Comp 1, Comp 8, Comp 7, Comp 6, Comp 5, Comp 4, Comp 3, Comp 2
Diverticulosis
High fiber diet
Peritonitis-
N/V
Patient on met Forman going for CT
Notify HCP
Patient scheduled for CT has creatinine of 1.8
Notify HCP
No honey before
1year old
Emergent
See now (lung collapse, MI)
Dysphasia follow up wrong answer
Tuck chin when swalllowing
PUD
Type and cross
Send home during mass disaster
Ulcerative colitis taking prednisone
DI
Urine goes from 500 to 125ml
Sanguineous to serosanguinours drainage =
Wound healing
Lateral violence
Wrong answer sexual
Domestic violence (neg stem)
Abusers have low self-stem and think of themselves as not important
A nurse working on a medical surgical unit has just received a hand off report on the following clients, the nurse should first plan to assess the client who has:
Acute pancreatitis and is reporting the development of pain on deep inspiration Rationale - acute could burst (septic)
Patient to see first
Acute pancreatitis with onset of pain
The primary health care provider has prescribed ampicillin 150 mg 3 times a day to a doodler the weighs 22lbs the drug available is ampicillin suspension that is 250mg/5ml. Which action should the nurse take
Administer 3ml (do the math)
The nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with severity of 6 out of 10. The nuse administers 1 sublingual nitroglycerin tablet, after 5 minutes the client states the pain is a severity level of 3 which of the following actions should the nurse be prepared to do next?
Administer another nitro sublingual tablet
Alcohol withdrawal and hard to arouse
Administer flumazenil
The nurse is caring for a client who has developed hypovolemic shock and has a heart rate of 160BPM and is receiving oxygen @ 2L via nasal cannula, which of the following actions would be a priority for the nurse to perform?
Administer the prescribed NS @150ml/hr
The nurse is caring for a 4yr old child at an outpatient clinic. The client is being seen for an excellent checkup after beginning amoxicillin 3 days prior for otitis media. The primary prescribes the following vaccinations varicella, MMR, deactivated polio & Dtap for the client which of the following actions by the nurse would be correct
Administer the vaccines as prescribed
Phototherapy
Adverse affect is gray baby
Incident reports
Adverse reaction to I medication is an insider t report: patient with phlebitis while on antibiotics
Furosemide
Adverse reaction to watch for tinnitus
Colonoscopy
Age 50, the Q 10yr, prostate Q1yrs with digital exam
Here's zoster
Airborne
Disseminated Zoster
Airborne precautions
Correctly charted in progress notes
Ambulated to the door without assistance
TBI
BP increases, high BP (autonomic dysreflexia)
DM
BS less than 100 patient should not be exercising Teach them to eat a carb snack before exercising
Which is concerning
Baby that has tripled weight @ 6months
Interdisciplinary
Baby withdrawing w/ rhinorrhea, hyperreflexia, and mother on drugs
Chest tube
Bad if drainage is >100ml
Cefriaxone
Be cautions when someone has severe PCN allergy
Lithium
Be sure to stay hydrated
Rinse mouth-asthma steroid med
Beclomethasone
Follow up or see fist
Bleeding gums with phenytoin or metoprolol prescribed for patient with HR 60
What to report to MD
Bloody ruptured membranes
Dig toxicity
Blurred vision and anorexia
Clononscopy
Bowel prep
Secondary prevention
Breast exam
Thoracentesis
Breath sounds (RR)
A nurse caring for a patient who had hypothyroidism which would the nurse expect to assess
Brittle nails Dry skin Menorrhagia (abnormal heavy bleeding when menstruating)
Cancer patient diet
Broil chicken and cottage cheese ( do not choose toast)
Lateral violence means
Bulling where other person gets offended
Only MD can remove
Chest tube
Chemo diet
Chicken, green beans, cottage cheese
Abnormal vital signs
Child with HR 160 and walking in hallway
Barium enema-
Clay colored stool
Patient with anxiety
Clear and simple sentences
Spontaneous birth
Clear nasopharyngeal
Peritoneal dialysis
Cloudy = infection
Discard used needles in
Coffee can or glass jar
Who to see first
Colonoscopy w/BP change, "I can't take this anymore", 2yr old 68 HR while playing w/ toys, burn 75%or CP, creatinine 2.7
5 yr old child
Coloring book( do not choose bike)
Dusky and dry call MD
Colostomy
Dying kid
Comfortable measures
GI bleed w/ black tarry stool
Common cause H. Pylori ulcer w/ GI bleeding
Left side CVA
Communication
Medication wasting
Complete with another nurse and waste first before giving
Urgent
Compound fracture with +1 edema or 30% burns to body (burns)
Which patient sent to hospital in disaster
Compound fracture with chest pain.
The nurse is assessing the client who has a suspected retinal detachment of the left eye which of the following client statements would be consistent with this diagnosis?
I see floating dark spots in my left eye
The nurse is caring for a pregnant client whose last menstrual period began on October 21st using the naegel's rule which of he following dates would be the due date?
July 28
Due date ( and 7 days and subtract 3 months )
July 28th
Priority patient with
K+ 2.4
Photo of cardiac strip
K+ is the answer
No ace inhibitors with
K+ sparing diuretics
Which prescribed medication should be given first
K+ to patient with low K+
Fidelity
Keep commitments
Internal radiation
Keep lead lined box, supplies, or lead apron in room
Which patient to discharge
Kid tonsillectomy 18hours ago
Metabolic alkalosis
Know ABGs
MOM W.FHR 180
LAY ON LEFT SIDE (NORMAL FHR 110-160)
Further teaching for fiscally responsibility
Letting family help (not a part of fiscally responsibility )
Ulcerative colitis
Liquid bloody stool 10-20 days is expected If it is less than 3-4 days send them home on prednisone
The nurse is caring for a client who has been prescribed a statin for TX hyperlipidemia. Which should the nurse check
Liver enzymes
Meniere's
Low Na diet
Blood transfusion reaction s/s
Low back pain, impending doom 1st stop transfusion 2nd disconnect and pull back 3rd new tube 4th normal saline
Diverticulitis
Low fiber diet
SIADH
Low sodium, bounding pulses
Enema cramp
Lower bag
Patient complaining of abdominal cramping during soap suds enema
Lower bag
A nurse is administering a soap suds enema to a client, the client reports abdominal cramping shortly after what actions should the nurse take
Lower the bag (slow it down)
Below the knee amputee
Risk for sepsis or Hypovolemia
The nurse is caring for a 2month old infant that is post operative following a surgical repair of a cleft lip and is crying
Rock the baby
PEG tube
Rotate 360 degrees, x1day
Mag sulfate
S/E response rate of 10
Suicide
S/s in teens-breakups, extreme weight loss, getting rid of personal belongings
A newly hired nurse has prepared a client for a transport to a surgical suite which of the following would require follow up
Shaving the clients operative side with shaving cream and a razor.
Liver enzymes
Shock statin use (give statins @night)
Mom loses baby
Sign no harm contract
Patient with depression
Sign safety contract
Needs additional teaching about informed consent
Signed by nurse to indicate patient understanding
The nurse attending a conference on informed consent it would indicate the need for additional teaching if the nurse states that informed consent
Signed by nurse to state patient understands procedure.
The nurse is planning care for a newly admitted client who has major depressive disorder following the death of her newborn 2 weeks ago, which of the following goals should the nurse identify as the priority?
Signing a no harm
Assessment for bucks traction
Skin breakdown
RH shot wrong answer
Something about placental lining
Pt. Angry and gets out of chair
Speak calm
Latex allergy
Spina big idea or multiple surgeries
Latex allergy includes
Spina big idea/ multiple surgeries
Fragile skin
Use wash cloth under tourniquet—-put over gown
Hearing aid follow up
Using alcohol swabs to clean
Veal chop
V- Variable C- Cord Comphression E- Early Decels H- Head Compression A- Accelerations O - OK L-Late Decels P - Placenta
Cardiac strips identify
V-tach
45% burns follow up
V/O 145 ml/8hr (4ML x% X kg)
Airborne
Varicella (M.T.V)
Slander
Verbal
Assault
Verbal abuse
Internal radiation see first
Visitor in room for 2hrs
Vitamin deficiency related to alcohol
Vit B6
UAP
Vital signs 2 hours post op
No vaccine for child w/
WBC 3.9
Pt who needs private room
WBC of 2,300
Small laceration—head
Wade when asleep
MD inhaler
Wait 2 minutes between each puff
The nurse working in the psychiatric inpatient unit is caring for a client who has bipolar disorder and is in the manic phase the client states to the nurse " I am bored" which of the following activities is appropriate for the nurse to suggest to the client?
Waking with the nurse in the courtyard
Bipolar patient in manic phase
Walk around with nurse
Continuous bubbling in chest tube
Wall suction container
Scabies (SATA)
Wash/dry hot water Ointment neck down -leave on 8-14hrs.
Prefilled injectable
Waste 1ml w/ witness before administering
Patient took whole bottle of amitriptyline
We're you trying to krill yourself?
A nurse is caring for a client who has a sealed radiation implant, which of the following precautions should the nurse implement?
Wear the lead shield while providing client care.
Buck traction
Weight free hanging, private room, skeletal pin care
Child follow up-
Weight triples at 6 months
Avoid decongestants
With BPH
Libel (defamaiton)
Writing something bad about someone on social media
Colostomy diet
Yogurt
The nurse has instructed the client who has a UTI about prescribed drug ciprofloxacin—which of the following instructions should the nurse give the client?
You should report the development of tendon pain while taking this medication, since tendon rupture is a potential complication
Blood can be hung max of
4hrs
Priority
4y/o kid with laceration and falling asleep
Math
54%
IM injections
5mL is too much for gluteal
See first
Acute pancreatitis with pain of 7 after medication
Pt. Suspected of flu
Droplet precautions —-gown, gloves, mask
Fluid volume depletion
Decreased pulse pressure or check creatinine?
Cirrhosis
Decreased sodium
LPN
Delegation -can obtain past medical history NOT assessment
Delirium is reversible,
Dementia is not
Seat alarm for
Dementia patient
Pertussis precautions include
Droplet, wear mask within 3ft of pt. Pt. Wears mask outside the room
Signs of hypothyroidism
Dry skin Menorrhagia Brittle nails
Hypothyroid (select all that apply)
Dry skin, brittle mails, menorrhagia
Increase protein, lay down after meals, no fluids while eating
Dumping syndrome
The nurse has provided dietary teaching to a client who recently had a surgical colostomy placed, which of the following statement made by the client indicates a correct understanding of the instructions?
Eating yogurt can help decrease the amount of gas that I have
Vent alarm
Either assess patient or bag them
Ileostomy
Empty 30 min after eating
The nurse working at a rehab center is managing care for a client with left sided stroke 3 weeks ago which is the goal
Establish communication ethically
left CVA
Establish means of communication
Blood reaction
Everything stopped and removed then run NS
Follow up at health fair
Ex-smoker of 2 months with BP greater than 140/90
Prevent PE
Exercise legs
Insulin
Fastest absorbed through abdomen
HPV vaccine
Female 9-26
OT
Fine motor skills
Evisceration
Call, cover, splint-client should be placed in a semi folders position, this reduces pressure on the abdominal wall. Moist dressing prevents drying of the organs.
Pacemaker
Can use electronic devices, but have to be used on the opposite side of the pacemaker (right side)
Urgent (multiple fx, 1+pedal pulses)
Can wait
Private room
Cancer patient, immune compromised, neutropenia, glove, gown, mask
Place on strong side, move with weak
Cane
Cane follow up
Carry on affected side
MAG
Check potassium
Beclomethasone
Rinse mouth
Patient with INR of 3.5 wants to leave AMA
Risk for bleeding
Priority teaching for thrombocytopenia
Risk for bleeding
Anxiety attack
Tell patient i will stay with you
LPN cannot give medication through
Central line
Macular degeneration
Central vision loss
When does the 2nd stage of labor start
Cervix is completely dilated and baby at - 1 station
BP
Change by 20 either way is priority
TPN/lipids
Change dressing
Foot drop with high top sneakers
Check every 2hrs
CFS
Check for halo, notify HCP
Statins
Check liver enzymes
Sexual assault
Check patient first
If you give patient wrong med
Check patient first, then call MD
Med error
Check patient of allergic reaction
PVC
Check peripheral pulses
Rhythm strip with 3 PVC's
Check postassium
A charge nurse is planning to admit several clients in the medical unit, it would be necessary for the nurse to admit which client to a private room?
Has a fever of unknown origin
The nurse is caring for a client who had lumbar spinal surgery 8hrs. Ago. It would be a priority for the nurse to notify the surgeon if
Has a numerate amount of clear drainage on the surgical dressing
Cleft lip
Have family rock baby
Fiscal barrier follow up
Having family get involved
A nurse is teaching a female client about positive signs of pregnancy which of the following client statements would indicate a correct understanding of the teaching?
Heartbeat (lung sounds)
A nurse is reviewing the lab results of a male client who is scheduled to have a cardiac catheter in one hour which of the following should the nurse immediately report to the HCP
Hematocrit of 32%
AKI
Hemoglobin 33
Priority decreased urine output (480ml in a 24 hr. Period)
Hepatic encephalopathy
Ethical issues
Hospice patient goes home w/ pick line
Testicular exam after
Hot bath/shower
The nurse is talking with a client who has MS what would need follow-up by the nurse
Hot showers
A nurse is caring for a client who has developed tumor lysis syndrome. What should the nurse expect?
Hyperkalemia
Tumor lysis
Hyperkalemia: cloudy urine
Addison's disease
Hyperkalemia: hyponatremia, and decreased blood glucose (hypoglycemic)
Respiratory alkalosis for
Hyperventilation
Respiratory alkalosis
Hyperventilation, panic attack
Below the knee amputation (BKA)
Hypovolemic shock
Thoracentesis with elevated HR (90-110)
Hypovolemic shock
The nurse working in the PACU is assessing the client who had a below-the-knee amputation the nurse should give priority to assessing the client for?
Hypovolemic shock —possible bleeding
Prostatectomy Foley catheter wrong answer
I CAN'T SHOWER FOR 2 WEEKS
Hearing aid wrong answer
I can clean with alcohol
Hepatic encephalopathy
Increased ammonia levels build up toxins causing confusion and slurred speech.
Dumping syndrome
Increased protein and lay down after meals
Spina bifida and multiple surgeries
Increased risk for latex allergy
Answer -patient with ——put in droplet precautions
Influenza
Emphysema-
Inhaler before exercise
A nurse is caring for a patient who has metastatic colon cancer who is undergoing chemotherapy the client has been admitted the acute care medical center due to prolonged Messi and assessment findings include HR 120, BP 80/48, RR 14, AND ABG'S OF pH 7.46,CO2 45, BICARBONATE 29, which of the following prescriptions would the nurse give first?
Initiate D5
The nurse working in the ED has received the following prescriptions for a newly admitted client, which prescriptions should the nurse implement first?
Initiate IV sodium and potassium for a client admitted with diarrhea and dehydration who has a serum potassium level of 2.9
Coumadin DVT and a-fib
Ink 2-3 Antidote vit k
The nurse is caring for a client who is currently prescribed bed rest which of the following actions should the nurse take to help prevent the development of pulmonary embolism?
Instruct the client to perform leg exercises (prevent DVT)
The nurse is teaching a group of clients about insulin administration which of the following informations should the nurse include?
Insulin absorption is fastest when injected into the abdomen
NG tube (SATA)
Irrigate w/ sterile water, reposition q2h, tun off suction to listen to bowel sounds.
Declomethasone is a corticosteroid
It is a daily use inhaler to prevent asthma flare ups, it is not a rescue inhaler. It can increase the risk of oral thrush, therefore, you need to rinse your mouth after each use.
Right side heart failure
JVD
Glomerulonephritis
JVD, crackles, increased fluid r/t kidney not working properly infection
Pancarditis
JVD, lwan forward if pain: pain on inspiration
Intussusception
Jelly like stool: knee to chest position
Delegation
LPN to get blood sugar
APGAR @
1 min and 5 min
3yr old speaks
3-4 word sentences
ABG
DKA (metabolic acidosis
TURP
Flow to keep the urine pink tinged Hang NS and keep flushing
Tumor lysis syndrome
Hyperkalemia
Wrong answer
I will work out at insulin peak
PT
Mobility
Battery
Nurse grabs pts arm when leaving
Kidney transplant-
Temp change
GERD
Use wedge pillow
IM injection
Z track method (iron)
LPN NO
central lines
The nurse is prioritizing patient care after a change of shift report and nurse should first plan to see the patient who:
-had an endoscopic retrograde cholangiopancreatography 30 min. Ago and is reporting difficulty swallowing
Deltoid muscle needle size
1-1 1/2
Skin to skin
1-2 hrs
Laceration
10 inch gash that is gushing blood —priority apply pressure then obtain IV access
TPN
10 ml syringe (do not pick 3ml syringe)
Umbilical cord fall off
10-15 days < 5problem
CPR
100 compressions
Follow up-
11 yr old sitting in front seat
Further seat belt safety teaching
11 yrs old sitting in front seat
Infant HR
110-160
Lipids IV
12 hrs
Snippy cup
12 months (14 months is concerning)
Chest tube follow up
175 ml/hr
70/30
70 NPH, 30 regular insulin salt, sex
Smile
2-3 months
Smallest needle for blood is
20 gauge
Suicide risk
20 yr old alcoholic and gun
A nurse is caring for a client who has a potassium level of 2.4 which of the following prescriptions should the nurse question?
20MEqL KCL IV/15 minutes (running to fast)
Increased risk for cervical cancer
24y/o African American female with history of HPV
Appropriate IM needle gauge and size
25 gauge 1' needle
Aortic
2nd intercostal space right eternal border
A nurse is auscultation the client's aortic valve it would be the correct technique if the nurses placed the stethoscope on the
2nd intercostal space, right eternal border
Auscultation aortic
2nd space right of the eternal border
A nurse is working on a pediatric cardiac unit is reviewing the telemetry monitors for assigned clients, which client should the nurse initially plan to assess?
2yr old toddler who is walking in the hallway and has a HR of 160 BPM (abnormal HR)
Priority setting
2yr old walking hall with HR 160
Give self-great exam
7days after period
Breast feed main form of nutrition
8-12x
COPD 02 sat
89% is normal
Child follow up
9 months stand up
Med math
325 burn answer
Catch lab
33% HCT is bad: 37 normal
Rotate peg tube
360 degrees
Expected urine output for a baby
3ml/hr
Hold vaccines for 2 weeks
4 yr old on ABX
Male prostate high risk
40-49y/o
CT contrast cannot receive meteor in within
48hrs.
The nurse working on a pediatric unit is caring for the following children who have been admitted in the past 12 hrs. It would be a priority goal for the nurse to initiate an interdisciplinary conference for the child who:
5yrs old with diagnosed cystic fibrosis at birth and has been hospitalized 4 times in the past 2 months.
Cholesterol
65 y/o on low cholesterol with high LDL -send to PCP there is a problem
A nurse is working in a community health clinic is assessing clients who are waiting to be seen, which client should the nurse have the primary health care provider see first?
A 57 yrs old with Graves' disease with a team. 100.5 (thyroid issue)
The nurse is assessing a client who has developed an Addisonian crisis which of the following finding is consistent with this diagnosis?
A blood glucose of less than 60
Question about an 11yr old in the front seat what are the teachings for that?
A child should not be allowed in the front seat until 12 yrs. Old
The nurse is monitoring a client following at Horace tests it would be a priority for the nurse to notify the primary health care provider if the client develops
A heart rate that has increased from 95 to 110BPM
The nurse working on the mom/baby unit has become aware of the following client situation, which of he following clients should the nurse initially assess?
A neonate who is 4hr. Old, whose resting HE is 95BPM NormalHR 120-140
The nurse is caring for a client who is receiving prescribed magnesium sulfate IV which of the following client finding s would indicate the client is experiencing a side effect of that medication?
A respiratory rate of 10 breaths per minute
A nurse is caring for a male client who has a deep partial thickness and a full thickness burn 45%of the lower body, it would be a priority for the nurse to notify the primary health care physician if the client has:
A urinary output of 45ml over the past two hours (normal 30ml/hr)
Cardiac strip
A-fib give heparin
Perform ADLs in
AM for rheumatoid arthritis
Cirrhosis of the liver
AST, ALT increased Teach no alcohol, proper diet, transplant
Insulin teaching
Abdomen absorbs faster
Peg tube
Abdominal wall- stomach- annotate swallow comatose or stroke patient
Flumazenil
Antidote for benzodiazepines
Profuse bleeding
Apply pressure then start IV
Delegation order
Asses, plan, communicate, surveillance, evaluate, feedback
Order of action
Assess Plan Communicate Surveillance/supervise Evaluate/feedback
Colostomy
Assess bowel sounds ?
Foot drop patient in high top shoes
Assess pressure points
The nurse is delegating tasks to staff members on the unit, which of the following is the appropriate offer of action for delegating tasks?
Assess, plan, communication, survey, supervise, evaluate, give feedback
The nurse working on a medical surgical unit is delegating tasks to unlicensed personnel which of delegated task would require follow up by the charge nurse?
Assisting a client who had a paracentesis 2 hours ago to get out of bed for the first time. -RN needs to do the first
New RN should get what patient
Asthma patient getting discharged or ETOH patient with protocols
2nd space right of eternal border
Auscultation aortic
Bronchovesicular
Auscultation between scapulae
Sickle cell
Avoid high altitiudes
A-fib
CCB like dilitazem (very neat drugs)
Reduces spread of MRSA
CNA give CHG bath
Cardiac strip—asystole
CPR
After spinal surgery
Call DR moderate clear drainage
Stoma pink and dry
Call HCP
ETOH cart
Call MD
Child becomes Hypovolemic with HR of 116
Call help or give fluids? (Most people said to give fluids)
Surgery on femur and restless
Call rapid response (could be fat emboli)
A nurse is assessing a patient who had a colostomy created 6 hrs. Ago. The stoma appears dark red dry and flaccid with a small amount of mucous drained in the bag. Which action would be a priority for the nurse?
Call the doctor
The nurse is caring for a 3yr. Old who has had 160ml of urine output over the past 8hrs. The child weighs 33lbs which of the following actions should the nurse take?
Continue to monitor
V/s on child
Continue to monitor
Water seal at 2cm
Continue to monitor
End stage renal
Creatinine 2.7 is expected Normal levels 0.6-1.2
Interdisciplinary patient
Cystic fibrosis
Multidisciplinary question
Cystic fibrosis kid
The nurse working on the med/surg unit has been made aware of situation, who would she assess first?
DM type 2, premeal BG 85, and now has a post meal BG of
Novice nurse gets
DVT waiting for ultrasound
Retinal detachment
Dark floating spots (pay attention to the eye they are asking)
High iron foods
Dark green leafy vegetables, beans
Detached retinal of right eye
Dark spots in right eye
Math-
Decrease 15ml
Cirrhosis and acute ascites
Decrease Na
Yogurt w/ colostomy to
Decrease gas
The nurse has received the handoff report for the client who has a prescription for dobutamine to ensure at 5mcg/kg/min. The client is receiving 500mg in 250mg in 250ml dextrose at 18ml/hr. What action should the nurse take?
Decrease the infusion rate to 15ml/hr
Magnesium toxicity
Decrease urine output
Cardiac tamponade are
Decreased BP, JVD, muffled heart sounds with clear lungs
A nurse is caring for a client who has acute kidney injury and is at risk for volume depletion which of the following findings would indicate the client is developing this complication
Decreased pulse pressure
The nurse is preparing to administer prescribed medication to the following client it would be essential for the nurse to follow up the primary health care provider for the client who has?
Diabetes mellitus, just had a CT scan with IV contrast and has been prescribed met for in.
Correct technique
Diaphragm of stethoscope to hear bronchovesicular sounds
Myasthenia Gravis priority
Difficulty swallowing and muscle weakness
Schizophrenic with command hallucinations yelling " i will do it!"
Distract them
Restraints—2 fingers
Distracted with music
low fiber
Diverticulitis
High fiber
Diverticulosis
Question with vital signs and low K+
Do EKG first
Patient with insomnia
Do activities in AM
Old patient having trouble steeping
Do activities when patient is awake
Pt. With o+ blood receiving B+ blood
Do not assess patient (o universal donor , AB+ universal receiver)
Diet for patient on Coumadin
Do not change
PRBC
Do not flush with D5W
Patient with potassium 2.4
Do not get patient OOB
Glargine
Do not mix
Kid with (what seems to be low but isn't) urinary output
Document and continue to monitor Kid urinary output=15ml/hr Adult=30ml/hr
RhoGam is given for the mom so that she
Does not develop antibodies toward an A+ baby. RhoGam is given once per pregnancy
Informed consent
Does not indicate the patient understands the procedures -neg stem
ERCP
Does not need bowel prep Priority if patient is still having difficulty swallowing 1 hr after
Fever of unknown origin (neg stem)
Does not need private room
A nurse is teaching another of five tear old child about age appropriate toys which of the following toys would be appropriate for the nurse to recommend?
Doll and coloring book (do not pick the 100 piece puzzle)
Clean catch urine
Dominant hand holds cup
Restraints
Don't attach to movable part
DYSPHAGIA (NEG SEM QUESTION)
Don't ignore cough I will not tilt head down when swallowing
Isolation precaution for inhalation anthrax
Droplet precautions
Droplet precautions
Flu Gown, gloves, mask
PICC line or triple lumen
Flush with 10ml NS
Post thoracenteses
Follow up —HR increase form 99 to 110
Administering eye gel
From nose outward
Digoxin-neg stem question
Further education if patient states " i need to avoid food high in vit k including avocado, potatoes, and bananas"
Sit up after eating, no caffeine, carbonated, spicy, smoking-wedge pillow
GERD
Why would HDL be high if patient is on correct diet
Genetics
Suspect abuse
Get detailed hx
Delegate to LPN
Get patient history
Negative titles to measles and pregnant
Gets MMR after delivery (only give immunizations that aren't live: no nasal influenza)
Chest pain reduced after one nitro tab
Give 2nd dose
Medication math answer for child 22 lbs
Give 3ml
Septic shock
Give LR @ 30 mg/kg but BP still low —administer vasopressin to increase BP
HPV
Give ages from 9-26
4 yr old on ABX
Give all vacccines
MI pain went from 6-3
Give another nitro
HHS
Give fluids
Hypovolemic shock
Give fluids then O2
Kawasaki
Give immunoglobulins
Rubella titer negative
Give vaccine after delivery
Patient with colostomy
Give yogurt
Take off PPE-
Gloves
Sequence for doffing (removing )PPE
Gloves Goggles Gown Mask
PPE used with MRSA
Gloves and gown (contact)
Take off PPE
Gloves, gown, goggles, mask,
Addison's
Glucose less than 60
Addisonian crisis
Glucose of 60
Celiac disease
Gluten allergy
NG
Gold standard x-ray of KUB and pH
Second prevention
Great exam
Polycystic kidney disease
Gross hematuria
Metabolic alkalosis No ketones
HHS
The nurse has provided medication instruction to a patient who has asthma and been prescribed beclomethasone which of the following client statements indicates a correct understanding of this instruction?
I should rinse my mouth out after this medication
The nurse has instructed a female client who recently received hearing aids. Which of the following client statements indicates the need for additional teaching?
I will clean them with alcohol wipes
Digoxin wrong answer
I will decrease the amount of potassium in my diet
The nurse has provided discharge teaching to a client who had an open radical prostatectomy and has been discharged home with a urinary catheter which of the following statements made by the patient would require follow up by the nurse.
I will not be able to take a shower for the next 2 weeks
The nurse has instructed a client who regularly menstruates about performing self-breast examinations at home which of he following client statements indicates correct understanding of eh teaching?
I will perform myself breast examination 7 days after my period ends-you do it 7 days post as the hormones have decreased and any natural lumps will disappear, and breast will not be at tender and sore.
The nurse has instructed a client who must ambulate with a cane which of the following client statements indicates a correct understanding of the teaching?
I will place the cane on the side of the unaffected lib and walk with the weaker leg first.
The nurse is working on a crisis hotline speaking with a client who states " I just took an entire bottle of amitriptyline" which of the following responses should the nurse initially make to the client?
I'm glad you called, and I want to sen an ambulance to help you
Crisis hotline
I'm glad you called: I'd like to send help
Warfarin-
INR 2-3
Warfarin check
INR of 2
Follow up
IV K+ 20mEq
Kidney transplant 1 week ago
If BP decreases=good
Heimlich maneuver
If someone is showing the shocking sign do abdominal thrusts
Sexual harassment is not lateral violence
In the work place
Lost dentures
Incident report
Incorrect note
Incident reports do not get charted
Digoxin
Increase K+ and decrease calcium, green leafy veggies, bananas, and sweet potatoes
Allopurinol
Increase fluids
Patients aPTT while on heparin is 30 sec
Increase heparin
Bacterial meningitis
Mask when outside the room
Soaked pad
Massage fundus
HCP orders 150mg to be given TID Give 3ml TID
Math
Tube feed
Max 24 hours
Antimboloism stockings
Measure calf circumference and width
GCS
Measures eye, verbal, and motor responses (15= the best outcome: 3=worst outcome)
Vaccine for 18yrs
Meningitis
The nurse is caring for a client that has acute kidney injury which of the following arterial blood gas results would the nurse expect to find?
Metabolic acidosis
ABG-AKI
Metabolic acidosis (identify it by pH and bicarbonate)
AKI-
Metabolic alkalosis
Eternal radiation
Mild soap and water, do not rub, leave on tattoos/ markings. No washcloth
Following bronchoscope
Monitor for any hemoptysis
Addison disease
Monitor v/s BP
Activity for mother that lost child 2 weeks ago
Mourning
Digoxin toxicity
N/V, blurred vision Check level-greater than 2 is toxic 1st check v/s
Peritonitis
N/v
Atherosclerosis
NO EGGS
Barium enema
NPO
Peptic ulcer disease
NPO and NG tube (coffee ground eyes is-GI bleed)
GI bleed
NPO until HCP clears
SIADH-
Na 120
Spontaneous delivery
Nasopharynx suction
Suicide risk-
Native American with gun permits OUR test- old man whose wife died
Command hallucinations
Needs more supervision (worst hallucinations)
Priority patient in mon/baby unit
Neonate with HR of 95
Hearing aid care
No alcohol, mild soap/water only Use a hearing aid on the lowest setting
External radiation
No direct sunlight for one year
SCIP
No disposable razors (use electric razor & start ABX 1hr before surgery)
Neutropenia
No fruits/flowers in room
Multiple sclerosis
No hot baths
Brace maker—set between 60-70
No lifting arms above head for 4 weeks Magnet to reset
IBS
No loperamide (ain't diarrhea drug)
Abruptly placenta
No oxygen, painful
Ace
No potassium sparing diuretics
Lateral violence means bullying
No sexual harassment
Patient with pericarditis
No vesicular breath sounds
8hrs post delivery with moderate bleeding
Normal
Dawn phenomenon
Normal to have high BG in AM
The nurse is teaching a class on health promotion and illness prevention which of the following actions by the nurse is an example of secondary prevention?
Performing monthly self-breast examinations.
The nurse is caring for a patient who has paranoid schizophrenia and a history auditory hallucinations the client is yelling and pacing in the day room " I will do it" what of the following actions will the nurse take?
Obtaining increased supervision for the client
HIT
On heparin > one week
Cane
On unaffected side and forward with weak leg
Testicular exam
Once a month after shower
Emphysema
One activity at a time like walking and talking
Restraints for violent behavior
One to one monitoring
Lispro
Onset in 15-30 min
Sterile dressing change Which requires to follow up
Opening towards self first
Phenytoin
Oral hygiene to prevent gingival hyperplasia
Bronchiole lungs sounds
Over trachea
Delegate
PCA to check v/s after biopsy
Stop novice nurse if starting 22gIV-needs to be 20g or larger
PRBC
DVT prevention
PROM
Health fair
PSA testing
The nurse is caring for a client that develops the following cardiac rhythm
PVC check potassium —-peripheral pulses
The patient is having an anxiety attack and is hyperventilating which ABG results would be consistent with the findings?
PaCO2 of 98
Assess first
Pacemaker and dizzy
Post-op priority
Pacemaker feeling dizzy
Interdisciplinary care
Parkinson's and cystic fibrosis
Stroke
Patient becomes restless see first
Identification
Patient form PACU first thing we do is identify the patient
Put patient in room first for DR to see
Patient who had TB test 48 hr ago
Novice nurse
Patient with asthma and d/c
Increased temp
Patient with temp greater than 101.5 get them out of the waiting room and into a private room
Denial
Patient with terminal cancer wants 2nd opinion
Draw trough before
Peak
The nurse is discussing health screening guidelines with a group of men it would be appropriate for the nurse to state
Perform monthly testicular exams immediately after a bath or shower
I pro
Report tendon
Chest not moving
Resp acidosis
Circumcision
Petroleum jelly, no wipes, warm water, loose diaper
The charge nurse in the ED is reviewing the care provided for recently admitted clients: which of the following reflects implementation of an accepted standard of care?
Placing the client who has suspected hemophilia influenza on droplets precautions.
Which would be a concern while on anti-coagulants
Platelet <100,000
Heparin drip -adverse reaction
Platelet less than 100,000- normal 150-400K
Heparin —bleeding concern
Platelets 90,000 LOW Antidote protamine sulfate
Priority-
Post ERCP can't swallow after 30min
Priority patient 2hr.
Post lumbar puncture reports headache
Arm laceration
Pressure, insert new IV, clean, suture
Child with asthma using rescue inhaler Q2HR while awake
Priority
Patent with BP 92/58
Priority
Patient with internal radiation has visitor >2hrs
Priority
Cardiac strip of V-fib
Priority -defibrillator
Lithium toxicity
Priority does not need to limit sodium
Paranoid schizophrenia
Priority is patient yelling don't make me do it
6y/o 130 @ rest
Priority see first
Sodium 125
Priority see first Normal levels 135-145
Burns on chest
Priority see first.
Pyloric stenosis
Projectile vomiting infants
Who to see first?
Pt. Who is supposed to be getting 100 ml/hr and has received 400 ml in 2hr.
Enoxaparin
Retain air bubble
Hypothermia
Rewarm trunk before extremities
9 months
Pull up
Hypovolemic shock-
Pulse increase HT from 80-100
Wrong sterile
Put on gloves before opening packages
Alcohol based rub before
Putting gloves for standard precautions
A preceptor is working with a newly hired nurse who is preparing to perform a sterile dressing change,which of the following actions by the newly hired nurse would require intervention by the preceptor?
Putting on sterile gloves prior to opening the outer packaging.
When transferring patient —-after endoscopy
RN assess to see if they can bear weight
Restraints priority
ROM every 2hrs
Mag side effects
RR 10
Mask photo
RSV if it says child
Further education
Radiation materials have to stay in room (such as v/s machine) decimeter stays -measures radiation
Post op VP shunt
Raise HOB 30 degrees
Infant car seat anchored in middle of seat
Rear for 2years
LPN can
Recheck liver biopsy vital signs
LPN-
Recheck vitals
Histrionic personality disorder
Redirect/ don't let interrupt group
Transcribing telephone order
Repeat back
Teach care
Replace with new ties before remove the old ones
Kidney transplant
Report temp change of 1 degree
Grave's disease and thyroid storm
Report temp increase of 1 degree
Ciprofloxacin
Spontaneous tendon rupture
Outside agency
Stage 3 pressure ulcer on adult patient should be reported.
Hepatitis B
Standard precautions
Itching, wheezing during transfusion
Stop disconnecting get another bad, new tube-return to the blood bank-do not flush
Oxytocin
Stop w/contractions over 2.5
Community program for primary prevention
Stress management
70 yr old who lost his wife
Suicide risk
Evisceration (protruding organ)
Supine position Wet gauze Notify Physician
Spontaneous abortion
Support group (sorry for your loss)
Teach ties —not secured (moving in and out while coughing)
Supposed to be one finger under ties
Crying baby w/ cleft palate
Swaddle, hold close and rock
Crying baby with cleft palate
Swaddle, hold close and rock
Endoscopic retrograde cholangiopancreatography (ERCP
Swallowing irritability
24hrs-feeling fullness-stop feed, check residual, check the tubing for kinks
TPN
Always have 2 nurse check order, change tubing q24hr
TPN
Always have 2 nurses check order: change tubing Q24hrs
TPN check
Psych with manic bipolar
Take for a walk
MS painted should not
Take hot bath
MS wrong answer
Take hot bath
Postmortem neg-stem
Take lines out before autopsy
Carpal tunnel
Take v/s first
PACU following regional anesthesia
Take vitals
TURP-
Teach kegels
TPN watch for
Temp increase
Invading privacy of famous patient
Terminate
HIPPA breach
Terminate employees
Teaching men group
Testicular checks after shower
Amitriptyline OD
Thanks for calling I'm sending an ambulance
The nurse is assessing clients at the scene of a mass casualty disaster and is prioritizing care based on the disaster triage tag system which of the following clients should be transported to the health care facility first?
The client who has multiple compound fractures and is reporting chest pain
Desmopressin
Therapeutic effect would be ruin output going from 2500m; to 1200ml
Therapeutic communication
This is a rough time for you
A nurse is teaching a client who had a spontaneous abortion about the need to receive a RhoGam shot, which of the following client statements indicates a need for further teaching?
This medication will allow my body to fully remove the placenta lining -false statement
Medications should be given
Through a central line
Temperature 100 degrees indicates
Thyroid storm
Medication treatment for open angle glaucoma
Timolol (hold for HR <60)
D/C for disease
Tonsillectomy
Rhythm strip is V-tach
Treat with valsalva's maneuver or lidocaine
Blood transfusion reaction
Tubing and blood has to get sent back to the blood bank
The nurse is caring for a client who had abdominal surgery and has developed an evisceration after calling for assistance which of the following actions would the nurse take next?
Use a moist ABD to cover the abdomen
Carbamazepine
Use condom with birth control because it deactivates it
Someone w/ cast
Use crutches up with good, down with bad and resume normal activity
Adrenal Glands
corticosteroids, catecholamines
Chart pic
d5 fluid
Child dying
essential activities only
ABG—respiratory alkalosis
hyperventilation
Follow up before surgery
nurse uses disposable razor
Late decelerations
poor placental perfusion (POOF, LION)
TORB
telephone order read back
