemask in the care of this client) -I should clean the facemask once per shift. -The client should take a 1 to 2 minute break from the facemask each hour. -I should put gauze under the elastic straps over the ears. -I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation greater than 94%. -The mask should cover only the mouth and leave the nose open for expiration. -I should place the mask first...
-I should clean the facemask once per shift. (UNDERSTANDING) -The client should take a 1 to 2 minute break from the facemask each hour. (NOT UNDERSTANDING) -I should put gauze under the elastic straps over the ears. (NOT UNDERSTANDING ????) -I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation greater than 94%. (UNDERSTANDING) -The mask should cover only the mouth and leave the nose open for expiration. (NOT UNDERSTANDING) -I should place the mask first... (UNDERSTANDING) ???????
NGN: client was brought in for his five-year-old well visit and to update vaccines. The mother reports that the child is having some trouble paying attention in school and has had a poor appetite in the past few weeks. (Each row must have at least one, but may have more than one response option. Determine what is not included and included to manage lead poisoning level of 7.) -Monitor H&H for potential anemia. -Monitor blood lead levels at one month, then every 3 to 4 months. -Chelation therapy. -Provide family with lead education, regular developmental and behavioral surveillance, and social service referral if necessary. -Ask Parents about the age of their home and any home remedies that may have been taken. -Providing supplemental oxygen. -Monitor urine glucose and protein for renal effects of lead.
-Monitor H&H for potential anemia. (NOT INCLUDED) -Monitor blood lead levels at one month, then every 3 to 4 months. (INCLUDE) -Chelation therapy. (NOT INCLUDED) -Provide family with lead education, regular developmental and behavioral surveillance, and social service referral if necessary. (INCLUDE) -Ask Parents about the age of their home and any home remedies that may have been taken. (INCLUDE) -Providing supplemental oxygen. (INCLUDE) -Monitor urine glucose and protein for renal effects of lead. (NOT INCLUDED) ??????
NGN: the client is a 26 year-old female who was in a car accident six months ago that killed her mother, husband, and two-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression. (which findings are effective or ineffective) -The client states she feels less jumpy and more relaxed. -The client states she feels numb when thinking about the crash. -The client talks to her father and her best friend when she starts to feel sad. -The client reports sleeping 6 to 7 hours per night. -The client states that she avoids driving altogether and takes the bus.
-The client states she feels less jumpy and more relaxed. (EFFECTIVE) -The client states she feels numb when thinking about the crash. (INEFFECTIVE) -The client talks to her father and her best friend when she starts to feel sad. (EFFECTIVE) -The client reports sleeping 6 to 7 hours per night. (EFFECTIVE) -The client states that she avoids driving altogether and takes the bus. (INEFFECTIVE)
The nurse is preparing a dose of 60mcg of teriparatide. The medication is labeled 750mcg/2.4 mL. How many milliliters should the nurse administer? (enter a numeric value only. If rounding is required, round to the nearest 10th)
0.2mL
A client who weighs 176 pounds receives a prescription for enoxaparin sodium 1.5mg/kg/day subcutaneously. The medication is available in 120mg/0.8mL prefilled syringe. How many milliliters should the nurse administer? Enter numerical value only.
0.8
A client receives a prescription for norepinephrine three MCG per minute IV. The IV bag contains norepinephrine 4 mg in dextrose 5% in water 1000 mL (D5W). How many milliliters per hour should the nurse program the infusion pump? (Enter numerical value only)
45
A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg IV every 12 hours. The vile is labeled 10 mg/mL. How many milliliters should the nurse administer? (Enter numeric value only)
4mL
NGN: the client has returned to work at an accounting firm and has started going to a grief support group. She states she is seeking care from a healthcare professional because her father is worried about her. The client states she only gets 2 to 3 hours of sleep due to nightmares about the crash. She states that exercising right after work helps her get better sleep and to relax. She feels that she is jumpy after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything... (highlight the areas that the nurse should....)
??????
NGN: 1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles soft, mongolian spot noted on lower back, Ballard maturity rating 37 weeks. (The day shift nurse reviews the nurses notes, labs, and flow sheet from the night before. The nurse plans on providing health teaching for the client and her family in preparation for discharge.) For each teaching point, click to indicate whether it is indicated or contraindicated. Only one right option per row. A) You will need to se
A) B) C) D) Indicated E) ?????????
I'm making rounds the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bedside table. The client is currently receiving oxygen at 2 L per minute via nasal cannula. The client is wheezing and is using pursed lip breathing. Which intervention should the nurse implement? A) Administer a nebulizer treatment. B) Call for an Ambu resuscitation bag. C) Increase oxygen to 6 L per minute. D) Assist the client to lie back in bed.
A) Administer a nebulizer treatment.
The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention? A) An 18-year-old client with antisocial behavior who is being yelled at by other clients. B) A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby. C) A 16-year-old client diagnosed with major depression who refuses to participate in a room. D) A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack
A) An 18-year-old client with antisocial behavior who is being yelled at by other clients.
After receiving report, the nurse can most safely plan to assess which client last? A) An adult client with no postoperative drainage in the Jackson Pratt drain with the bulb compressed. B) An older client with distended abdomen and no drainage from the nasogastric tube. C) An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. D) An adult client with a rectal tube draining clear, pale red liquid drainage.
A) An adult client with no postoperative drainage in the Jackson Pratt drain with the bulb compressed.
The nurse is planning care for a client who admits to having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on the suicidal thoughts? A) Begins to show signs of improvement in effect. B) Expresses feelings of sadness and loneliness. C) Neglects personal hygiene and has no appetite. D) Lacks interest in the activities of family and friends.
A) Begins to show signs of improvement in effect.
A male client is admitted for the removal of an internal fix ation device that was inserted for a fractured ankle. During the clients admission history, he tells the nurse that he recently received vancomycin for a methicillin-resistant staphylococcus aureus (MRSA) wound infection. Which actions should the nurse take? SATA. A) Collect multiple site screening cultures for MRSA. B) Place the client on contact transmission precautions. C) Call healthcare provider for a prescription of linezolid. D) Obtain a sputum specimen for culture and sensitivity. E) Continue to monitor the client for signs of an infection
A) Collect multiple site screening cultures for MRSA. B) Place the client on contact transmission precautions. E) Continue to monitor the client for signs of an infection
NGN: a client is a 42 year old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place in a surgical dressing that will need to be changed by the surgeon on postop day. (what other medication's would the nurse expect the surgeon to prescribe along with morphine? SATA) A) Docusate sodium B) Methadone C) Propofol D) Naloxone E) Senna F) Ibuprofen
A) Docusate sodium (for constipation) D) Naloxone (PRN for respiratory depression) F) Ibuprofen (help maintain breakthrough pain)
NGN: Orders Breast-feed immediately once stable then on demand. If unstable, may feed breastmilk via orogastric tube. If two feeding attempts failed to increase the glucose levels or if symptoms of hypoglycemia develop, apply dextrose gel inside the babies cheek. If the above are ineffective, IV glucose should be administered to maintain glucose levels above 45. Bolus of 2mL/kg glucose 10% IV, hello by a continuous glucose perfusion of 6 to 8mg/kg/min, maintain glycemic levels over 40. Which 6 orders take priority? A) Feed Immediately B) Monitor for respiratory distress C) Apply dextrose gell inside the baby's cheek D) Keep in warmer with bilirubin lights E) Monitor temp every 30 min F) Bolus 2 mL/kg glucose 10% IV G) Contact RT for ABG and oxygen therapy H) Echo I) Transfer to NICU J) Blood glucose level
A) Feed Immedicately B) Monitor for Respiratory Distress D) Keep in warmer with bili lights E) Monitor temp q30min G) Contact RT for ABG and O2 therapy J) Blood glucose level
NGN: ORDERS: diagnosis, depression, and posttraumatic stress disorder. Diphenhydramine 12.5 mg by mouth every night before bed. Buspirone hydrochloride 7.5 mg by mouth twice a day (What would be some effective strategies that the nurse could use to decrease the clients risk for suicide in the future?) A) Have the client sign a non-suicide contract. B) Refer the client for cognitive behavioral therapy. C) Make the client feel too guilty to commit suicide. D) Place the client in a locked unit. E) Have the client remove any sharp objects from the home. F) Help the client enlist the help of friends and family
A) Have the client sign a non-suicide contract. B) Refer the client for cognitive behavioral therapy. F) Help the client enlist the help of friends and family
An older client admitted for observation following a fall while getting out of the bathtub becomes increasingly confused. The family arrives with the home medication list and the clients healthcare power of attorney. When providing a report to the medical provider using SBAR communication, which information should the nurse provide first? A) Increasing confusion of the client. B) Clients health care power of attorney. C) Fall at home as a reason for admission. D) Currently prescribe medication's.
A) Increasing confusion of the client.
Actions should the school nurse implement to provide secondary prevention for school age children? A) Initiate a hearing and vision screening program for first graders. B) Prepare a presentation on how to prevent the spread of lice. C) Observe a person with type one diabetes self administer a dose of insulin. D) Collaborate with a science teacher to prepare a health lesson.
A) Initiate a hearing and vision screening program for first graders.
NGN Laboratory Results (same case of patient who just gave birth) Which actions are appropriate for the nurse to take at this time? SATA A) Keep infant in warmer with bili lights to maintain temp of 97.6F B) Monitor Temp C) Continue to monitor glucose level D) Tell the mother that she will need to discuss this with the neonatologist E) Explain to the mother that the babys RR needs to be below 60 F) Inform the mother that the baby is stable enought to take out of the warmer G) Observe for signs of respiratory distress and monitor O2 with pulse ox
A) Keep infant in warmer with bili lights to maintain temp of 97F E) Explain to the mother that the babys RR need to be below 60 F) Inform the mother that the baby is stable enough to take out of the warmer G) Observe for signs of respiratory distress and monitor oxygenation by pulse ox
A client who is hypotensive is receiving dopamine, an adrenergic agonist, ivy at the rate of 8mcg/kg/min. Which intervention should the nurse implement while administering this medication? A) Measure urinary output every hour. B) Initiate seizure precautions. C) Monitor serum potassium frequently. D) Assess pupillary response to light hourly.
A) Measure urinary output every hour.
Nurse is caring for a group of clients with the help of a practical nurse. Which nursing actions should the nurse assigned to the PN? SATA. A) Perform daily surgical dressing change for a client who had an abdominal hysterectomy. B) Administer a dose of insulin per sliding scale for a client with type two diabetes mellitus. C) Initiate patient-controlled analgesia (PCA) pumps for two clients immediately post operatively. D) Start the second blood transfusion for a client 12 hours following a below knee amputation. E) Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.
A) Perform daily surgical dressing change for a client who had an abdominal hysterectomy. B) Administer a dose of insulin per sliding scale for a client with type two diabetes mellitus. E) Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.
A male client admitted with chronic pulmonary obstruction disease exacerbation is receiving assisted ventilation with continuous positive airway pressure. His vital signs are temperature 98.8 F, heart rate 118 bpm, respirations 46 breaths per minute, blood pressure 176/92. While completing the pulmonary assessment, his oxygen saturation reading is 78% and he is difficult to arouse. Which action should the nurse implement? A) Prepare for rapid sequence intubation. B) Increase the oxygen delivery by 10%. C) Administer PRN nebulizer treatment. D) Complete neurological assessment.
A) Prepare for rapid sequence intubation.
NGN: a client is a 42 year old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place in a surgical dressing that will need to be changed by the surgeon on postop day. ORDERS: 1400 admit to the surgical floor. Clear liquid diet, advance as tolerated. Continuous cardio respiratory monitoring. Morphine 1 mg/h IV. Alert surgeon to signs of bleeding or infection in the surgical site. 1500 docusate sodium 240 mg orally every a.m. Naloxone 2 mg IV as needed for respiratory depression. Ibuprofen 600 mg orally every six hours. A) Provide rescue breaths with a manual ventilation bag. B) Call for rapid response. C) Apply oxygen via nasal cannula. D) Perform chest compressions. E) Print an electrocardio gram strip. F) Give naloxone 2 mg IV.
A) Provide rescue breaths with a manual ventilation bag. B) Call for rapid response. D) Perform chest compressions. F) Give naloxone 2 mg IV.
The nurse is preparing a 50 mL dose of 50% dextrose IV for a client with insulin shock. How should the nurse administer the medication? A) Push the undiluted dextrose slowly through the currently infusing IV. B) Dilute the dextrose in 1 L of 0.9% normal saline solution. C) Makes the dextrose in a 50 mL piggyback for a total volume of 100 mL. D) Ask the pharmacist to add the dextrose to a TPN solution.
A) Push the undiluted dextrose slowly through the currently infusing IV.
Client who is newly diagnosed with type two diabetes mellitus receives a prescription for metformin 500 MGPO twice daily. Which information should the nurse include in this clients teaching plan? SATA A) Report persistent polyuria to the healthcare provider B) you sliding scale insulin for fingerstick glucose elevations. C) Take met Forman with a morning and evening meal. D) Recognize signs and symptoms of hypoglycemia. E) Take an additional dose for signs of hyperglycemia.
A) Report persistent polyuria to the healthcare provider C) Take met Forman with a morning and evening meal. D) Recognize signs and symptoms of hypoglycemia.
A client with cirrhosis of the liver is admitted with complications related to end-stage liver disease. Which interventions should the nurse implement? SATA. A) Report serum albumin and globulin levels. B) Provide diet low in phosphorus. C) Increase oral fluid intake to 1500 mL daily. D) No signs of swelling and edema. E) Monitor abdominal girth.
A) Report serum albumin and globulin levels. D) No signs of swelling and edema. E) Monitor abdominal girth.
Which intervention is most important for the nurse to include in the plan of care for a client who is 12 hours post thyroidectomy? A) Resume anti-thyroid drug therapy. B) Prepare to administer radioactive iodine treatment. C) Anticipate and monitor for hypothermia. D) Maintain a semi fowler position.
A) Resume anti-thyroid drug therapy.
NGN: Nurses Notes: 0400, the client is awake and alert but restless. He states I am feeling extremely anxious right now. The client has decreased breath sounds in the left lower lobe. His mucus membranes are dry. He has a productive cough with thick, yellow secretions. His capillary refill is four seconds. Heart rate 101 BPM, oxygen saturation 90%. Blood pressure 145/89, temperature 100.2 F, respiratory rate 28 BPM. 0500: Placedthe client in semi-Fowlers position. No improvement in oxygen saturation on 3L nasal cannula... (are the three most important goals?) A) The client will remain free of skin breakdown. B) The client will have quit smoking. C) The client will be afebrile for 24 hours. D) The client will maintain oxygen saturation of 96% without supplemental oxygen. E) The client will report pain less than 3/10.
A) The client will remain free of skin breakdown. C) The client will be afebrile for 24 hours. D) The client will maintain oxygen saturation of 96% without supplemental oxygen. ???????
NGN: ORDERS: diagnosis, depression, and posttraumatic stress disorder. Diphenhydramine 12.5 mg by mouth every night before bed. Buspirone hydrochloride 7.5 mg by mouth twice a day (can the nurse build a therapeutic relationship with the client? SATA) A) The nurse can establish a meaningful connection. B) The nurse can be open, honest, and sincere. C) The nurse can communicate acceptance to the client as she is. D) The nurse can talk as much as needed to get the client talking. E) The nurse can focus energy on the client. F) The nurse can show no emotion when talking to the client.
A) The nurse can establish a meaningful connection. B) The nurse can be open, honest, and sincere. C) The nurse can communicate acceptance to the client as she is.
In caring for a client who is receiving linezolid for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider? A) Watery diarrhea. B) Increased fatigue. C) Yellow-tinged sputum. D) Nausea and headache.
A) Watery diarrhea.
A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client? A) What are the voices saying? B) Which medication works best? C) When do you hear voices? D) How do you cope with the voices?
A) What are the voices saying?
While caring for a toddler receiving oxygen via facemask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A) Use a water-soluble lubricant on affected oral and nasal mucosa. B) Use a topical lidocaine analgesic for cracked lips. C) Ask the mother what she usually uses on the child's lips and nose. D) Apply a petroleum jelly to the child's nose and lips.
A) use a water-soluble lubricant on affected oral and nasal mucosa
NGN: the client is a 74-year-old female with a history of hypertension and hyperlipidemia. She takes lisinopril, simvastatin, and melatonin for sleep. She was admitted today for pneumonia. She visited her primary care physician last week, and she has lost 2.8kg since that visit. (Complete the diagram by dragging from the choices below to specify one potential condition, to actions, and two parameters.)
ACTIONS: Measure blood pressure. Ask the client for a nutrition history. CONDITION: Dehydration. PARAMETERS: Capillary refill. Blood glucose.
NGN: The client is a 42-year-old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place in the surgical dressing that will need to be changed by the surgeon on postop day. (Choose the most likely options for the information missing from the statement.) Morphine is a ______________ and it activates ________________ receptors and is used to relieve ______________.
Agonist-antagonist opioid , beta , pain?
An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? A) 9% B) 36% C) 18% D) 45%
B) 36%
When conducting an admission assessment, the nurse notes that an adult female client has developed new allergies since her last admission. The client describes herself as lactose intolerant and states that she is unable to eat eggs. Which intervention should the nurse implement? SATA. A) Ask the client to describe her reaction to milk and eggs. B) Add egg allergy to clients identification armband. C) Eliminate the chicken selections from the clients menu. D) Notify the dietary department of the clients egg intolerance. E) Enter new allergy information in the clients electronic medical record.
B) Add egg allergy to clients identification armband. D) Notify the dietary department of the clients egg intolerance. E) Enter new allergy information in the clients electronic medical record.
A nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the impaired nurse has asked nursing administration to allow return to work. When the nurse administrator approaches the charge nurse with the impaired nurses request, which action is best for the charge nurse to take? A) Meet with staff to assess their feelings about the impaired nurses return to the unit. B) Allow the impaired nurse to return to work and monitor medication administration. C) Ask to meet with the impaired nurses therapist before allowing the nurse to return back on the unit D) Since treatment is completed assigned the nurse to routine R responsibilities.
B) Allow the impaired nurse to return to work and monitor medication administration.
NGN: a client is a 42 year old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place in a surgical dressing that will need to be changed by the surgeon on postop day. (What actions should the nurse take to assure safety during morphine administration? SATA) A) Have a manual resuscitation bag at the bedside. B) Ask the client about other medication's she takes. C) Perform a 12 lead electro cardiogram. D) Take an initial respiratory rate. E) Suction the client to clear the airway. F) Restrain the client with soft restraints.
B) Ask the client about other medication's she takes. D) Take an initial respiratory rate. ??????
An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postbur infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8F, heart rate 108 bpm, and respirations 32 breaths/minute. Which action should the nurse implement first? A) Provide bedside equipment for transmission and protective precautions. B) Culture sputum urine burn wound, and all IV access sites. C) Implement central line-associated bloodstream infection (CLABSI) protocols. D) Evaluate daily serum electrolytes and hydration status. Starting to hurt Mario
B) Culture sputum urine burn wound, and all IV access sites.
A nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement made by the client should the nurse recognize as needing additional education? A) Keep a food diary. B) Eat more canned vegetables. C) Consume foods with saturated fat. D) Walk 30 minutes per day. E) Include oatmeal for breakfast. F) Use a salt substitute
B) Eat more canned vegetables. C) Consume foods with saturated fats.
The nurse is caring for a client on the first day post-operative for a descending aortic aneurysm repair. Which assessment finding should the nurse prioritize reporting to the healthcare provider? A) Serum potassium 4.8. B) Electrocardiogram ST segment elevation. C) Urine output 30 mils per hour. D) Blood pressure 130/80
B) Electrocardiogram ST segment elevation
The nurse is planning to teach infant care and preventative measures for student infant death syndrome to a group of new Parents. Which information is most important for the nurse to include? A) Prop the infant with a pillow when in a side-lying position. B) Ensure that the infant's crib mattress is firm. C) Place the infant in a prone position whenever possible. D) Swaddle the infant in a blanket for sleeping.
B) Ensure that the infant's crib mattress is firm.
Adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. Which action should the nurse take first? A) Report the findings to the police department. B) Explore client's readiness to discuss the situation. C) Determines the frequency and type of client abuse. D) Discussed treatment options for abusive partners.
B) Explore client's readiness to discuss the situation.
NGN: the client is a 49-year-old who reports flu like symptoms including fever and chest congestion for four days. He came to the emergency department last night when he was having more difficulty breathing. He has a history of 1/2 pack a day cigarette smoking for 20 years. He has no significant medical or surgical history. (Start the client on oxygen as ordered, what should the nurse collect from the supply room? SATA) A) Sterile water. B) Flow meter. C) Lambs wool. D) Suction canister. E) Humidifier bottle. F) Tape. G) Nasal cannula.
B) Flow meter. E) Humidifier bottle. G) Nasal cannula. ??????
The nurse is providing teaching to a client with type 2 DM about important points for disease and symptom management. Which statement by the client indicates understanding? A) Using salt, herbs, and spices will improve the flavor of foods B) Get an eye exam with an opthalmologist annually C) Arrange diet schedule around three regular meals a day D) Inspect feet every month for ingrown nails, cuts, and caluses
B) Get an eye exam with an opthalmologist annually
The daughter of an older woman who has Parkinson's disease, call the clinic and reports that her mother has been confused for the past week. Which actions should the nurse take? SATA. A) Encourage increased intake of high protein foods. B) Instructed the daughter to check her mothers temperature. C) Determine if the mother has recently experienced a fall. D) Ask if the mother is experiencing any pain with urination. E) Review the clients current food and medication allergies.
B) Instructed the daughter to check her mothers temperature. C) Determine if the mother has recently experienced a fall. D) Ask if the mother is experiencing any pain with urination.
Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium? A) Confront the clients denial of substance abuse. B) Maintain a quiet, non-stimulating environment. C) Force oral fluids and provide frequent small meals. D) Encourage attendance and group participation.
B) Maintain a quiet, non-stimulating environment.
Which assessment showed the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter? A) Assess the perineal area. B) Observe the insertion site. C) Palpate flank area. D) Measure abdominal girth.
B) Observe the insertion site.
The client is admitted to the hospital after experiencing a stroke or cerebrovascular accident. The nurse should request a referral for speech therapy if the client exhibits which finding? A) Inappropriate or exaggerated mood swings. B) Persistent coughing while drinking. C) Abdominal responses for cranial nerves I and II. D) Unilateral facial drooping.
B) Persistent coughing while drinking.
NGN: the client is a 49-year-old who reports flu like symptoms including fever and chest congestion for four days. He came to the emergency department last night when he was having more difficulty breathing. He has a history of 1/2 pack a day cigarette smoking for 20 years. He has no significant medical or surgical history. (What two orders should the nurse complete first?) A) Speedom culture. B) Place the client on cardiorespiratory monitor. C) Start a PIV. D) NPO. E) Acetaminophen 350mg PO q6h for temperature greater than 101F. F) Start oxygen 3L via nasal cannula. G) Chest x-ray. H) Normal saline 150 ML per hour.
B) Place the client on cardiorespiratory monitor. F) Start oxygen 3L via nasal cannula.
A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement? A) Rains HOB to 90 degrees B) Position bedside table so the client can lean across it C) Place bed in a reverse tren posiiton D) Encourage rest until the analgesic becomes effective.
B) Position bedside table so the client can lean across it
A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the IV line. The abdominal dressing is no longer inclusive, and the IV insertion site is pink. Which intervention should the nurse implement? A) Leave the lights on in the room at night. B) Re-dress the abdominal incision. C) Apply soft bilateral wrist restraints. D) Replace the IV site with a smaller gauge.
B) Re-dress the abdominal incision.
The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medication's through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention? A) Circumferential skin irritation. B) Red streak tracking the vein. C) Cool sensation above the site. D) A sluggish blood return.
B) Red streak tracking the vein.
Laboratory results should the nurse closely monitor in a client who has end-stage renal disease? A) Erythrocytes, hemoglobin, and hematocrit. B) Serum potassium, calcium, and phosphorus. C) Blood pressure, heart rate, and temperature. D) Leukocytes, neutrophils, and thyroxine.
B) Serum potassium, calcium, and phosphorus.
An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which interventions should the nurse include in the clients plan of care? SATA. A) Record the clients desire to live. B) Teach clients how to use guided imagery. C) Instruct client and family to reconsider end of life choices. D) Encourage family to bring the client old photographs. E) Encourage family to visit frequently.
B) Teach clients how to use guided imagery. D) Encourage family to bring the client old photographs. E) Encourage family to visit frequently.
A preschool age child who is being treated for streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the Streptococcus bacteria? A) Red bumps across chest. B) White coating on tongue. C) High, protracted fever. D) Flaky, peeling skin.
B) White coating on tongue.
An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? A) blood alcohol level of 0.09% (90 mmol/L) B) serum lithium level of 1.6 mEq/L C) six hours of sleep in the past three days. D) Weight loss of 10 pounds in the past month
B) serum lithium level of 1.6 mEq/L
The charge nurse is planning for the shift and has a RN and a PN on the team. Which client should the charge nurse assign to the RN? A) A 75-year old client with renal calculi who requires urine straining B) A 64-year old client who had a total hip replacement the preious day C) A 30-year old depresses client who admits to suicide ideation D) An adolescent with multiple contusions due to a fall that occurred 2 days ago
C) A 30-year old depresses client who admits to suicide ideation
A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet? A) Avoid eating of foods that contain any vitamin K because it is an antagonist of warfarin. B) Increase the intake of dark green leafy vegetables while taking warfarin. C) Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. D) Eat two servings of raw dark green leafy vegetables daily and continue for 30 days after warfarin therapy is completed.
C) Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.
A six week old infant with pyloric stenosis is scheduled for a pyloromyotomy which pre-operative nursing action has the highest priority? A) Instruct Parents regarding care of the incisional area. B) Mark and outline of the olive shaped mass in the right epigastric area. C) Initiate a continuous infusion of IV fluids per prescription. D) Monitor the amount of intake and infant's response to feedings.
C) Initiate a continuous infusion of IV fluids per prescription.
A client with cancer develops tumor lysis syndrome following chemotherapy. Which nursing action has the highest priority in responding to the symptoms of the syndrome? A) Instruct the client to take analgesics on a regular schedule. B) Encouraged the client to verbalize anxiety and grief. C) Maintain IV therapy. D) Identify potential sources of infection.
C) Maintain IV therapy.
An older adult client recently transferred to a rehabilitation facility after aortic valve replacement surgery is experiencing anxiety and difficulty adjusting to the transition to healthcare provider prescribes an antidepressant and a mild sedative for sleep. Which intervention is most important for the nurse to include in the clients plan of pet care? A) Measure and record the clients urinary output every day. B) Provide the client with teaching regarding a cardiac diet. C) Obtain a blood pressure reading before client gets out of bed. D) Obtain client vital signs every four hours one week.
C) Obtain a blood pressure reading before client gets out of bed.
The nurse is providing educations to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to informations about prescribed medications and administration, which instruction should the nurse include in the teaching? A) Center attention on positive upbeat music B) Find outlets for more social interaction C) Practice using muscle relaxation techniques D) Think about reasons the episodes occur
C) Practice using muscle relaxation techniques
An older adult client with a history of cataracts is recovering from intraocular lens implant surgery to the left eye. During the post-procedure., Which intervention should the nurse implement? A) Encourage deep breathing and coughing exercises. B) Obtain vital signs every two hours during hospitalization. C) Provide an eye shield to be worn while sleeping. D) Teach a family member to administer eyedrops.
C) Provide an eye shield to be worn while sleeping.
A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease and peripheral vascular disease is being discharged from the skilled nursing facility. Which action is most important for the nurse to implement? A) Explain exercise daily regimen. B) Demonstrate specific strengthening exercises. C) Provide typed instructions for healthy diet selection. D) Reinforce need for adequate hydration.
C) Provide typed instructions for healthy diet selection.
The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet? A) Roast pork, fresh strawberries. B) Baked potato with skin, raw carrots. C) Roasted turkey, canned vegetables. D) Pancakes, whole-grain cereals.
C) Roasted turkey, canned vegetables.
When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take? A) Explain to the client that the dosage has been changed. B) Tell him to take the medication and then verify the dosage at the next healthcare team meeting. C) Withhold the medication until the dosage can be confirmed. D) Inform him that he may refuse the medication and document whether or not he takes it.
C) Withhold the medication until the dosage can be confirmed.
NGN: a client is a 42 year old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place in a surgical dressing that will need to be changed by the surgeon on postop day. (what side effects of morphine could contribute to this client's fall risk?) A) urinary retention B) seizures C) orthostatic hypotension D) sedation E) nausea F) itching G) euphoria
C) orthostatic hypotension D) sedation E) nausea ????????
A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. Which action should the nurse take? A) tell the client to have someone bring him to an emergency department immediately. B) instruct the client to increase his intake of oral fluids until the skin flushing is relieved. C) reassure the client that skin flushing is a common side effect of the medication. D) advise the client to place one nitroglycerin tablet under his tongue as a precaution.
C) reassure the client that skin flushing is a common side effect of the medication.
The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions? A) Twin siblings admitted with scarlet fever that is complicated with pneumonia. B) An older adult with scabies who is admitted from an extended care facility. C) A female adolescent admitted with multiple genital herpes simplex I lesions. D) A client with a positive Mantha hooks and sputum cultures results positive for AFB.
D) A client with a positive Mantha hooks and sputum cultures results positive for AFB.
Which environmental factor is most significant when planning care for a client with osteomalacia? A) Cool, mist air. B) Stimulating sounds and activity. C) Quiet, calm surroundings. D) Adequate sunlight.
D) Adequate sunlight.
Client is unable to void following a procedure, so the nurse obtains a prescription to perform a street Catherine is ation. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next? A) Remove the catheter and palpate the clients bladder for residual distention. B) Clamp the catheter for 30 minutes and then resume training. C) Remove the catheter and replace it with an indwelling catheter. D) Allow the bladder to empty completely or up to 1000 mL of urine.
D) Allow the bladder to empty completely or up to 1000 mL of urine.
What nursing intervention is particularly indicated for the second stage of labor? A) Assessing the fetal heart rate and pattern for signs of fetal distress. B) Monitoring effects of oxytocin administration to help achieve cervical dilation. C) Providing pain medication to increase the clients tolerance of labor pains. D) Assisting the client to push effectively so that expulsion of the fetus can be achieved.
D) Assisting the client to push effectively so that expulsion of the fetus can be achieved.
When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three finger breaths above the umbilicus. What action should the nurse implement first? A) Increase IV infusion. B) Massage the uterus to decrease attorney. C) Review the hemoglobin to determine hemorrhage. D)Check for a distended bladder.
D) Check for a distended bladder
The parents of a six year old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming lessons. How should the nurse respond? A) Suggest that the child be encouraged to participate in a team sport to encourage socialization. B) Explain that their child is too young to understand the risks associated with swimming. C) Provide a list of alternative activities that are less likely to cause the child to experience fatigue. D) Encourage the parents to allow the child to continue attending swimming lessons with supervision.
D) Encourage the parents to allow the child to continue attending swimming lessons with supervision.
A 46 year old male client who had a myocardial infarction 24 hours ago comes to the nurses station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care? A) Anxiety related to treatment plan. B) Decisional conflict due to stress. C) Deficient knowledge of lifestyle changes. D) Ineffective coping related to denial.
D) Ineffective coping related to denial.
A client is receiving lactulose for signs of hepatic and cephalopathy. To evaluate the clients therapeutic response to this medication, which assessment should the nurse obtain? A) Blood glucose level. B) Percussion of abdomen. C) Serum electrolytes. D) Level of consciousness.
D) Level of consciousness.
The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet? A) Fresh fruits and vegetables. B) Iron-rich meats. C) Water and herbal teas. D) Low-fat dairy products.
D) Low-fat dairy products.
The nurse is caring for a client with a fractured femur following removal of traction and the application of a full leg cast, which action should the nurse prioritize? A) Leg elevation. B) Pain management. C) Ambulation teaching. D) Neurovascular checks.
D) Neurovascular checks.
I am days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client may have had a blue Menary embolus. Which action should the nurse take first? A) Bring the emergency crash cart to the bedside. B) Prepare a continuous heparin infusion per protocol. C) Notify the healthcare provider. D) Provide supplemental oxygen.
D) Provide supplemental oxygen.
The nurse is caring for a client with the sexually transmitted infection syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide? A) Inform that follow up may end after the treatment is finished. B) Emphasize that using safe sex practices removes the risk of STI's. C) Clarify that all STI's are transmitted through sexual intercourse. D) Remain nonjudgmental and assure the client of confidentiality.
D) Remain nonjudgmental and assure the client of confidentiality.
The nurse observes an unlicensed assistive personnel applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take? A) Instruct the UP to return to the clients room to perform handwashing. B) Advise the UP to wear gloves when obtaining vital signs for all clients. C) Supervise the UP in the next clients room to evaluate hand hygiene. D) Remind the UAP to continue rubbing their hands together until they are dry.
D) Remind the UAP to continue rubbing their hands together until they are dry.
The nurse is preparing a four day old infant with a serum bilirubin level of 19 for discharge from the hospital. When teaching the parents about home photo therapy, which instruction should the nurse include in the discharge teaching plan? A) Cover with a receiving blanket. B) Perform diaper changes under the light. C) Feed the infant every four hours. D) Reposition the infant every two hours.
D) Reposition the infant every two hours.
A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel donning gloves and a gown to assist the client. Which action should the nurse take? A) Remind the UP to apply a fitted respirator mask before entering the clients room. B) Assign the UP to provide care for another client and assume full care of the client. C) Instruct the UP to notify the nurse of any changes in the clients respiratory status. D) Review the need for the UPA to wear a facemask while in close contact with the client
D) Review the need for the UPA to wear a facemask while in close contact with the client
The nurse is caring for a client who arrives to the ED with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes R-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action? A) Maintain elevated positioning of the dependent joints on the affected side. B) Keep the bed in the lowest position and initiate seizure and fall precautions C) Place an indwelling urinary catheter and measure strict I/Os D) Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
D) Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy
A client with a prescription for do not resuscitate begins to manifest signs of impending death. After notifying the family of the client status, what priority action should the nurse implement? A) The nurse manager should be updated on the client status. B) The client status should be conveyed to the chaplain. C) The impending signs of death should be documented. D) The clients need for pain medication should be determined.
D) The clients need for pain medication should be determined.
A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic colonic seizure that last 50 seconds. Following the seizure, the client is lethargic and confused, and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take? A) ask the wife to wait outside the room until the nurse can talk with her. B) keep orienting the client the client to time in space until he is less confused C) notify the emergency response team of the client's seizure D) explain the postictal state that usually follows seizures
D) explain the postical state that usually follows seizures
NGN: (Nurses Notes) 1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles soft, mongolian spot noted on lower back, Ballard maturity rating 37 weeks. (For each assessment finding, click to indicate whether the findings are associated with an infant of a diabetic mother or normal presentation.) Soft Fontanelles Blood Glucose 35 Axillary temp. 96F Acrocyanosis Ballard score maturity rating 37
Diabetic Findings: BG 35 Axillary temp 96 Ballard score maturity rating 37 ??????? Normal Presentation: Soft Fontanelles Acrocyanosis (normal findings include acrocyanosis, soft fontanelles, mongolian spots, and Apgar scores 7 to 10)
NGN: 1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles soft, mongolian spot noted on lower back, Ballard maturity rating 37 weeks. (Click to highlight notes that demonstrate a positive outcome) Day 2, 0630: Vitals have remained stable throughout the night. Oxygen 98% on nasal canal. Mother to breastfeed in the nursery on demand. Able to tolerate breastmilk. Glucose after feeding was 60, temp 97.8F, when returned to warmer and bili light. CXR and echo results were
Glucose after feeding was 60 Direct bili 5 Temp 97.8 Oxygen 98% Able to tolerate breastmilk ??????????
NGN: (Nurses Notes) 1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles soft, mongolian spot noted on lower back, Ballard maturity rating 37 weeks. The nurse recognizes that the infant of a diabetic mother is at risk for _________ , _____________ , and _________________
Hyperbilirubinemia , Resppiratory Distress Syndrome , and Cardiomyopathy
An unlicensed assistive personnel leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UP's behavior? (Please to actions in order from first on top to last on bottom) Discuss the issue privately with the UAP Plan for scheduled break times Evaluate the UP for signs of improvement Note date and time of the behavior
Note date and time of the behavior. Discuss the issue privately with a UAP. Plan for scheduled break times. Evaluate the UPC for signs of improvement.
NGN: the client is a 26 year-old female who was in a car accident six months ago that killed her mother, husband, and two-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression. The client is exhibiting symptoms of __________ related to _____________ and __________
Post-traumatic stress disorder , experiencing a life-threatening event , losing a loved one
NGN: Nurses Notes: 0400, the client is awake and alert but restless. He states I am feeling extremely anxious right now. The client has decreased breath sounds in the left lower lobe. His mucus membranes are dry. He has a productive cough with thick, yellow secretions. His capillary refill is four seconds. Heart rate 101 BPM, oxygen saturation 90%. Blood pressure 145/89, temperature 100.2 F, respiratory rate 28 BPM. (for each body system click to specify the assessment findings that indicates hypoxia) Respiratory: respiratory rate 28 BPM, productive cough, oxygen saturation 90% Cardiovascular: heart rate 101 BPM, BP 145/89, capillary refill for seconds
Respiratory: respiratory rate 28 BPM, oxygen saturation 90% Cardiovascular: capillary refill for seconds ???????
NGN: the client is a 49-year-old who reports flu like symptoms including fever and chest congestion for four days. He came to the emergency department last night when he was having more difficulty breathing. He has a history of 1/2 pack a day cigarette smoking for 20 years. He has no significant medical or surgical history. Nurse should place the client in a __________________ position to promote _________
Semi Fowlers , lung expansion
NGN: the client is a 26 year-old female who was in a car accident six months ago that killed her mother, husband, and two-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression. (Who is the most likely options for the information missing from the statement by selecting from the list of options provided.) The statement by the client presents _______________ and should be followed up with _____________.
Suicidal ideation, assessment of respecters for suicide.
