EXIT EXAM FOR RN PROGRAM
The client in an alcohol treatment program asks the nurse, "Why do we need to talk about relapse? I know I'll never drink again." Which of the following responses by the nurse is best?
"Anyone can slip. Relapse commonly occurs during the first few months after a treatment program."
A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. Which of the following is the most appropriate response by the nurse?
"RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby." Explanation: RhoGAM is indicated to suppress antibody formation in women with Rh negative blood after giving birth to an RH positive baby. It is also given to Rh negative women after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis
A postpartum client decides to bottle-feed her neonate. Which client statement indicates the need for further teaching about preventing engorgement?
"i will take a hot shower" this releases milk and promotes production
where does the drainage bag go after cholecystectomy? how much drainage a day from Ttube? What position after Ttube is removed? what do we assess during followup visit?
-on bed the same level as gall bladder -500-1000ml -semi fowlers -stool and urine for claycolor and concentration indicating bile is draining into liver
maintanence dose of digoxin is?
0.125-0.5
what is a normal lithium range?
0.5-1.5
In general, new mothers who are breast-feeding should consume
2-3L fluids 2300-2700 cal or 500 more cal than normal intake
what interventions to perform on emergency care for burns?
ABC, wrap in warm blanket to prevent temp drop
TB treatment regimen
AIRBORNE PRECAUTION chemo, 9 months of isoniazid, combined with streptomycin, rifampin, ethambutol, pyrazinamide
What is lactovegan?
ALL VEGAN WITH ADDED MILK YOGURT AND CHEESE
A nurse is teaching new staff members about groups considered at highest risk for suicide. Which group should the nurse emphasize
Adolescents, men older than age 45, and persons who are unemployed
Before the neonate's discharge, the mother tells the nurse that she is worried that her 5-year-old daughter will be jealous of the new baby when they get home. After explaining ways to deal with sibling rivalry, the nurse determines that the mother understands the instructions when she says she will do which of the following?
Allow the 5-year-old undivided attention several times a day.
obesity is defined as ? and morbid obesity?
BMI greater than 30 and BMI greater than 40
While assisting a primiparous client with her first breastfeeding session, which of the following actions should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple?
Brush the neonate's lips lightly with the nipple. Explanation: Lightly brushing the neonate's lips with the nipple causes the neonate to open the mouth and begin sucking
The nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client?
Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative.
A client whose blood type is A− gives birth to a neonate whose blood type is A+. The client is scheduled to have Rho(D) immune globulin administered. Before administering the medication, which action by the nurse is most important?
Ensuring that the client understands the procedure and signs a consent for the vaccination Explanation: Before Rho(D) immune globulin administration, the nurse must educate the client about the medication, and the client must sign consent.
What virus causes infectious mono?
Eppstein barr
A clinic nurse is assigned to care for a suicidal client. During the preinteraction phase, what should the nurse's priority be?
Exploring the nurse's own feelings about suicide. The nurse's values, beliefs, and attitudes toward self-destructive behavior influence her responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse must initially explore her personal feelings about suicide to avoid conveying negative feelings to the client.
A client is receiving ergonovine to treat postpartum hemorrhage. Which client complaint indicates the drug should be stopped?
Headache Explanation: Ergonovine may cause severe hypertension, which may be indicated by a headache. If hypertension occurs, the drug should be discontinued.
azotemia?
High levels of BUN and creatinine
A client who is experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mm Hg and pulse is 92 bpm. Which of the following medications should the nurse expect to administer?
Lorazepam, Benzo, The benzodiazepine substitutes for the alcohol to suppress withdrawal symptoms. The client experiences symptoms of withdrawal because of the "rebound phenomenon" when sedation of the central nervous system (CNS) from alcohol begins to decrease.
is there pain with full thickness burns?
NO!! the pain receptors are burnt off
what are the five Ps for neurovascular status?
Pallor Paralysis Pulselessness Pain Paresthesia
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next?
Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. Explanation: The nurse should place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus to palpate the fundus. This prevents uterine inversion and trauma, which can be very painful to the client.
A client is beginning to participate in the alcohol treatment program. Which nursing approach would be most effective in decreasing his denial about his alcoholism?
Point out concrete problems that are a direct consequence of his alcoholism.
A nurse is assigned to care for a client with anorexia nervosa. During the first 48 hours of treatment, which nursing intervention is most appropriate for this client?
Providing one-on-one supervision during meals and for 1 hour afterward Explanation: Because a client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 to 2 hours afterward
Lochia normally progresses in which pattern?
RSA! rubra serosa alba (really silly andrea)
A hospitalized client craves a drink after withdrawing from alcohol. Which of the following measures is the best way to help the client resist the urge to drink?
Support from other alcoholic clients. Explanation: Group support has proved more successful than individual attention from the staff in influencing positive behavior in alcoholics.
A nurse is evaluating a client for probable amphetamine overdose. Which assessment finding supports this diagnosis?
Tachycardia
Which statement summarizes the underlying principle for the development of a parent-child relationship?
The relationship is based on the need for early and frequent parent-infant contact.
A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which of the following actions in the infant's plan of care?
Urine toxicology screening. Explanation: A urine toxicology screening will be collected to document that the infant has been exposed to illegal drug use. This documentation will be the basis for legal action for the protection of this infant.
BUN and creatinine levels
a BUN has 7-18 seseme seeds and "create" 0.7-1.4 burgers
what do you do 30 mins before wound care?
admin analgesics
A client is being treated for alcoholism. After a family meeting, the client's spouse asks a nurse about ways to help the family deal with the effects of her husband's alcoholism. The nurse should suggest that the family join which organization?
al-anon Al-Anon is an organization that assists family members in sharing common experiences and increasing their understanding of alcoholism.
Meds for IBD?
anticholinergics, analgesics, sulfonamides, corticosteroids, antidiarrheals, antiperistalics,
PHENYTOIN
anticonvulsant side effects: gingival hypertrophy *never mix with other IV meds or dextrose *sweat or urine may become red or pink *take with 1/2 glass water or food
A client is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with:
antisocial personality disorder. Correct Explanation: This client's history of delinquency, running away from home, vandalism, and dropping out of school is characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is characterized by a pattern of self-involvement, grandiosity, and demand for constant attention.
schizophrenia negative symptoms....
apathy (no feeling) a motivation (no motivation) flat affect (empty expression) social withdrawal, poverty of speech, anhedonia (inability to feel pleasure)
what to avoid in infectious mononucleosis?
aspirin, streneous activity to prevent rupturing the spleen
stomatitis care
assess q4h, offer mouth care before and after meals, no commercially prepared mouth products, rinse with water or saline
What does joint pain in hemophilia indicate?
bleeding; priority over abdominal pain
what is a thermal injury
burn from hot substance (solid, liquid, or gas)
what PPE worn for burn vitim care?
cap gown gloves and mask ALL OF IT!
Four hours after cesarean birth of a neonate weighing 4,000 g (8 lb, 13 oz), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which of the following?
classic (vertical incision) is contraindicated Transverse incision is not contraindicated
When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the
clients safety needs TP over physical
what are some atypical antipsychotics used for schizo?
clonzapine, olanzapine, and risperidone
The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for her clients during a fire alarm?
close all the doors to prevent smoke spreading to the unit
when and what does colustrum do
comes first for 3-4 days and delivers mothers antibodies to infant
pre lumbar puncture?
consent, explain procedure, assure patient that paralysis will not occur, have pt void, position in lateral recumbant fetal
what two conditions are involved with inflammatory bowel disease?
crohns and ulcerative coloitis
what does digoxin do?
decreases HR, increases force of contraction
what are anticholinegics useful for?
drying secretions controlling tremors and rigidity
During a home visit 4 days after delivery, the breast-feeding primiparous client tells the nurse that her breasts are hard and tender. The nurse determines the client has breast engorgement and should instruct the client to:
express a small amount before feeding
syncope
fainting
coercive power uses....
fear and punish to achieve goals
Corticosteroids are classified as either:
glucocorticoids (anti-inflammatory) which suppress inflammation and immunity and assist in the breakdown of fats, carbohydrates, and proteins, or as. mineralocorticoids (salt retaining) that regulate the balance of salt and water in the body.
schizophrenia positive symptoms....
hallucinations, delusions
post lumbar puncture?
have pt lie prone for first 2-3 hours, then supine or prone for 6 hours, assess q15-30, encourage fluids to reduce post headache, assess drainage on dressing
what assess diabetes long term control?
hgb A1C
what diet for IBD?
high cal high pro low fat low fiber
what are acid reducing meds?
histmine 2 blockers and proton pump inhibitors
A client and her boyfriend of 5 months are celebrating the birth of a healthy baby boy when the client's estranged partner arrives to visit the baby he believes is his son. The nurse caring for the client knows that the estranged partner has the right to:
hold the baby after the mother gives permission
side effects from atypical and typival antipsych meds....
hypotension, EPS, neuroleptic malignant syndrome, anticholinergic effects,
minimize breast engorgement by....
ice/cool compress, supportive bra, take warm shower before feeding, use good latch technique
A breastfeeding primiparous client with a midline episiotomy is prescribed ibuprofen 200 mg orally. The nurse instructs the client to take the medication:
immediately after a feeding
what is ovovegan?
includes all vegan (fruit veggies nuts seeds beans) AND EGGS (OVO)
what is the vegan diet?
includes no animal proteins; FRUITS VEGGIES NUTS SEEDS BEANS
what is an electrical burn?
injury from electrical current, internal damage can be worse than external
sputum specimen steps....
instruct pt to clear nose and throat, rinse mouth, take deep breath and cough into a sterile specimen cup, deliver to lab within two hours
why is alka seltzer contraindicated in chemo?
it contains aspirin, increase bleeding risk
what solution is used for fluid replacement in burn victims?
lactated ringers, 50% replaced in first 8 hours and 50 % replaced in the next 16 hours totaling 24 hours
A nurse is palpating the uterine fundus of a client who gave birth to a neonate 8 hours ago. Identify the level in the abdomen where the nurse should expect to feel the fundus?
level of umbilicus for first 24hrs postpartum
what do we monitor in cirrhosis?
liver disease!! increased bleeding tendencies(check skin stool vomit and gums on the REG), assess fluid retention, avoid soap for skin breakdown, observe for behavioral/personality changes *ESOPHOGEAL VARICES are risk for bleed
A nurse works with a client diagnosed with bulimia. What is an appropriate long-term client goal for this client?
managing stress without bingeing or purging
LITHIUM
mood stabilizer ANTIMANIC; used in manic episodes of bipolar disorder; get adequate salt intake; check levels 2-3 times/wk initially then moves to monthly; 2500-3000 fluid intake daily
The nurse evaluates the mothering skills of an adolescent primigravida changing her baby's diaper for the first time. When caring for this client, the nurse should focus on the client's need for which of the following?
praise and encouragement
The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be:
red and moderate During the first 3 days, the lochia will be red (lochia rubra) with moderate flow. Note, however, that the client shouldn't be soaking more than one pad every hour. A continuous flow of moderately clotted blood from the vagina isn't normal and should be reported. Clots may indicate retained pieces of placenta. Lochia changes to pink or brown (lochia serosa) after 3 to 10 days. By day 10, the lochia should be white (lochia alba) and continue for several weeks.
A woman who has given birth to a healthy baby is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the healthcare provider about?
saturating pad in one hr A postpartum client who saturates a pad in an hour or less at any time in the postpartum period is considered to be hemorrhaging. As the normal postpartum client heals, bleeding changes from red to pink to off-white. It also decreases in amount each day. Passing blood clots the size of a fist or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up to 6 weeks postpartum
After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective in the client does not develop:
seizures
Flumazenil has been ordered for a client who has overdosed on oxazepam. Before administering the medication, the nurse should be prepared for which common adverse effect?
seizures
where should incident reports be kept
separate from pt chart, only chart care given in regards to incident
hypothyroidism with myxedema is....
slowed metabolism, social isolation is a concern because of weight gain and lethargy. goiter can develop(mass in the neck)
what is administered in burn victims to help with infection barrier? what kind of dressing?
standard dressing (layers of guaze) tetanus prophylactic, silver sulfadiazine, silvadene,
A client recently gave birth to a boy. Two minutes before breast-feeding the baby, she administers one nasal spray (40 units/ml) of oxytocin into each nostril. Why is the client using this drug?
stimulate lactation
oral oxytocin?
stimulates lactation
what to do before admin digoxin?
take apical 1 full minute, with hold med if less than 60 and notify HCP
Thirty hours after a client has given birth, the nurse plans discharge teaching for the client about infant care, because at this time the client is in which of the following phase of postpartal psychological adaptation?
taking hold Beginning after completion of the taking-in phase, the taking-hold phase lasts about 4 to 5 weeks. At this time, she is ready to learn self-care and infant care skills. The taking-in phase occurs 1 to 2 days postpartum. The letting-go phase is the final phase of postpartal psychological adaptation. This phase is characterized by readjustment, viewing the infant as a separate being, refocusing on her relationship with her partner, and maternal role attainment. Resolution is not considered an accepted phase of postpartal psychological adjustmen
referent power is...
the follower desiring to be like the leader; student to instructor or staff nurse
typical antipsychotic for schizo?
thorazine/chlorpromazine
how is mono transmitted?
through oral secretions, blood, or genital contact
what is the overall goal in IBD?
to rest the bowel which may require TPN
What is a lumbar puncture used for?
to withdraw fluid specimen, relieve pressure, admin meds, inject dye
where are lymphatic tissues located?
tonsils, GI tract, spleen, and thymus
what condition requires oral hypoglycemics? and what do they do?
type 2 diabetes; stimulates insulin production
what to monitor in burn victim?
urine output (30ml/hr) CVP (3-12) vital signs and pulmonary artery pressures, maintain warm humid environment
what to assess before IV potassium supplement?
urine output, to make sure clearance will be adequate thus preventing cardiac dysrhythmias
when do you notify PCP regarding I&O?
when the totals change significantly over 24hrs
signs of successful latch and feeding (3)
wide-open mouth position, aubible sucking noise, tongue and jaw movements indicating swallowing
when should b-feeding begin?
within 1 hour after birth of healthy infant
The nurse is caring for a client hospitalized for anorexia nervosa. Which of the following interventions should the nurse include for the plan of care? Select all that apply.
• Encourage the client to talk about non-food-related topics during mealtimes. • Collaborate with nutritional counselors and dieticians at the hospital. • Have highly structured mealtimes. • Provide regular meals of sufficient caloric intake to promote weight gain. Explanation: Structured mealtimes should be encouraged. During mealtimes, non-food-related social conversation is the encouraged treatment. Nutritional counseling is also encouraged. Sneaking food, laxatives, and diuretics is a much greater concern in clients with bulimia nervosa than in those with anorexia nervosa
