Final Prep
Which finding should the nurse expect to note in a child with chronic hypoxia?
Clubbing of fingers
The RN delegates the care of a client in the immediate postoperative period to the patient care associate (PCA). Which tasks are in the scope of practice for the PCA?
Feeding the client Assisting the client with bathing
The nurse is teaching a client self-management care in preventing and spreading methicillin-resistant Staphylococcus aureus (MRSA). Which statements made by the client indicate the need for further learning?
I can share athletic equipment I can participate in contact sports I should sit on upholstered furniture
Which part of the electrocardiogram (ECG) represents depolarization of the ventricles ?
QRS interval
Which finding in a client who has home oxygen therapy with a tracheostomy collar requires immediate action by the home health nurse?
Scented candle burning in the room
How would the nurse position a client with epistaxis?
Upright leaning forward
When a client with a health care-acquired respiratory tract infection asks the nurse what this means, which response will the nurse give?
Your infection occurred because of exposure to a health care facility
Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication?
Atelectasis
The nurse provides discharge instructions to the parents of a child who has undergone tonsillectomy. Which statement indicates that the parents need further teaching?
Cherry milkshakes will ease the pain
When taking the history of a client who is being treated for obstructive sleep apnea, which findings would the nurse expect?
Chronic fatigue, enlarged tonsils, poor concentration
Which would the nurse do when obtaining consent for surgery?
Determine wether the client's knowledge level is sufficient to give consent.
Which statement made by the nurse will be most significant when teaching strategies to reduce the risk for developing antibiotic-resistant infections?
Do not skip any prescribed doses of your antibiotics
Which laboratory test will be elevated in a client with inflammatory arthritis?
Erythrocyte sedimentation rate (ESR)
Which findings occur with orthostatic hypotension?
Feeling of faintness Decreased systolic pressure
When getting a post operative client out of bed, which action will the nurse take to avoid postural hypotension?
Have the client sit on the edge of the bed for a few minutes before getting the client up
Which symptoms would the nurse expect in a 3 year old child with mild iron-deficiency, anemia and fatigue?
Increased pulse rate
A client is hospitalized for intravenous antibiotic therapy and an incision and drainage for an abscess that developed at the site of a punctured wound. When would the nurse begin to teach the client about how to care for the wound?
In the pre-operative period
Which leukocyte values determine the adequacy of a client's response to inflammation?
Monocytes Neutrophils Macrophages
The nurse is assessing the client who reports excessive daytime sleepiness, sudden muscle weakness during intense emotions, and inability to walk just after waking or before going to sleep. Which disorder would the nurse suspect the client is experiencing?
Narcolepsy
Which type of immunity is acquired through the transfer of colostrum from the mother to the child?
Natural passive immunity
Which criteria would the nurse consider when determining if an infection is a health care associated infection?
Occurred in conjunction with treatment for an illness
Which waveform represents Atrial depolarization?
P wave
When the nurse needs to determine atrial rate and rhythm. which component of electrocardiogram will be used?
P waves
The nurse demonstrates correct understanding of anemia related to chronic disease with which statement?
Red Blood cells are normal in size and colour, however the number of cells produced is decreased.
The nurse us caring for a client in respiratory distress. The health care provider prescribes oxygen therapy with a Venturi mask to be set at 35% oxygen. Which mask would the nurse use to implement the prescription?
Venturi mask which can be set at 24,28,31,35,40 and 5% oxygen.
Which type of immunity would a 4 year old child develop during the course of an infection with varicella?
Active natural immunity
Which collaborative and nursing actions would help prevent venous thrombosis in a client during the perioperative period?
Administer subcutaneous heparin injections Assist the client to don antiembolism stockings Apply pneumatic compression device to legs
Which action describes the process of artificial active immunity?
Antibodies are made after an antigen is injected into the body
What type of immunity will clients acquire through immunizations with live or killed vaccines?
Artificial active immunity
A child who has iron-deficiency anemia tells the school nurse, "I get dizzy in gym class." Which is the most likely explanation for this symptom.
Insufficient cerebral oxygenation
Tetanus immune globulin is prescribed for the client with a puncture wound. Which information will the nurse include when teaching the client about this medication?
It provides immediate, passive short term immunity.
The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to ?
Nosocomial
When the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which finding indicates a need for more staff education about oxygen therapy?
Oxygen flow rate is set to 8L/min - max is 6
The nurse instructs a client to breathe deeply to open collapsed alveoli. Which explanation could the nurse offer to explain the relationship between alveoli and improved oxygenation?
Oxygen is exchanged for carbon dioxide in the alveolar membrane.
Which therapeutic outcomes are expected after administering ibuprofen?
Pain relief Temperature reduction Reduced inflammation
Which action by a client who requires an above the knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery?
Participates in learning perioperative care
The nurse reviews the principles of oxygen administration. Which is the primary consideration when determining which method of oxygen delivery will be the most effective for a client?
Pathological condition
Which intervention is most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client?
Removing the catheter within 24 hours
Which nonpharmacological nursing intervention is effective in helping relieve postoperative pain?
Repositioning
When a client with blunt trauma to the nose is noted to have nasal swelling, ecchymosis around the eyes, and watery pink-tinged nasal drainage, which action will the nurse take?
Send a specimen of the fluid to the laboratory for analysis
A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing?
Sinus tachycardia
As a part of informed consent, a surgeon explains to the client who is scheduled for surgery the details of the surgery and the related care. The nurse leader witnesses the complete procedure. What information does the nurse leader ensure was provided to the client? Select all that apply.
Surgical procedure Name of the surgeon Explanation of the possible risks
Which task is classified as low priority when planning client care for the day?
Teaching self administration of insulin injections before discharge
A client who is scheduled for a bowel resection is to receive antibiotics preoperatively. Which explanation would the nurse include when teaching the client about the purpose of the antibiotics?
They are given to eliminate bacteria from the GI tract
A client is unlikely to undergo reconstructive surgery for which purpose?
To restore function and/or appearance
Which method of oxygen delivery would the nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%?
Nonrebreather mask - Delivers upto 90% at a liter flow of 10-15 L/min
